Tuberculosis And AIDS Essay

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Tuberculosis is or TB is an infectious disease that usually affects the lungs. The most common form is caused by Mycobacterium tuberculosis, a slender, rod-like bacterium commonly called the tubercle bacillus. The tubercle bacillus is very hardy, surviving when many other bacteria cannot. In addition to affecting the lungs, tuberculosis can affect almost all other organs of the body.

             Tuberculosis, which in the past called phthisis and consumption, has afflicted man for thousands of years. Evidence of the disease has been found in Egyptian mummies. Tuberculosis was once a leading cause of death in all age groups, but its severity has decreased with improved medical care and better living standards.

            Most persons have a natural resistance to the tubercle bacillus. Even though large numbers of persons, especially in cities, become infected by the bacillus early in life, only a small percentage actually develops the disease.

            This paper intent to: (1) know the occurrence of tuberculosis and how it is being spread; (2) be aware of its symptoms and detection and; (3) figure out its treatment and control.

            Tuberculosis is an infectious disease caused by the bacterium Mycobacterium tuberculosis, a slender rod and an obligate aerobe. The rods grow slowly (20-hour generation time), sometimes form filaments and tend to grow in clumps. On the surface liquid media, their growth appears moldlike, which suggested the genus name Mycobacterium, from the Greek mykes, meaning fungus.

            These bacteria are relatively resistant to normal staining procedures. When stained by the ZiehlNeelson or Kinyoun technique that stains the cell with carbolfuchsin dye, they cannot be decolorized with a mixture of acid and alcohol and are therefore classified as acid-fast. This characteristic reflects the unusual composition of the cell wall, which contains large amounts of lipid materials (American Thoracic Society, 2000).  These lipids might also be responsible for the resistance of mycobacteria to environmental stresses, such as drying. In fact, these bacteria can survive for weeks in dried sputum and are very resistant to chemical antimicrobials used as antiseptics and disinfectants.

            Tuberculosis is a good example of the importance of the ecological balance between host and parasite in infectious disease. Hosts are not usually aware of pathogens that invade the body and are defeated. If defenses fail, however, hosts become very much aware of the resulting disease. Several factors may affect host resistance levels”the presence of other illness and physiological and environmental factors such as malnutrition, overcrowding, and stress.

            Tuberculosis is most commonly acquired by inhaling the tubercle bacilli reach the lungs, where they are usually phagocytized by a macrophage in the alveoli. The macrophages of a healthy individual usually destroy the bacilli. If they do not, the macrophages actually protect the microbe from the chemical and immunological defenses of the body, and many of the bacilli survive and multiply within the macrophage (American Thoracic Society, 2000).

            These macrophages eventually lyse, releasing an increased number of pathogens. The tubercle bacilli released from dying macrophages form a lesion. A hypersensitivity reaction against these organisms causes formation of a tubercle, which effectively walls off the pathogen. These small lumps are characteristics of tuberculosis and give the disease its name. Tubercles are composed of packed masses of tissue cells and the disintegration products of bacilli and leukytes; they usually have a necrotic center. Few bacteria are present in the tubercle (Diehl, 2003).

            The tubercle bacillus does not produce any injurious toxins. Tissue damage is mostly from the hypersensitivity reaction. As the reaction continues, the tubercle undergoes necrosis and eventually forms a caseous lesion that has a cheeselike consistency. If the caseous lesions heal, they become are called Ghon complexes. If the disease is not arrested at this point, the caseous lesions progress to liquefaction. An air-filled tuberculous cavity is formed from the caseous lesion.

Conditions within the cavity favor the proliferation of the tubercle bacillus, which then grows for the first time extracellularly. Bacilli soon reach very large members, and eventually the lesion ruptures, releasing the microorganisms into the blood and lymphatic system (American Thoracic Society and Centers for Disease Control and Prevention, 2000).  This condition of rapidly spreading infection that overwhelms the bodys remaining defenses is called miliary tuberculosis (the name is derived from the numerous millet seed-sized tubercles formed in the infected tissues).

            This condition leads to a progressive disease characterized by loss of weight, coughing (often with a show of blood), and general loss of vigor. (At one time, tuberculosis was commonly was known as consumption.) Even when patients are considered cured, tubercle bacilli often remain in the lung, and the disease may be reactivated. Reactivation may be precipitated by old age, poor nutrition, or immunosuppression.

III. Discussion

            When a person with tuberculosis coughs or sneezes, tiny droplets containing thousands of tubercle bacilli are sprayed into the air. The disease is spread when non-infected persons inhale the bacilli thus released into the air. A person can also contract tuberculosis by drinking unpasteurized milk from cows having the disease. This form of tuberculosis is caused by the bacterium Mycobacterium bovis.

            Resistance to tuberculosis depends largely upon the general health of the individual. Persons who are undernourished or weakened by disease are more likely to develop tuberculosis. Outbreaks tend to occur in areas with crowded living conditions, such as nursing homes and prisons (Centers for Disease Control and Prevention, 2003).

            About 90 percent of tuberculosis infections occur first in the lungs. Tuberculosis of the lungs is called pulmonary tuberculosis. When tubercle bacilli are inhaled into the lungs, they are either destroyed by white blood cells or surrounded by special cells and fibers in the infected area of the lung, forming tiny nodules called tubercles.

            If the immune system is effective, the bacteria are kept from multiplying and an active case of tuberculosis does not develop. In some cases, however, the bacteria enter the bloodstream or lymphatic system and are carried to other parts of the body. The bacteria usually lodge in the brain, kidneys, bones, or heart (Murray, 2000).

              Early pulmonary tuberculosis commonly gives no specific warning. Later, fatigue, weight loss, or a low fever may be the only symptoms. In advanced stages, severe coughing, hoarseness, chest pain and the appearance of blood in the sputum (a mixture of saliva and discharges from the respiratory passages) can occur.  If the patient is untreated and his resistance is low, large areas of lung tissue can be destroyed and there is considerable weight loss.

            The best way of detecting infection by tubercle bacilli is by means of a tuberculin test. In a tuberculin test, tuberculin”a liquid containing substance obtained from tubercle bacilli”is injected between the layers of the skin. After 48 to 72 hours, the point of injection is examined for redness and swelling (Centers for Disease Control and Prevention, 2003). A tuberculin test will reveal whether a person has been infected by tubercle bacilli, but it will not indicate whether he has an active case of the disease.

            Diagnosis of active tuberculosis can usually be made by a chest X ray and other tests. Diseased areas of the lungs usually cast a characteristic shadow on the X-ray film. Another method of diagnosis involves a microscopic examination of the patients sputum for the presence of tubercle bacilli (Centers for Disease Control and Prevention, 2003).

            Prior to 1945, practically the only methods for treating tuberculosis were prolonged bed rest and (in advanced cases) immobilization of the infected lung by collapsing it. Since the time, drugs have been produced that can stop the tubercle bacilli from multiplying, thus allowing the natural defenses of the body to be effective. The most important of these drugs are streptomycin (INH). In addition, improved surgical techniques permit the safe removal of areas of the lung where infection persists despite treatment with drugs (American Thoracic Society, 2000).

            Most important in tuberculosis control is early detection, so that persons with the disease can be treated and isolated from others. A vaccine known as BCG can create immunity to tuberculosis. However, in the United States this vaccine is recommended only in special circumstances. One reason is that vaccinated persons react positively to a tuberculin test and therefore cannot be differential from infected persons.

            The major goals for the patient include maintenance of a patient airway, increased knowledge about the disease and treatment regimen and adherence to the medication regimen, increased activity tolerance, and absence of complications.

            a.) Promoting Airway Clearance

            Copious secretions obstruct the airways in many patients with TB and interfere with adequate gas exchange. Increasing fluid intake promotes systematic hydration and serves as an effective expectorant. The nurse instructs the patient about correct positioning to facilitate airway drainage (Diehl, 2003).

            b.) Advocating Adherence to Treatment Regimen

            The multiple- medication regimen that a patient must follow can be quite complex. Understanding the medications, schedule, and side effects is important. The patient must understand that TB is a communicable disease and that taking medications is the most effective means of preventing transmission. The major reason treatment fails is that patients do not take their medications regularly and for the prescribed duration. The nurse carefully instructs the patient about important hygiene measures, including mouth care, covering the mouth and nose when coughing and sneezing, proper disposal of tissues, and hand hygiene (Diehl, 2003).

            c.) Promoting Activity and Adequate Nutrition

            Patients with TB are often deliberated from a prolonged chronic illness and impaired nutritional status. The nurse plans a progressive activity schedule that focuses on increasing activity tolerance and muscle strength. Anorexia, weight loss, and malnutrition are common in patients with TB. The patients willingness to eat may be altered by fatigue from excessive coughing, sputum production, chest pain, generalized debilitated state, or cost, if the person has few resources. A nutritional plan that allows for small, frequent meals may be required. Liquid nutritional supplements may assist in meeting basic caloric requirements (Centers for Disease Control and Prevention, 2003).

            a.) Malnutrition

            This may be a consequence of the patients lifestyle, lack of knowledge about adequate  nutrition and its role in health maintenance, lack of resources, fatigue, or lack of appetite because of coughing and mucus production. To counter the effects of these factors, the nurse collaborates with dietitian, physician, social worker, family, and patient to identify strategies to ensure an adequate nutritional intake and availability of nutritious food.

Identifying facilities that provide meals in the patients neighborhood may increase the likelihood that the patient with limited resources and energy will have access to a more nutritious intake (Centers for Disease Control and Prevention, 2003). High-calorie nutritional supplements may be suggested as a strategy for increasing dietary intake using food products normally found in the home. Purchasing food supplements may be beyond the patients budget, but a dietitian can help develop recipes to increase calorie intake despite minimal resources.

            In conclusion, persons infected with tuberculosis develop cell-mediated immunity against the bacterium. This form of immune response, rather than humoral immunity, is because the pathogen is located mostly within macrophages. This immunity, involving sensitized T cells, is the basis for the tuberculin skin test. In this test, a purified protein derivative (PPD) of the tuberculosis bacterium, derived by precipitation from broth cultures, is injected continuously.

If the injected person has been infected with tuberculosis in the past, sensitized T cells react with these proteins and a delayed hypersensitivity reactions appears in about 48 hours. This reaction appears as an induration (hardening) and reddening of the area around the injection site. Probably the most accurate tuberculin test is the Mantoux test, in which dilutions of 0.1 ml of antigen are injected and the reacting area of the skin is measured. A number of similar tests are also in common use.

            A positive tuberculin test in the very young is a probable indication of an active case of tuberculosis. In older persons, it might indicate only hypersensitivity resulting from a previous infection or vaccination, not a current active case. Nonetheless, it is an indication that further examination is needed, such as a chest X-ray for the detection of lung lesions and attempts to isolate the bacterium.




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AIDS




            Although progress has been in treating HIV infection and AIDS, the epidemic remains a critical public health issue in all communities across the country and around the world. Prevention, early detection, and ongoing treatment remain important aspects of care for people with HIV infections and AIDS. Nurses in all settings encounter people with this disease; thus, nurses need an understanding of the disorder, knowledge of the physical and psychological consequences associated with the diagnosis, and expert assessment and clinical management skills to provide optimal care for people with HIV infection and AIDS.

            In 1987, just 6 years after the first cases of AIDS were reported, the U.S. Food and Drug Administration (FDA) approved the first antiretroviral agent; in 1988 the first randomized controlled trial of primary prophylaxis of Pneumocystis carinii pneumonia appeared in the literature; and in 1995 protease inhibitors joined the growing number of antiretroviral agents. Improved treatment of HIV and AIDS has resulted in increased survival times; in 1996, 1997, and 1998, age-adjusted death rates fell 29%, 48%, and 21%, respectively.

            This paper intent to:

            Although progress has been in treating HIV infection and AIDS, the epidemic remains a critical public health issue in all communities across the country and around the world. Prevention, early detection, and ongoing treatment remain important aspects of care for people with HIV infections and AIDS. Nurses in all settings encounter people with this disease; thus, nurses need an understanding of the disorder, knowledge of the physical and psychological consequences associated with the diagnosis, and expert assessment and clinical management skills to provide optimal care for people with HIV infection and AIDS.

            In 1987, just 6 years after the first cases of AIDS were reported, the U.S. Food and Drug Administration (FDA) approved the first antiretroviral agent; in 1988nthe first randomized controlled trial of primary prophylaxis of Pneumocystis carinii pneumonia appeared in the literature; and in 1995 protease inhibitors joined the growing number of antiretroviral agents. Improved treatment of HIV and AIDS has resulted in increased survival times; in 1996, 1997, and 1998, age-adjusted death rates fell 29%, 48%, and 21%, respectively.

            Since acquired immunodeficiency syndrome (AIDS) was first recognized more than 20 years ago, remarkable progress has been made in improving the quality and duration of life of persons with HIV infection. During the first decade, this progress was associated with recognition of opportunistic disease processes, more effective therapy for complications, and introduction of prophylaxis against common opportunistic infections (OIs).

The second decade has witnessed progress in developing highly active antiretroviral therapies (HAART) as well as continuing progress in treating OIs (Letvin, Bloom & Hoffman, 2001). Since the HIV serologic test (enzyme immunoassay [EIA], formerly enzyme-linked immunosorbent assay [ALISHA], became available in 1984, allowing early diagnosis of the infection before onset of symptoms, HIV infection has been best managed as a chronic disease  and most appropriately managed in an outpatient care setting (Gallant, 2001).

            In fall 1982, the Centers for Disease Control and Prevention (CDC) issued a case definition of AIDS after the first 100 cases were reported. Since then, the CDC has revised the case definition a number of times (1985, 1987, and 1993). All 50 states, the District of Columbia, U.S. dependencies and possessions, and independent nations in free association with the United States report AIDS cases to the CDC using a uniform surveillance case definition and case report from (CDC, 2002). Starting in the late 1990s, more states started to implement HIV case reporting in response to the changing epidemic and the need for information on persons with HIV infection who have not developed AIDS.

As of December 2001, there were 816,149 reported cases of HIV/AIDS and 506, 154 adults, adolescents, and children in the United States (including U.S. dependencies, possession, and associated nations) living with AIDS. Unprotected sex and sharing of injection drug use equipment are the major means of transmission of HIV. A total of 43, 158 AIDS cases were diagnosed in 2001.

For men diagnosed with AIDS during 2001, 59% were in the exposure category of men who have sex with men; 24% in injection drug use; and 7% in heterosexual contact. In women diagnosed with AIDS during that same period, 44% reported injection drug use and 52% reported heterosexual contact. Comparing race/ethnicity amount the three largest groups diagnosed in 2001, 20,752 were black, not Hispanics (CDC, 2002).

            The number of people living with AIDS is not evenly distributed throughout the United States. States with the largest number of reported AIDS cases during 2001 were New York (7,476), Florida (5,138), California (4,315), Texas (2,892), and Maryland (1,860) (CDC, 2002).

            AIDS has reached epidemic proportions in some other parts of the world. According to the Joint United Nations Program on HIV/AIDS, more than 18.3 million people worldwide have died of AIDS and 34.3 million people are infected with HIV, with 5.4 million people newly infected with HIV in 1999 alone (Letvin, Bloom & Hoffman, 2001).  UNAIDS (2001) reports that since the epidemic began, more than 60 million people have been infected with the virus, making it the most devastating disease ever.

            The earliest confirmed case of HIV infection was found in blood drawn from an African man in 1959 (Stephenson, 2003). Although factors associated with the spread of HIV in Africa in the 1960s; however, social changes such as easier access to transportation, increasing population density, and more frequent sexual contacts may have been more important (Stephenson 2003).

III. Discussion

            HIV-1 is transmitted in body fluids containing HIV and/or infected CD4+ (or CD4) T lymphocytes. These fluids include blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk. Mother-child transmission of HIV-1 may occur in utero, at the time of the delivery, or through breastfeeding, but transmission frequency during each period has been difficult to determine (Nduati et al., 2000). Any behavior that results in breaks in the skin or mucosa results in the increased probability of exposure to HIV. Since HIV is harbored within lymphocytes, a type of white blood cell, any exposure to infected blood results in a significant risk of infection. The amount of virus and infected cells in the body fluid is associated with the risk of new infections.

            Until an effective vaccine is developed, preventing HIV by eliminating or reducing risk behaviors is essential. Primary prevention efforts through effective educational programs are vital for control and prevention. HIV is not transmitted by causal contact.

            Effective educational programs have been initiated to educate the public regarding safer sexual practices to decrease the risk of transmitting HIV-1 infection to sexual partners. Latex condoms should be used during vaginal or anal intercourse. Non-latex condoms are available for people with latex allergy. A condom should be used for oral contact with the penis, and dental dams (a piece of latex used by dentists to isolate a tooth for treatment) should be used for oral contact with the vagina or rectum. As a result of a clinical trial that found female sex workers who used a nonoxynol-9 (N-9) gel intravaginally in addition to condoms were 50% more likely to be infected with HIV than those who did not use N-9 gel, The CDC issued the recommendation that intravaginal application of N-9 should no longer be recommended as an effective means of HIV prevention (AIDS Institute, 2000).

            Other topics important in preventive education include the importance of avoiding sexual practices that might cut or tear the lining of the rectum, penis, or vagina and avoiding sexual contact with multiple partners or people who are known to be HIV positive or injection drug users. In addition, people who are HIV positive or use injection drugs should be instructed not to donate blood or share drug equipment with others.

Increasingly, needle exchange programs are available to enable injection drug users to obtain sterile drug equipment at no cost. Extensive research has demonstrated that needle exchange programs do not promote increased drug use; on the contrary, they have been found to decrease the incidence of blood-borne infections in persons who use injection drugs (Trzcianowska & Mortensen, 2001). In the absence of needle exchange programs, injection drug users should be instructed on methods to clean their syringes and to avoid sharing cotton and other drug use equipment.

            Because HIV infection in women usually occurs during the child-bearing years, family planning issues need to be addressed. Attempts to achieve pregnancy by couples in which one partner has HIV and the other does not expose the unaffected partner to the virus. Efforts at artificial insemination using processed semen from an HIV-infected partner are underway. Studies are needed because HIV has been found in the spermatozoa of patients with AIDS, with possible HIV replication in the male germ cell. Women considering pregnancy need to have adequate information about the risks of transmitting HIV infection to themselves, their partner, and their future children and about the benefits of antiretroviral agents in reducing perinatal HIV transmission. Other than abstinence, the condom has been the only method that has proved to decrease the risk of sexual transmission of HIV infection.

            Certain contraceptive methods may pose additional health risks for women. Estrogen in oral contraceptives may increase womens risks for HIV infection. In addition, women infected with HIV who use estrogen oral contraceptives have shown increased shedding of HIV in vaginal and cervical secretions.

The intrauterine contraceptive device (IUD) may also increase the risk for HIV transmission because the devices string may serve as a means to transmit HIV infection. It also can cause penile abrasions. The female condom is as effective in preventing pregnancy as other barrier methods, such as the diaphragm and the male condom. Unlike the diaphragm, the female condom is also effective in preventing the transmission of HIV infection and sexually transmitted diseases (STDs). The female condom has the distinction of being the first barrier method that can be controlled by women.

            Treatment of specific manifestations of HIV infection and AIDS in the person with advanced disease targets symptoms. Patients with HIV/AIDS experience a number of symptoms related to the disease as well as the effects of treatment. Some of the vivid symptoms are as follows:

            Respiratory Manifestation. Shortness of breath, dyspnea (labored breathing), cough, chest pain, and fever associated with various OIs, such as those caused by Pneumocystis carinii, Mycobacterium avium-intracellulare, CMV, and Legionella species. The most common infection in people with AIDS is Pneumocystis carinii pneumonia (PCP), one of the first OIs described in association with AIDS.

            PCP. PCP is the most common OIs resulting in an AIDS diagnosis. Without prophylactic therapy, PCP will develop in 80% of all HIV-infected individuals. P. carinii was originally classified as a protozoan; however, studies and analysis of its ribosomal RNA structure suggest that it is a fungus. Its structure and antimicrobial sensitivity are very different from other disease-causing fungi. P. carinii causes disease only in immunocompromised hosts, invading and proliferating within the pulmonary alveoli with resultant consolidation of the pulmonary parenchyma.

            Mycobacterium avium Complex. Mycobacterium avium complex (MAC) disease is a leading OI in people with AIDS. Organisms belonging to MAC include M. avium, M. intracellulare, and M. scrofulaceum. MAC, comprising a group of acid-fast bacilli, usually causes respiratory infection but is also commonly found in the GI tract, lymph nodes, and bone marrow. Most patients   with AIDS who have T-cell counts less than 100 have widespread disease at diagnosis and are usually debilitated. MAC infections are associated with rising mortality rates (Stephenson 2003).

            Tuberculosis. Mycobacterium tuberculosis tends to occur in injection drug users and other groups with preexisting high prevalence of tuberculosis (TB) infection. Unlike other OIs, TB tends to occur early in the course of HIV infection, usually preceding the diagnosis of AIDS. This early occurrence associated with the development of caseating granulomas (dry, cheeselike masses of granulation tissue), which should raise the suspicion of TB. At this stage, TB responds well to antituberculosis therapy.

            There are two basic areas of AIDS research. Some researchers are working on vaccines to prevent the disease, and others are looking for drugs to treat AIDS.

            Vaccines. There are great obstacles to production of an AIDS vaccine, among them the lack of a suitable animal host for the virus. However, researchers are now optimistic that a vaccine, once produced, could be effective. One reason for optimism is that a very few persons who were once HIV-positive have spontaneously become HIV-negative, indicating that the immune system is probably capable in rare instances of eliminating the virus.

Because of the extreme virulence of the virus, many think it unlikely that any whole-virus vaccine, either killed or attenuated, would be acceptable for use on uninfected persons. However, such a vaccine would be acceptable for use in attempting to clear the virus after infection. Most efforts are directed at subunit vaccines based on surface envelope antigens of the virus.  However, such vaccines must overcome the problem of many antigenic variants. In addition, an effective vaccine would have to stimulate cell-mediated as well as humoral immunity to deal with HIV contained within macrophages or other cells (Gallant, 2001).

            Chemotherapy. A promising approach to arresting HIV infection is to flood the body with artificially produced, soluble CD4-type molecules that would bind to circulating viruses before they could locate a CD4 receptor on a T-cell. In early experiments, the interceptor CD4 molecules were rapidly degraded, requiring repeated injections at an impractical rate. The soluble CD4 would have to be modified in some way so as to remain in circulation for an extended time for this approach to be practical.

            Most early anti-HGIV drugs such as Zidovudine (AZT) are inhibitors of the enzymes reverse transcriptase. HIV is a retrovirus that copies RNA into DNA. The drugs, mostly analogs of nucleic acids, trick the enzyme into terminating the synthesis of viral DNA.

Such drugs have slowed the progress of the disease but have not led to a cure. Other than the reverse transcriptase step, there are at least 13 other points at which the production of HIV could be selectively interrupted by drugs. For example, because it has no equivalent in human cells, an attractive target is the viral enzyme protease. This enzyme cuts proteins into pieces that are then reassembled into new HIV particles. Inhibiting it would prevent viral synthesis. Numerous other approaches are being intensively studied, and the most successful solutions might well be some that are not even anticipated now.

             Although many infectious diseases, such as poliomyelitis and tuberculosis, have been all but eliminated as health risks in developed countries, sexually transmitted diseases are still rampant.

            HIV does not actually destroy the immune system. In fact, the B-cells of the immune system, which actually attack invading bacteria and viruses, are not harmed by HIV. Instead, HIV attacks the T-4 cells inoperative, invading germs wreak havoc on the body, because the immune system is incapable of fighting the infections, Research on HIV and the nature of immune system continues at a furious pace, and much has been learned in recent years. Still, most experts believe that an AIDS vaccine is a distant goal, not likely to be reached in the next decade.













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