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Mycobacterium Tuberculosis has been known to exist since times of Ancient Egypt. Ever since the ancient times it has exhibited the same symptoms affecting a sufferer today. As prevalent as is the disease in this modern day societies as widespread as it were thousands of years ago. Commonly, tuberculosis is known as drug-sensitive however recent mutations saw a new type of emergence of the disease rendering therapy somewhat inadequate. This is found involving a resistant strain of the bacterium allowing it to survive antibacterial drugs specifically aiming to target the infectious disease but failing to do so. Hence tuberculosis is now known as the resurgent disease affecting populations of poorer backgrounds and less economically developed societies, strongly interlinking it to poverty. The role of tuberculosis as an opportunistic infection in individuals suffering the Human Immunodeficiency Virus-1 is also closely correlated to the new Multi-Drug Resistant-Tuberculosis.
Tuberculosis is the most common major infectious disease today, infecting two billion people or one-third of the world's population, with nine million new cases of active disease annually, resulting in two million deaths, mostly in developing countries. (14)
Myobacterium tuberculosis is the mycobacterium that is responsible for the tuberculosis infection. The most common type of tuberculosis is pulmonary tuberculosis and so affecting the lung however meningitis and military tuberculosis are also found to exist, which are conditions affecting the central nervous system and the lymphatic or circulatory system, respectively.
Statistically, approximately 9% of all new tuberculosis cases in adults have been linked to Human Immunodeficiency Virus (HIV) infection. However, the proportions were much greater in the WHO African Region, being around 31% and some industrialised countries like the United States, seeing about 26% demonstrating a clear case of urbanization. In total, an estimated 1.8 million deaths were as a result of tuberculosis infection, of which 12% were attributable to HIV (2). Hence this made tuberculosis to be the cause of approximately 11% of all adult AIDS deaths.
For this reason, it is acceptable to suggest that:
'The increasing global burden of tuberculosis (TB) is linked to human immunodeficiency virus (HIV) infection.' (2)
Tuberculosis may infect an individual and remain asymptomatic, a condition known as Latent Tuberculosis Infection (LTBI), comprising 90% of those infected with the disease. If LTBI is left untreated however, there is a 10% lifetime likelihood it may progress to the active form of the tuberculosis disease. In this case, statistics have found that 50% of those suffering conditions result in death. TB is one of the top three infectious killing diseases in the world: HIV/AIDS kills 3 million people each year, TB kills 2 million, and malaria kills 1 million. (14).
Mycobacterium tuberculosis can be referred to as an ancient disease, with evidence dating it back to many ancient eras and cultures like the Egyptians and the Greeks. The earliest existence is presented in the skeletal remains of prehistoric humans dating back to times around 4000 BC. From 3000 BC to 2400 BC, the Ancient Egyptians mummies were found with tubercular decay in their spines highly suggestive of its existence amongst their population. Many reviews consider the 2000 BC existence of tuberculosis in India, however more significantly researched is the first signs of its existence in The Americas (14). This poses a research topic of the history of tuberculosis and its re-emergence due to urbanization as this has a causal relationship on the more recent incidence rates and prevalence of the disease. Additionally and worth mentioning, are the Greeks for their discovery of a 'similar disease' whereby around 460 BC, Hippocrates identified phthisis as the most widespread disease of the times which was almost always fatal (14). Phthisis is a Greek term for consumption (2a).
The resurgence of tuberculosis infection is mainly attributable to HIV and AIDS as mentioned above, the poor control and education about tuberculosis, and immigration of populations, which will be discussed later.
TB is an airborne infectious disease spreading when infected individuals cough, spit or sneeze. Classically sufferers will have a chronic cough with 'blood-tinged sputum', weight loss and fever.' (25) It is possible to diagnose TB through identifying the Mycobacterium tuberculosis organism in a given clinical sample. This method may be used in combination with X-Ray or scan imaging as well as a 'tuberculin-skin test'.
This condition is typically treated with multiple antibiotic courses prescribed over long periods. Unfortunately, effective treatment is difficult as the chemical composition of the mycobacterial cell wall is very complex and not very well understood hindering drug entry. A growing problem today is antibiotic resistance associated with multi-drug resistant TB (MDR-TB). MDR-TB is TB that is resistant to the two most powerful first-line anti-TB drugs, isoniazid (INH) and rifampicin (RMP). This develops when an interruption to the course of treatment occurs or when drug levels are found to be insufficient in the body. MDR-TB is as easily transmitted as drug-sensitive TB and via the same ways. To prevent the risk of infection a vaccination is available, usually with a 'Bacillus Calmette-Guérin vaccine' (25).
The World Health Organization declared TB a global health emergency in 1993. (14)
Foundations Of Mycobacterium Tuberculosis
'The oldest legal text in the world - formulated by the Babylonian monarch Hammurabi in 1948 and 1905 BC â€¦ mentions a chronic lung disease, which was very probably TB' (2). Hence this disease has strong foundations of existence and many definitions gained throughout history. The Greeks and the Indians also describe conditions which accusingly may be tuberculosis; however the first clear definition of the disease came after the fifth decade AD from the Roman physician Caelius Aurelianus. The clinical symptoms of the disease were clearly described, stating;
'The patients suffer from a latent fever that begins towards evening and vanishes again at the break of day. It is accompanied by violent coughing, which expels thin purulent sputum. The patient speaks with a hoarse voice, breathes with difficulty and has hectically flushed cheeks. The skin on the rest of the body is ashen in colour. The eyes have a weary expression; the patient is gaunt in appearance but often displays astonishing physical or mental activity. In many cases, wheezes are to be heard in the chest, and when the disease spreads, sweating is seen on the upper parts of the chest. The patients lose their appetite or suffer hunger pangs. They are often also very thirsty. The ends of the fingers swell and the fingernails curve greatly.' (2)
This was astonishing considering the time period it was announced. There were many similar clinical definitions thereafter. As the clinical definition quoted above, the various symptoms meant it was difficult for the identification and recognition of it as a disease unifying all the associated indicators. In 1839, J. L. Schoenlein was the first to finally term the condition as 'tuberculosis'.
Consequently and as a result of all the available evidence, it is acceptable to speculate the origin of the Mycobacterium being over 150 million years old. This genus has many strains, which upon close analysis indicate a common ancestor. Each strain of mycobacterium causes a slightly different infection affecting different areas or organs. Many publications and articles researching their origin and the different types that exist have associated each strain with a specific habitat and geographic distribution. The mycobacterium genome responsible for tuberculosis has been sequenced using modern techniques to allow for the determination of the time of origin. Hence all the work and studies that Gutierrez et al conducted into this investigation found that Myobacterium tuberculosis did indeed exist in East Africa from as early as three million years ago (14). Moreover, strong supportive evidence exists that all the different variants of the mycobacterium had a common ancestor until a more recent time period, around 20 000 years ago, again being East Africa. As a result of this more recent ancestry, the proposed idea is that the diversity within begun from as recent as 250 to 1000 years ago.
Though in general in East Africa over the past there has been very limited or little archaeological evidence supporting the incidence and history of any disease, tuberculosis has been strongly demonstrated in Ancient Egyptian times. This was found documented through artistic paintings on the walls of the Egyptians depicting the typical characteristics of associated skeletal abnormalities. In addition, upon analysis of mummies found in an Egyptian kingdom burial ground, many specimens were found to have had Potts Disease. This particular disease, so named after Percivall Pott, is extrapulmonary tuberculosis affecting the spine. Hence and for this reason it was easy for the ancient Egyptians to portray such symptoms of the affected lower thoracic and upper lumbar vertebrae areas of the spine, allowing us to, today, associate what we know as tuberculosis with what existed as an unknown, or differently referenced disease back then, over 5000 years ago.
In fact and to further support the ancient existence of tuberculosis, in the Biblical books of Deuteronomy and Leviticus, 'schachepheth' was the ancient word used to refer to this disease, establishing its early presence and recognition in East Africa before the migration of the Europeans at a much later chronological time (2). This started the idea of migration and thus urbanization as it was clear to associate increased upsurges of tuberculosis with the development and establishment of urban cities or structures. This was seen when a large percentage of the population was found to be overcrowded in a given area, as is this case observed in many countries now, however previously seen in ancient times at Nile Valley, Greek Polis and Rome of the early imperial period (14).
If we were to closely consider the ancient Egyptians as this is the first noted existence of tuberculosis, then we must rely on the new investigations carried out on the ancient mummies of the pharaohs of Egypt. One such set of investigations and studies were carried out by A R David who analysed ancient DNA, with the objective of enabling gathering of information about the mummies and the diseases they had contracted during their lifetime (25).
The German Institute of Archaeology in Cairo have recently led research into this field and closely analysed tombs of the New Kingdom, which is the time period between 1550-500 BC. These analysed tombs were located in the Necropolis of Thebes West, Upper Egypt. Of the mummies buried at this site, 39 vertebral bodies were found to be suitable for examination to aid the presence of tuberculosis among the era. The sample of 39 selected vertebrae yielded varying results where 5 were found to exhibit physical alterations, clearly indicating the presence of tuberculosis. Three of the five samples with these alterations were molecularly analysed and demonstrated clear signs typically present in any sufferer of tuberculosis. Meanwhile, 12 vertebras from the same sample showed non-specific physical alterations, of which two were later identified as having suffered from the bacterium infection during their lifetime. The 22 remaining cases regarded as non-altered were also examined, giving one case of tuberculosis.
Of these in particular, one male mummy was examined dating 1550-1080 BC. Only the lower parts of this mummy were found and obtained for analysis as the original body was broken into two. Though nothing is for certain and all remains hypotheses based on analysis of evidence, this mummy aged less than 35 years and upon dissection of the body wall the investigators found solid proof of residues of the lung with extensive pleural adhesions to the chest wall in the right thoracic cavities (25). Further careful analysis of the lumbar vertebral body showed many symptoms including destruction as well as irregular osteolyses.
Henceforth deducing from all the molecular analysis the existence of tuberculosis and the time period of its presence amongst ancient Egyptians is acceptable. And so owing to the nature of tuberculosis as transmittable and persistent, it is supported with strong evidence that one can say that tuberculosis was highly prevalent amid the ancient Egyptians. (25).
Tuberculosis: Advancement In the Past 100 Years
Evidence collected between 1913 through 2006 stated "The prevalence of T.B. in Great Britain has declined dramatically over the last 100 years..." The availability of antibacterial drugs and vaccinations allowed the number of TB suffering individuals to significantly decrease, reaching its trough in 1987 with the biggest decline. Additionally, and possibly more importantly, the improved lifestyle of the modern world and social provisions are a major contribution to the near abolishing of TB:
"A principal determinant of mortality from tuberculosis is nutrition. Mortality from T.B. increases considerably as one passes from the economically
prosperous to the poor districts of any area"
Mycobacterium tuberculosis is the causative bacterium in the infectious disease, tuberculosis. This was identified Robert Koch (1843-1910) who is a pioneer in the field of tuberculosis (2). Besides the isolation of the bacterium and its identification, Koch also found tuberculin which was later to be used as part of the diagnostic testing for the disease in individuals. Wilhelm Conrad von Rontagen (1885) developed the X-rays that could measure the vertebral effect of infection. These two methods are usually used in conjunction with each other to diagnose a patient.
The turning point for this disease at which it became more under control was during the 1930's where initially sanatorium treatment was acknowledged as a having poor long term results. At first it, Christian Saugmann in 1908 introduced a procedure of collapse therapy involving artificial pneumothorax, used in conjunction with the sanatorium. However, later works of Bayaii in 1933 developed this idea farther, augmenting the results of treatment as well as improving the life overall life expectancy.
Graph 1 of Appendix 1 shows the incidence rates of tuberculosis in the UK, depicting a clearly marked severe decline over the past 100 years. Primarily, this reflects development of the BCG vaccination, one of the prevention methods of the disease. This significant fall in affected individuals may be attributed to the development of the anti-TB drugs, including streptomycin (1949) and rifampin (1963), both of which proved to be highly successful in preventing antibacterial resistance whilst exhibiting powerful antibacterial effects. Freidman and Hinshaw developed streptomycin, alongside Pfuetze, proving to be an effective specific anti-TB drug rendering treated patients with normal lives henceforth. This suggested that most cases identified as TB sufferers could be treated using the above stated drugs, as well as others. Due to recurrent infections, more potent drugs such as Cycloserine and Viomycin were developed which correspond to a decreased mortality rate of infections by mycobacterium tuberculosis.
Antituberculosis drugs such as sulphonamides, penicillin and others were first introduced throughout World War II, and later developed targeting mainly and attacking the mycobacterium tuberculosis. Waksman, of the 1940's isolated Actinomycin, which in 1943 allowed low toxicity yet high inhibition of the bacterium resulting in astonishingly pleasing outcomes leaving patients with a successful combat against the disease.
Recently, the problem of drug resistance has increased, primarily reflecting the corresponding increase in number of TB sufferers, a rise illustrated in a table of data collected from 1987 to 2006 (appendix 1, table 1). This rise may also be reflected by the increasing proportion of the population suffering from HIV/AIDS and receiving antiretrovirals and other TB therapies. The evidence from appendix 1 is clear in its implication of the rise in cases of TB since 1987. This upswing of incidence is caused by a significant contributing factor that is the development of transport methods thus resulting in an imported TB from different countries worldwide.
Also, the ensuing rise in incidence rates of TB since 1987 are perhaps correlated to the rise in individuals affected by the Human Immunodeficiency Virus (HIV) with the subsequent treatments using immunosuppressant drugs. This is because such drugs tend to decline the body's ability to defend itself naturally and so increasing susceptibility to TB.
Arguably the most important factor associated with an increase in the incidence of tuberculosis in the UK since 1987 reflects global multidrug resistance. As mentioned earlier in this study, it is a challenging problem resulting in a narrower range of drugs able to be used in the treatment of tuberculosis. Some cases illustrate some instances where drug resistance has become so substantial rendering drug therapy useless in their treatment.
Past And Present
From analysis of the ancient evidence available in the forms of tomb portraits, anatomical examination of mummified individuals, medical papyri and molecular analysis, the existence of tuberculosis amongst the ancient Egyptians is for certain. As was understood from the analysis, TB endured for a period longer than 1750 years, highly suggestive of the prevalence of the disease amongst ancient Egyptians, especially given its highly transmittable nature. (25)
Recent advancements in the antituberculosis drugs available and the vaccines that now exist have meant there is a significantly lower rate of modern day infection in comparison to 100 years ago. For these reasons it can so be inferred that prevalence of TB amongst the ancient Egyptian population was much greater than what it is in this present day. This can be hypothesized due to their unawareness and lack of knowledge in drugs, therapies and also vaccines. Nevertheless, evidence supporting the extent of disease prevalence in the ancient times remains sketchy, simply reasoned by the lack of written evidence to support this hypothesis. Even though many studies may have been able to molecularly prove the existence of tuberculosis among the ancient Egyptians, including the ones carried out by the German Institute of Archaeology, the samples obtained are too small to be representative for the entire ancient population, and so no definite conclusions can be drawn.
Assessments performed on trends in antituberculosis drug resistance periodically would and will help inform on the progress and performance of the currently prescribed medication and its affectivity. Assessing the performance of national tuberculosis control programmes over time will inform of the necessary adjustments required to improve the control of the disease. The Global Project has already completed a third round of surveys and surveillance in 2002, combining the data from all three rounds to provide information on 109 countries or geographical settings worldwide. These areas represent almost 40% of notified smear-positive pulmonary cases of tuberculosis.
The epidemiology of disease is ever-changing especially in more recent years with the vicissitudes of the social and economic patterning. The global restructure of economy has meant that poverty and wealth no longer exhibit the old geographic locations whereby social classes, though extremely different, were in much closer proximity. Urbanization has presented less threat to capital investments mobility as the patterns of movement is marked by systematic social and spatial discontinuities (3).
Table 4 in appendix 1 shows a table taken from an article by Matthew Gandy and Alimuddin Zumla named 'The resurgence of disease: social and historical perspectives on the 'new' tuberculosis' where contributory factors of the 'new tuberculosis' are typified. The table summarises all that is believed to contribute to the re-emergences of the tuberculosis disease and how each category is specifically linked to a particular outcome. For example, and with special interest to this study, bio-medical factors affecting the resurgence of mycobacterium tuberculosis infection include the co-infection with HIV-1 infected individuals as well as the evolution and henceforth the resistance of the MDR-TB type of disease.
In the American state of New York City in 1975, the fiscal crisis saw a dramatic fall in public health expenditure on tuberculosis control leading to loss of health care workers who were primarily ensuring patient compliance to treatment (4). Interruption in medical treatment is believed to be the major cause of resistive strains of the bacterium leading to MDR-TB; hence for this reason during that period, the state saw an emergence of this disease in the 1980's. At the time, there was an increasing rate of poverty and identified cases of HIV infection were also on the rise, working together to bring back tuberculosis disease. This presents a perfect example of disease epidemiology and urban decline (4).
Tuberculosis is an example of a chronic illness with long term impacts on general public health. The population density of industrial cities have meant the nature of urbanization is no longer defined the same as in the nineteenth century. The near-revolutionary resurgence of tuberculosis is not only the effect of economic changes, but rather a complex interconnection of social, biological and indeed cultural factors.
It can be appreciated that there are many contributors in tuberculosis outbreak including gender, poverty and more importantly, medical service adequacy. The importance of these can be demonstrated using an example of such cases in less economically developed countries. In such developing countries, the likelihood of being treated by modern health services is rare and dependent on dire cases, typically, a pregnant woman who is also a sufferer of the disease (14). Racism is also another factor of resurgence demonstrated in a case in South Africa where tuberculosis was found more widespread among migrant workers. Recent studies have correlated an interaction between race, gender and geographical location or place in susceptibility to disease (9).
Comprehension of the fact that nature may be perceived as a social factor and that tuberculosis is not only a biological phenomenon but also a social one, studying the disease and linking its resurgence and mutant strains to bio-physical systems is feasible. The experimental insight of studies is as important as molecular analysis in understanding the development of the human health in the more recent modern societies. This idea is of extreme importance as it aids the reasoning for tuberculosis re-emergence with urbanization as causality even though the relationship is more complex.
Multi-Drug Resistant-Tuberculosis (MDR-TB)
Though thus far this study has considered mainly the development of tuberculosis, the impact of this disease in the 19th and 20th century on the general public and its uncontrolled widespread must also be considered. Around that time (1920's) tuberculosis was automatically associated with the poor, especially those of urban localisation. In 1913 to be exact, the Medical Research Council was set up, with its first and main concern being tuberculosis. At this point, the disease rates of incidence in Europe had already seen a significant decline suggesting that even before the development of antibiotics; tuberculosis was starting to be controlled.(24) This was a strong sign of raised clinical awareness and health advancements.
Treatment for Myobacterium tuberculosis was soon possible henceforth with streptomycin. This advancement surpassed the surgical intervention as a form of treatment, but as is the problem with any given case of bacteria and antibiotics, it soon saw a resistive strain. Having reduced number if infected individuals to a minimal in the 1980's, by the year 2000 the drug resistant strains allowed this number to rise almost one and a half times. This resurgence destroyed the hope that existed to wipe out this disease. This caused for the employment of more research which unfortunately resulted in the disabling a set of genes. The consequences were drastic as a more lethal and rapidly reproducing strain of tuberculosis bacteria was produced (24).
The HIV/TB dual infection
Tuberculosis is the most common co-infection in individuals infected with HIV-1 (3). The causes of TB tend to occur intermittently and seldom is there any epidemiological correlation between incidences of infection. However in the more recent years it has become evident that the rising outbreaks of TB are caused by the resistance of the organism to multiple antituberculosis drugs. Most of the reported occurrences are found primarily involving persons infected with HIV-1 who are thought to have been exposed to strains throughout medical facilities. Of the nearly 15 million cases of HIV/TB infection worldwide, over two thirds of the cases were reported to exist in Sub-Saharan Africa. Though this is an alarmingly large ratio, this dual infection may be conjectured to continue expansion with increased interaction between the pathogens due to the spreading of HIV-1 in areas such as South-east Asia and other parts of the world.
The Human Immunodeficiency Virus (HIV) is an incurable type of retrovirus that eventually leads to the failure of the immune system causing Acquired Immunodeficiency Syndrome (AIDS). The individual may die as a result of contracting an Opportunistic Infection (OPI) during their time of infection by HIV. Unlike TB, HIV spreads via contact with blood, breast milk, vaginal fluid or semen where the virus is found to be present as free virus particles or within infected immune cells. In the more recent years, blood products for things such as blood transfusion have had less infectious rate due to blood screening, enabling the improvement of the control of the virus spread in the 'developed countries' (25).
The World Health Organization (WHO) in 2005 reported this 'pandemic infection' to affect 0.6% of the world's total population (25) with AIDS having killed over 25 million individuals since it was first discovered in 1981 up until 2006. Though this virus to date cannot be cured, it can be controlled and individuals can survive longer increasing their life expectancy with the use of antiretroviral treatment. The problem presented here is the availability of such drugs to treat the infected individuals especially with a third of reported cases found to reside in Sub-Saharan Africa, where poverty and development are major issues.
HIV is an infection of the T helper cells of the immune system; in particular, it is typified by the significantly low CD4+ T cell count. This count is decreased via three mechanisms involved in the life cycle of the retrovirus; direct killing of the infected cells at the first stage, followed by apoptosis of these cells, ending the cycle with the killing of the CD4+ T cells by CD8 cytotoxic lymphocytes (25). As the CD4+ cells decline in number, the body begins to lose its cell mediated immunity which is essential in fighting infections. This henceforth makes the body more susceptible to any OPIs.
During the replication process of the HIV-1 infection an OPI may be developed leading to AIDS. TB as an OPI may occur at any stage of the HIV-1 infection and is evidently correlated to the virus' mortality rates. In MDR-TB, the infection is believed to occur through antimicrobial agent-resistant organisms. Another possibility for the resistance is inadequate therapy leading to the selection of the drug-resistant strain throughout drug therapy.
Several studies that took place in the pre-HIV era demonstrated that drug resistance in TB comes about in two ways; throughout treating an individual, the drugs may be inadequate in conception, hence a resistant mutant emerges. This drug-resistant strain originally from drug-sensitive tuberculosis, is naturally selected for survival of the mycobacterium, and may well be transmitted to other uninfected persons ensuing primary drug resistance.
It was only recently discovered that, during HIV-1 replication, it is induced by mycobacterium tuberculosis from HIV-1 infected individuals, where mononuclear cells from these individuals are found more susceptible to contraction of infection (10). Particularly favoured by the virus, the mycobacterium environment is ideal for replication. A considerable amount of research has gone towards studying the impact of TB on the HIV-1 viral load, where one cross sectional study conducted by 'Toossi, Z et al' on the 'Impact of tuberculosis (TB) on HIV-1 activity in dually infected patients' found 'circulating HIV-1 load was significantly higher in patients with the HIV/TB dual infection in comparison to individuals without the dual infection but matching CD4 count' (25). This same group conducted another longitudinal study on the HIV-1 patients who later went on to develop TB showed a significant rise in viral load at or around the time of diagnosis' (25).
In HIV-1 infection dually with TB, progressive primary TB is seen alongside the reactivation of the initial mycobacterium tuberculosis infection. The latter can bear a resemblance in early HIV-1 TB making it more favourable and responsive as a target to preventive treatment. As a further outlook for future ideas in preventive therapy, it may be considered that chemoprevention of TB given to individuals suffering from HIV-1 with higher CD4+ T cell counts is of greater reward. The reason for this lies in the effect of TB on the viral load in those patients that cause it to increase significantly. The abortion of TB via this method at this stage is beneficial however chemoprophylaxis may not be feasible to all infected patients, especially considering countries where HIV-1 and TB are found prevalent (25).
The spread and resurgence of tuberculosis does not come from a single simple explanation but rather a complicated and intricate relationship between many social, political and biological factors. With respect to the impact of TB and the widespread of MDR-TB and of course the HIV/AIDS endemic, employment of further research and strategies into controlling the disease will most undoubtedly not go astray. Instead, treatment and compliance may be improved which effectively would help decrease the prevalence of tuberculosis and its resistant strain form. These would consequently improve living standard and aim to confront some social problems as well as minimize racial and gender inequality.
From the many studies in the field of tuberculosis conducted, there has been enough evidence rendering science today with strong indications that there has indeed been a rise in incidences over the last twenty years. This rise can only be accounted for once the correct reasoning is applied to the corresponding issue associated with tuberculosis outbreak. Historical evidence shows a decline in number of reported incidents of tuberculosis over the past 100 years and that can be related to the improved education, health care and employment rates in the nineteenth century. Unfortunately, the recent rise over the last 20 years is indicative of the failure to improve further or even continue on such pathways to enhance the social environment. As a result, a decline is demonstrated strongly linking tuberculosis to poverty.
An increased rate of prevalence and incidence of tuberculosis correspondingly is in turn reflected in the increased rate of prescribed medication to treat the disease. Initially, before the first great decline, the success of methods including BCG vaccination and medical treatments using antibiotic drugs such as rifampicin and isoniazid saw near to complete control of the infectious disease. Complacency allowed room for the regrowth of the number of suffering individuals. This ill-advised of the complex nature of the bacterium which helplessly leads to the assumption that ill-health is closely associated to poverty and lower social standard of living. For this reason the greatest challenge imposed will be to overcome this social injustice (9) and proposing for political action to take place in order to prove the uses of the medical advancements of the present century. Complying fair rules on providing the same medical attention and facilities to all social classes equally would be a good place to start.
What else can be done?
An employment of further research in this field would benefit medical advancement and patients alike in combating this disease and possible outbreaks of resistance. NICE (national institute for clinical excellence) in 2006 issued documented interventional guidelines hoping to improve rates of individuals completing treatment and in turn achieving 85% success; a standard set by CMO action plan and WHO. All of those suspected of an infection or seemingly at a high risk, including immigrants, prisoners, and the homeless will have greater screening and subsequent treatment of the disease. NICE has put forward a recommendation to strengthen surveillance systems acting as a method of control, as well as informing the groups considered at risk of infection. Also recommended by NICE to measure the on-going disease transmission, the strain typing scheme must be improved. It has been considered with great importance to decrease tuberculosis levels internationally.
Due to the increased numbers of immigrants from poorer socio-economic backgrounds into more developed and advanced countries, the numbers of individuals infected with tuberculosis is on the increase. As the contact between the two regions is rising and intensifying, numerous methods have been implemented on an international scale to prevent a global epidemic. The main objective is to keep the already existing conditions under control and prevent further contractions of the infection by new individuals. With the world population increasing at an exponential rate, and immigration incidences high, the question presents itself; can the government cope with increased pressure with limited resources, or will the Economically Developed Countries, such as the USA and Europe, that think they are 'safe' be subjected to 'the white plague'?
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