INVESTIGATING THE CONSEQUENCES OF TUBERCULOSIS IN THE HUMAN

BODY IN DEVELOPING COUNTRIES (GHANA)

BUKU KASSIM

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 TABLE OF CONTENTS

INTRODUCTION...........................................................................................................................2

DISCUSSIONS................................................................................................................................3

Mycobacterium tuberculosis............................................................................................................4

Transmission of Mycobacterium Tuberculosis...............................................................................5

Effects of the Mycobacterium Tuberculosis in the Human Body...................................................6

Diagnosis of Tuberculosis...............................................................................................................7

Tuberculosis Control in Ghana......................................................................................................10

CONCLUSIONS...........................................................................................................................13

References......................................................................................................................................14

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INTRODUCTION

The bacillus Mycobacterium tuberculosis is responsible for the infectious disease known as

tuberculosis (TB) (Mtb). An alarming rise in fatalities has been attributed to this infection,

making it the deadliest bacterial disease in history. Robert Koch identified the tubercle bacillus

in 1882. There are a number of accounts that place tuberculosis (TB) in the ancient world.

Diseases that consumed their victims from the inside out earned the name "consumption" in the

past (Manipal College Pharmaceutical Science, 2016). Chronic granulomatous infectious illness

best describes tuberculosis. Aerosols composed of a few drops containing M. tuberculosis bacilli

can be inhaled and cause infection. There are two phases of M. tuberculosis pathogenesis

following infection. Latent tuberculosis is the earliest stage and describes an asymptomatic state

that might last for years in the host. Cough, chest pain, exhaustion, and unexplained weight loss

are some of the symptoms caused by the bacteria's reproduction when the immune system is

compromised. As the condition progresses, death is the inevitable outcome if no treatment is

given (Jean-Paul, 2019). Eighty percent of the time, it manifests in the lungs with symptoms

including cough, hemoptysis, chest pain, shortness of breath, fever, loss of weight, and profuse

nocturnal sweating. TB is spread mostly by the air inform of droplets.

Airborne Mycobacterium TB droplets are released when infected patients cough, sneeze, talk,

laugh, or spit. The bacterium could spread via the air and infect those in close proximity.

Droplets of airborne Mycobacterium tuberculosis or TB-infected house dust can float in the air

and continue to replicate for weeks. However, transmission typically takes prolonged contact

with a person who has active TB. Mycobacterium TB infection can be unnoticed for a long time

and transmit from person to person. (Anon, 2014). The average number of people infected by a

sick person who is not treated is 10–15 per year. More women die from tuberculosis than from

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all other causes of maternal mortality combined, making it the leading cause of death among

young females (2.5% of the global burden of disease). It is currently the sixth leading cause of

death worldwide. Understanding the nature of tuberculosis and how to diagnose and treat it is

crucial to effective management and positive patient outcomes. The next steps taken depend on

the health staff's reaction, even when TB services are sought out. There is a need to address the

information gaps linked to care seeking and inappropriate actions of care providers in their

encounters with possible TB-cases in order to increase the rate of case notification (Syed et al.,

2017).

DISCUSSIONS

In developing countries, tuberculosis (TB) poses a significant threat to the general population's

health. Every 40 minutes, a new case was found in 2013, totaling over 13,000. Cases are being

found at an increasing rate, with an estimated 532 new cases for every 100,000 people infected in

2016. (Mohammed, 2017). After HIV infection, tuberculosis (TB) is the greatest infectious

disease killer worldwide. WHO predicted 9 million new cases of tuberculosis and 1.5 million

deaths worldwide in 2013, with low- and middle-income countries accounting for 80 percent and

70 percent, respectively. Latent tuberculosis infection (LTBI) is the presence of Mycobacterium

tuberculosis in the host without the development of overt disease signs. In 2000, mathematical

models speculated that more than 30% of the world's population carried LTBI. One-third of the

world's population has latent infection, yet only 5-10% show overt symptoms (Tariro et al.,

2016).

Mycobacterium tuberculosis is the causative agent of tuberculosis, which is a contagious,

airborne disease. Approximately one-third of the global population has latent TB, which is

noninfectious and asymptomatic but can be transmitted to others. On the other hand, between 5

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and 15% of all latently infected people will get active TB during their lifetime; those with HIV

have a significantly higher risk. Active tuberculosis has a high mortality rate and might remain

contagious if it is not recognised and treated (Meenal, 2016). After HIV/AIDS, tuberculosis (TB)

is the biggest cause of death from a single infectious agent in the world. Despite significant

progress, TB remains a major cause of illness each year, affecting millions worldwide. Within

the HIV-negative population, tuberculosis was responsible for an estimated 1.3 million fatalities

(range, 1.2-1.4 million) in 2017, whereas within the HIV-positive population, TB was

responsible for an additional 300,000 deaths (range, 266 000-335 000).

In 2017, TB was estimated to have infected a total of 10.0 million (9.0-11.1 million) persons

worldwide; this included an estimated 5.8 million men, 3.2 million women, and 1.0 million

children. There were cases in every region and age bracket, but the vast majority occurred in just

a handful of countries: India (27%), China (9%), Indonesia (8%), the Philippines (6%), Pakistan

(5%), Nigeria (4%), Bangladesh (3%), and South Africa (3%). Eighty-seven percent of the

world's TB cases were concentrated in these nations and the other 22 on the WHO's list of 30

high TB burden countries. Only 6% of all cases were found in Europe and the Americas

combined. Epidemics can vary greatly in impact from country to country. Most high-income

countries saw new cases of TB in 2017 of less than 10 per 100,000 people, while most of the 30

countries with a high TB burden saw new cases of between 150 and 400 per 100,000 people, and

in a handful of countries like Ghana, Mozambique, the Philippines, and South Africa, the rate

was above 500 (WHO, 2018).

Mycobacterium tuberculosis

Tuberculosis is an infection caused by the rod-shaped, non-spore-forming, aerobic bacterium

Mycobacterium tuberculosis. Mycobacterium commonly measure 0.5 μm by 3 μm, are classified

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as Acid-fast bacilli, and have a unique cell wall structure crucial to their survival. A significant

amount of a fatty acid, my colic acid, is covalently bonded to the mature cell wall.

Polysaccharide arabinogalactan (Biopolymer Consisting of arabinose and galactose

monosaccharides) is attached to the peptidogly that lies below it, creating an exceptional lipid

barrier. Many of Tuberculosis' physiological properties, such as its resistance to drugs and the

host immune system, present significant medical challenges because of this barrier. The

pathogenicity and proliferation of bacteria are both influenced by the make-up and abundance of

their cell walls. Mycobacteria's permeability barrier also benefits from the Peptidogly can

polymer, which is located immediately outside the bacterial cell-membrane and confers cell wall

stiffness.

A carbohydrate structural antigen on the surface of the organism that is immunogenic and allows

mycobacteria to survive within macrophages is lipoarabinomannan (Glycolipid and significant

virulence factor in the Bacteria genus Mycobacterium). Mycobacteria rely on their cell wall for

survival, hence research into the biosynthetic processes and gene activities involved, as well as

the creation of antibiotics that can inhibit cell wall synthesis, are of major interest (Knechel,

2019).

Transmission of Mycobacterium Tuberculosis

Mycobacterium tuberculosis is disseminated by minute airborne droplets in most cases (97%),

termed Droplet nuclei, created by the coughing, sneezing, talking, or singing of a person with

Pulmonary or laryngeal tuberculosis. After being breathed in, these pathogenic bacilli will

remain in the pulmonary alveoli until they are phagocytosed (to envelop and destroy bacteria and

other foreign materials). In other cases, you may not experience any symptoms from the primary

illness. When infectious particles are aerosolized, they are carried by air currents throughout a

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space and can be inhaled by everyone who enters that space. One droplet nucleus contains not

more than 3 bacilli. The nuclei of droplets are so tiny that they can float in the air for a long time.

The average diameter of a nucleus is 5um. About 3000 droplet nuclei are created every time you

cough. Singing produces the same number of droplet nuclei as five minutes of talking does in

just one minute. The majority of droplet nuclei are produced after a sneeze and can travel up to

10 feet. Once the nuclei of the droplets enter the alveoli, tuberculosis has begun. Larger droplets

inhaled through contaminated air tend to be caught in the upper respiratory system, such the nose

and throat, where they are less likely to cause infection. A lot of factors affect how easily an

aerosolized bacterium can spread, including the number of bacilli in the droplets, the bacilli's

virulence, the amount of UV light the bacilli are exposed to, the ventilation level, and the

frequency of aerosolization. When Mycobacterium tuberculosis is inhaled, it infects the lungs.

However, if the bacterium survives and multiplies, it can travel to other organs and produce extra

pulmonary or extra respiratory disease (Knechel, 2019).

Effects of the Mycobacterium Tuberculosis in the Human Body

When infected droplets are breathed in, they spread throughout the respiratory tract. The mucus-

secreting goblet cells in the upper airways act as a trap for the bacilli. The mucus that is secreted

acts as a trap for invading substances, and the cilia on the cells' surfaces are constantly beating

the mucus and the particles it has trapped upward and out of the body. Most people who are

exposed to tuberculosis are protected from contracting the disease thanks to this system's ability

to mount an immediate physical resistance. Droplets of bacteria that escape the mucociliary

system and land in the alveoli are swiftly absorbed by alveolar macrophages, the most numerous

immune effector cells in the alveoli. Macrophages are the second line of defence against

invading mycobacteria; they are a part of the innate immune system. Macrophages are a type of

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phagocytic cell that can fight off many different types of pathogens without the need for the host

to have been exposed to them in the past.

Uptake of the mycobacteria involves many processes including macrophage receptors.

Macrophages are a type of phagocyte that can fight off infections without the host having to be

exposed to the harmful microbes in advance. An essential ligand for a macrophage receptor is

lipoarabinomannan, which is produced by mycobacteria. Phagocytosis of the bacteria also

involves the complement system. C3 complement protein attaches to the cell wall, making it

easier for macrophages to recognise mycobacteria. Rapid C3 opsonization (an immunological

process in which particles like bacteria are targeted for elimination by an immune cell known as

a phagocyte) occurs even in the air spaces of a host with no prior exposure to M tuberculosis.

When macrophages ingest tuberculin, it sets off a chain reaction that can be halted, resulting in

latent tuberculosis, or it can cause the illness to become active, a condition known as primary

progressive tuberculosis.

Mycobacteria continue to proliferate slowly8 after being absorbed by macrophages, with each

generation of bacteria taking between 25 and 32 hours. In the early stages of an infection,

macrophages try to degrade the bacteria by producing proteolytic enzymes and cytokines. Cells

that make up cell-mediated immunity, known as T lymphocytes, are drawn to the area when

cytokines are released. Then, the mycobacterial antigens on the surface of the macrophages are

presented to the T cells. After 2–12 weeks, the bacteria will have multiplied to a point where the

host's cell-mediated immune response will be fully elicited and will be detectable via skin test

(Janssen, 1940).

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Diagnosis of Tuberculosis

Patients who present themselves to the OPD of healthcare facilities are a common source for

tuberculosis diagnoses. The severity of exposure can only be determined by first screening those

who appear with a cough that has lasted for two weeks or more using a TB screening

questionnaire. The patient's responses to this screening question can be broken down into nine

distinct categories. Symptoms of tuberculosis include a persistent cough, the production of

sputum, the coughing up of blood, a loss of weight in the previous three months, excessive

perspiring during sleep, a high body temperature, chest pains, previous contact with a TB patient,

and a history of alcohol or tobacco use. The answers to these questions help guide the next steps

in the diagnostic process. The Mantoux tuberculin skin test (TST), chest x-rays, and sputum

smear microscopy are the big three when it comes to diagnosing tuberculosis (WHO, 2018). M.

tuberculosis infection can be detected using either the Mantoux tuberculin skin test or the TB

blood test. The Mantoux tuberculin skin test is performed by injecting a little amount of fluid

called tuberculin into the skin in the lower region of the arm. A qualified medical professional

examines the arm for a reaction (induration) within 48-72 hours of the test's administration

(CDC, 2011). In cases when this test comes out positive, however, further examination is needed

to definitively diagnose tuberculosis.

The lung abnormalities that may be indicative of tuberculosis can be seen on a chest x-ray taken

from the back to the front. These alterations can show up anywhere in the lungs and range in

size, density, and shape (CDC, 2011). While these irregularities may raise suspicion for

tuberculosis, they cannot be used to provide a certain diagnosis of the disease (Mburu &

Richardson, 2013). Nonetheless, a chest radiograph may be utilised to rule out the possibility of

pulmonary TB in a person who has had a positive reaction to a TST or TB blood test without

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symptoms of the disease (Mburu & Richardson, 2013). The presence of acid-fast bacilli (AFB) in

the sputum is a third diagnostic microbiological test for tuberculosis. The presence of AFB on a

sputum smear or other samples often may suggest TB illness (Mburu & Richardson, 2013). Since

not all acid-fast bacilli are M. tuberculosis, the diagnosis of TB cannot be confirmed by utilising

the simple and fast method of acid-fast microscopy using the Ziehl-Neelsen stained smear. It was

also discovered that roughly 60% of potential TB cases could be missed when utilising only

direct Ziehl-Neelsen microscopy (Muwonge et al., 2014). Therefore, sputum is obtained for

culture as a step toward verifying the diagnosis. Obtaining a positive result from a

Mycobacterium culture is the gold standard for a TB diagnosis (Burman et al., 1997; Muwonge

et al., 2014). However, in more recent years, doubts have been raised concerning the accuracy of

employing culture to verify a TB diagnosis. This is because a study in some developing countries

indicated that 50% of smear-positive TB cases had their culture findings being negative (Sekandi

et al., 2014).

In Ghana, all persons with cough reporting at the OPD are mandated to be screened using the

screening checklist. Sputum is collected from patients who meet the criteria for additional testing

in order to isolate tuberculosis bacilli by microbiology. Labs are required to notify primary care

physicians of positive smear and culture results within 24 hours of test completion so that

patients can be properly registered and begin treatment (NTP, 2012). This practise is

implemented to lessen the likelihood that the infected person would spread the bacilli to others.

Case detection is hindered, however, if the test is unavailable or if health care providers don't

request it. In addition, case detection will be hindered by the healthcare provider's lack of ability

to identify the bacterium in sputum. Chest x-rays are available in Ghana and utilised to detect

abnormalities in the lungs indicative of TB. Therefore, TB diagnosis is an important aspect of

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health systems that can either help or hurt the detection of TB cases. Once a diagnosis has been

made, the patient can begin treatment.

Treatment of Tuberculosis
Five primary drugs are utilised in the treatment of tuberculosis. Codes are assigned to these drugs

so that they can be quickly and easily identified by their short names. Rifampicin (R), isoniazid

(H), pyrazinamide (Z), streptomycin (S), and ethambutol (E) are commonly used antibiotics, and

they are frequently prescribed together (WHO, 2018). Isoniazid is often prescribed in

conjunction with rifampicin (HR), pyrazinamide and rifampicin (HRZ), and ethambutol and

pyrazinamide (HRZE) (NTP, 2014). TB treatment consists of two distinct periods. That's right,

these are the extensive and in-depth (WHO, 2018). The first two months of therapy are the most

rigorous, and a direct observation treatment (DOT) technique is commonly used when

administering drugs during this time. For this method to function, patients need to take their

medication in the company of a medical professional. In order to ensure that patients who live in

remote areas get access to their medications, those who require DOT on a daily basis are first

provided with their medications at the treatment centre and then sent to a nearby medical centre.

Patients who are in close proximity to treatment facilities are required to participate in DOT by

attending a daily morning clinic.

During the intensive phase of treatment, which lasts for a total of two months in Ghana, about

90% of patients are routinely cared for daily in an outpatient setting (NTP, 2014). Patients who

are too unwell or have other medical difficulties that prevent them from being treated in an

outpatient setting are instead admitted to the hospital (NTP, 2012). The cost of transportation to

and waiting time at health care facilities for daily medicine administration in the presence of a

health worker should be considered. As a result, this might discourage consistent consumption.

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Since tuberculosis is a socially and culturally stigmatised illness, patients' regular doctor

appointments may be fraught with secrecy. People with a cough may avoid going to health care

institutions to begin the two months of DOT required for the intense phase of TB treatment,

which could reduce the likelihood of detecting new cases.

Tuberculosis Control in Ghana

The fight against tuberculosis dates back long before Ghana's independence. The Ghana Society

for the Prevention of Tuberculosis was founded in July 1954, according to reports found at

Ghana Health Service (www.ghanahealthservice.org). The government was going to enlist the

help of this society to spearhead its efforts to lessen the disease's impact. In the early 1960s, after

the formation of this society, nurses were sent to Israel to receive training on TB case treatment

through a sponsorship programme (GHS, 2015b). Mobile x-ray vans were also deployed to

communities to aid in the diagnosis and treatment of tuberculosis. Winneba government

hospital's former Director of Medical Services, Dr. Moses Adibo, recommended the creation of

the National Tuberculosis Control Programme (NTP) in July 1965. (GHS, 2015b). Since its

inception, NTP has been responsible for coordinating all initiatives in Ghana intended to combat

tuberculosis.

In 1994, the National Tuberculosis Program in Ghana (NTP) adopted the World Health

Organization's (WHO) DOTS policy, with the goal of finding 70% of patients with infectious TB

and treating such cases with an 85% cure rate (NTP, 2014). According to World Health

Organization (WHO) criteria, the DOTS approach has been implemented in Ghana, benefiting

over 80.6% of the population (WHO, 2009a). Ghana was claimed to be one of the few African

countries to have met the World Health Assembly target of 70% TB case detection and 85%

treatment success through various measures employed by the NTP. Regional variations exist in

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Ghana across all dimensions of TB control, despite the fact that TB incidence and prevalence had

decreased by nearly 50% (WHO, 2013a).

The NTP puts into action the World Health Organization's (WHO) new Stop TB Strategy along

six operational axes. The primary tactic is to continue developing and improving a high-quality

DOTS growth and enhancement programme. The initiative anticipated that this would

necessitate strong political will and more funding for TB-related activities. In order to boost case

detection, the quality of bacteriology must also rise. Furthermore, NTP implemented measures to

standardise TB treatment by providing patient supervision, enhancing the drug supply system,

and practising good monitoring and evaluation. The first tactic involves adjusting aspects of the

healthcare system to enhance diagnostics and broaden access to treatment centres. TB/HIV,

MDR-TB is the focus of the second major strategic plan. Increasing cooperation between TB and

HIV control activities, implementing programmes to control MDR-TB, and focusing on high-

risk populations like prisoners and refugees will help achieve this goal. The goal of this strategy

is to identify those at a higher risk for tuberculosis and then screen them. With more people in

the most at-risk demographic being screened, we hope to increase our rate of successful case

detection.

A third pillar of the plan is improving healthcare delivery. In order to accomplish this goal, NTP

adopted and implemented a number of innovations developed in conjunction with its partners.

Public-public and public-private mix (PPM) in TB control operations, as well as ensuring

adherence to international standards for TB case reporting, is the fourth pillar of the new stop TB

strategy (ISTC). In order to increase TB case detection, the NTP works with NGOs and roughly

135 CSOs to raise public awareness about the disease (Bonsu et al., 2014). The third and fourth

pillars, respectively, focus on studies that investigate novel approaches to better diagnose and

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treat patients. The goal of this public-private collaboration is to increase the number of facilities

capable of identifying and treating tuberculosis patients.

The fifth tactic is to encourage self-determination among TB patients and their communities

through initiatives like patient charter creation and social mobilisation. To help tuberculosis (TB)

patients and their supporters defray part of their operating costs, an Enablers Package (EnP) was

implemented. Each TB patient in Ghana who enrolls in the EnP is worth $40 USD (NTP, 2014).

The final plan of action is to foster an atmosphere conducive to operational research and the

creation of novel diagnostics, therapeutics, and vaccinations. In general, these methods have

been implemented to enhance the health care system's capacity to diagnose TB cases early and

begin appropriate treatment.

CONCLUSIONS

Since the 1950s, tuberculosis has been widely acknowledged as a serious global health concern.

Despite the World Health Organization's (WHO) efforts to apply the DOTS strategy in the 1990s

and reduce the problem's impact, tuberculosis (TB) continues to be a serious health issue in

Tuberculosis (TB) has been a problem for humans for a very long time. In conclusion,

tuberculosis places a heavy financial burden on society, significantly reduces household income,

has a detrimental effect on social welfare, and drains limited national resources in the process of

managing the disease.

Control strategies should prioritise early detection and sufficient treatment. Lack of information

about TB is a persistent problem that hinders control efforts even though Africa has one of the

world's highest TB burdens. Any chance to educate the public about tuberculosis should be taken

advantage of, especially in regions where the illness is rampant. The study suggest that

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community-level TB education is necessary to fill up knowledge gaps on the disease, with the

ultimate goal of distributing accurate information about its prevention and control. Health

education initiatives within the TB preventive and control plan must be increased to combat

widespread misinformation about the disease.

References

Anon. (2014). Logistic Model in Reliability of TB Drugs. LAP LAMBERT Academic

Publishing., 12-67page.

Janssen, T. (1940). Manual of the international list of causes of death as adopted for use in the

United States. Washington: U.S. Govt. Print. Off.

Jean-Paul I. M. (2019). Knowledge, attitude and practice with regard to Tuberculosis. University

of Western Cape, 1-119page.

Knechel, N. ((2019). Tuberculosis: Pathophysiology, Clinical Features, and Diagnosis. Critical

Care Nurse. http://ccn.aacnjournals.org/content/29/2/34.short.

Manipal College Pharmaceutical Science (2016). Tuberculosis report: 1-11page.

Mohammed H. M. (2017). The impact tuberculosis has on people in the developing world. 1-

6page.

Syed, F. and Mayosi, B. (2017). A Modern Approach to Tuberculous Pericarditis. Progress in

Cardiovascular Diseases, 50(3), p.218-236.

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Tariro J. B., Jabulani N., Mark E. E., (2016). Prevalence and risk factors of latent tuberculosis

infection in Africa. 1-5page.

WHO. (2018). Global tuberculosis report. World Health Organization Executive Summary, 1-

6page.

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