RECENT OUTBREAKS OF TUBERCULOSIS INFECTIONREVIEW ARTICLE
SUBMITTED TO
DR. ISHFAQ
SUBMITTED BY
SADIA RIAZ
MS.BT42F17

RECENT OUTBREAKS OF TUBERCULOSIS INFECTION
ABSTRACT
Tuberculosis is an airborne infectious disease caused by Mycobacterium Tuberculosis. It is a contagious disease which spreads from one person to another through sneezing, coughing or close contact with the infected person and can affect almost all parts of the body. It is a worldwide epidemic. Most TB are not the cause of outbreaks. Outbreaks usually occur in poor living conditions, poor hygienic conditions and among immunocompromised people such as those suffering from HIV, Diabetes Mellitus or any other immunocompromised state .MDR (Multi-Drug Resistant) TB and XDR (Extensive Drug Resistant) TB, which is caused by bacteria resistant to the routine first-line drugs, is the emerging problem worldwide for which second-line drugs are being used. The commonly used second line drugs are fluoroquinolones and aminoglycosides. Many new second-line drugs such as Bedaquiline and Nitroimidazoles are in line to fight this emerging problem. Millennium Development Goals (MDGs) set the main target for global TB control for declining the incidence rate. Directly Observed Treatments (DOTS) is the main strategy adopted by WHO against this evil disease.

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KEY WORDS: Tuberculosis, contagious, immunocompromised, MDR, XDR, second-line drugs, MDG, DOTS,
INTRODUCTION
Tuberculosis (TB) is an airborne disease caused by the bacterium Mycobacterium tuberculosis that usually affects the lungs. Most TB cases do not start outbreaks. Contact investigations undertaken after a person receives a diagnosis of infectious TB ideally should identify and treat infected contacts before the infection progresses to disease (Centers for Disease Control and Prevention, 2005). Genotyping data in the United States provide reassurance that most cases do not result from recent transmission (Moonan et al., 2012).

However, when TB outbreaks do occur, they can put tremendous strain on local public health resources (Mitruka et al., 2011). A necessary component of all outbreaks is that they must begin with a source case. Recognizing the characteristics of such patients soon after the TB diagnosis could help focus interventions to interrupt transmission and reduce the risk for an outbreak (Borgdorff et al., 2001).
TUBERCLOSIS
Tuberculosis (TB) is a disease caused by bacteria called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but they can also damage other parts of the body. TB spreads through the air when a person with TB of the lungs or throat coughs, sneezes, or talks. TB spreads through the air when a person with TB of the lungs or throat coughs, sneezes, or talks. If you have been exposed, you should go to your doctor for tests. You are more likely to get TB if you have a weak immune system (MedlinePlus, 2016).

SYMPTOMS
Symptoms of TB in the lungs may include: (MedlinePlus, 2016)
A bad cough that lasts 3 weeks or longer
Weight loss
Loss of appetite
Coughing up blood or mucus
Weakness or fatigue
Low Grade Fever
Night sweats
WORLDWIDE EPIDEMIC
The highest prevalence of tuberculosis infection and estimated annual risk of tuberculosis infection are in sub-Saharan Africa and Southeast Asia. Overall, almost 3.8 million cases of tuberculosis were reported in the world in 1990, of which 49% were in Southeast Asia. From the period 1984 through 1986 to the period 1989 through 1991, notification rates increased in all World Health Organization regions, except the American and the European regions. In 1990, there were an estimated 7.5 million cases of tuberculosis and 2.5 million deaths worldwide (Mario et al., 1995).

OUT BREAK OF TB
Tuberculosis (TB) is an airborne disease caused by the bacterium Mycobacterium tuberculosis that usually affects the lungs. Most TB cases do not start outbreaks. Contact investigations undertaken after a person receives a diagnosis of infectious TB ideally should identify and treat infected contacts before the infection progresses to disease (Centers for Disease Control and Prevention, 2005).
Genotyping data in the United States provide reassurance that most cases do not result from recent transmission (Moonan et al., 2012). However, when TB outbreaks do occur, they can put tremendous strain on local public health resources (Mitruka et al., 2011 and Centers for Disease Control and Prevention, 2007).
A necessary component of all outbreaks is that they must begin with a source case. Recognizing the characteristics of such patients soon after the TB diagnosis could help focus interventions to interrupt transmission and reduce the risk for an outbreak (Borgdorff et al., 2001).
GLOBAL TUBERCULOSIS REPORT
The purpose of WHO’s Global Tuberculosis Report is to provide a comprehensive and up-to-date assessment of the TB epidemic and of progress in care and prevention at global, regional and country levels.1 This is done in the context of recommended global TB strategies and associated targets, and broader development goals. For the period 2016–2035, these are WHO’s End TB Strategy and the United Nations’ (UN) Sustainable Development Goals (SDGs), which share a common aim: to end the global TB epidemic (WHO, 2017 ).

TB RESEARCH AND DEVELOPMENT
Few diagnostic technologies emerged in 2017 and the evaluation of GeneXpert Omni®, which is intended as a close-to-care platform for rapid molecular testing, has been delayed. There are 17 drugs in Phase I, II or III trials, including eight new compounds, two drugs that have received accelerated or conditional regulatory approval based on Phase IIb results, and seven repurposed drugs. Various new combination regimens are in Phase II or Phase III trials. There are 12 vaccine candidates in clinical trials: three in Phase I, and nine in Phase II or Phase III (WHO, 2017 ).

PREVENTION AND CONTROL
Tuberculosis (TB) has been one of the major causes of death and disability in the world for several decades. Millennium Development Goals (MDGs) published in 2000 by major world countries set the main target for global TB control for declining the incidence rate, halving TB prevalence and halving death rate for 1990 by 2015 (MDG Target 6c).A Stop TB Strategy was initiated in 2006 by World Health Organization to achieve the MDGs’ target.
DOTS (Directly Observed Treatment) is the strategic plan to stick to the treatment for Tb patients in which patients are called upon in clinic once daily and are given medications under observation.. The strategy also set the ultimate goal of eliminating TB by reducing the incidence to less than 1 case per million populations per year by 2050. In this program, prevention of TB is done at three different levels as follows:
 Control of tuberculosis: triangle and levels of prevention.

Agent Host Environment
Primary Vaccination (BCG) Health education Decrease crowding
Secondary Early diagnoses (Tuberculin Skin Test (TST), chest X rays and sputum examination. TB medications Isolation of the patient
during first week
Tertiary Nil Rehabilitation; TB medication; DOT Restriction from daily activities
WORLD TB DAY
World TB Day is recognized each year on March 24, which commemorates the date in 1882 when Dr. Robert Koch announced his discovery of Mycobacterium tuberculosis, the bacillus that causes tuberculosis (TB). World TB Day provides an opportunity to raise awareness about TB and the measures needed to tackle this devastating disease. In 2017, for the second year, CDC will join the global Stop TB Partnership in adopting the World TB Day theme “Unite to End TB” (Schmit et al., 2017).

TUBERCULOSIS IN UNITED STATES
OUTBREAK IN 2018
In New York ,the number of tuberculosis cases reported increased by 10 percent last year (Carl campanile-march,26, 2018) and it was the largest increase since 1992.TB is a highly infectious bacterial disease that largely attacks the lungs, but can also infect and spread to other organs, including the kidneys, spine or brain. There were 613 reported cases in 2017, as compared to 556 in 2016. After reaching its peak level with 3,811 cases in1992, TB has been on the decline in the city. People at high risk for TB include substance abusers and those with HIV. It urges the local health authorities to thoroughly test high-risk patients for TB. After getting AFB Smear positive, Chest X-ray of such patients is done.

OUTBREAK IN KANSAS, 2018
In Northwest High School in Olathe, Kansas on Mar. 18, one index case was reported and then further investigations revealed twenty seven people positive for Tuberculosis in a 300 plus community.

In 2017, 40 cases of tuberculosis were diagnosed in Kansas, while in 2013 there were 36 cases. Countrywide, there were 9,582 cases in 2013. The disease used to be much more prevalent in the past in U.S. with 84,304 cases reported in 1953.

Clinically, there is a difference between a tuberculosis infection, or latent tuberculosis, and tuberculosis disease, or active tuberculosis. The 27 people who tested positive for tuberculosis infection do not have symptoms and are not contagious to other people. However, without proper antibiotic treatment, tuberculosis infection can turn into tuberculosis disease, which causes symptoms and can spread from one person to another through the air. To prevent an outbreak of tuberculosis disease, people tested positive for infection were had chest x-rays and a course of antibiotics started to kill the latent tuberculosis bacteria in their bodies. The people initially tested negative for the disease were re-tested after eight weeks (as it can take up to eight weeks for the bacteria to show up in a test).

According to the World Health Organization, Tuberculosis is second only to HIV/AIDS as the “greatest killer worldwide”. Because of this infection, 9 million people got tuberculosis disease, and 1.5 million died from it worldwide.

There is a vaccine for tuberculosis, but it isn’t commonly administered in the U.S. Instead, it would be normally given to small children in countries where the disease is common, like Afghanistan, Bangladesh, Brazil, Cambodia and Pakistan. Currently, Europe is facing rising numbers of tuberculosis disease, including drug-resistant tuberculosis. The condition, which is very difficult to treat, is caused when people with tuberculosis begin but don’t finish their antibiotics regimen, contract tuberculosis again after undergoing treatment or have spent time with others who have drug-resistant TB.

OUTBREAK IN MINNESOTA IN 2017
17 confirmed cases including six fatalities were reported by health officials in Minnesota country (MPR news, Nov 6 2017). The Minnesota Department of Health has linked three of the six deaths in Ramsey County directly to the disease. The illness, which can spread when an infected person talks, sneezes, coughs or sings, can be treated with antibiotics, but the then outbreak involved a multi-drug resistant strain. Therefore, it required second line drugs and more time to treat it. The state has tallied 160 cases of tuberculosis so far that year, with previous year’s total counted at 168. 
OUTBREAK IN 2016
In 2016, a total of 9,287 new tuberculosis (TB) cases were reported in the United States; this provisional count represents the lowest number of U.S. TB cases on record and a 2.7% decrease from 2015. The 2016 TB incidence of 2.9 cases per 100,000 persons represents a slight decrease compared with 2015 (-3.4%). However, epidemiologic modeling demonstrates that if similar slow rates of decline continue, the goal of U.S. TB elimination will not be reached during this century. Although many programs were being run in the country to identify and treat active TB disease, additional measures to identify and treat latent TB infection (LTBI) among populations at high risk were also needed to accelerate progress toward TB elimination (Kristine et al., 2016).

OUTBREAK IN 2009-2015
In this period, Tb load was greater in the region. The 21?TB outbreaks during 2009-2015 involved 457 outbreak patients (range, 3-99 patients per outbreak). Out of the total outbreaks, 16 were first identified through genotype data. In sum, 118 (26%) patients were identified through contact investigations of other patients in the outbreak. Most outbreak patients (79%) were US born. The proportion of patients experiencing homelessness doubled between 2002-2008 and 2009-2015; other characteristics were similar between the 2 periods. TB outbreaks challenge frontline public health resources. Genotyping and contact investigations are important strategies for detecting and controlling TB outbreaks, particularly among people experiencing homelessness or those with mental illness.

OUTBREAK IN CANADA
Jul 11, 2012 | Lauren Edmundson
An outbreak of tuberculosis infected eight percent of the people in the small Northern Quebec community of Kangiqsualujjuaq, Nunavik. Officials believed the outbreak stemmed from poor living conditions such as overcrowded housing and poor ventilation. Total cases reported were 86.

Dr. Patrick Tang, a medical microbiologist at the British Columbia Centre for Disease Control, explained that addressing the social causes of the disease, such as poor living conditions, is “more difficult” than providing testing and treatment for TB. Because of the highly contagious nature of the bacterium, people who are in close contact with infected people have a thirty percent chance of infection.

A person who is infected but does not show symptoms may have latent TB and can still transmit the bacteria to others. TB can be cured with antibiotics, and prevented with a vaccine. However, the vaccine is not used regularly in Canada except in First Nation and Inuit communities where outbreaks occur more often
OUTBREAK IN SOUTH ASIA
Tuberculosis (TB) remains the most common cause of infectious disease deaths worldwide. The caseload of tuberculosis patients in South Asia is staggering .(PubMed,march,2018)
South Asia has almost 40% of the global TB burden with 4,028,165 cases in 2015. This region also has a disproportionate share of TB deaths (681,975 deaths, 38% of the global burden). Only 12.5% of TB cases are in HIV positive individuals worldwide. Only 3.5% of patients with tuberculosis in South Asia have HIV co-infection. With such a huge burden of disease, this region has an estimated 184,336 multi drug resistant (MDR) cases among notified TB cases which accounts for a third of global MDR burden. Crucially, at least 70% of the estimated MDR cases remain untreated in this region and MDR treatment success ranged from only 46% for India to 88% for Sri Lanka. This region has many conditions which provoke TB epidemic: rapid urbanization and high density populations with dramatically rising incidence of diabetes, a largely unregulated private sector with escalating drug resistance and high air pollution both outdoor and households.

OUTBREAK IN SOUTHEAST ASIA
The South East Asia (SEA) Region of WHO is home to one fourth of the world’s population; (WHO Report 2015). However, nearly half of the global TB burden in terms of new TB cases lies in this region. In 2015, there were an estimated 4.74 million new cases of TB and nearly 800,000 people died due to TB (and TB-HIV) in the Region. Six SEAR Member States are in the list of 30 high TB burden countries globally- Bangladesh, Pakistan, DPR Korea, India, Indonesia, Myanmar and Thailand. The estimated incidence of multi-drug-resistant and Rifampicin resistant (MDR/RR-TB) in the Region is 200,000 out of which only 32,648 were started on treatment in 2015 or just around 16% of the incident cases. Extensively drug resistant TB had been reported by 6 countries in SEAR by 2015. An estimated 227,000 cases (4.7%) of the 4.7 million incident cases were HIV positive. With current level of efforts, the Region is achieving only 1.5-2% annual decline in incidence of TB which is grossly insufficient compared to the required decline of at least 10-15% if we are to reach the WHO End TB Strategy targets (aligned with the SDG goals). 
OUTBREAK IN NEW GUINEA
With one of the highest tuberculosis (TB) infection rates in the world, Papua New Guinea’s TB pandemic was referred as a “national emergency” by National Health Authorities(Geoorgia Eccles March, 2016). With approximately 30,000 people in the country newly infected with the TB bacteria every year, increasing incidences of drug-resistant strains, and limited access to adequate healthcare, the nation has been again receiving support from international governments and medical humanitarian agencies.

TB is a communicable disease that can lie dormant within the body for many years. However, for those with compromised immunity, TB develops into a disease that destructs organ tissue – most commonly in the lungs. It presents symptomatically as a fever-like condition and can be fatal if left untreated.

Throughout the latter half of the 20th century, the global fatality rate for TB was greatly reduced through the administration of rigorous antibiotic treatment. However, the development of antibiotic resistance has led to the rise of two aggressive strains of the disease. The increased incidence of both Multidrug-Resistant TB and Extensively Drug Resistant TB in PNG has occurred at an alarming rate. These drug resistant strains are less susceptible to treatment by the most effective TB medication. Thus, patients are left with a more severe strain of infection and less effective treatment options.

OUTBREAK IN PAKISTAN
OUTBREAK IN 2016
The World Health Organisation’s Global TB Report 2016, estimated that there were 510,000 people afflicted with the disease in the country last year. However, the country only notified 331,809 cases indicating a gap of around 200,000. Further the report said that the total number of new and relapse cases in the country were about 323,856.

Despite coming in the six countries with the highest incidence of cases, Pakistan had a substantial reduction in mortality from over 75 per cent in 2000 to just 24 per cent in 2015 when 46,000 people died from the disease.

While monitoring treatment of the disease in Pakistan, the report said there was 63 per cent of treatment coverage in the country. Worryingly, the report had found high levels of  Ofloxacin resistance in the country. There were 26,000 multi-drug resistant TB (MDR-TB)cases reported in the country last year.

OUTBREAK IN 2010
The Sindh province, with an estimated population of 42.4 million people in 2010 ,(Journal of Infection and Public Health,2017) has roughly equal rural and urban populations (51.2% and 48.8%, respectively). While Sindh has 23 districts, there are very limited studies and data on TB for any of those districts in the WHO, World Bank or any National TB control organizations including provincial health ministries in Pakistan. According to Javaid . TB control was almost absent because of a dormant and ineffective NTP until 2001. According to the NTP report , a comparison of the CNR from 2010 to 2011 indicates that among 23 districts in the Sindh province, there was an increase in the CNR of Sputum Smear-positive (SS+) cases in 11 districts and a decrease in 12 districts. Sindh has a higher CNR among males compared to females aged 15 or more years old.

CONCLUSION
Tuberculosis (TB) is an airborne disease caused by the bacterium Mycobacterium tuberculosis that usually affects the lungs. Currently, it is affecting a large number of populaiont. However, the disease is treatable with proper medication. When TB outbreaks occur, they can put tremendous strain on local public health. As the frequency of TB cases continues to decline in the United States, however, so does provider experience with its diagnosis, which raises the possibility that the recent trend towards more cases of pulmonary TB being diagnosed in later disease stages might be a related consequence.. TB and more importantly MDR TB has become a major health problem worldwide in the recent decade. The problem is more prevalent is regions with poor socioeconomic conditions. Improved timeliness of diagnosis and thorough contact investigations for such cases, on-time treatment for proper duration, measures to prevent it from spreading through contact and screening in epidemic areas are the mainstays to win this war against Tuberculosis and reduce the risk for outbreaks. The need of the hour is to arise awareness among people worldwide about prevention and treatment and develop new more potent drugs which are more effective against multi-drug resistant bacilli.
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