Tuberculosis

Tuberculosis or TB (tubercle bacillus) is caused by various strains of mycobacteria. It typically attacks the lungs, but can also affect other parts of the body. Most TB infections are asymptomatic and latent, but about one in ten of those eventually progresses to the active disease. If the disease is left untreated in kills more than half of those infected. The disease is spread though air transmission and inhalation of droplets from people that have an active TB infection. Crowded living or working conditions increase the likelihood of it spreading. Malnourishment, illness or a generally weak immune system makes people more vulnerable to develop active TB than healthy individuals. Another common source of infection is from the bacterium Mycobacterium bovis which particularly affects cattle. People can become affected by drinking infected milk or working closely with cattle. Other groups at risk of developing TB are those on long courses on medication such as corticosteroids or chemotherapy. However, although TB is spread in the same way as a cold or flu it is not contagious. In order to contract the disease around eight hours in close contact have to be spent with an infected person. TB affects the respiratory system, particularly by destroying and damaging lung tissue. It also suppresses the immune system making the body less able to fight the disease. Once the bacteria have been inhaled into the lungs they multiply slowly in the primary infection, often causing no obvious symptoms. If the infected person has a healthy immune system, there will be a localised inflammatory response forming a mass of tissue called a tubercule, which contains dead bacteria and macrophages. Within about 8 weeks the immune system controls the bacteria, the inflammation dies down and the lung tissue heals. However, some bacteria survive the primary infection stage by producing a thick waxy outer layer, which protects them from the enzymes of the macrophages. These bacteria will remain deep in the tubercules in the lungs, dormant or growing slowly for years until the person is malnourished or has a weak immune system. They then produce active tuberculosis. About 20% of infected people become infected by simply taking up a large load of bacteria that multiply faster than the immune system is able to respond. With active TB the bacteria multiply rapidly in the lungs. They cause all the typical symptoms of TB such as fever, night sweats, loss of appetite and loss of weight. Other symptoms include a persistent cough, which brings up sputum sometimes accompanied with blood, extreme tiredness and a sense of feeling unwell. Without treatment the infected individuals lungs will steadily be destroyed as the

alveoli break down to produce large, inefficient air spaces. Mycobacteria also target T cells, reducing the production of antibodies and so disarming a critical part of the immune system. The bacteria are temperature sensitive and stop reproducing above 42 degrees. This puts the patient at risk of dying before the bacteria are actually inhibited. Eventually TB causes death, either because the individual cannot get enough oxygen from the air through the damaged lungs, or because their organs fail through lack of nutrition. Also, because TB affects the immune system itself this leaves space for other opportunistic infections to also infect the individual. In some cases, a TB infection can spread from the lungs to other parts of the body. TB infections that occur outside the lungs are known as extrapulmonary TB. This is common particularly amongst people with AIDS. This can then lead to other types of TB such as skeletal, gastrointestinal, genitourinary and lymph node TB. These types can cause additional symptoms. TB can be diagnosed through a chest X-ray that shows the damage imposed on the lungs by the bacteria. The damaged areas are opaque and large, thick walled cavities. However, other chest diseases can give similar images. So chest X-rays can suggest that TB is present but they cannot confirm it. New tests, examining the DNA of these bacteria, are being developed in order to give immediate and reliable results. The main treatment for TB is with antibiotics. The first two months a cocktail of different antibiotics is used, so that even if the mycobacteria are resistant to some of the drugs there will be others, which not only destroy the rapidly reproducing bacteria but also attack the ones that are metabolizing slowly, hidden in the cysts of within the immune system. This treatment is followed by another 4-7 months of taking two antibiotics. Most patients will be completely free of TB within 9 months, but it can take up to 12-18 moths before all traces of active disease have gone. The most effective way to control the spread of this disease is to improve living conditions. Less crowded housing and working conditions will decrease the spread of TB. If people are nourished well and generally healthier this will decrease the development of active TB once a person gets infected. By prevention and treatment of TB in cattle, along with pasteurisation and heating of milk before its drunk can help people prevent the spread of M. bovis. Immunisation with the BCG (Bacillus Calmette-Guerin) vaccine, which is a live attenuated strain of mycobacterium and is given as a single injection, has been proven to be effective. However, the spread of AIDS, intravenous drug use and foreign travel are new factors contributing to the spread of TB. Furthermore, the evolution of increasingly drug resistant bacteria poses a huge problem in terms of the spread of TB.

HIV
AIDS is a relatively new disease that developed from HIV. Human immunodeficiency virus (HIV) is a type of virus called a retrovirus, which infects humans when it comes in contact with tissues such as those that line the vagina, anal area, mouth, or eyes, or through a break in the skin. An HIV infection is generally a slowly progressive disease in which the virus is present throughout the body at all stages of the disease. Three stages of HIV infection have been described. The initial stage of infection (primary infection), which occurs within weeks of acquiring the virus, and often is characterized by a flu- or mono-like illness that generally resolves withi weeks. The stage of chronic asymptomatic infection (meaning a long duration of infection without symptoms) lasts an average of eight to 10 years. The stage of symptomatic infection, in which the body's immune (or defense) system has been suppressed and complications have developed, is called the acquired immunodeficiency syndrome (AIDS). The symptoms are caused by the complications of AIDS, which include one or more unusual infections or cancers, severe loss of weight, and intellectual deterioration (called dementia). When HIV grows (that is, by reproducing itself), it acquires the ability to change (mutate) its own structure. This mutation enables the virus to become resistant to previously effective drug therapy. The goals of drug therapy are to prevent damage to the immune system by the HIV virus and to halt or delay the progress of the infection to symptomatic disease.Therapy for HIV includes combinations of drugs that decrease the growth of the virus to such an extent that the treatment prevents or markedly delays the development of viral resistance to the drugs. The best combination of drugs for HIV has not yet been defined, but one of the most important factors is that the combination be well tolerated so that it can be followed consistently without missing doses. In 1985, a blood test became available that measures antibodies to HIV that are the body's immune response to the HIV. The test used most commonly for diagnosing infection with HIV is referred to as an ELISA. If the ELISA finds HIV antibodies, the results must be confirmed, typically by a test called a Western blot. HIV antibody tests remain the best method for diagnosing HIV infection. Recently, tests have become available to look for these same antibodies in saliva, some providing results within one to 20 minutes of testing. Antibodies to HIV typically develop within several weeks of infection. During this interval, patients have virus in their body but will test negative by the standard antibody test, the so called "window period." In this setting, the diagnosis can be made if a test is used that actually detects the presence of virus in the blood rather than the antibodies, such as tests for HIV RNA or p24 antigen. Recently, a new test has been approved that measures both HIV

antibodies and p24 antigen, shrinking the duration of the window period from infection to diagnosis. There also are many testing centers around the country that are routinely screening blood samples that are HIV-antibody negative for HIV RNA.

HIV is present to variable degrees in the blood and genital secretions of virtually all individuals infected with HIV, regardless of whether or not they have symptoms. The spread of HIV can occur when these secretions come in contact with tissues such as those lining the vagina, anal area, mouth, eyes (the mucus membranes), or with a break in the skin, such as from a cut or puncture by a needle. The most common ways in which HIV is spreading throughout the world include sexual contact, sharing needles, and by transmission from infected mothers to their newborns during pregnancy, labor (the delivery process), or breastfeeding. (See the section below on treatment during pregnancy for a discussion on reducing the risk of transmission to the newborn.)

The best way to avoid sexual transmission is abstinence from sex. Because the HIV antibody test can take months to turn positive after infection occurs, both partners would need to test negative for at least 12 and up to 24 weeks after their last potential exposure to HIV. The spread of HIV by exposure to infected blood usually results from sharing needles, as in those used for illicit drugs. To prevent the spread of HIV, as well as other diseases including hepatitis, needles should never be shared. At the beginning of the HIV epidemic, many individuals acquired HIV infection from blood transfusions or blood products, such as those used for hemophiliacs. Currently, however, because blood is tested for both antibodies to HIV and the actual virus before transfusion, the risk of acquiring HIV from a blood transfusion in the United States is extremely small and is considered insignificant.