TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

Table of content
INTRODUCTION…………………………………………………………………….1
DEFINITION OF TUBERCULOSIS………………………………………………..2
STAGES OF TUBERCULOSIS……………………………………………………...3
MODE OF TUBERCULOSIS TRANSMISSION…………………………………..4
RISK FACTORS OF TUBERCULOSIS ……………………………………………5
PATHOPHYSIOLOGY OF TUBERCULOSIS………………………………………5
DISEASE ASSOCIATED WITH TUBERCULOSIS…...…………………………….8
TREATMENT ……………………………………………………………………….….9
TEST AND DIAGNOSIS OF TUBERCULOSIS……………………………………..9
MEDICAL TREATMENT…………………………………………………………….10
WHICH MEDICINE TO USE ………………………………………………………..12
WHICH THERAPEUTIC REGIMEN FOR WHICH PATIENT…………………..12
PREVENTION OF TUBERCULOSIS…………………..…………………………...13

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

INTRODUCTION
Tuberculosis is an infection disease that arises from the bacterium Mycobacterium
tuberculosis which typically affects the lungs (pulmonary TB) but affects other sites as
well (extrapulmonary TB). The disease spread through the air when people who are sick
with pulmonary TB expel bacteria. TB is also more common among men than women
and affects mostly adults in the economically productive age group. The probability of
developing TTB is much higher among people infected with the human
immunodeficiency virus HIV (WHO 2016).
TB primarily affects the lungs, but also affects other part of the body in up to one -third
of cases. TB transmitted through the air from infectious people to other people while
coughing, sneezing, singing and talking. A single cough may bring up out 4.000 droplets.
Most infections do not have symptoms, knows as latent TB. It is estimated that up to 10%
of infected persons may gradually develop active tb in their lifetime and fatally may
reach up to 50% of the patients if left untreated (Nicas et al.,2005).
TB is a major global health problem. TB causes ill-health among millions of people each
year and ranks alongside the HIV as a leading cause of death worldwide. In 2014, there
were an estimated 9.6 million new TC cases. 5.4 million among men, 3.2 million among
women and 1.0 million among children (Global tuberculosis report., 2015). The spread of
this disease is fuelled by several factors, notably the HIV/AIDS epidemic, low socio-
economic status, overcrowding and malnutrition (Harries et al, 2006).
African countries in the south of the Sahara including Ethiopia, are heavily affected by
TB. The World Health Organisation (WHO) global reports on TB showed that Ethiopia is
among the ten top high burden countries regarding the prevalence or incidence cases of
TB (WHO 2011). However, the real burden of the TB in Ethiopia is not known due to
several reason. First, the is neither a reliable disease notification system nor has any
regular nationwide epidemiological. According to the WHO 2011 reported, globally,
3.2% (290000) of the incident cases of TB are estimated to have multidrug-resistant TB
(MDR-TB). There are 27 identified high burden countries that carry per 100.000 people
in the year 2014, respectively.
Poor knowledge of the symptoms indicative of TB and visiting traditional healers could
be a delay in seeking proper medical advice. Deficiencies in the national TB control
program are compounded with widespread misconceptions and false beliefs among
patients with TB. These myths have turned TB into a social stigma. This stigmatisation
can play an important role in reluctant of patients in self-referral and seeking treatment.
Future education should be based on existing scientific knowledge and presented in a
manner that can be easily comprehended and accepted the patients social and cultural
factors. These should be taken in to account as they play an important role in the
compliance of patients with TB (WHO 20111). In this context knowledge and practices
(KP) study is essential to help plan, implements and evaluate TB activities. KP may
identify the knowledge gap, cultural beliefs and behavioural patterns that may facilitate

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

understanding and actions as well as may pose problems or build barriers for TB
transmission and prevention effort. The results enable to set TB program priorities and to
identify determinants of behavioural changes.
DEFINITION OF TUBERCULOSIS
Tuberculosis (TB) is an infection disease cause by Mycobacterium tuberculosis (MTB)
bacteria. Tuberculosis generally affects the lungs, but can also affects other organs of the
parts of the body. Most infections show no symptoms in which case it is known as Latent
tuberculosis. About 10% of latent infections program to active disease which, if left
untreated, kills about half of those affected. Typically, symptoms of active TB are a
chronic cough with blood-containing mucus, fever, night sweat and weight loss. A TB
doesn’t always mean you will get sick.
SIGNS AND SYMPTOMS OF TUBERCULOSIS.
Major s/s
 Coughing for three or more weeks.
 Coughing up blood or mucus.
 Chest pains
 Weight loss
Other symptoms of tb are
 Weakness or fatigue
 Weight loss
 Mo appetite
 Chills
 Fever
 Sweating at night
STAGES OF TUBERCULOSIS
 LATENT TB: this type of Tb you have the germs in your body, but your immune
system keeps them from spreading. You don’t have any symptoms and you’re not
contagious but the infection is still alive and can one day become active. The only
manifestation of this encounter may be reaction to the tuberculin skin test (TST)
or interferon-gramma release assay (IGRA) (Minesh et al, 2020)
 ACTIVE TB: It refers to disease that occurs in someone infected with
Mycobacterium tuberculosis. It is characterized by signs or symptoms of both
disease or both and is distinct from latent tuberculosis infection which occurs
without signs or symptoms of active disease. (WHO 2013).
Tuberculosis is caused by a bacterium that spread from one person to another through
microscopic droplets released into the air. This can happen when someone with an
untreated active form of tuberculosis coughs, sneezes, speaks, laughs, spits. Although
tuberculosis is contagious, it’s not easy to catch. You’ve much more likely to get

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

tuberculosis from someone you live or work with than from a stranger. Most people with
active tuberculosis who’ve had appropriate drug treatment for at least two (2) weeks are
no longer contagious.
Droplet nuclei containing tubercle bacilli may remain suspended in room air currents for
several hours, increasing the chance of spread. However, once these droplets land on
surface, it is difficult to resuspend the organisms (e.g. by sweeping the floor, shaking out
bed linens) as respirable particles. Although such actions can resuspend dust particles
containing tubercle bacilli, these particles are far too large to reach the alveolar surfaces
necessary to initiate infection (Dylan et al.,).
Environment factors are also important. Transmission is enhanced by frequent or
prolonged exposure to untreated patients who are dispersing large number of tubercle
bacilli in overcrowded, poor ventilated enclosed spaces; consequently, people living in
poverty or in institute are at particular risk. Health care practitioners who have close
contact with active cases have increased risk of the spread of the disease. Health care
practitioners who have close contact with active cases have increased risk.
MODE OF TUBERCULOSIS TRANSMISSION
Mycobacterium tuberculosis is carried in airborne particles called droplet nuclei of 1-5
microns in diameter. Infectious droplets nuclei are generated when a person who have
pulmonary TB disease cough, sneezes, talks or sings. Depending on the environment
these tiny particles can remain suspended in the air for several hours. M. tuberculosis is
transmitted through the air not by surface contact. Transmission occurs when a person
inhales droplet nuclei containing M. tuberculosis and the droplet nuclei traverse the
mouth or nasal passage, upper respiratory tract and bronchi to reach the alveoli of the
lungs.
Figure 1.transmission of TB

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

RISK FACTORS OF TUBERCULOSIS

A number of factors make individual more susceptible to TB infection. They can be listed
as follows;
1) People recently exposed to someone who has symptomatic TB disease.
2) People who live in congregate settings with high risk persons.
3) People who live with or have lived in countries where TB is common.
4) People who are health healthcare workers who are in contact with TB patients
when proper infection control procedure are not followed.
5) People with TB infection who have weaker immune systems due to some
pathologies like; diabetes, HIV infection, kidney failure may be more likely to
develop active TB disease with symptoms.
6) Alcoholic people are also at risk of developing TB disease
7) Person who weight is less than 90% of their ideal body weight

PATHOPHYSIOLOGY OF TUBERCULOSIS
Infections occur when a person inhale droplets nucleus containing tubercle bacilli that
reach the alveoli of the lungs. These tubercle bacilli are ingested by alveolar
macrophages, the majority of these bacilli are destroyed or inhibited. A small number
may multiply intracellularly and are released when the macrophages die. If alive, these
bacilli may spread by way of lymphatic channels or through the bloodstream to more
distant tissues and organs (including areas of the body in which TB disease is most likely
to develop regional lymph nodes, apex of the lungs, kidneys, brain, and bone). This
process of dissemination primes the immune systems for a systemic response. Further
details about pathogenesis of latent tuberculosis infection (LTBI) and TB disease are
described below (CDC. United state, 2010).
Figure 2: Droplets containing tubercle bacilli are inhaled, enter the lungs and
travels to the alveoli.

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

Figure 3: Tubercle bailli multiply in the alveoli.

Figure 4:Spread of tubercule bacilli spreading in the bloodstream to other parts.

A small number of tubercle bacilli enters the bloodstream and spread through out the
body. The tubercle bacilli may reach any part of the body, including areas where TB
disease is more likely to develop (such as the brain, bones, lungs or kidney).

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

Figure 5:Macrophages ingest and surround the tubercle bacilli.

Within 2 and 8weeks special immune cells called macrophages ingest and surround the
tubercle bacilli. The cells form a barrier shell, called a granuloma, that keeps the bacilli
contained and under control (LTBI).
Figure 5:multiplication of the tubercle bacilli.

If the immune system cannot keep the tubercle bacilli begin to multiply rapidly (TB
disease). This process can occur in different areas in the body such as the lungs, kidneys,
brain or bone ( see diagram in box 3).

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

DISEASE ASSOCIATED WITH TUBERCULOSIS

The most important risk factors developing globally for developing active TB concurrent
HIV infection, 13% of those with TB are also infected with HIV. This is a particular
problem in sub-Sahara Africa, where HIV infection rates are high. Of those without HIV
infection who are infected with tuberculosis, about 5-10% develop active disease during
their lifetimes, in contrast 30% of those co-infected with HIV develop the active disease.
TB is an opportunistic disease (OI). OIs are disease that occur more often or are more
severe in people with weakened immune systems than in people with healthy immune
systems. HIV weakens the immune system, increasing the risk of TB in people with HIV.
Infection with HIV and TB is called HIV/TB coinfection. Untreated latent TB infection is
more likely to advance to TB disease in people with HIV than in people without HIV. In
people with HIV, TB disease considered an AIDS- defining conditions. AIDS-defining
condition are infections and cancers that are life-threatening in people with HIV.
Treatment with HIV medicines is called antiretroviral therapy (ART). HIV medicines
protect the immune system and prevent HIV from advancing to Acquired
immunodeficiency syndrome (AIDS). In people with HIV and TB medicines reduces the
chances that latent TB infection will be advanced to TB disease.
WHY IS TUBERCULOSIS COMMON AMONG PEOPLE WITH HIV.
The immunological effect of HIV manifest itself mainly on cell-mediated immunity. This
is part of the system immune system which plays the most important role in the response
of the organism against M. tuberculosis. Immunodeficiency caused by HIV infection and
prevent further infection or reinfection with M.tuberculosis. he modifies also the delayed
hypersensitivity reaction which occurs in the tuberculin skin test. The interaction of HIV
and TB is bi-directional because M. tuberculosis increase the replication of HIV in vitro
and Active tuberculosis accelerate the progression of HIV infection in tuberculosis
patients coinfected with HIV.

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TREATMENT DURATION
Six months should be considered the minimum duration of the treatment for HIV-
infected adults, even the patient with culture regime TB disease.if there is evidence of a
slow or sub optimal response, the continuation phase should be prolonged to 9 months.
DOT(directly observed therapy) and others adherence- promoting strategies should be
used in all patients with HIV-related TB disease. (CDC. MMWR 2008;57(04) ;98).
TEST AND DIAGNOSIS OF TUBERCULOSIS
There two common tests for tuberculosis that is
 SKIN TEST: This is also known as the Mantoux tuberculin test were a technician
injects a small amount of fluids into the skin of your lower arm. After 2-3 days,
they’ll check for swelling in your arm. If your results are positive, you probably
have TB bacteria. But you may also have false results that is if you have taken the
tuberculosis vaccine called Bacillus Calmette-Guerin (BCG), the test could show
you have the bacteria meanwhile you don’t.
 BLOOD TEST: It is a test that can confirm or rule out latent or active
tuberculosis. These tests measure your immune system’s reaction to TB bacteria.
These tests require only one office visit. A blood might be useful if you’re at high
risk of TB infection but have a negative response to the skin test, or if you’ve
recently received the BCG vaccine.
 SPUTUM TESTS: if your chest X-ray shows signs of tuberculosis, your doctor
might take samples of your sputum. The mucus that comes up when you cough.
The samples are tested for TB bacteria. Sputum samples can also be test for drug-
resistance strains of TB. This helps your doctor choose the medications that are
most likely to work. Getting results of these tests can take four to eight weeks.
 IMAGING TEST: If you’ve had a positive skin test, your doctor is likely to
order a chest or CT-scan. This might show white spots in your lungs where your
immune system has walled off TB bacteria or it might reveal changes in your
lungs caused by active tuberculosis.
MEDICAL TREATMENT.
The following agents are useful in the management of tuberculosis. They are commonly
given in combination and in the absence of individuals contraindication. These drugs will
be classified according to the types of tuberculosis. The drugs are for the treatment of
tuberculosis are (RIPE): Rifampin (RIF), Isoniazid (INH), Pyrazinamide (PZA), and
Ethambutol (EMB);
 Rifampin (RIF): it is given orally, is bactericidal, is well-absorbed, penetrated
well into cells and CSF, and acts rapidly. It also eliminates dormant organisms in
macrophages or caseous lesions that can cause late relapse. Thus, RIF should be
used throughout the course of therapy.
 Posiology: 1Omg/kg/day

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

SIDE EFFECTS;
 skin rash
 Diarrhoea
 inflamed pancreas
 nausea and vomiting.
Adverse effects of RIF;
 cholestatic jaundice(rare)
 fever
 renal failure

 Isoniazid (INH): it is given orally once/day, has good tissue penetration

(including CSF), and is highly bactericidal. It remains the single most useful and
least expensive drugs for TB treatment.
 posiology: 5mg/kg /day.
SIDE EFFECTS;
o loss of appetite
o weakness
o upset stomach
o nausea and vomiting.
Adverse effects of INH: include
 rash
 fever
 anaemia
 agranulocytosis.

 Pyrazinamide (PZA):is an oral bactericidal drug. When used during the

intensive initial 2 months of treatment, it shortens the duration of therapy of
6months and prevents development of resistance of Rifampin.
 Posiology; 15-30mg/kg/day

SIDE EFFECTS;
 lack of energy
 loss of appetite
 nausea and vomiting
 muscle or joint pain.
Adverse effects of PZA: GI
 upset and hepatitis.

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

 It often causes hyperuricemia, which is generally mild and only rarely

induces gout. PZA is commonly used during pregnancy, but its safely has
not been confirmed.

 Ethambutol (EMB): ethambutol is a competitive inhibitor of bacterial fatty acid

synthesis 2, and enzymes involve in the synthesis of Mycobacterium cell walls,
that is it prevent the formation of mycobacterium cell walls.
 Posiology; 15-25mg/kg daily for 8 weeks and continuing for up to 4to 7 months
SIDE EFFECTS;
 loss of appetite
 headache
 confusion
 belly pain
 nausea and vomiting
 swollen joint.
ADVERSE EFFECTS:
 Restlessness
 Insomnia
 muscle twitching
 peripheral neuropathy
 bone marrow suppression
 anaemia.

SECOND LINE DRUGS

 These are drugs mainly used for multi-drugs resistance tuberculosis (MDR-
TB), that is the treatment of tuberculosis? The commonness cause of MB-TB
treatment failure or relapse is Non-compliance to therapy.
 Example of these drugs are;
-Ethionamide and prothionamide (both oral).
-Para-aminosalicy (oral).
-Thioacetazone(oral).
-Capreomycin (IM, adult only).
-Kanamycin (IM, adults only).
These drugs are toxic and should be used by a specialised experienced in their
used.

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WHICH MEDICINE TO USE.

The main drugs used in the treatments of tuberculosis by the program are
(RIPE) Rifampicin(R), Isoniazid (H), Pyrazinamide (Z), and Ethambutol (E).
To avoid monotherapies generating acquired resistance, the program recommends the use
of combined forms of drugs: ( RHEZ) (RHZ) (RH).

WHICH THERAPEUTIC REGIMEN FOR WHICH PATIENT?

The programm recommends 2 therapeutic regimens ;
-A scheme for all new cases of tuberculosis whatever the form ;
-A scheme for patients to be reprocessed.

Regime for all new cases

2 (RHEZ)/ 4(RH).
This regime includes 2month of Rifampicin(150mg)-Isoniazid(75mg)-Ethambutol-
(275mg)Pyrazinamide(400mg)which is giving depending on the weight. combination
taken daily followed by 4 months of the rifampicin-isiniazid combination taken daily ( a
total of 6 month of continuous treatment).
A) Procedures for carrying out this therapeutic regimen for New cases of
BPD+.Initial intensive phase:
Daily intake (one(1) intake per day in the morning on an empty stomach, at least one
hour before eating) under the strict supervision of nursing staff of the following
medications: rifampicin-isoniazid-ethambutol-pyrazinamid(RHEZ);
Duration: 2 month on an outpatient basis (in hospitalization if the clinical condition is
serious or if it is impossible to supervise on an outpatient basis)
At the end of the second month, repeat a single sputum examination.
2.2.1Contraindications
The following antituberculosis drugs are contraindicated in pregnant women:
 Streptomycin
 Kanamycin
 Amikacin
 Capreomycin
 Fluroquinolones

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

THE GUIDE LINE TREATMENT OF TUBERCULOSIS.

The patient to be treated with tuberculosis are defined according to;
 Their bacteriological status;
 The location of the disease; that is the pulmonary and the entra-pulmonary.
 The patient therapeutic history; never treated or already treated for tuberculosis.
 The patients are classified as new cases or cases to be reprocessed.
The new cases;
These are patient who have never been treated before with anti-tuberculosis drugs (or
treated for less than a month). They are distributed as follows :
-pulmonary tuberculosis bacteriologically confirmed by micr0scopy, molecular test
(Xpert TB Lamp) and/or culture (TPB+);
-Pulmonary tuberculosis not bacteriologically confirmed(TPB+);
-Extra-pulmonary tuberculosis (EPT).

Cases to be reprocessed;
There are three groups that should benefit systematically using the Xpert MTB/RIF test
to assess the susceptibility to rifampicin :
Relapses:
These are the patient who currently present with bacteriologically confirmed
pulmonary tuberculosis, but who have already been treated for tuberculosis in the
past active (bacteriologically confirmed or not) and who had been declared
``cured`` or ``treatment completed`` after a comprehensive anti-tuberculosis
chemotherapy.

Chess:
It is the patient undergoing treatment who present positive bacilloscopic
examination during the control bacteriologically of the 5th month or later in the
treatment.
Resumption of treatment:
These are patient who have taken anti-tuberculosis treatment for a month or
more and who having interrupting this treatment for at least two month, present
with symptoms of pulmonary tuberculosis and test positive sputum. Those who
have a negative sputum test when they return must go to the end of the duration of
the treatment they were initially prescribed.

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

Dosage of medicines to be used for case pf tuberculosis to be reprocessed

Initial
intensive Continuation
phase phase
everyday, everyday,month
month 1, 4 and 6
2, and 3

Different weights at (RHEZ) (RHEZ) cp

which drugs are cp R:150mg
been given R:150mg H:75mg
H:75mg E:275mg
E:275mg Z:400mg
Z:400mg

30 to 39
2
2
40 to 54 3
3
55 to 70 4 4

Greater than 5 5
70

PREVENTION OF TUBERCULOSIS
 Primary prevention; aims to block infection
 Secondary prevention; aims to block progression of an infection to active disease.

1. Triage TB suspects to fast tract or separation

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

2. Cough hygiene.
3. Rapid TB diagnosed and treatment.
4. Improve room air ventilation.
5. Protect health care workers.
6. Monitors infection control practices.
7. Early diagnosed and prompt effective treatment of infection cases
8. Drugs therapy
9. Other factors better housing, nutrition, alcohol reduction.
10. Bacillus Calmette Guerin (BCG).
11. Antiretroviral therapy (ART) for people with HIV.
12. Patient should maintain a well-balanced diet to keep the immune system strong
13. Patient should stop smoking and minimizing intake of alcohol.
14. Patient should hold a cloth or handkerchief over mouth when coughing.

THE ROLE OF A NURSE IN THE MANAGEMENT OF A TB PATIENT.

 Patients with TB should be monitored regularly to ensure that:
 No interruptions occur in treatment;
 Serious side-effects from the treatment are quickly identified;
 There is improvement in the patient’s condition, although this is often very
gradual.
 Many patients find the treatment course difficult at the start because they have to
take numerous tablets, some of which are very large and have various side-effects.
Later, when symptoms have resolved but the patient still have the disease, they
may question the need for continued treatment.
 TB nurse specialists can ensure that patients are given the correct medication and
can provide support for patients and their relatives or carers to prevent lapses in
treatment.
 The TB nurse specialist can help to manage side-effects or drug formulations,
take routine blood samples or occasionally arrange admission to hospital.

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

Nursing care plan for Tuberculosis patients

NEEDS
1) To breath normally

Nursing Objectives Nursing intervention Rational Evaluation

diagnosis
Ineffective Maintain  Assess Diminished Patient is
airaway patient respiratory breath sounds able to
clearance airway function may reflect breath
related to within 3days noting breath atelectasis. normally
thick, of nursing sound, rate, Rhonchi, since airway
viscous or care rhythm, and wheeze are free from
bloody depth and use indicate mucus.
secretion of accessory accumulation
muscles. of secretions
and inability to
clear airway
that may lead
to use of
accessory
muscles and
increased work
of breathing.
 Note ability to Expectoration
expectorate may be
mucus and difficult when
cough secretions are
effectively very thick as a
document result of
character, infection
amount of and/or
sputum, inadequate
presence of hydration.
hemoptysis.
 Place patient Positioning
in the semi or helps maximize

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

high- fowler`s lung expansion

position.Assist and deceases
patient with respiratory
coughing and effort.
deep-breathing Maximal
exercises. ventilation may
open atelectatic
areas and
promote
movement of
secretions into
larger airways
for expectorate
 Clear Prevents
secretions obstruction and
from mouth respiration.
and trachea; Suctioning may
suction as be necessary if
necessary. patient is
unable to
expectorate
secretions.
 Maintain fluid High fluid
intake of at intake helps
least thin secretion,
2500ml/day making them
unless easier to
contraindicate expectorate.
d.
Prevent drying
 Humidity of mucous
inspired air membranes and
amd oxygen. helps thin
 Administered secretion.
drugs are
prescribed

RELATIONSHIP BETWEEN TUBERCULOSIS AND MENTAL HEALTH

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

 Both TB and mental health are urgent global health priorities with 4.1 million TB
dealth worldwide in 2019 and approximately 14% of the global burden of disease
attributable to neuropsychiatric disorder.
 Stress
Having TB can be a source of major stress. The stress associated with living
with a serious illness or condition, such as TB, can affect a person's mental health.
People with TB have a higher chance of developing mood, anxiety, and cognitive
disorders. For example, depression is one of the most common mental health
conditions faced by people with TB.
 Life experience
In addition, people with TB may also experience situations that negatively impact
their mental health, such as:
o Having to tell others about an TB diagnosis
o Managing TB medicines and medical treatment
o Facing stigma and discrimination associated with TB/HIV.

 Additionally, TB treatment is long and mentally exhausting with numerous side

effects. Several anti-TB medicines like cycloserine which is used for drug
resistant TB, cause mental health problems such as anxiety or psychosis.

REFERENCES :

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 TUBERCULOSIS AND ITS RELATION TO MENTAL HEALTH

 Bhebhe, LT, Van Rooyen C, Steinberg WJ, Attitude occupational exposure to

pulmonary tuberculosis 2014.
 Cruz- Knight W, Blake- Gumbs L. Tuberculosis an overview. Prim care 2013
 World health organisation Global tuberculosis 2016.
 World Health Organization country coorperation strategy at a glance.WHO 2011.
 Nicas M, NazaroffWW, Hubbard A. Toward understanding the risk of secondary
airborn infection; emission of respirable pathogens.J Occup Environ hqyg 2005.
 Malangu N, Mngomrzulu M, Evaluation of tuberculosis infectiom control
measures implemented at primary health care facilities in Kwazulu- Natal
province of South Africa BMC infect Dis 2015.
 CDC. Treating opportunistic infections among HIV- infected adults and
adolescents.MMWR 2004.
 CDC.Notice to readers : Updated guidelines on managing drug interactions in the
treatment of HIV-related tuberculosis.MMWR 2008.
 CDC.Updated guidelines for using interferon gamma release assays to detect
Mycobacterium tuberculosis infection- United state,2010 MMWR 2010.
 Harries AD. Dye C. Tuberculosis.Ann Trop Med Parasitol 2006.

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