DESCRIPTION

Tuberculosis (TB) is a very old and highly contagious, wasting disease cause by any of several mycobacteria. Many years ago, this disease was referred to as "consumption" because without effective treatment, these patients often would waste away.

There are 3 major types of tubercle bacilli that affect humans. The human type of bacteria Mycobacterium tuberculosis was first identified in 1882 by Robert Koch and is spread by people themselves and is the most common one. The bovine type (M. Bovis) is spread by infected cattle but is no longer a threat in areas where pasteurization of milk and the health of cattle are strictly supervised. The avian type (M. Avis) is carried by infected birds but can occur in humans. Other mycobacteria such as M. Africanum, M. Canetti, and M. Microti also cause tuberculosis, but these species are less common. The tubercle bacillus can live for a considerable period of time in air or dust.

There is also a group of organisms referred to as atypical tuberculosis. These involve other types of bacteria that are in the Mycobacterium family. Often, these organisms do not cause disease and are referred to a "colonizers," because they simply live alongside other bacteria in our bodies without causing damage. At times, these bacteria can cause an infection that is sometimes clinically like typical tuberculosis. When these atypical mycobacteria cause infection, they are often very difficult to cure. Often, drug therapy for these organisms must be administered for one and a half to two years and requires multiple medications.

TB is primarily a disease of the lungs, but it can affect any body organ, including the bones and joints, kidneys, intestines, spleen, and liver. The skin and the genitourinary, lymphatic, and nervous systems may also be affected.

COURSE OF THE DISEASE

Tuberculosis of the lungs usually results in no or minimal symptoms in its early stages. In most persons the primary infection is contained by the body's immune system, and the lesion, called a tubercle, becomes calcified. In many the infection is permanently arrested. In others the disease may break out again and become active years later, usually when the body's immune defenses are low. Untreated, the infection can progress until large areas of the lung and other organs are destroyed. Symptoms of the disease include cough, sputum, bleeding from the lungs, fever, night sweats, loss of weight, and weakness.

When the inhaled tuberculosis bacteria enter the lungs, they can multiply and cause a local lung infection (pneumonia). The local lymph nodes associated with the lungs may also become involved with the infection and usually become enlarged. The hilar lymph nodes (the lymph nodes adjacent to the heart in the central part of the chest) are often involved.

In addition, TB can spread to other parts of the body. The body's immune (defense) system, however, can fight off the infection and stop the bacteria from spreading. The immune system does so ultimately by forming scar tissue around the TB bacteria and isolating it from the rest of the body. Tuberculosis that occurs after initial exposure to the bacteria is often referred to as primary TB. If the body is able to form scar tissue (fibrosis) around the TB bacteria, then the infection is contained in an inactive state. Such an individual typically has no symptoms and cannot spread TB to other people. The scar tissue and lymph nodes may eventually harden, like stone, due to the process of calcification of the scars (deposition of calcium from the bloodstream in the scar tissue). These scars often appear on x-rays and imaging studies like round marbles and are referred to as a granuloma. If these scars do not show any evidence of calcium on x-ray, they can be difficult to distinguish from cancer.

Sometimes, however, the body's immune system becomes weakened, and the TB bacteria break through the scar tissue and can cause active disease, referred to as reactivation tuberculosis or secondary TB. For example, the immune system can be weakened by old age, the development of another infection or a cancer, or certain medications such as cortisone, anticancer drugs, or certain medications used to treat arthritis or inflammatory bowel disease. The breakthrough of bacteria can result in a recurrence of the pneumonia and a spread of TB to other locations in the body. The kidneys, bone, and lining of the brain and spinal cord (meninges) are the most common sites affected by the spread of TB beyond the lungs.

INCIDENCE

The incidence of tuberculosis of the lungs, the white plague that formerly affected millions of people, declined from the 1950s until 1984; sanatoriums were closed and routine screening was abandoned in the United States. Then, between 1984 and 1992, the incidence increased by 20 percent, chiefly because of immigration from countries where it is common and because of AIDS, which leaves people particularly vulnerable to the disease. Renewed efforts at control and advances in treatment have been rewarded with incidence declines each year, amounting to a total decline of 31 percent from 1992 to 1998.

Worldwide the outlook has been far less encouraging. In 1993 the World Health Organization declared TB a global health emergency. Approximately one third of the world's population is infected.

One of the most lethal among infectious diseases, TB is found throughout the world. It kills about 1.6 million people each year worldwide, which includes more than 1 million in Asia, 400,000 in Africa, and 100,000 in the Americas and Europe. The vast majority of new cases occur in sub-Saharan Africa. It is especially devastating in places such as Asia and Africa, where HIV and AIDS are widespread and have compromised the immune systems of so many people that the tuberculosis bacteria often meet with little or no resistance. Spread of TB is especially rapid in areas with poor public health services and crowded living conditions. In homeless shelters and prisons, crowded conditions and inadequate treatment often go together. Areas where living conditions are disrupted by wars, famine, and natural disasters also are heavily affected.

It is estimated that by the year 2020, there will be 200 million new cases of this disease, and 70 million people worldwide will die from it.

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CAUSE

The Mycobacterium tuberculosis bacteria that causes TB is usually spread by infected airborne droplets that are coughed up by individuals with the active disease and then inhaled by susceptible persons. Once inhaled, the bacteria normally lodge in the lungs. The body may successfully battle the infection at this point. If the immune system is not functioning optimally, however, or if another onslaught of the bacteria reaches the lungs, chances are the bacteria will multiply and proceed to liquefy and destroy lung tissue.

Overcrowded, poorly ventilated housing and overpopulated prisons are fertile breeding grounds for the spread of TB. Studies in India have confirmed that smoking contributes to half the deaths from TB in that country, perhaps by weakening the immune system.

Tuberculosis may also be contracted from contaminated food or from milk that has not been pasteurized. In such cases, the primary focus of the infection usually is in the digestive tract. This type of tuberculosis is more common in developing countries. It is rare in the Western world.

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SYMPTOMS

Symptoms of TB may be slow in developing and initially resemble those of influenza. These may include:

• General malaise.
• Coughing.
• Loss of appetite.
• Night sweats.
• Chest pain.
• Low-grade fever.

At first, the cough may be non-productive, but as the disease progresses, increasing amounts of sputum are produced. As the condition worsens, these symptoms may occur:

• Fever.
• Night sweats.
• Chronic fatigue.
• Weight loss.
• Chest pain.
• Shortness of breath may occur.
• Sputum may become bloody.

In advanced cases of TB, the larynx can be infected, making it impossible to speak above a whisper. Infection of other organs causes a wide range of symptoms. Symptoms will depend upon the organs involved.



DIAGNOSIS & TREATMENT

SEEING YOUR HEALTH CARE PROVIDER FOR DIAGNOSIS & TREATMENT

APPOINTMENT PREPARATION

If you suspect that you have tuberculosis or have been exposed to someone with TB, contact your family health care provider, a general practitioner or your state health department. You may be referred to an infectious disease or lung specialist (pulmonologist). You can help your health care provider by being prepared with as much information as possible. Here is some information to help you get ready for your appointment.

Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there is anything you need to do in advance. In particular, ask if you should wear a face mask to your appointment.

Write down any symptoms you are experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.

Write down key personal information, including your HIV status (if known), country of origin, any recent travel outside the United States, contact with people who may have tuberculosis, any past infection with TB, and any medical conditions or diseases you have.

Make a list of all medications, as well as any vitamins or supplements, that you are taking.

Take a family member or friend along, if possible. Sometimes it can be difficult to absorb all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.

Write down questions to ask your health care provider. Your time with your health care provider is limited, so preparing a list of questions ahead of time will help you make the most of your time together. For TB, some basic questions to ask your health care provider include:

• What kinds of tests do I need?
• What is the best course of action?
• How long will my treatment last?
• What can I do to stay on track with my treatment?
• I have these other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow, especially with respect to preventing the spread of infection?
• Should I see a specialist?
• What will that cost, and will my insurance cover it?
• Is there a generic alternative to the medicine you are prescribing me?
• Are there any brochures or other printed material that I can take with me?
• What Web sites do you recommend?
• Will I work with a nurse or other health care provider to oversee my treatment?
• What are the side effects of my treatment?

In addition to the questions that you have prepared to ask your health care provider, do not hesitate to ask questions during your appointment at any time that you do not understand something.

Your health care provider is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to spend more time on. Your practitioner may ask:

• When did you first begin experiencing symptoms?
• Have you been in contact with anyone who has TB?
• Were you born in another country, or have you traveled in another country?
• Have you ever had tuberculosis or a positive skin test in the past?
• What kind of work do you do?
• Do you use alcohol or recreational drugs?
• What is your typical diet?
• Do you have HIV infection or AIDS, cancer, diabetes or any other medical condition?

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DIAGNOSIS

If your health care provider suspects TB, you will need a complete medical evaluation and tests for TB infection.

A person with latent TB infection cannot spread germs to other people. You do not need to be tested if you have spent time with someone with latent TB infection. However, if you have spent time with someone with TB disease or someone with symptoms of TB, you should be tested.

People with TB disease are most likely to spread the germs to people they spend time with every day, such as family members or coworkers. If you have been around someone who has TB disease, you should go to your health care provider or your local health department for tests.



THE SKIN TEST OVERVIEW

Diagnosis is most commonly used diagnostic tool for TB is made by a tuberculin skin test. Several types of skin tests are used to screen for TB infection. These so-called tuberculin skin tests include the Tine test and the Mantoux test, also known as the PPD (purified protein derivative) test. The Mantoux test is preferred because it is more accurate.

In each of these tests, a small amount of purified extract from dead tuberculosis bacteria (called PPD tuberculin) is injected under the skin of your inside forearm. If you are being tested with the Mantoux test, this will be done using a syringe. You should feel only a slight needle prick. Within 48 to 72 hours, a health care professional will check your arm for swelling at the injection site, indicating a reaction to the injected material. A hard, raised red bump (induration) means you are likely to have TB infection. The size of the bump determines whether the test results are significant, based on your risk factors for TB. If a person is not infected with TB, then no reaction will occur at the site of the injection (a negative skin test).

The Mantoux test is not perfect. If the infection with tuberculosis has occurred recently, however, the skin test can be falsely negative. The reason for a false negative test with a recent infection is that it usually takes two to 10 weeks after the time of infection with tuberculosis before the skin test becomes positive. The skin test can also be falsely negative if a person's immune system is weakened or deficient due to another illness such as AIDS or cancer, or while taking medications that can suppress the immune response, such as cortisone or anticancer drugs. Some people who are infected with TB, including children, older people and people with AIDS, may have a delayed or no response to the Mantoux test.

WHAT IF MY TEST IS NEGATIVE? Having little or no reaction to the Mantoux test usually means that you are not infected with TB bacteria. But in some cases it is possible to have TB infection in spite of a negative test. Reasons for a false-negative test include: Recent TB infection. It can take eight to 10 weeks after you have been infected for your body to react to a skin test. If your health care provider suspects that you have been tested too soon, you may need to repeat the test in a few months. Severely weakened immune system. If your immune system is compromised by an illness, such as AIDS, or by corticosteroid or chemotherapy drugs, you may not respond to the Mantoux test, even though you are infected with TB. Diagnosing TB in HIV-positive people is further complicated because many symptoms of AIDS are similar to TB symptoms. Vaccination with a live virus. Vaccines that contain a live virus, such as the measles or smallpox vaccine, can interfere with a TB skin test. Overwhelming TB disease. If your body has been overwhelmed with TB bacteria, it may not be able to mount enough of a defense to respond to the skin test. Improper testing. Sometimes the PPD tuberculin may be injected too deeply below the surface of your skin. In that case, any reaction you have may not be visible. Be sure that you are tested by someone skilled in administering TB tests. It is harder to diagnose TB in children than in adults. Children may swallow sputum, rather than coughing it out, making it harder to take culture samples. And infants and young children may not react to the skin test. For these reasons, tests from an adult who is likely to have been the cause of the infection may be used to help diagnose TB in a child.

A false-positive test suggests that you have TB when you really do not. This is most likely to occur if you are infected with a different type of mycobacterium other than the one that causes tuberculosis, or if you have recently been vaccinated with the bacillus Calmette-Guerin (BCG) vaccine. This TB vaccine is seldom used in the United States, but widely used in countries with high TB infection rates.

Normally, for most people, if a person is infected with tuberculosis, a raised and reddened area will occur around the site of the test injection. This reaction, a positive skin test, occurs about 48 to 72 hours after the injection. This is why it is important to have the test read by your health care provider within this 48-72 hour window for the best test outcome.

Ideally, treatment begins after a skin test signals exposure but before active disease has developed.

A positive test for TB infection only tells that a person has been infected with TB germs. It does not tell whether or not the person has progressed to TB disease. Other tests, such as a chest x-ray and a sample of sputum, are needed to see whether the person has TB disease.

MANTOUX TEST (PURIFIED PROTEIN DERIVATIVE TEST [PPD])

Tuberculin is a glycerine extract of the tubercle bacilli. Purified protein derivative (PPD) tuberculin is a precipitate of non-species-specific molecules obtained from filtrates of sterilized, concentrated cultures. It was first described by Robert Koch in 1890. The test is named after Charles Mantoux, a French physician who developed on the work of Koch and Clemens von Pirquet to create his test in 1907. In 1939, M. A. Linnikova in the USSR created a modified version of PPD. In 1954, the Soviet Union started mass production of PPD-L, named after Linnikova.

The Mantoux skin test consists of an intradermal injection of exactly one tenth of a milliliter (mL) of PPD tuberculin. The size of induration is measured 48-72 hours later. Erythema (redness) should not be measured. The Mantoux test (also known as the Mantoux screening test, Tuberculin Sensitivity Test, Pirquet test, or PPD test for Purified Protein Derivative) is a diagnostic tool for tuberculosis. It is one of the two major tuberculin skin tests used in the world, largely replacing multiple-puncture tests such as the Tine test. Until 2005, the Heaf test was used in the United Kingdom, but the Mantoux test is now used. The Mantoux test is also used in Australia, Canada, Hungary, The Netherlands, Portugal, South Africa and the United States and is endorsed by the American Thoracic Society and Centers for Disease Control and Prevention (CDC). It was also used in the USSR and is now prevalent in most of the former Soviet states.

TEST PROCEDURE

A standard dose of 5 Tuberculin units (0.1 mL) (The standard Mantoux test in the UK consists of an intradermal injection of 2TU of Statens Serum Institute (SSI) tuberculin RT23 in 0.1ml solution for injection.) is injected intradermally (between the layers of dermis) and read 48 to 72 hours later. A person who has been exposed to the bacteria is expected to mount an immune response in the skin containing the bacterial proteins.

The reaction is read by measuring the diameter of induration (palpable raised hardened area) across the forearm (perpendicular to the long axis) in millimeters. If there is no induration, the result should be recorded as "0 mm". Erythema (redness) should not be measured.

If a person has had a history of a positive tuberculin skin test, another skin test is not needed.



TEST RESULTS & CLASSIFICATION OF TUBERCULIN REACTION

The results of this test must be interpreted carefully. The person's medical risk factors determine at which increment (5 mm, 10 mm, or 15 mm) of induration the result is considered positive. A positive result indicates TB exposure.

• 5 mm or more is positive in:
• HIV-positive person.
• Recent contacts of TB case.
• Persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB.
• Patients with organ transplants and other immunosuppressed patients.
• 10 mm or more is positive in:
• Recent arrivals (less than 5 years) from high-prevalence countries.
• Injection drug users.
• Residents and employees of high-risk congregate settings (e.g., prisons, nursing homes, hospitals, homeless shelters, etc.).
• Mycobacteriology lab personnel.
• Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight, etc).
• Children less than 4 years of age, or children and adolescents exposed to adults in high-risk categories.
• 15 mm or more is positive in:
• Persons with no known risk factors for TB.
• (Note: Targeted skin testing programs should only be conducted among high-risk groups).

A tuberculin test conversion is defined as an increase of 10 mm or more within a 2-year period, regardless of age.

FALSE POSITIVE RESULT

A false positive result may be caused by non-tuberculous mycobacteria or previous administration of BCG vaccine. Prior vaccination with BCG may result in a false-positive result for many years afterwards.

BCG VACCINE & THE MANTOUX TEST

BCG is a vaccine for TB disease. BCG is used in many countries, but it is not generally recommended in the United States. BCG vaccination does not completely prevent people from getting TB. It may also cause a false positive tuberculin skin test. However, persons who have been vaccinated with BCG can be given a tuberculin skin test or special TB blood test.

There is disagreement about the role of Mantoux testing in people who have been vaccinated. The US recommendation is that tuberculin skin testing is not contraindicated for BCG-vaccinated persons and that prior BCG vaccination should not influence the interpretation of the test. The UK recommendation is that interferon-gamma testing should be used to help interpret positive Mantoux tests, and that serial tuberculin skin testing must not be done in people who have had prior BCG vaccination. In general, the US recommendation results in a much larger number of people being falsely diagnosed with latent tuberculosis, while the UK approach probably misses patients with latent tuberculosis who should be treated.

According to the U. S. guidelines, latent TB infection (LTBI) diagnosis and treatment for LTBI is considered for any BCG-vaccinated person whose skin test is 10 mm or greater, if any of these circumstances are present:

• Was in contact with another person with infectious TB.
• Was born or has lived in a high TB prevalence country.
• Is continually exposed to populations where TB prevalence is high.

ANERGY TESTING

In cases of anergy, a lack of reaction by the body's defence mechanisms when it comes into contact with foreign substances, the tuberculin reaction will occur weakly, thus compromising the value of Mantoux testing. For example, anergy is present in AIDS, a disease which strongly depresses the immune system. Therefore, anergy testing is advised in cases where suspicion is warranted that it is present. However, routine anergy skin testing is not recommended.

TWO-STEP TESTING

Some people who were previously infected with TB may have a negative reaction when tested years after infection, as the immune system response may gradually wane. This initial skin test, though negative, may stimulate (boost) the body's ability to react to tuberculin in future tests. Thus, a positive reaction to a subsequent test may be misinterpreted as a new infection, when in fact it is the result of the boosted reaction to an old infection.

Use two-step testing for initial skin testing of adults who will be retested periodically (e.g., health care workers). This ensures that any future positive tests can be interpreted as being caused by a new infection, rather than simply a reaction to an old infection.

• Return to have first test read 48-72 hours after injection.
• If first test is positive, consider the person infected.
• If first test is negative, give second test 1-3 weeks after first injection.
• Return to have second test read 48-72 hours after injection.
• If second test is positive, consider person previously infected.
• If second test is negative, consider person uninfected.

A person who is diagnosed as "infected" on two-step testing is called a "tuberculin converter". The US recommendation that prior BCG-vaccination be ignored results in almost universal false diagnosis of tuberculosis infection in people who have had BCG (mostly foreign nationals). Please refer to the chapter on BCG for a discussion of boosting. The UK guidelines avoid this error.

HEAF TEST

The Heaf test is a tuberculin skin test formerly used in the United Kingdom, but discontinued in 2005. The equivalent Mantoux test positive levels done with 10 TU (0.1 mL 100 TU/mL, 1:1000) are

• Less than 5 mm induration (Heaf 0-1)
• 5-15 mm induration (Heaf 2)
• Greater than 15 mm induration (Heaf 3-4)

OTHER TEST DEVELOPMENTS

As a replacement for the Mantoux test, several other tests are being developed. QuantiFERON-TB Gold is a blood test that measures the patient's immune reactivity to the TB bacteria and is useful for initial and serial testing of persons with an increased risk of latent or active tuberculosis infection. Guidelines for the use of QuantiFERON-TB Gold were released by the CDC in December 2005. QuantiFERON-TB Gold is FDA approved in the United States, has CE Mark approval in Europe and has been approved by the MHLW in Japan.

Tuberculin tests have the disadvantage in that they may produce false negatives, especially when the patient is co-morbid with sarcoidosis, Hodgkin's lymphoma, malnutrition, or most notably active tuberculosis disease. New TB tests are being developed that offer the hope of cheap, fast and more accurate TB testing. These include polymerase chain reaction detection of bacterial DNA, and assays to detect the release of interferon gamma in response to mycobacterial proteins such as ESAT-6. These are not affected by immunization or environmental mycobacteria, so generate fewer false positive results. The development of a rapid and inexpensive diagnostic test would be particularly valuable in the developing world.

BLOOD TESTS

Blood tests may be used to confirm or rule out latent or active TB. These tests use sophisticated technology to measure the immune system's reaction to Mycobacterium tuberculosis. These tests are quicker and more accurate than is the traditional skin test. They may be useful if you are at high risk of TB infection but have a negative response to the Mantoux test, or if you received the BCG vaccine.

BLOOD TEST BETTER THAN SKIN TESTING AT DETECTING TB Tuesday, 21 October 2008 Science Online, 15 July 2008 ABC/Reuters Article Ancient bones may hold clues to TB. TB may be among oldest human diseases New TB blood test A new blood test will allow health care providers to more accurately pinpoint patients likely to develop the symptoms of tuberculosis, say researchers. Traditional testing for the disease involves injecting the subject with components of the tuberculosis (TB) bacterium; a resultant swelling of the skin can signal its presence. Such skin tests are prone to false positives - people wrongly identified as needing treatment - and, conversely, can sometimes wrongly show TB carriers to be free of the infection. Professor Ajit Lalvani, a researcher at Imperial College London, says the new blood test, known as enzyme-linked immunospot, or ELISpot, is one and a half times better at spotting tuberculosis carriers. "On a global level, when you stack up those numbers, that is going to make a huge difference," says Lalvani, whose findings are published in the Annals of Internal Medicine. TB is caused by a bacterium which attacks the lungs, but can also cause inflammation in other body parts, including the lymph nodes. Around a third of the world's population is infected with TB and approximately 9 million new cases of active TB are diagnosed around the world each year, according to World Health Organization estimates. The majority of those infected live in the developing world. Patients with active TB experience symptoms such as fever, persistent cough, and loss of appetite, whereas patients with the dormant, 'latent' form of TB do not. Treatment can prevent many patients with latent TB from progressing to active TB. The emergence and spread of drug-resistant germs makes treating tuberculosis more difficult and could make the disease even deadlier in the future. RESEARCH STUDY Lalvani and colleagues examined 908 healthy children in Turkey exposed to tuberculosis in their homes. The skin test indicated that 580 children had the latent form of TB and required drugs to prevent it transforming into the active form. The blood test found only 380 had latent TB. After treatment 12 children developed active TB, of which 11 were identified by the blood test. "By using the blood test you only need to treat 380 children instead of 550 children to prevent the same number of active cases," says Lalvani. "We now know that the blood test really helps to target treatment to those who most need it in order to prevent them from developing active TB." He says the next step is to make the test more accurate and establish its use in the developing world.

FURTHER TB TESTING

If the results of a TB test are positive (referred to as "significant"), you may have further tests to help determine whether you have active TB disease and whether it is a drug-resistant strain.

RADIOLOGY DIAGNOSTICS

TB can be confirmed by radiology (commonly X-rays of the chest or CT scan). If you have had a positive skin test, your health care provider is likely to order a chest X-ray. Sometimes, the chest x-rays can reveal evidence of active tuberculosis pneumonia. Other times, the x-rays may show scarring (fibrosis) or hardening (calcification) in the lungs, suggesting that the TB is contained and inactive.

In some cases, this may show white spots in your lungs where your immune system has walled off TB bacteria. In others, it may reveal a nodule or cavities in your lungs caused by active TB. A computerized tomography (CT) scan, which uses cross-sectional X-ray images, may show more subtle signs of disease.

MICROSCOPIC EXAMINATION

If your chest X-ray shows signs of TB, your health care provider may take a sample of your stomach secretions or sputum - the mucus that comes up when you cough. The samples are tested for TB bacteria, your health care provider can have the results of special smears in a matter of hours.

Samples may be sent to a laboratory where they will be examined under a microscope. Examination of the sputum on a slide (smear) under the microscope can show the presence of the tuberculosis-like bacteria. Bacteria of the mycobacterium family, including atypical mycobacteria, stain positive with special dyes and are referred to as acid-fast bacteria (AFB).

CULTURE TESTING

Microbiological culture of bodily fluids and sputum is usually taken, placed on a special medium that encourages the growth of bacteria (culture). The samples are grown (cultured) in special incubators so that the tuberculosis bacteria can subsequently be identified as tuberculosis or atypical tuberculosis. The bacteria that appear are then tested to see if they respond to the medications commonly used to treat TB. Your health care provider uses the results of the culture tests to prescribe the most effective medications for you. The main problem with traditional culture tests for tuberculosis diagnosis is the difficulty in culturing this slow-growing organism in the laboratory (it may take 4 to 12 weeks for blood or sputum culture).

DIAGNOSIS BY PCR

A special test to diagnose TB called the PCR (polymerase chain reaction) detects the genetic material of the bacteria. This test is extremely sensitive (it detects minute amounts of the bacteria) and specific (it detects only the TB bacteria). One can usually get results from the PCR test within a few days.

NUCLEAR ACID AMPLIFICATION

Testing called nuclear acid amplification (NAA) can detect genes associated with drug resistance in Mycobacterium tuberculosis. This test is generally available only in developed countries.

MODS ASSAY

A test used primarily in developing countries is called the microscopic-observation drug-susceptibility (MODS) assay. It can detect the presence of TB bacteria in sputum in as little as seven days. Additionally, the test can identify drug-resistant strains of the TB bacteria.

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CONVENTIONAL MEDICAL TREATMENT

Antibiotic regimens that could successfully combat the disease have been developed, and living standards have risen so that the poor nutrition and inadequate hygienic standards that had once helped TB to spread and flourish are less prevalent in the United States.

Medications are the cornerstone of tuberculosis treatment. But treating TB takes much longer than treating other types of bacterial infections. Normally, you take antibiotics for at least six to nine months to destroy the TB bacteria. The exact drugs and length of treatment depend on your age, overall health, possible drug resistance, the form of TB (latent or active) and its location in the body. Several promising new TB drugs are in development, and some may become available within the next 10 years.

TREATING LATENT TB

If tests show that you have TB infection but not active disease, your health care provider may recommend preventive drug therapy to destroy bacteria that might become active in the future. You are likely to receive a daily or twice-a-week dose of the TB medication isoniazid. For treatment to be effective, you usually take isoniazid for nine months. Long-term use of isoniazid can cause side effects, including the life-threatening liver disease hepatitis. For this reason, your health care provider will monitor you closely while you're taking isoniazid. During treatment, avoid using acetaminophen (Tylenol, others) and avoid or limit alcohol use. Both increase your risk of liver damage.

TREATING ACTIVE TB

If you are diagnosed with active TB, you are likely to begin taking four medications - isoniazid, rifampin (Rifadin), ethambutol (Myambutol) and pyrazinamide. This regimen may change if tests later show some of these drugs to be ineffective. Even so, you will continue to take several medications. Depending on the severity of your disease and whether the bacteria are drug-resistant, one or two of the four drugs may be stopped after a few months. You may be hospitalized for the first two weeks of therapy or until tests show that you are no longer contagious.

Sometimes the drugs may be combined in a single tablet such as Rifater, which contains isoniazid, rifampin and pyrazinamide. This makes your treatment less complicated while ensuring that you get all the drugs needed to completely destroy TB bacteria. Another drug that may make treatment easier is rifapentine (Priftin), which is taken just once a week during the last four months of therapy, in combination with other drugs.

MEDICATION SIDE EFFECTS

Side effects of TB drugs are not common, but can be serious when they do occur. All TB medications can be highly toxic to your liver. Rifampin can also cause severe flu-like signs and symptoms - fever, chills, muscle pain, nausea and vomiting. When taking these medications, call your health care provider immediately if you experience any of the following:

• Nausea or vomiting.
• Loss of appetite.
• A yellow color to your skin (jaundice).
• Dark urine.
• A fever that lasts three or more days and has no obvious cause.
• Tenderness or soreness in your abdomen.
• Blurred vision or color-blindness.

DRUG RESISTANT TB

In spite of the fact that multi-drug-resistant strains of TB exist (if a strain of TB is resistant to both of the drugs most often widely prescribed for TB, it is considered multi-drug-resistant, while extreme drug resistant strains are also resistant to three or classes of the more toxic second-line drugs), rates of TB have declined. For the United States, since 1995 incidence has decline from 53 per 100,000 population to 5.1 per 100,000 in 2003. Just over 14,800 cases of the disease were reported to the CDC in 2003.

There are two types of drug-resistant TB:

• Multidrug-resistant TB (MDR TB). This form of TB cannot be killed by the two most powerful antibiotics for TB, isoniazid and rifampin. Although MDR TB can be successfully treated, it's much harder to combat than is regular TB and requires long-term therapy - up to two years - with drugs that are very expensive and can cause serious side effects. People with untreated MDR TB can transmit this serious type of TB to others.



• Extensively drug-resistant TB (XDR TB). XDR TB is a less common form of MDR TB in which the bacteria resist isoniazid and rifampin as well as most of the alternative or second line drugs used to treat TB. XDR TB has shown up across the world, including 49 cases in the United States between 1993 and 2006. Treatment for XDR TB is challenging and lengthy and leads to serious side effects and a higher rate of failure. Recently, the first cases of completely drug-resistant TB were reported - the bacteria could not be killed by any available TB drug.

But the global epidemic of tuberculosis, together with the migration of people from one country to another, probably means that unless aggressive action is take to eradicate TB everywhere in the world, the United States will again see an upsurge of this disease in coming decades. Some believe that unless major new treatment strategies are initiated in source countries, drug-resistant TB will eventually become epidemic even in areas with good control programs, such as Europe and America.

TREATING DRUG-RESISTANT TB

Multidrug-resistant TB (MDR TB) cannot be cured by the two major TB drugs, isoniazid and rifampin. Extensive drug-resistant TB (XDR TB) is resistant to those drugs as well as three or more of the second line TB drugs. Treating these resistant forms of TB is far more costly than is treating non-resistant TB. Treatment of drug-resistant TB requires taking a "cocktail" of at least four drugs, including first line medications that are still effective and several second line medications, for 18 months to two years or longer. Even with treatment, many people with these types of TB may not survive. If treatment is successful, you may need surgery to remove areas of persistent infection or repair lung damage.

TREATING TB IN PEOPLE WITH HIV/AIDS

HIV-positive people are especially likely to develop active TB, and drug-resistant forms of the disease are especially dangerous for them. The most powerful AIDS drugs (antiretroviral therapy) interact with rifampin and other drugs used to treat TB, reducing the effectiveness of both types of medications.

To avoid interactions, people living with both HIV and TB may stop taking antiretroviral therapy while they complete a short course of TB therapy that includes rifampin. Or they may be treated with a TB regimen in which rifampin is replaced with another drug that is less likely to interfere with AIDS medications. In such cases, health care providers carefully monitor the response to therapy, and the duration and type of regimen may change over time.

TREATING CHILDREN & PREGNANT WOMEN

Treating TB in children is largely the same as treating adults, except that ethambutol is not used for young children because of the possible side effect of vision problems. Instead of ethambutol, children may take streptomycin.

For pregnant women with active TB, initial treatment often involves three drugs - isoniazid, rifampin and ethambutol. Pyrazinamide is not recommended because its effect on the unborn baby is not known. Some second line TB medications also are not recommended.

COMPLETING TREATMENT IS ESSENTIAL

After a few weeks, you will not be contagious and you may start to feel better. It might be tempting to stop taking your TB drugs. But it is crucial that you finish the full course of therapy and take the medications exactly as prescribed by your health care provider. Stopping treatment too soon or skipping doses can allow the bacteria that are still alive to become resistant to those drugs, leading to TB that is much more dangerous and difficult to treat. Drug-resistant strains of TB can quickly become fatal, especially if your immune system is impaired.

In an effort to help people stick with their treatment, a program called directly observed therapy (DOT) is recommended. In this approach, a nurse or other health care professional administers your medication so that you do not have to remember to take it on your own. Sometimes clinics provide incentives, such as food coupons or transportation, for people to show up for their appointments.

DRUGS USED IN TB DRUG THERAPY Tuberculosis treatment is difficult and requires long courses of multiple antibiotics. Contacts are also screened and treated if necessary. The treatment of choice for prevention and for active cases is the antimicrobial drug isoniazid (INH), available since 1956. In infected individuals it is usually used in combination with other anti-tuberculosis drugs such as rifampin, pyrazinamide, and ethambutol. Tuberculosis drugs have to be taken regularly, typically for 6 to 12 months. A person with a positive skin test, a normal chest x-ray, and no symptoms most likely has only a few TB germs in an inactive state and is not contagious. Nevertheless, treatment with an antibiotic may be recommended for this person to prevent the TB from turning into an active infection. The antibiotic used for this purpose is called isoniazid (INH). If taken for six to 12 months, it will prevent the TB from becoming active in the future. In fact, if a person with a positive skin test does not take INH, there is a 5-10 percent lifelong risk that the TB will become active. A person with a positive skin test along with an abnormal chest x-ray and sputum evidencing TB bacteria has active TB and is contagious. As already mentioned, active TB usually is accompanied by symptoms, such as a cough, fever, weight loss, and fatigue. Active TB is treated with a combination of medications along with isoniazid. Rifampin (Rifadin), ethambutol (Myambutol), and pyrazinamide are the drugs commonly used to treat active TB in conjunction with isoniazid (INH). Four drugs are often taken for the first two months of therapy to help kill any potentially resistant strains of bacteria. Then the number is usually reduced to two drugs for the remainder of the treatment based on drug sensitivity testing that is usually available by this time in the course. Streptomycin, a drug that is given by injection, may be used as well, particularly when the disease is extensive and/or the patients do not take their oral medications reliably (termed "poor compliance"). Treatment usually lasts for many months and sometimes for years. Successful treatment of TB is dependent largely on the compliance of the patient. Indeed, the failure of a patient to take the medications is the most important cause of failure to cure the TB infection. In some locations, the health department demands direct monitoring of patient compliance with therapy. Taking isoniazid can be inadvisable (contraindicated) during pregnancy or for those suffering from alcoholism or liver disease. Also, isoniazid can have side effects. The side effects occur infrequently, but a rash can develop, and the patient can feel tired or irritable. Liver damage from isoniazid is a rare occurrence and typically reverses once the drug is stopped. Very rarely, however, especially in older people, the liver damage (INH hepatitis) can even be fatal. It is important therefore, for the health care provider to monitor a patient's liver by periodically ordering blood tests called "liver function tests" during the course of INH therapy. Another side effect of INH is a decreased sensation in the extremities referred to as a peripheral neuropathy. This can be avoided by taking vitamin B-6 (pyridoxine), and this is often prescribed along with INH.

GENERIC NAME: ISONIAZID (INH) Isoniazid is an antibacterial available as 100 mg or 300 mg tablets for oral administration. Isoniazid is chemically known as isonicotinyl hydrazine or isonicotinic acid hydrazide. Isoniazid is odorless, and occurs as a colorless or white crystalline powder or as white crystals. It is freely soluble in water, sparingly soluble in alcohol, and slightly soluble in chloroform and in ether. Isoniazid is slowly affected by exposure to air and light. Inactive Ingredients: Anhydrous lactose, microcrystalline cellulose and stearic acid. BRAND NAME(S): Laniazid, Tubizid, Nydrazid (Please Note: This brand name drug is no longer available in the US.) BRAND NAME(S) OF COMBINATION PRODUCTS: Rifamate (Containing Isoniazid & Rifampin) Rifater (Containing Isoniazid, Pyrazinamide, & Rifampin) IMPORTANT WARNING: Isoniazid may cause severe and sometimes fatal liver damage. Severe and sometimes fatal hepatitis associated with isoniazid therapy has been reported and may occur or may develop even after many months of treatment. The risk of developing hepatitis is age related. Approximate case rates by age are: less than 1 per 1, 000 for persons under 20 years of age, 3 per 1,000 for persons in the 20-34 year age group, 12 per 1,000 for persons in the 35 -49 year age group, 23 per 1,000 for persons in the 50-64 year age group, and 8 per 1,000 for persons over 65 years of age The risk of hepatitis is increased with daily consumption of alcohol. Precise data to provide a fatality rate for isoniazid related hepatitis is not available; however, in a U. S. Public Health Service Surveillance Study involving 13,838 persons taking isoniazid, there were 8 deaths among 174 cases of hepatitis. Therefore, patients given isoniazid should be carefully monitored and interviewed at monthly intervals. For persons 35 and older, in addition to monthly symptom reviews, hepatic enzymes (specifically, AST and ALT (formerly SGOT and SGPT, respectively)) should be measured prior to starting isoniazid therapy and periodically throughout treatment. Isoniazid-associated hepatitis usually occurs during the first three months of treatment. Usually, enzyme levels return to normal despite continuance of drug, but in some cases progressive liver dysfunction occurs. Other factors associated with an increased risk of hepatitis include daily use of alcohol, chronic liver disease and injection drug use. A recent report suggests an increased risk of fatal hepatitis associated with isoniazid among women, particularly black and Hispanic women. The risk may also be increased during the postpardum period. More careful monitoring should be considered in these groups, possibly including more frequent laboratory monitoring. If abnormalities of liver function exceed three to five times the upper limit of normal, discontinuation of isoniazid should be strongly considered. Liver function tests are not a substitute for a clinical evaluation at monthly intervals or for the prompt assessment of signs or symptoms of adverse reactions occurring between regularly scheduled evaluations Patients should be instructed to immediately report signs or symptoms consistent with liver damage or other adverse effects. These include any of the following: unexplained anorexia or loss of appetite, nausea (upset stomach), vomiting, dark yellow or brown urine, icterus (yellowing of skin and eyes), rash persistent paresthesias of the hands and feet, persistent fatigue or excessive tiredness, lack of energy, weakness or fever of greater than 3 days duration and/or abdominal tenderness, especially right upper quadrant discomfort. If these symptoms appear or if signs suggestive of hepatic damage are detected, isoniazid should be discontinued promptly, since continued use of the drug in these cases has been reported to cause a more severe form of liver damage. Patients with tuberculosis who have hepatitis attributed to isoniazid should be given appropriate treatment with alternative drugs. If isoniazid must be re-instituted, it should be re-instituted only after symptoms and laboratory abnormalities have cleared. The drug should be restarted in very small and gradually increasing doses and should be withdrawn immediately if there is any indication of recurrent liver involvement Preventive treatment should be deferred in persons with acute hepatic diseases. USES: Isoniazid is used alone or with other drugs to treat tuberculosis (TB) and to prevent it in people who have had contact with tuberculosis bacteria. It eliminates only active (growing) bacteria. Since the bacteria may exist in a resting (non-growing) state for long periods, therapy with isoniazid (and other anti-tuberculosis drugs) must be continued for a long time (usually 6-12 months). This medication is sometimes prescribed for other uses; ask your health care provider or pharmacist for more information. HOW TO USE: Isoniazid comes as a tablet and a syrup to take by mouth. It usually is taken once a day, on an empty stomach, 1 hour before or 2 hours after meals. However, if isoniazid causes an upset stomach, it may be taken with food. Follow the directions on your prescription label carefully, and ask your health care provider or pharmacist to explain any part you do not understand. Take isoniazid exactly as directed. Do not take more or less of it or take it more often than prescribed by your health care provider. SIDE EFFECTS: Isoniazid may cause side effects. Tell your health care provider if any of these symptoms are severe or do not go away: Diarrhea. Vision problems. If you experience any of the following symptoms or those listed in the IMPORTANT WARNING section, call your health care provider immediately: Eye pain. Numbness or tingling in the hands and feet. Skin rash. Fever. Swollen glands. Sore throat. Unusual bleeding or bruising. Stomach pains or tenderness. If you experience a serious side effect, you or your health care provider may send a report to the Food and Drug Administration's (FDA) MedWatch Adverse Event Reporting program online [at Medwatch] or by phone [1-800-332-1088]. PRECAUTIONS: Before taking isoniazid, tell your health care provider and pharmacist if you are allergic to isoniazid or any other drugs. Tell your health care provider and pharmacist what prescription and non-prescription medications you are taking, especially acetaminophen (Tylenol), antacids, carbamazepine (Tegretol), disulfiram (Antabuse), ketoconazole (Nizoral), phenytoin (Dilantin), theophylline (Theobid, Theo-Dur), valproic acid (Depakene, Depakote), and vitamins. In addition to the conditions listed in the IMPORTANT WARNING section, tell your health care provider if you have or have ever had kidney disease; diabetes; tingling, burning, and pain in the fingers or toes (peripheral neuropathy); or human immunodeficiency virus (HIV). Tell your health care provider if you are pregnant or plan to become pregnant. If you become pregnant while taking isoniazid, call your health care provider. Be aware that you should not drink alcoholic beverages while taking this drug. OVERDOSE: In case of overdose or if overdose is suspected, call your local poison control center at 1-800-222-1222. If the victim has collapsed or is not breathing, call local emergency services at 9-1-1 and immediately transport to the nearest emergency room. Canadian residents should call their local poison control center directly. NOTES: If you have diabetes, do not use Clinitest to test your urine for sugar because isoniazid can cause false results in this test. Do not let anyone else take your medication. Ask your pharmacist any questions you have about refilling your prescription. It is important for you to keep a written list of all of the prescription and non-prescription (over-the-counter) medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. You should bring this list with you each time you visit a health care provider or if you are admitted to a hospital. It is also important information to carry with you in case of emergencies. Laboratory tests will be done frequently to monitor the effectiveness of this medication and to prevent side effects. Unless your health care provider tells you otherwise, continue your normal diet. MISSED DOSE: Take the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one. STORAGE: Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (not in the bathroom). Throw away any medication that is outdated or no longer needed. Talk to your pharmacist about the proper disposal of your medication.

GENERIC NAME: RIFAMPIN - INJECTION BRAND NAME(S): Rifadin, Rimactane USES: This medication is used in the treatment of tuberculosis or other infections when the oral form cannot be taken. Use of only rifampin and pyrazinamide as a two-drug, two-month therapy to treat tuberculosis (specifically "latent" TB infection) is no longer recommended. Infrequently, serious (sometimes fatal) liver disease has occurred with the use of these two drugs alone. Several other effective alternative treatments can be used to treat latent tuberculosis (e.g., isoniazid for 9 months). Use of rifampin and pyrazinamide as part of a multi-drug (3 or more drugs) treatment plan for tuberculosis is still acceptable. Consult your health care provider or pharmacist for more details. HOW TO USE: This medication is given by injection into a vein usually once or twice a day. Avoid injecting intramuscularly or subcutaneously. Inject into a vein only. Do not stop taking this medication without your health care provider's approval. Stopping therapy too soon may result in ineffective treatment. Full course of therapy may take several months or longer to complete. SIDE EFFECTS: Sore mouth, drowsiness, dizziness or flushing may occur the first several days as your body adjusts to the medication. If any of these effects continue or become bothersome, inform your health care provider. Tell your health care provider immediately if any of these unlikely but serious side effects occur: weakness, unusual bruising or bleeding, flu-like symptoms (fever, chills, headache, muscle ache), nausea, vomiting, stomach pain, dark urine, yellowing of the eyes or skin, pale stools, numbness or tingling of the hands or feet, changes in vision, confusion, memory trouble, sore throat. This medication may cause urine, saliva, tears, stools and sweat to turn red-orange in color. Do not be alarmed. This will disappear when the medication is stopped. Notify your health care provider if the injection site becomes swollen or irritated. Another injection site may be necessary. In the unlikely event you have an allergic reaction to this drug, seek immediate medical attention. Symptoms of an allergic reaction include: rash, itching, swelling, dizziness, trouble breathing. If you notice other effects not listed above, contact your health care provider or pharmacist. PRECAUTIONS: Tell your health care provider if you have: liver disease, blood disorders, history of alcohol use, any allergies. Alcohol can reduce the effectiveness of this medication and increase side effects. Limit alcohol consumption while taking this medication. Use caution operating machinery or participating in activities requiring alertness if this medication makes you feel drowsy or dizzy. Soft contact lenses may be permanently discolored by this medication. This medication should be used only if clearly needed during pregnancy or while breast-feeding. Discuss the risks and benefits with your health care provider. DRUG INTERACTIONS: This drug is not recommended for use with: delavirdine. Ask your health care provider or pharmacist for more details. Inform your health care provider about all the medicines you may use (both prescription and non-prescription), especially of: warfarin, oral medicines for diabetes, azole antifungals (e.g., itraconazole, ketoconazole), theophylline, halothane, verapamil, certain protease inhibitors (e.g., nelfinavir), live vaccines, corticosteroids (e.g., prednisone), disopyramide, beta-blockers (e.g., metoprolol), isoniazid, digitoxin, quinidine, mexiletine, phenytoin, cyclosporine, zidovudine. Rifampin can decrease the effectiveness of oral contraceptives. Discuss the use of other birth control methods with your health care provider. Also report drugs which cause drowsiness such as sedatives, tranquilizers, psychiatric medicines, anti-seizure or anti-anxiety drugs, narcotic pain relievers and certain antihistamines (e.g., diphenhydramine). Do not start or stop any medicine without health care provider or pharmacist approval. OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US national poison hotline at 1-800-222-1222. Canadian residents should call their local poison control center directly. Symptoms of overdose may include swelling of face or around eyes, itching over the entire body, orange or red discoloration of skin or eyes, nausea, vomiting, drowsiness, and loss of consciousness. NOTES: Laboratory tests will be done frequently to monitor the effectiveness of this medication and to prevent side effects. MISSED DOSE: Try to use each dose at the scheduled time. If you miss a dose, use it as soon as remembered; do not use it if it is near the time for the next dose, instead, skip the missed dose and resume your usual dosing schedule. Do not "double-up" the dose to catch up. STORAGE: The undiluted vials of this medication may be stored at room temperature as directed. If diluted in 10 ml, use within 24 hours. If diluted in 100 ml or 500 ml use within 4 hours. Check the expiration date on the label and properly discard of any unused medication after that date.

GENERIC NAME: ETHAMBUTOL - ORAL BRAND NAME(S): Myambutol USES: Ethambutol is used to treat tuberculosis, often in combination with other medications. Tuberculosis is a very serious infection and requires a combination of antibiotics to cure the infection. OTHER USES: This medication may also be used to treat an infection known as "MAC" (Mycobacterium avium complex). HOW TO USE: This works best when taken with food or milk to prevent stomach upset. Take as directed. Do not stop taking this medication without your health care provider's approval. Stopping therapy too early may result in ineffective treatment. Treatment usually lasts for several months. SIDE EFFECTS: May cause stomach upset, dizziness, fatigue, or headache. These effects should disappear as your body adjusts to the medication. If they persist or worsen, notify your doctor promptly. Notify your health care provider immediately if you develop: skin rash, numbness or tingling of the hands or feet. Infrequently, eye problems can occur (optic neuritis). Tell your health care provider immediately if you have any vision changes, sudden color blindness, or blurred vision. Very rarely, permanent blindness has occurred. Rare (possibly fatal) liver disease may occur. Tell your health care provider immediately if you have persistent, severe nausea, vomiting, dark urine, stomach/abdominal pain, yellowing eyes/skin. If you notice other effects not listed above, contact your health care provider or pharmacist. PRECAUTIONS: Tell your health care provider your medical history, especially of: gout, kidney disease, vision problems such as cataracts. This medication should be used only when clearly needed during pregnancy. There have been reports of eye problems in infants born to mothers using ethambutol. Discuss the risks and benefits with your health care provider. Ethambutol passes into breast milk. Though, to date, no problems have been noted in nursing infants, consult your health care provider before you breast-feed. DRUG INTERACTIONS: Tell your health care provider of all prescription and non-prescription drugs you may use, especially: antacids. Antacids may decrease the absorption of this drug. Therefore, space antacid doses several hours apart from ethambutol doses. Do not start or stop any medicine without health care provider or pharmacist approval. OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US national poison hotline at 1-800-222-1222. Canadian residents should call their local poison control center directly. NOTES: Do not share this medication with others. Laboratory/medical tests (e.g., eye exams, liver function) should be performed periodically to monitor for drug side effects. Tell your eye practitioner you are taking this medication. MISSED DOSE: If you miss a dose, take as soon as remembered; do not take if it is almost time for the next dose, instead, skip the missed dose and resume your usual dosing schedule. Do not "double-up" the dose to catch up. STORAGE: Store at room temperature between 59-86°F (between 15-30°C) away from moisture and sunlight. Do not store in the bathroom.

GENERIC NAME: PYRAZINAMIDE - ORAL USES: This medication is used in the treatment of tuberculosis. It is often used in combination with other anti-tuberculosis medications. Use of only rifampin and pyrazinamide as a two-drug, two-month therapy to treat tuberculosis (specifically "latent" TB infection) is no longer recommended. Infrequently, serious (sometimes fatal) liver disease has occurred with the use of these two drugs alone. Several other effective alternative treatments can be used to treat latent tuberculosis (e.g., isoniazid for 9 months). Use of rifampin and pyrazinamide as part of a multi-drug (3 or more drugs) treatment plan for tuberculosis is still acceptable. Consult your health care provider or pharmacist for more details. HOW TO USE: Take this medication as prescribed. To be most effective, be sure to take each dose on time. Try not to miss any doses. Do not increase your dose or take this more often than directed. It is important to continue taking this for the full time prescribed. Sometimes it is necessary to take this for 2 months or longer to be sure the infection is completely cleared. This medication is usually given once a day, but may be divided into 3 or 4 doses if needed. In some cases, this medication is given only twice a week. Talk to your health care provider about this alternative dosing schedule. SIDE EFFECTS: Stomach upset, muscle aches or acne may occur the first several days as your body adjusts to the medication. If any of these effects continue or become bothersome, inform your health care provider. Tell your health care provider immediately if any of these unlikely but serious side effects occur: fever, nausea, vomiting, stomach pain, dark urine, yellowing eyes or skin, weakness, pain or swelling of the joints. If you notice other effects not listed above, contact your health care provider or pharmacist. PRECAUTIONS: Tell your health care provider if you have: kidney problems, liver disease, gout, diabetes, allergies (especially drug allergies). This medication should be used only if clearly needed during pregnancy. Discuss the risks and benefits with your health care provider. Since small amounts of this medication are found in breast milk, consult your health care provider before breast-feeding. DRUG INTERACTIONS: Tell your health care provider of any over-the-counter or prescription medication you may take. Limit your intake of alcoholic beverages while taking this medication since the risk of side effects may be increased. Do not start or stop any medicine without health care provider or pharmacist approval. OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US national poison hotline at 1-800-222-1222. Canadian residents should call their local poison control center directly. NOTES: Laboratory tests will be done periodically while taking this medication to monitor its effectiveness and to prevent side effects. MISSED DOSE: If you miss a dose, take it as soon as remembered; do not take it if it is near the time for the next dose, instead, skip the missed dose and resume your usual dosing schedule. Do not "double-up" the dose to catch up. STORAGE: Store at room temperature between 59-86°F (15-30°C) away from heat and light. Do not store in the bathroom.

Many patients abandon their treatment when they feel better; similarly, preventive treatment is often abandoned because of the inconvenience. Such non-compliance is believed to be the main reason for the upsurge in drug-resistant strains of the TB bacilli, many of which are resistant to more than one drug. Drug-resistant TB is difficult to treat and has a much higher death rate; extreme drug resistant TB is especially worrisome because it can be essentially untreatable. The combination drug rifater (rifampin, isoniazid, and pyrazinamide) has simplified drug administration. Directly observed treatment, where health-care workers watch patients take each dose of medicine, has proved effective in eliminating the problem of non-compliance in the United States, but monitoring has been less effective in many other parts of the world.

SURGERY

Surgery on the lungs may be indicated to help cure TB when medication has failed, but in this day and age, surgery for TB is unusual. Treatment with appropriate antibiotics will usually cure the TB. Without treatment, however, tuberculosis can be a lethal infection. Therefore, early diagnosis is important. Those individuals who have been exposed to a person with TB, or suspect that they have been, should be examined by a health care provider for signs of TB and screened with a TB skin test.

PREVENTION

In general, TB is preventable. From a public health standpoint, the best way to control TB is to diagnose and treat people with TB infection before they develop active disease and to take careful precautions with people hospitalized with TB. But there also are measures you can take on your own to help protect yourself and others:

The best defense against tuberculosis is a strong, healthy immune system and a healthy diet. Eat plenty of healthy foods including fruits and vegetables, get enough sleep, and exercise at least 30 minutes a day most days of the week to keep your immune system in top form.

Preventive measures include strict standards for ventilation, air filtration, and isolation methods in hospitals, medical and dental offices, nursing homes, and prisons. If someone is believed to have been in contact with another person who has TB, preventive antibiotic treatment may have to be given. Infected persons need to be identified as soon as possible so that they can be isolated from others and treated.

TB prevention and control takes two parallel approaches. In the first, people with TB and their contacts are identified and then treated. Identification of infections often involves testing high-risk groups for TB. In the second approach, children are vaccinated to protect them from TB. Unfortunately, no vaccine is available that provides reliable protection for adults. However, in tropical areas where the levels of other species of mycobacteria are high, exposure to non-tuberculous mycobacteria gives some protection against TB.

Get tested regularly. Experts advise people who have a high risk of TB to get a skin test once a year. This includes people with HIV or other conditions that weaken the immune system, people who live or work in a prison or nursing home, health care workers, people from countries with high rates of TB, and others in high-risk groups.

Consider preventive therapy. If you test positive for latent TB infection, your doctor will likely advise you to take medications to reduce your risk of developing active TB. Vaccination with BCG is not recommended for general use in the United States, because it is not very effective in adults and it causes a false-positive result on a Mantoux skin test. But the vaccine is often given to infants in countries where TB is more common. Vaccination can prevent severe TB in children.

An anti-tuberculosis vaccine, bacille Calmette-Guérin, or BCG vaccine, was developed in France in 1908. Although there is conflicting evidence as to its efficacy (it appears to be effective in 50 percent of those vaccinated), it is given to over 80 percent of the world's children, mostly in countries where TB is common; it is not generally given in the United States. BCG provides some protection against severe forms of pediatric TB, but has been shown to be unreliable against adult pulmonary TB, which accounts for most of the disease burden worldwide.

Researchers are working on developing a more effective TB vaccine. Federal health officials in the United States have stated (1999) that a new vaccine is essential to TB prevention. It is hoped that the determination of the complete DNA (genome) sequence of Mycobacterium tuberculosis, achieved in 1998, will hasten the development of an effective vaccine.

Finish your entire course of medication. This is the most important step you can take to protect yourself and others from TB. When you stop treatment early or skip doses, TB bacteria have a chance to develop mutations that allow them to survive the most potent TB drugs. The resulting drug-resistant strains are much more deadly and difficult to treat.

To help keep your family and friends from getting sick if you have active TB:

• Stay home. Do not go to work or school or sleep in a room with other people during the first few weeks of treatment for active TB.
• Ensure adequate ventilation. Open the windows whenever possible to let in fresh air.
• Cover your mouth. It takes two to three weeks of treatment before you are no longer contagious. During that time, be sure to cover your mouth with a tissue anytime you laugh, sneeze or cough. Put the dirty tissue in a bag, seal it and throw it away. Also, wearing a mask when you are around other people during the first three weeks of treatment may help lessen the risk of transmission.

TB RISK FACTORS

Anyone can get tuberculosis, but certain factors increase your risk of the disease. Over 8 million new cases of TB occur each year worldwide. In the United States, it is estimated that 10-15 million people are infected with the TB bacteria and 22,000 new cases of TB occur each year. Although anyone can get TB, certain people are at higher risk, including:

• Lowered immunity and people with diabetes, certain cancers, and HIV infection (the AIDS virus). A healthy immune system can often successfully fight TB bacteria, but your body cannot mount an effective defense if your resistance is low. A number of factors can weaken your immune system. Having a disease that suppresses immunity, such as HIV/AIDS, diabetes, end-stage kidney disease, certain cancers or the lung disease silicosis, can reduce your body's ability to protect itself. Your risk is also higher if you take corticosteroids, certain arthritis medications, chemotherapy drugs or other drugs that suppress the immune system.



• Malnutrition. A poor diet or one too low in calories puts you at greater risk of TB.



• Close contact with someone with infectious TB. People who live with individuals who have an active TB infection. In general, you must spend an extended period of time with someone with untreated, active TB to become infected yourself. You are more likely to catch the disease from a family member, roommate, friend or close co-worker.



• Poor or homeless people. Lack of medical care or if you are on a low or fixed income, live in a remote area, have recently immigrated to the United States or are homeless, you may lack access to the medical care needed to diagnose and treat TB.



• Country of origin. Foreign-born people from countries that have a high prevalence of TB. People from regions with high rates of TB - especially sub-Saharan Africa, India, China, the islands of Southeast Asia and Micronesia, and parts of the former Soviet Union - are more likely to develop TB. In the United States, more than half the people with TB were born in a different country. Among these, the most common countries of origin were Mexico, the Philippines, India and Vietnam.



• International travel. As people migrate and travel widely, they may expose others or be exposed to TB bacteria.



• Nursing home residents and prison inmates. Living or working in a residential care facility. People who live or work in prisons, immigration centers or nursing homes are all at risk of TB. That is because the risk of the disease is higher anywhere there is overcrowding and poor ventilation.



• Living in a refugee camp or shelter. Weakened by poor nutrition and ill health and living in crowded, unsanitary conditions, refugees are at especially high risk of TB infection.



• Substance abuse - alcoholics and intravenous drug users. Long-term drug or alcohol use weakens your immune system and makes you more vulnerable to TB.



• Age. Older adults are at greater risk of TB because normal aging or illness may weaken their immune systems. They are also more likely to live in nursing homes, where outbreaks of TB can occur.



• Health-care workers. Regular contact with people who are ill increases your chances of exposure to TB bacteria. Wearing a mask and frequent hand washing greatly reduce your risk.

RISK FACTORS OF TB INFECTION PROGRESSING TO TB DISEASE

Progression from TB infection to TB disease occurs when the TB bacilli overcome the immune system defenses and begin to multiply. In primary TB disease - 1-5 percent of cases - this occurs soon after infection. However, in the majority of cases, a latent infection occurs that has no obvious symptoms. These dormant bacilli can produce tuberculosis in 2-23 percent of these latent cases, often many years after infection. The risk of reactivation increases with immunosuppression, such as that caused by infection with HIV. In patients co-infected with M. tuberculosis and HIV, the risk of reactivation increases to 10 percent per year.

Patients with diabetes mellitus are at increased risk of contracting tuberculosis, and they have a poorer response to treatment, possibly due to poorer drug absorption.

Other conditions that increase risk include:

• Recent TB infection or a history of inadequately treated TB.
• Chest X-ray suggestive of previous TB, showing fibrotic lesions and nodules.
• Silicosis.
• Prolonged corticosteroid therapy and other immunosuppressive therapy.
• Head and neck cancers.
• Hematologic and reticuloendothelial diseases, such as leukemia and Hodgkin's disease.
• End-stage kidney disease.
• Intestinal bypass or gastrectomy.
• Chronic malabsorption syndromes.
• Vitamin D deficiency.
• Low body weight.

Twin studies in the 1940s showed that susceptibility to TB was heritable. If one of a pair of twins got TB, then and the other was more likely to get TB if he was identical than if he was not. Since then, specific gene polymorphisms in IL12B have been linked to tuberculosis susceptibility.

Some drugs, including rheumatoid arthritis drugs that work by blocking tumor necrosis factor-alpha (an inflammation-causing cytokine), raise the risk of activating a latent infection due to the importance of this cytokine in the immune defense against TB.

COMPLICATIONS

Without treatment, tuberculosis can be fatal. Drug-resistant strains of the disease are more difficult to treat. Untreated active disease typically affects your lungs, but it can spread to other parts of the body through your bloodstream. Complications vary according to the location of TB bacteria:

• Lung damage can occur if TB in your lungs (pulmonary TB) is not diagnosed and treated early.
• Severe pain, abscesses and joint destruction may result from TB that infects your bones.
• Meningitis can occur if TB infects your brain and central nervous system.
• Miliary TB is TB that has spread throughout your entire body, a serious complication.

COPING WITH TB & SUPPORT

Undergoing treatment for TB is a complicated and lengthy process. But the only way to cure the disease is to stick with your treatment. You may find it helpful to have your medication given by a nurse or other health care professional so that you do not have to remember to take it on your own. In addition, try to maintain your normal activities and hobbies and stay connected with family and friends.

Keep in mind that your physical health can affect your mental health. Denial, anger and frustration are normal when you must deal with something difficult and unexpected. At times, you may need more tools to deal with these or other emotions. Professionals, such as therapists or behavioral psychologists, can help you develop positive coping strategies.

RELATED LINKS

CDC: Division of TB Elimination - Fact Sheets Tuberculosis Information

KNOL: Tuberculosis Information

Wikipedia.org: Tuberculosis

Bovine TB: Gamma Interferon (g-IFN) Blood Test Across Great Britain

NIH: Analysis of Possible Factors Affecting The Specialty of the Gamma Interferon Test in TB-Free Cattle Herds

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HOLISTIC & NUTRITIONAL INFORMATION

RECOMMENDATIONS

Recommendations and other therapies recommended here are not meant to replace conventional TB therapy but may be used as preventive measures by building up a health immune system to fight potential infection and/or to complement conventional therapy. Always consult your health care provider before using any alternative or complementary therapy in conjunction with prescribed medications.

If you suspect you may tuberculosis, or that you may have been exposed to it, see your health care provider. Prompt, proper treatment is essential.

Follow the prescribed treatment regimen exactly. If any medications cause side effects, contact your health care provider. Do Not discontinue taking the medications on your own.

NUTRITIONAL THERAPY

To promote healing, eat a diet consisting of at least 50 percent raw vegetables and fruits. Also eat alfalfa sprouts, fish, fowl, pomegranates, raw cheeses, raw seeds and nuts, whole grains, and garlic.

Drink fresh pineapple and carrot juice and a green drink daily. Drink fresh raw potato juice; potato juice contains compounds called protease inhibitors, which block carcinogens and prevent cell mutation. Drink plenty of distilled or quality water daily to help remove toxins from the body.

MoonDragon's Nutrition Therapy: Juicing

Make a puree of steamed asparagus in a blender. Refrigerate and take 4 tablespoons twice a day with meals. Asparagus stimulates immune function and is anti-carcinogenic.

Do not consume any caffeine, carbonated soft drinks, fried foods, processed or refined foods, salt, or sugar in any form during recovery period. These foods slow healing.

Make kefir, buttermilk, and fresh sugar-free yogurt a part of your daily diet. Also take acidophilus supplements for as long as you are taking antibiotics, to relieve stress on the gastrointestinal tract and enhance nutrient absorption. Do not take acidophilus at the same time as the antibiotics, however, or the antibiotics will kill the friendly bacteria, but do make sure you take it.

Herbal Remedies: Acidophilus Supplement Powder, Non-Dairy, 3 oz. Bulk

Herbal Remedies: Acidophilus, 3 Billion, NOW Foods, 90 Tabs

Herbal Remedies: Lactobacillus Acidophilus Supplement, Non-Dairy, 100 Caps

Herbal Remedies: Lactobacillus Acidophilus, Kosher Liquid, All Natural, Vegetarian Medium, Lactose Free, Apple Strawberry Flavor, Dynamic Health, 16 fl. oz.

OTHER RECOMMENDATIONS

Get plenty of rest and avoid stress. This is vital for recovery. Rest, sunshine, and fresh air are most important. A dry climate is recommended.

Do not smoke, consume alcohol, or use recreational drugs. All of these affect the ability of the immune system to fight infection. Smoking is even more dangerous than usual in the presence of a lung infection.

MoonDragon's Health Therapy: Smoking Cessation

MoonDragon's Health & Wellness: Alcoholism

MoonDragon's Health & Wellness: Drug & Substance Abuse

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CONSIDERATIONS

Modern treatment regimens include long-term treatment with the antibiotics isoniazid (INH, Laniazid, Nydrazid, Tubizid), rifampin (Rifadin, Rimactane), pyrazinamide, streptomycin, and/or ethambutol (Myambutol). Whatever antibiotic treatment is prescribed, it is important to take it for the full course recommended, even if you start to feel better.

People infected with TB should not use cortisone preparations. Cortisone suppresses the immune function and makes the infection more difficult to treat.

Vaccines and drugs cannot control TB if poor lifestyle practices are followed. Cleanliness and proper nutrition are vital in combating this disease.

Experts estimate that up to 90 percent of the population may have encountered the tubercle bacillus sometime in their lives, but in the majority of cases, the immune system successfully keeps a full-blown infection from developing. People who do not defeat it outright often carry the germ in a dormant state, sometimes for decades, before immunity weakens and the bacteria begin replicating and infect the host.

The Air Supply personal air purifier from Wein Products is a small unit worn around the neck. It sets up an invisible pure air shield against microorganisms (such as viruses, bacteria, and mold) and microparticles (such as dust, pollen, and pollutants) in the air. It also eliminates vapors, smells, and harmful volatile compounds in the air.

The tubercle bacillus has an incredible capacity for reproduction. A single organism is capable of producing billions of descendants within one month.

People with AIDS are more likely than most to have tuberculosis at some point during their lifetimes.

MoonDragon's Health & Wellness: AIDS (Acquired Immune Deficiency Syndrome)

MoonDragon's Health & Wellness: AIDS - Additional Information

MoonDragon's Health & Wellness: AIDS & Nutrition

MoonDragon's Health & Wellness: AIDS & Women

The World Health Organization has recommended a global strategy - directly observed treatments short course or DOTS - as a method of conquering TB. The basis of the program is to both treat and then monitor the TB-infected subjects very closely, making sure they complete their course of antibiotics. Cure rates in this type of program have reached as high as 95 percent, even in the poorest of conditions where TB used to thrive.

The Bacillus Calmette-Guerin vaccine (BCG), which consists of a weakened form of tubercle bacilli, can be used for vaccination against tuberculosis. Many medical authorities believe BCG is an effective preventive measure against TB, while others have serious doubts about its safety. A TB skin test may indicate if you are carrying TB bacteria even before you have the symptoms of the disease.

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HERBS

Butcher's Broom, Calendula, Cayenne (Capsicum), Chamomile, Peppermint, and Yarrow have anti-inflammatory properties.

Herbal Remedies: Butcher's Broom, Tincture, 2 fl. oz.

Herbal Remedies: Butcher's Broom Root, Nature's Way, 470 mg, 100 Caps

Herbal Remedies: Cayenne Products & Supplements

Herbal Remedies: Chamomile Products & Supplements

Herbal Remedies: Peppermint / Mint / Menthol Supplements & Products

Herbal Remedies: Yarrow Products & Supplements

Elecampane (Inula helenium), taken as tea, Goldenseal Root, Horehound, Licorice, Marshmallow Root, Mullein, Myrrh Gum, and Thyme have decongestant and expectorant properties. Caution: You should not take Elecampane if you have had a known allergic reaction to insulin or if you are pregnant or breastfeeding. Goldenseal should not be taken internally for an extended period, and should not be used by people with high blood pressure, pregnant women, or nursing mothers.

Herbal Remedies: Elecampane Products & Supplements

Herbal Remedies: Goldenseal Products & Supplements

Herbal Remedies: Horehound Products & Supplements

Herbal Remedies: Licorice Products & Supplements

Herbal Remedies: Lobelia Products & Supplements

Herbal Remedies: Marshmallow Products & Supplements

Herbal Remedies: Mullein Products & Supplements

Herbal Remedies: Myrrh Products & Supplements

Herbal Remedies: Thyme Products & Supplements

A combination of Echinacea and Pau D'Arco tea is beneficial. Echinacea is a powerful antioxidant and bolsters the immune system. Pau d'arco benefits the body by cleansing the blood and acting as an antibacterial agent, as well as possessing anti-tumor agents. Drink 3 cups of this tea daily. Or combine Echinacea Tincture with equal parts of Elecampane Tincture and Mullein Tincture, and take 1 teaspoon of this mixture 3 times daily.

Herbal Remedies: Echinacea Products & Supplements

Herbal Remedies: Pau D'Arco Products & Supplements

Herbal Remedies: Mullein Products & Supplements

Herbal Remedies: Elecampane Products & Supplements

Herbal Remedies: Goldenseal Root, Nature's Way, 570 mg, 100 Caps

Herbal Remedies: Echinacea-Goldenseal Supplement, Vegetarian, Herbal Remedies USA, 1,000 mg, 60 Liquid VCaps

Herbal Remedies: Goldenseal Root Tincture, 100% Organic, 2 fl. oz.

Herbal Remedies: Echinacea-Goldenseal Tincture, Nature's Way, Alcohol Free, 1 fl. oz.

ClearLungs from RidgeCrest Herbals is a Chinese herbal formula that relieves bronchial and lung congestion.

Lung Tonic from Herbs, Etc. and others, supports lung function.

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NUTRITIONAL SUPPLEMENTS

Unless otherwise specified, the following recommended dosages are for persons over the age of 18 years. For children between 12 and 17 years old, reduce the dose to 3/4 the recommended amount. For children between the ages of 6 and 12, use 1/2 the recommended dose, and for children under 6 years old, use 1/4 the recommended amount.

NUTRIENTS
Supplement	Suggested Dosage	Comments
Very Important
Acidophilus	As directed on label.	Especially important if antibiotics are prescribed. Use a non-dairy source. Acidophilus Supplement Powder, Non-Dairy, 3 oz. Bulk, Acidophilus, 3 Billion, NOW Foods, 90 Tabs, Lactobacillus Acidophilus Supplement, Non-Dairy, 100 Caps, Lactobacillus Acidophilus, Kosher Liquid, All Natural, Vegetarian Medium, Lactose Free, Apple Strawberry Flavor, Dynamic Health, 16 fl. oz.
AE Mulsion Forte (American Biologics)	As directed on label, to supply 200,000 IU vitamin A daily. If you are pregnant, do not exceed 10,000 IU daily.	To supply vitamins A and E, vital for healing of lung tissue and protection against free radicals. This emulsion form is easily assimilated and is safe at high doses.
Or Vitamin A	25,000 IU daily. If you are pregnant, do not exceed 10,000 IU daily.	Vital for healing of lung tissue. Important potent antioxidants and immune system enhancers. Use emulsion forms for easier assimilation. Vitamin A, 100% Natural, Nature's Way, 10,000 IU, 100 Softgels, Vitamin A, Fish Liver Oil, NOW Foods, 25,000 IU, 250 Softgels, Dry Vitamin A & D, Nature's Way, 15,000 IU / 400 IU, 100 Caps, Shark Liver Oil With Vitamin A, NOW Foods, 400 mg / 10,000 IU, 120 Softgels
Plus Carotenoid Complex With Beta Carotene	25,000 IU daily.	Potent antioxidants and immune system enhancers. Beta Carotene (Natural Dunaliella Salina), Nature's Way, 100% Natural, 25,000 IU, 100 Softgels, Multi-Carotene Antioxidant, Nature's Way, 60 Softgels
Coenzyme Q-10	75 mg daily.	Helps carry oxygen to tissues for healing. Boosts immune function. CoQ10, Vegetarian Coenzyme, NOW Foods, 30 mg, 60 VCaps, CoQ10, Now Foods, 400 mg, 60 Softgels
Colloidal Silver	As directed on label.	An antiseptic that subdues inflammation and heals lesions. Natural antibiotic and antiviral properties. Good for infections and promotes healing. Colloidal Silver, Trace Minerals, 8 fl. oz., Colloidal Silver Liquid, Silva Solution, Super Strength Pro 50, 8 fl. oz., Colloidal Silver, Silva Pro 50 Spray, 2 fl. oz., Colloidal Silver Pump Spray, Silva Solution, 2 fl. oz.
Free-Form Amino Acid Complex	As directed on label.	Needed for tissue repair. Free-form amino acids are rapidly absorbed and assimilated by the body. Amino 1000 Complete, NOW Foods, 120 Caps, Amino 1500, Chewable Blend of 20 Amino Acids, Predigested, NOW Foods, 150 Tabs, Branched Chain Amino Acid Powder, NOW Foods, 12 oz., Branched Chain Amino Acids, Free Form, 120 Caps
Garlic (Kyolic)	2 capsules 3 times daily, with meals.	Stimulates immune function and acts as a natural antibiotic that fights infection, keeping infection in check. Destroys free radicals. Aged Garlic Extract, Cardiovascular Formula 100, Wakunaga Kyolic Supplements, 300 Caps, Kyolic Liquid Aged Garlic Extract, Cardiovascular, Vegetarian, Wakunaga Kyolic, 4 fl. oz., Kyolic Aged Garlic Extract, One Per Day, Vegetarian, Wakunaga Kyolic, 1,000 mg, 30 Caplets,
Grape Seed Extract	As directed on label.	A powerful antioxidant that enhances immunity. Grape Seed (Grapeseed) (Vitus vinifera), 100% Pure, NOW Foods, 16 fl. oz.
L-Cysteine And L-Methionine	500 mg of each twice daily, on an empty stomach. Take with water or juice. Do not take with milk. Take with 50 mg vitamin B-6 and 100 mg vitamin C for better absorption.	To protect the lungs and liver by detoxifying harmful toxins. See Amino Acids for more information. L-Cysteine Structural Support With Vitamin B-6 & Vitamin C, Vegetarian, NOW Foods, 500 mg, 100 Tabs, L-Methionine, Plus B-6, NOW Foods, 500 mg / 10 mg, 100 Caps
Selenium	200 mcg daily. If you are pregnant, do not exceed 40 mcg daily.	Protects against free radicals and promotes a healthy immune system, enhancing the body's ability to fight infection. Caution: Do not take supplemental selenium if you are pregnant or have heart, kidney, or liver disease. Selenium Supplement, Yeast Free, NOW Foods, 200 mcg, 180 Caps, Selenium Ionic Mineral Supplement, Fully Absorbable, 50 +/- ppm, 16 fl. oz., Ionic Selenium, Trace Minerals, 300 mcg, 2 fl. oz., Selenium, 100% Natural, Nature's way, 200 mcg, 100 Caps
Vitamin B Complex	100 mg of each major B vitamin 3 times daily (amounts of individual vitamins in a complex will vary).	Needed for production of red blood cells and antibodies. Aids in utilization of oxygen. Use a high- stress formula. Injections (under a health care provider's supervision) may be necessary. If injections are not available, us a sublingual form for best absorption. Ultimate B (Vitamin B Complex), Nature's Secret, 60 Tabs, Vitamin B-100 Complex, w/ Coenzyme B-2, Nature's Way, 631 mg, 100 Caps
Plus Extra Pantothenic Acid (Vitamin B-5)	100 mg 3 times daily.	The anti-stress vitamin. Enhances the effectiveness of Coenzyme Q-10. Pantethine (Coenzyme A Precursor), Highly Active Form of Vitamin B-5, 300 mg, NOW Foods, 60 Softgels, Pantothenic Acid, Natural Vitamin B-5, Nature's Way, 250 mg, 100 Caps,
And Vitamin B-6 (Pyridoxine)	50 mg 3 times daily.	Some drugs used to fight TB can cause a deficiency of this vitamin. Vitamin B-6 (Pyridoxine), Nature's Way, 100 mg, 100 Caps
Vitamin C With Bioflavonoids	5,000-20,000 mg daily, in divided doses. See Ascorbic Acid Flush.	Strengthens immune system function and promotes healing. Vitamin C Liquid w/ Rose Hips & Bioflavonoids, Kosher, Natural Citrus Flavor, Dynamic Health, 1000 mg, 16 fl. oz., Ester C With Bioflavonoids, Nature's Way, 1000 mg, 90 Tabs, Vitamin C 1000 With Bioflavonoids, Nature's Way, 100% Natural, 1000 mg, 250 VCaps, The Right C, Nature's Way, 1000 mg, 120 Tabs, Vitamin C Liquid For Baby & Children, 4 fl. oz.
Vitamin D-3	Start with 1,000 IU daily and decrease slowly to 400 IU daily over the course of 1 month.	Needed for healing and absorption of minerals, especially calcium. Vitamin D, NOW Foods, 2000 IU, 120 SoftGels, Vitamin D, NOW Foods, 1000 IU, 180 SoftGels, Dry Vitamin D, Nature's Way, 100% Natural, 400 IU, 100 Caps
Plus Vitamin E	Start with 200 IU daily or 400 IU every other day and increase slowly to 800 IU daily.	Vital for healing of lung tissue. Powerful antioxidant, free radical scavenger and immune system enhancer. Protects the lung tissues and provides oxygen to the cells. Emulsion form is recommended for easier assimilation and greater safety at high doses. Use d-alpha-tocopherol form. Ester E Natural Vitamin E, California Natural, 400 IU, 60 Softgels, Vitamin E, 400 IU, 100% Natural, NOW Foods, 100 Gels, Vitamin E-1000, NOW Foods, 1000 IU, 100 Gels, Vitamin E, d-alpha-tocopherol, 400 IU, 100 Softgels
Important
ACES Plus Zinc (Carlson Labs)	As directed on label. Do not exceed 100 mg of zinc daily from all sources.	Contains vitamins A, C, and E plus the minerals selenium and zinc. A formula that fights free radicals with enzymes and antioxidants.
ClearLungs (Ridgecrest Herbals)	2 capsules 3 times daily.	Reduces inflammation and protects the lungs.
ConcenTrace (Trace Minerals)	As directed on label.	To supply trace minerals. Increases energy. ConcenTrace Trace Mineral Supplement Drops, Trace Minerals, Original Flavor, 8 fl. oz., Trace Mineral Drops, ConcenTrace Travel Size, Refillable, Trace Minerals, 0.5 fl. oz.
CTR Support (PhysioLogics)	As directed on label.	To diminish damage caused by inflammation.
Essential Fatty Acids (Ultimate Oil)	As directed on label.	Important in formation of all cells, including lung tissue. Ultimate Oil, Essential Fatty Acids Supplement, Nature's Secret, 90 SoftGels, Essential Fatty Acids For Baby & Children, Organic, 8 fl oz., Barlean's Flax Oil, 100% Highest Lignan Content, Organic, Pesticide & Herbicide Free, 16 fl. oz., Barlean's Flax Oil, Highest Lignan, 1000 mg, 250 Caps
L-Glutathione	500 mg daily, on an empty stomach. Take with water or juice. Do not take with milk. Take with 50 mg vitamin B-6 and 100 mg vitamin C for better absorption.	To protect the lungs and cells from free radical damage. See Amino Acids for more information. L-Glutathione, NOW Foods, 250 mg, 60 Caps
Kelp	2,000-3,000 mg daily.	For a natural supply of minerals. Rich in iodine. Kelp Supplement, Nature's Way, Certified, 650 mg, 100 Caps, Kelp Seaweed, Norwegian, NOW Foods, 100% Natural, 550 mg, 250 Caps, Kelp Seaweed, Norwegian Powder, 4 oz. Bulk
L-Serine	500 mg daily, on an empty stomach. Take with water or juice. Do not take with milk. Take with 50 mg vitamin B-6 and 100 mg vitamin C for better absorption.	Helps the body maintain immune function. See Amino Acids for more information. Phosphatidyl Serine Supplement (PS), Nature's Way, 500 mg, 60 Softgels, Phosphatidyl Serine (PS), NOW Foods, 100 mg, 60 VCaps,
Multi-Enzyme Complex Plus Proteolytic Enzymes	As directed on label. Take Multi-Enzymes complex with meals and Proteolytic Enzymes between meals.	Needed to keep inflammation down, to digest essential nutrients, and to improve absorption. MetabolicZyme (Hypoallergenic), Allergy Research Group / Nutricology, 900 Tabs, Plant Enzymes, NOW Foods, Vegetarian, 120 VCaps, Enzymes, All Complete, 250 mg, 90 Caps
Multi-Vitamin & Mineral Complex	As directed on label, Take with meals.	All nutrients are needed in balance for strength, healing and for immune response. Use high-potency formula. Do not use a sustained-release formula. Super Multi-Vitamin & Multi-Mineral, Pure Vital Earth, 32 fl. oz. (98% Bio-Available for Absorption), Damage Control Master Formula, High Potency, Multi-Vitamin & Mineral, 60 Packets (30 Day Supply), Daily Two Iron Free Multi-Vitamin Supplement, 100% Natural, Nature's way, 100 Tabs, Multi-Vitamin & Mineral, Baby & Children's Liquid, ChildLife, 8 fl. oz.,
With Boron	3 mg daily. Do not exceed this amount.	Needed for strength and healing. Boron is a mineral that aids in the production of natural steroid compounds within the body, which is necessary for healthy bones and muscle growth. It is also vital for the metabolism of calcium, phosphorus, and magnesium. This mineral is found naturally in apples, carrots, grapes, dark green leafy vegetables, raw nuts, pears, and whole grains. Boron increases brain function, promotes alertness, and helps the body utilize energy from fats and sugars. Boron supplementation can help prevent post-menopausal osteoporosis and build muscle, and is a benefit for elderly people to aid in calcium absorption. Boron Ionic Mineral Supplement, Fully Absorbable, 20 +/- ppm, 16 fl. oz., Ionic Boron, Single Mineral, Trace Minerals, 6 mg, 2 fl. oz., Tri-Boron Plus, With Magnesium, Vitamin D & Co-Factors, TwinLab, 240 Caps, Boron Chelate, Nature's Way, 3 mg, 100 Caps
And Calcium	1,000 mg daily.	Needed for strength and healing. Important nutrient that works together with magnesium. Use chelate form. Calcium Ionic Mineral Supplement, Fully Absorbable, 700 +/- ppm, 16 fl. oz., Liquid Calcium W/ConcenTrace, Orange Vanilla, Trace Minerals, 1000 mg, 32 fl. oz., Cal-Mag Pre-Chelated Calcium & Magnesium, Vital Earth, 240 Gelcaps
And Magnesium	750 mg daily.	Needed for strength and healing. Works with calcium. Use chelate form. Magnesium Ionic Mineral Supplement, Fully Absorbable, 350 +/- ppm, 16 fl. oz., Just An Ounce Calcium & Magnesium Liquid, Almond Flavor, 16 fl. oz., Calcium & Magnesium Mineral Complex, 100% Natural, Nature's Way, 500 mg / 250 mg, 250 Caps
And Silica	25-100 mg daily.	Needed for strength and healing. Silica Liquid Drops, CellFood, 4 fl. oz., Silica Complex Supplement, 8% Extract, NOW Foods, 500 mg, 90 Tabs, Horsetail Herb Grass, Nature's Way, 440 mg, 100 Caps
Liquid Oxygen Supplement	As directed on label.	Increases oxygen intake and aids the body in eliminating toxins. Oxy Boost, Peter Gillham's Natural Vitality, 2 oz., Oxy Boost Plus, Therapeutic Strength, Peter Gillham's Natural Vitality, 2 oz., Stabilized Oxygen OxyDrops, Liquid Electrolytes, Sodium Chlorite Solution, 4 fl. oz.
Oxy-5000 Forte	As directed on label.	Oxy-5000 Forte is an antioxidant formula with superoxide dismutase (SOD). Assists the immune system and helps stress.
Zinc	50-80 mg daily. Do not exceed a total of 100 mg daily from all supplements.	Needed for tissue repair, healing and promotes immune function. Zinc gluconate lozenges are very effective. Zinc Ionic Mineral Supplement, Fully Absorbable, 100 +/- ppm, 16 fl. oz., Colloidal Silver & Zinc Lozenges, Silva Solution, 90 Lozenges, Zinc Lozenges W/ Echinacea & Vitamin C, Nature's Way, 23 mg, 60 Lozenges, Zinc (Chelated), 100% Natural, Nature's Way, 30 mg, 100 Caps

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TUBERCULOSIS (TB) SUPPLEMENTS & PRODUCTS

Information, supplements and products for tuberculosis and TB, a chronic infectious disease that usually affects the lungs.

Amino 1000 Complete, NOW Foods, 120 Caps AMINO 1000 Complete contains a balanced blend of 20 essential and non-essential amino acids.

Bayberry Root Bark, Nature's Way, 475 mg, 100 Caps Bayberry Root Bark is often used for its astringent properties and can boost the immune system.

Bio Defender, Antibacterial, Antiviral & Antifungal Formula, Balanceuticals, 56 Caps This unique antibacterial, antiviral and antifungal formula is a clinical nutritionist response to bio terrorism such as anthrax.

Black Elderberry Extract, Premium Quality, Kosher, Dynamic Health, 8 fl. oz. Dynamic Health's Black Elderberry extract is of premium quality and kosher.

Black Seed Theramune Ultimate With Garlic, 100 Caps Promotes healthy circulation, useful for arthritis and cardiovascular & respiratory support. It also supports digestion and is a natural remedy for ulcers. Garlic is known to lower cholesterol naturally.

Calcium Ionic Mineral Supplement, Fully Absorbable, 700 +/- ppm, 16 fl. oz. WaterOz Ionic Calcium is a pure liquid Calcium supplement. Calcium is one of the most essential of the major biochemical elements needed in human nutrition. It is needed in every organ of the body, including the brain. Calcium is called the "knitter" because it promotes healing or knitting everywhere in the body. It is valuable for tone, power, strength, longevity, vitality, and endurance, healing of wounds, counter-acting acids, and helping regulate metabolism.

Colloidal Silver Liquid, SilvaSolution, 10 ppm, 16 fl. oz. Colloidal Silver is a potent yet non-toxic natural food supplement that has shown to support the immune system during the cold and flu season.

Colloidal Silver & Zinc Lozenges, 90 Lozenges Now you can get powerful liquid silver in the most convenient form ever with new Silva Solution Silver and Zinc Lozenges.

Colloidal Silver, Liquid Silver Homeopathic Formula, SilvaSolution Advanced Immune System Activator For Colds & Flu, 8 fl. oz. TriMedica SilvaSolution Advanced Liquid Silver Homeopathic Formula integrates the basic principles of homeopathy and is a profound healing system designed to increase the body's ability to respond to immune challenges and restore optimal health.

Colloidal Silver Liquid, SilvaSolution, Super Strength Pro 50, 8 fl. oz. Colloidal Silver Super Strength Liquid provides for a strong immune system, ears, sinuses, throat and lung support for the winter season.

Colostrum, 480 mg, 120 Caps Colostrum known for its powerful healing factors offers optimal health. Colostrum research proves a wide spectrum of immunoglobulins, antibodies, and accessory immune factors.

Colostrum Chewables, Natural Vanilla Flavor, 480 mg, 90 Chewables Colostrum known for its powerful healing factors offers optimal health. Colostrum research proves a wide spectrum of immunoglobulins, antibodies, and accessory immune factors.

CoQ10, All Natural, Hypoallergenic, Nature's Way, 60 mg, 60 Softgels CoQ10 is vital for cellular energy production and is a powerful antioxidant and free radical scavenger.

CoQ10, NOW Foods, 400 mg, 60 Softgels As an active contributor to all aspects of cellular function, coq10 has become universally regarded as one of the most vital nutrients ever made available to the public.

CoQ10, Vegetarian Coenzyme, NOW Foods, 30 mg, 60 VCaps A coenzyme for several key steps in the production of energy within each cell, and an antioxidant important in its clinical effects. It is these two properties make CoQ10 one of the best supplements available today.

CoQ10 With Vitamin E, NOW Foods, 200 mg, 90 Lozenges Our new orange flavored chewable CoQ10 200 mg is formulated with 100 IU of Vitamin E in a base of non-genetically engineered Soy Lecithin.

Cordyceps Cs-4, 400 mg, 90 VCaps Clinically, Cordyceps is used to build and support immune function in various immune compromised conditions including chronic fatigue, cancer, and respiratory conditions.

Defense Plus, NutriBiotic, With Grapefruit Seed Extract, Maximum Strength Immune System Support, 250 mg, 90 Tabs Defense Plus with Grapefruit Seed Extract is the most powerful natural product available for enhancing the body's defense system and providing nutritional support for people with certain health concerns.

Echinacea, Astragalus & Reishi, Immune Support Supplement, Nature's Way, 400 mg, 100 Caps Nature's Way Echinacea Astragalus and Reishi is an Immune Support Supplement that helps support your immune system naturally.

Echinacea Herb, Nature's Way, 400 mg, 180 Caps Echinacea herb supports the immune system and promotes general well-being in cold and flu season.

Echinacea Immune Support Tea, Yogi Tea, Certified Organic, 16 Tea Bags Echinacea Immune Support tea is a superior blend of several species of Organic Echinacea Root (Echinacea angustifolia, purpurea, pallida) designed to boost your immune system.

Echinacea Root Complex, Nature's Way, 180 Caps Echinacea Root Complex helps promote general well-being during the cold and flu season and support the immune system.

Echinacea Root Tincture, 100% Organic, 2 fl. oz. Echinacea Root is also known as Purple Coneflower and considered very valuable by the North American Indians.

Echinacea Tea, Caffeine Free, 100% Natural, NOW Foods, 30 Tea Bags Echinacea is an American Indian favorite designed to boost your immune system.

Echinacea With Elderberry & Zinc, Nature's Way, 100 Caps Nature's Way Echinacea with Elderberry and Zinc is a synergistic combination of the latest scientific research and traditional herbal medicine to support the immune system.

Effer-C Instant Fizzy Vitamin C Drink Mix Powder, Punch Flavor, 1000 mg, 0.3 oz, 36 Packets This excellent tasting fizzy Vitamin C drink mix is for energy & immune support. Select orange, raspberry or cranberry flavor.

Elderberry Flower Powder (Sambucus Nigra), Alternative Health & Herbs, 4 oz. As a hot infusion, the flowers are sweat-inducing and in combination with yarrow and mint are specific for colds and flu. The flowers are used to treat bronchial and upper respiratory disorders as well as hay fever. A cold infusion of the flowers can be used as a compress for chilblains. (Chilblains are the inflammation of the toes, feet, or fingers, due to the presence of a cold.) The ointment of Elderflower is soothing, cooling and healing, used for irritations of the skin. Considered to have a mild laxative action and may be used for rheumatism and gout.

Elderberry Flower (Sambucus Nigra) Tincture, 100% Organic, 2 fl. oz. As a hot infusion, the flowers are sweat-inducing and in combination with yarrow and mint are specific for colds and flu. The flowers are used to treat bronchial and upper respiratory disorders as well as hay fever. A cold infusion of the flowers can be used as a compress for chilblains. (Chilblains are the inflammation of the toes, feet, or fingers, due to the presence of a cold.) The ointment of Elderflower is soothing, cooling and healing, used for irritations of the skin. Considered to have a mild laxative action and may be used for rheumatism and gout.

Elderberry Herb, Nature's Way, 575 mg, 100 Caps Elderberry herb is popular for health concerns during the winter season.

Elderberry Juice Concentrate, 12.5 fl. oz. Elderberry Juice Concentrate is a Non-Alcoholic source for the health benefits of Elderberries. A medically proven strong anti-viral and immune system enhancer, elderberry is recommended as part of a health maintenance program.

Elderberry Whole Powder, 4 oz. Bulk Elderberry is a purgative, anti-inflammatory, expectorant, and diuretic.

Elderberry Whole Tincture, 100% Organic, 2 fl. oz. Elderberry kills viruses and is well known as a natural cold and flu treatment. A gargle of Elderberry can be used for tonsillitis and as an herbal sore throat remedy.

Garlicin CF, Cold & Flu Formula, Odor Free Garlic, Nature's Way, 404 mg, 90 Enteric-Coated Tabs Garlicin CF Odor Free Garlic Immune Support Formula combines all the healthy benefits of high allicin release Garlicin with the added benefits of Echinacea, Ester-C, and OptiZinc.

Garlic Oil Tincture, Alcohol-Free, Nature's Way, 1 fl. oz. Garlic oil is often used to soothe the ear and as an antibiotic but most often used as a food and herb and also to lower serum cholesterol and blood pressure and to improve circulation as well as possibly inhibiting the growth of ulcer causing bacteria.

Garlic Tincture, 100% Organic, 2 fl. oz. The Europeans use garlic as an all-around treatment for preventing atherosclerosis, the cause of heart disease and strokes.

Germ Defense Hand Sanitizer, Improvita, 0.5 fl. oz. Germ Defense Personal Hand Sanitizer comes in a unique 15 mil spray bottle that fits in your pocket, purse of a child's back pack.

Goldenseal Herb, Nature's Way, 400 mg, 180 Caps Goldenseal herb (hydrastis canadensis), a perennial wild native American herb, is also called Yellow Root. Native Americans used Goldenseal both internally and externally and also derived a dye from the root. Golden Seal is a very important traditional herb.

Grape Seed Extract, Standardized, Nature's Way, 100 mg, 30 Caps Nature's Way Standardized Grape Seed Extract are technically and scientifically advanced herbal product.

Horehound Tincture, 100% Organic, 2 fl. oz. Horehound herb is often used to treat respiratory disorders and has 350 years of history as a soothing expectorant.

Immune-RX, Immune System Supplement, Hi-Tech Pharmaceuticals, 60 Tabs Immune-RX, Immune System Supplement, was formulated to strengthen your immune system because Immune-Rx offers the most powerful protection against the elements.

Immune System Formula Tincture, 100% Organic, 2 fl. oz. The Immune System Formula can be used for AIDS, Auto-immune Diseases, and Cancer.

Instant Energy B-12, NOW Foods, 2000 mcg, 75 Packets NOW® Vitamin B-12 Instant Energy is the perfect way to keep alert and energized, regardless of the situation. These convenient, fast-acting packets are perfect when traveling or for convenience.

Irwin Naturals Immune Shield, Immune System Support, 100 Gelcaps Irwin Naturals multi-herb complex addresses two key areas, immune support and bacterial/viral control.

Kombucha Tea, 100% Organic, Original Flavor, 64 fl. oz Kombucha's benefits to the physical body vary widely. It is said to enhance the immune system. By detoxifying the body, kombucha makes it unlikely for disease causing bacteria and viruses to find a suitable growth environment. This results in a healthier physical body!

Kombucha 2000, Concentrated Kombucha, 30 Caps Concentrated Kombucha Capsules are new to the market, but Kombucha 2000 is one of the very first successful kombucha tea producers in the United States.

Lactobacillus Acidophilus Supplement, Non-Dairy, 100 Caps Lactobacillus Acidophilus Supplement taken as a dietary supplement may help to detoxify and to rebuild a balanced intestinal flora.

L-Cysteine Structural Support With Vitamin B-6 & C, Vegetarian, NOW Foods, 500 mg, 100 Tabs NOW L Cysteine functions as an antioxidant and is a powerful aid to the body in protecting against radiation and pollution. Hair and skin are made up 10-14 percent Cysteine.

L-Glutathione, 250 mg, 60 Caps L-Glutathione is a tripeptide amino acid produced in the liver primarily from cysteine. L-Glutathione acts as a cellular antioxidant by inhibiting free radical proliferation.

L-Methionine, Plus B-6, NOW Foods, 500 mg / 10 mg, 100 Caps L-Methionine is an essential sulfur amino acid. The body cannot produce L-Methionine, which must be obtained from food or supplement sources.

Lung Support Formula Tincture, 8 fl. oz. Use the Lung Support Formula to support the health and function of the lungs.

Lymphatic Glands Formula Tincture, 2 fl. oz. Helps the lymphatic Glands cleanse the body of its wastes. May be used as a preventative and for acute conditions.

Mangosteen Juice, Kosher & Vegetarian, Dynamic Health, 32 fl. oz. Dynamic Health Mangosteen Juice is rich in the Xanthone Antioxidant, and Mangosteen Juice contains naturally occurring minerals, enzymes, vitamins, antioxidants, phytonutrients and bioflavonoids and stimulates your body to boost energy.

Meta C Vitamin C Supplement, 1000 mg, 100 Tabs Meta C Vitamin C Supplement is a unique form of vitamin C that is absorbed faster than regular vitamin C and maintains higher serum levels for longer period of time with no intestinal discomfort.

Odorless Garlic Supplement, NOW Foods, 50 mg, 250 SoftGels Odorless Garlic supplement is extracted from Allum sativum and is a specially made Japanese product. Our Odorless Garlic yields high amounts of Scordiin, a unique sulfur compound which may be responsible for many of garlic's renowned benefits.

Pau D'Arco Bark (Tabebuia Impetiginosa) Powder, 4 oz. Bulk Pau D'Arco bark is a rich source of iron, which contributes to the elimination of wastes from the body and the assimilation of nutrients.

Pau D'Arco Liquid Extract, Incan LaPacho, 100% Natural Herbal, 4 fl. oz. The Incan Lapacho Co. Pau d'Arco extract is made from the inner barks of Plantation Grown Purple Lapacho trees found on or near the ancient Inca Trail.

Pau D'Arco Tea, Incan LaPacho, 48 Tea Bags Pau d'Arco tea has shown that it may support the bodies own ability to ward off many diseases.

Pau D'Arco Tea, Purple LaPacho, 25 Tea Bags Pau d'Arco tea is a delicious, all-natural way to reduce Inflammation and Pain and to boost immunity.

Peppermint Leaf (Mentha X Piperita) Powder, 4 oz. Bulk Peppermint leaf calms the muscles of the stomach and improves the flow of bile, which the body uses to digest fats. As a result, food passes through the stomach more quickly.

Selenium, 100% Natural, 200 mcg, 100 Caps Selenium is an essential component of glutathione, the body's most potent natural antioxidant system. It is a popular choice in many antioxidant regimens.

Shiitake & Maitake Extract, Standardized, 200 mg, 60 Caps Nature's Way Shiitake and Maitake extract is formulated in a base of Oat powder standardized to a total of 8% beta glucan, the polysaccharide to which most of the health benefits are attributed.

Sinus & Lung Congestion Formula Tincture, 2 fl. oz. The Sinus & Lung Congestion Formula was created to help clear the lungs and sinuses of congested matter.

Sutherlandia (Sutherlandia Frutescens), 300 mg, 60 Tabs Sutherlandia powerfully assists the body to mobilize its own immunological physiological resources to cope with diverse physical, mental and chemical stressors.

SystemWell Ultimate Multi-System Immunity Supplement, 180 Tabs SystemWell Ultimate Multi-System Immunity Supplement is the multi-system defense formula for seven essential aspects of healthy immunity.

Ultimate Respiratory Cleanse, With Mullein, Nature's Secret, 60 Tabs A powerful, synergistic herbal blend that will cleanse, strengthen and rejuvenate the entire respiratory system. This formula also provides unique nourishment specifically for the immune system.

Vitamin A, 100% Natural, Nature's Way, 10,000 IU, 100 Softgels Nature's Way vitamin A is 100% natural from fish liver oil. It contains no artificial ingredients or preservatives.

Vitamin B-100 Complex With Coenzyme B-2, Nature's Way, 631 mg, 100 Caps A complete Vitamin B complex of 8 essential vitamins. B Vitamins are precursors of coenzymes involved in the conversion of cellular energy, manufacture of hormones and proteins, and repair and maintenance of nerve structures.

Vitamin C 1000 With Bioflavonoids, Nature's Way, 100% Natural, 1000 mg, 250 VCaps Nature's Way Vitamin C with Bioflavonoids provides antioxidant protection for many of the body's important enzyme systems.

Vitamin C Liquid With Rose Hips & Bioflavonoids, Kosher, Natural Citrus Flavor, Dynamic Health, 1000 mg, 16 fl. oz. Liquid Vitamin C with Natural Rose Hips & Bioflavonoids is an easy to swallow dietary supplement that exceeds the recommended daily intake of vitamin C.

Vitamin E, Natural D-Alpha-Tocopherol, 400 IU, 100 Softgels Vitamin E has potent antioxidant activity, supplies oxygen to the blood, aids in strengthening capillary walls, and plays a beneficial role in cancer and cardiovascular disease prevention, anti-aging benefits, circulation, wound-healing, immune function, nervous system function, PMS, hot flushes, diabetes, vascular disease, eye health, tissue repair, athletic performance, leg cramps, skin and hair health, and alleviating fatigue.

Yarrow Tincture (Achillea Millefolium), 2 fl. oz. yarrow is well-known for its use as a remedy for cold, flu and fever and also for its skin wound healing and antibiotic properties.

Zinc Lozenges With Echinacea & Vitamin C, Nature's Way, 23 mg, 60 Lozenges Nature's Way Zinc lozenge boosts cold season defense with zinc, widely recognized as an important nutritional support during the cold season, and echinacea pupurea, clinically shown to support the immune system, and Vitamin C, a vitally important vitamin for general health maintenance.

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FOR A COMPLETE LIST OF TUBERCULOSIS (TB) SUPPLEMENTS & PRODUCTS:

Herbal Remedies: Tuberculosis / TB Information

Herbal Remedies: Tuberculosis / TB Supplements, Information & Products

NOTIFY YOUR HEALTH CARE PROVIDER IF...

You have a fever, unexplained weight loss, night sweats and a persistent cough. These are often signs of TB, but they can also result from other medical problems. Your health care provider can perform tests to help determine the cause. TB can be diagnosed by your primary care provider or by a practitioner who specializes in lung diseases (pulmonologist) or by an infectious disease specialist. If you do not have a health care provider, your local public health department can help.

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