Chapter 131: Tuberculosis

Introduction

Tuberculosis (TB) is a severe and contagious disease caused by infection with

members of the Mycobacteria tuberculosiscomplex (MTBC). Most often involving the

lungs, TB is transmitted by cough, with an infectious dose of less than 10

bacteria.1Case fatality rates in untreated active pulmonary TB approach nearly

60%.2 Major medical advances of the past half-century have brought effective treatment

capable of cure in nearly all identified cases.3,4 Despite this TB causes hundreds of

thousands of deaths worldwide every year. The morbidity and mortality burden of TB is

not uniformly distributed throughout the globe but rather disproportionately affects those

living in poverty and those from resource-limited settings.5

Epidemiology and Microbiology

In this section, aspects of the epidemiology and microbiology of tuberculosis are

presented.

Global burden of TB and Recent Progress

In 1990, the World Health Organization (WHO) declared TB a global emergency and in

response, developed the directly observed therapy strategy (DOTS), promising to “Stop

TB” by finding and treating infectious cases in resource-limited settings.6,7 Within a few

years of its design, the World Bank labeled the DOTS strategy the most cost-effective

health-intervention ever deployed and by 2012, an estimated 51 million people had

been treated and an estimated 20 million lives saved.8–10 Since 2004, TB incidence is

falling in all WHO regions and in each of the 22 highest burden countries.
Although global TB incidence is falling, TB remains a leading cause of global infectious

mortality, second only to HIV infection.11,12 There were 8.7 million new cases of TB and

1.4 million deaths globally in 2011. Moreover, many TB deaths occur in young,

previously healthy adults, and as such, TB is a top 10 cause of lost disease adjusted life

years (DALYs).7

Broadly speaking, there are three major threats to global TB control: (1) Poor social

conditions including inadequate housing and nutrition,5 (2) Immune compromise related

to the HIV pandemic,2,13 and (3) Emergence of drug-resistant TB.14,15

Poverty and TB

Globally, TB distribution correlates closely with poverty and human development

indices.16–19 Population health factors such as water sanitation, childhood immunization

rates, and life expectancy also independently predict TB incidence.20,21 A corollary of

these relationships is that only 1% of the global TB burden occurs in the industrially

developed countries of North America and Europe while more than 90% arises in Asia

and Africa (Fig. 131-1) (Table 131-1).10

FIGURE 131-1

Estimated TB incidence by Country 2011. (Reproduced with permission from 2012.

Global Tuberculosis Report, World Health Organization.)