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Tuberculosis

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Tuberculosis is emerging anew. In 1993, the World Health Organisation declared it a global emergency. Figures from the United States showed that during the 1960's the prevalence of TB was decreasing. At this time compliance with drug regimes and reporting decreased. This allowed for the emergence of resistant TB strains. Because of this failure to report, the upturn in cases was missed. This increase is now recognised and there is renewed interest in many - but not all countries - in tuberculosis, with consequent increased publicity and funding for TB control programs.

Tuberculosis is an airborne disease. Of those exposed to the bacteria, only 10% develop the disease as either infectious (lung) or non-infectious (non-lung) TB. With treatment the disease can be cured but without treatment, the possible outcomes range from recovery to death. It is not certain why people respond in different ways to this bacterium and more research is needed. For example, why are men more likely to develop infectious TB than women, even if their exposure is the same?

Incidence of Tuberculosis in Indonesia

In global terms, there are one billion people infected with tuberculosis at any one time. Eight million new cases arise annually making a prevalence of 16 million cases. Three million persons die annually from TB. However, despite these grim figures, even without the influence of treatment and immunisation, the incidence is not as high as it was in the last century. The problem now is that with inadequate treatment regimes, a pool of persistent sputum positive cases is being created. The annual risk of TB infection in South East Asia is 1 to 2.5 per cent. This represents an upward trend. In Indonesia. there are at least half a million new cases of TB per year and 175,000 deaths. Tuberculosis is the second killer of adults after cardiovascular disease and the most important killer out of all the communicable diseases.

Diagnosis of Tuberculosis

At the local level, diagnosis is best achieved through microscopic examination of the bacillus in a sputum smear. Culturing the bacillus is expensive and impractical as it takes 6 weeks and X-rays can be misleading. Skin testing is recommended by WHO, however, it is not specific for human TB bacillus. Additionally, the size of the reaction is not always helpful as strong reactions may occur in healthy people with repeated occupational exposure to infectious tuberculosis patients and in those with old healed disease.

Good case finding is necessary as well. It has been found that males in the 25 to 34-year old age group are the most common transmitters of the bacillus. An infectious case will infect 10 others in a year. In case-finding, the general rule is that anyone who has had a cough for more than 3 weeks should have a sputum smear. Crowded dark places are the ideal areas for the spread of TB. Direct sunlight will kill TB in a few minutes, but in dark, dusty environments, it can live for up to 20 years.

Treatment of Tuberculosis

Whatever treatment regimes are used, basic rules must be followed:

drug intake must be supervised
drug intake must continue for long enough (many months)
there needs to be an uninterrupted drug supply to prevent emerging resistance.

Prevention of Tuberculosis

Vaccination with BCG has been used for many years and is usually given in the first month of life. There have been several studies to look at its effectiveness. Some have said it has limited usefulness and others say it gives 14 years protection. However, it only gives protection against serious disease.

Some countries, such as Canada and the USA prefer to concentrate their preventative efforts against TB by monitoring the spread of TB and treating these who prove positive to TB rather than immunizing the whole population. They feel that a positive Mantoux/Tine test then fails to differentiate those who have been immunized from those who actually have the disease. They believe the vaccine to be ineffective and it complicates diagnosis (diagnosis can take many weeks to be confirmed and can be difficult).

Other countries (e.g. Europe) believe even the partial protection for the population from BCG is worth the increased difficulty in making the individual diagnosis. They also believe that repeated Tine testing will cause a falsely positive reaction after a number of tests (a response to the inoculation with reactive parts of the organism in the previous tests).

BCG Vaccine

Now used worldwide and comes from the original bacterium - Bacillus Calmette-Guerin, which Calmette and Guerin isolated in Paris, France. It is freeze dried and a diluent is added when vaccination is to be given (it should be used within 3 hours after mixing).

Administration:

The vaccination is given by the intradermal route over the deltoid muscle (upper arm) IT SHOULD NEVER BE GIVEN subcutaneously AS THIS CAN CAUSE EXTENSIVE LOCAL REACTIONS

Result:

The result of a local lesion at the injection site is an indication that conversion to TB sensitivity has occurred. IF CORRECTLY PERFORMED THIS SHOULD RESULT IN CLOSE TO 100% CONVERSION. The lesion should be approx. 6-8 mm in diameter over a period of weeks and may cause some itching. It may even develop as a sore or shallow ulcer but should start to heal in 6-8 weeks causing a small scar. Inspection of the site should be carried out at this time (6-8 weeks). The upper left arm (deltoid region) should ALWAYS be used unless for sound medical reasons as this is the only site validated for efficiency and is easily observed in future checkups.

Tuberculin Testing

Three tuberculin tests are used In Indonesia/Jakarta the most commonly administered test is the Tine test.:

a. Heaf test

this uses a multiple puncture 'gun' with rings of spikes injects PPD (Purified Protein derivative) from the tuberculin mycobacteria. It is generally not used now as the same rings are used repeatedly (with sterilization between patients) and AEA does not recommend it as a screening procedure.

b. Mantoux test

5 IU (0.1 ml) of PPD (purified protein derivative) from the tuberculin mycobacteria is injected intradermally using a 25 gauge needle with a short bevel into the anterior surface of the forearm. The injection should raise a weal about 7 mm in diameter. The injection site is usually examined after 72 hours and the diameter of any induration (hardening) on light pressure, if any, is measured.

Results:

Negative: less than 5mm diameter

Weakly positive: 5-9mm diameter

Intermediately positive: 10-14mm diameter

Strongly positive: 15mm diameter or more with sores or spots

c. Tine test

Comparable to the Heaf test in that it involves inoculation of PPD (purified protein derivative) from the tuberculin mycobacteria by means of similar spikes, used once only.

Prevention of Spread of Infection from One Source

In order to limit the spread of infection especially in confined spaces and crowded areas (such as offices, institutions and schools), the following precautions should be observed as a minimum (in addition to medical and possibly radiological screening of personnel):

Sanitary and washing facilities in accommodation should be clean and cubicles should be available for individual ablutions, and preferably for sleeping.

There should be a supply of clean towels. Soap and warm or better still, hot water should be provided at all washing facilities, especially near the kitchen and toilets.

Messroom accommodation with facilities for keeping food covered and washing hands should be available.

Paper towels are preferable to linen handkerchiefs.

A responsible person should be in charge of inspecting the living and sleeping areas.

Especially in air-conditioned, moist, and confined environments, persons suffering from respiratory infections should not go to work when ill without consulting a doctor. Such environments are ideal for the spread of TB via droplet transmission.

There should be a system in place for reporting symptoms of throat and chest infections and a method of ensuring medical surveillance of the site staff.

Medical Prevention of Tuberculosis

There should be pre-employment medical assessments with chest X-ray and tuberculin testing especially in countries where TB is endemic. There should also be periodic medical examinations of all workers - at least once a year. Most doctors are now agree that the resumption of work at the earliest possible stage is well justified, and the few differences of opinion are mainly concerned with the duration of a possible cessation of work and the conditions under which it should be taken up again. Tuberculosis in general is no longer infectious after 2 - 4 weeks of specific and carefully prescribed treatment, HOWEVER in many countries there are multi-drug-resistant forms arising, and treatment for economic and cultural reasons is not appropriate or not carried on for long enough.

While in the case of correctly treated chronic TB carriers, sputum smears will have become negative in 36% of cases by the 15th day of treatment, in 50% by the 30th day, in 90% by the 60th day, and in 100% by the 90th day, this is not the case when there is primary resistance to the drug(s) used and there is not complete cooperation with the treatment regime.

For closed sites, it is recommended the period of removal of the patient from the worksite be for a minimum of 120 days provided treatment has been appropriate. In some countries there are regulations controlling this period which are more stringent.

After that time there is usually no medical reasons that the worker may not return to work. However, there is less ground for optimism bacteriologically speaking, when the patient is carrying resistant germs or atypical mycobacteria.

IT IS CLEAR THAT THE DIAGNOSIS OF TB MUST BE CONFIRMED BY SPUTUM CULTURE AND DRUG SENSITIVITIES ESTABLISHED BEFORE A DECISION CAN BE MADE ABOUT THE SAFETY OF ALLOWING AFFECTED PERSONNEL TO RETURN TO WORK AFTER TREATMENT.

With resistant strains where conversion to a negative TB culture can be delayed, and treatment may need to last 18 to 24 months, and, in the case of certain stubborn strains, even surgical intervention may have to be considered.

For the worker himself, the period of rest may have to be extended in unfavorable circumstances such as a particularly serious attack of the illness, resistance to particular antibiotics, an associated aggravating disease, special ethnic or social circumstances, and particularly unfavorable or unhealthy conditions of work.

The above comments apply to a case where the patient is ill and therefore at risk of spreading the disease by droplet spread. TB discovered by chance and with no clinical symptoms, and after two or three negative results from successive bacilloscopies using a gastric fluid culture, is not likely to pose a risk to other workers. Absence from work over a long period is no longer necessary when the major antibiotics can be used providing a proper course of treatment is followed and clinical and radiological supervision is assured.

The decision to stop work for such "otherwise well" patients must still be taken whenever certain types of tuberculosis are found, the patient shows signs of bacillary dissemination, or there is a progressive lesion under X-ray, clinical signs e.g. cough, fever, and weight loss, or a pleurisy. In all such cases a triple antibiotic treatment should be continued for a total period of about a year, while a return to work could be envisaged after 6-8 weeks of treatment, taking into account bacteriological findings and the results of follow-up.

Although a pulmonary tuberculosis correctly treated is usually cured without sequel, there may be rare cases where temporary or permanent job redeployment or reclassification may be required. Such cases would arise for example. where the job would involve exposure to toxic substances whose action might amplify the toxicity of the antibiotics, employment which puts the individual in contact with a dangerous chemicals, where the antibiotics could impair visual or auditory acuity, causing lack of vigilance or lack of equilibrium.

Where there are chronic respiratory insufficiency sequels, any work which involves a pneumoconiosis risk or where there are poor working conditions, poor diet or crowded living conditions is particularly ill-advised.

We trust this information will assist you to make correct choices for your health and welfare. However it is not, and is not intended to be, a substitute for personalized advice from your medical advisor.

Our appreciation to Dr. Rene de Jongh of International SOS, An AEA Company who has contributed this article in response to a growing health threat faced by expatriates in Indonesia.

If you have medical-related questions about living in Indonesia to ask of medical professionals, see Ask the Experts.

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