Tuberculosis: Symptoms, Testing and Why You Must Finish the Full Six Months

What is tuberculosis and how does it spread?

Tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis. It spreads through the air when a person with active TB in the lungs coughs, sneezes or speaks in a closed and poorly ventilated space. It does not spread through handshakes or shared crockery. Infection usually requires repeated or prolonged contact with someone who has the active disease.

When the bacteria are breathed in, the immune system can respond in two ways. It may wall them off inside small capsules in the lung, keeping them alive but inactive: this is latent TB. Or the bacteria may multiply and begin damaging the lung tissue and sometimes other organs: this is active TB. Roughly a quarter of the world's population is estimated to carry latent TB.

In the Middle East and North Africa, overcrowded housing, poor ventilation and undernutrition create conditions that favour spread. A 2020 study published in the International Journal of Infectious Diseases documented how armed conflict in Syria severely disrupted TB control programmes, damaging health facilities and breaking medicine supply chains. Sudan's national programme similarly came under severe pressure during the years of conflict between 2004 and 2014.

What is the difference between latent and active TB?

Latent TB means the bacteria are present inside the body but dormant and walled off. The person has no symptoms and cannot pass the infection to anyone else. A skin test or a blood test can reveal it. Many people discover their latent TB incidentally during a routine pre-travel or pre-employment screen.

Active TB means the bacteria are multiplying and causing disease. The person has symptoms and can spread the bacteria through the air to those nearby. Pulmonary TB, which affects the lungs, is the most common and transmissible form. The bacteria can also affect the lymph nodes, spine, kidneys and brain in what is called extrapulmonary TB.

Latent TB progresses to active disease in about 5 to 10 percent of carriers over a lifetime, but this risk rises sharply in people with diabetes, those living with HIV, and those taking medicines that suppress the immune system. A 2020 systematic review published in BMC Public Health found that refugees and asylum seekers carry significantly higher burdens of latent TB compared with surrounding populations.

What are the symptoms of active TB to watch for?

The most prominent sign is a cough lasting more than three weeks. It often begins dry, then produces sputum. If the sputum is streaked with blood, you need to see a doctor the same day, without delay.

Alongside the cough, many patients experience heavy night sweats that soak clothing and bedding, a low-grade fever that returns each evening and falls in the morning, loss of appetite and unexplained weight loss over several weeks. Persistent fatigue and shortness of breath on exertion are also common.

In extrapulmonary TB the symptoms vary by the organ affected. Lymph node TB typically causes painless swellings in the neck. Spinal TB causes back pain, sometimes with weakness in the legs. Tuberculous meningitis presents with severe headache, neck stiffness and altered consciousness. These forms are less common but significantly more dangerous.

How is TB diagnosed?

Diagnosis begins with a clinical examination and a chest X-ray or CT scan. Imaging may show patches, cavities in the upper lung or a miliary pattern spread throughout the lung. These findings suggest TB but alone they cannot confirm it.

The definitive method is culturing a sputum sample in the laboratory to identify the bacteria. This takes two to eight weeks. A faster option is the Xpert MTB/RIF molecular test, which gives a result within two hours and simultaneously detects rifampicin resistance, the most important first-line drug.

For latent TB specifically, the tuberculin skin test (TST) or a blood test called IGRA (Interferon-Gamma Release Assay) is used. A comprehensive health technology assessment published in 2024 confirmed that IGRA is more accurate than the skin test in people who received BCG vaccination in childhood, since BCG can cause false-positive skin test results.

What is the treatment and why must you complete the full course?

Standard treatment for active TB uses four antibiotics given together for two months, followed by two of those drugs for a further four months, making six months in total. The four first-line drugs are isoniazid, rifampicin, ethambutol and pyrazinamide. Your doctor calculates the dose according to your body weight.

The reason finishing six months is essential lies in the biology of the bacterium. Mycobacterium tuberculosis divides extremely slowly compared with most bacteria, and some cells are dormant at the time of each dose then become active later. Stopping early kills the weaker bacteria and leaves the stronger ones behind: those stronger organisms multiply and pass their resistance on, producing drug-resistant TB (MDR-TB) that requires a much longer and more toxic regimen.

A review published in 2023 in Innere Medizin noted that new shorter regimens are now available for selected cases, but six months remains the gold standard for drug-susceptible TB. If you miss doses, do not double the next one. Contact your doctor or treatment supervisor immediately so the missed doses can be accounted for.

What is drug-resistant TB and how is it treated differently?

Drug-resistant TB arises when the bacteria develop the ability to survive standard antibiotics, most often because of incomplete treatment or supply interruptions. The most common type is MDR-TB, which is resistant to both isoniazid and rifampicin. The most severe form, XDR-TB, is resistant to multiple first-line and second-line drugs.

MDR-TB treatment is far longer, ranging from nine months to two years depending on the case and available drugs. The medicines used carry heavier side effects, including hearing problems and sometimes psychiatric effects. Preventing MDR-TB by completing the standard course is incomparably better than having to treat it.

In some parts of the Middle East and North Africa, medicine shortages due to conflict or supply chain failures have interrupted courses, unintentionally driving resistance. If you experience a supply interruption, contact the nearest TB programme or health centre immediately. Switching to a different facility or programme to continue your course is preferable to an interruption, and national TB programmes in most countries of the region offer free first-line drugs.

Who is at highest risk in the Middle East and North Africa?

People living in crowded settings such as refugee camps and temporary shelters are at the front of the risk distribution, because the airborne bacteria accumulate in small, poorly ventilated spaces. The 2018 Sudan study documented how years of conflict raised TB rates measurably in affected communities.

People with diabetes face roughly double the general population risk because elevated blood glucose impairs immune cell function, making it easier for latent TB to progress. People living with HIV and those on immunosuppressive medicines for transplants or rheumatic conditions are also at significantly elevated risk. Children under five and the elderly are two further groups with heightened vulnerability.

Migrant workers moving between high-burden countries and their host countries sometimes carry latent TB acquired at home. Early screening of these groups and preventive treatment when indicated can interrupt the chain of transmission before latent infection turns active.

How can you protect yourself and your household?

The BCG vaccine given at birth protects well against the severe forms of TB in young children, including TB meningitis and miliary TB. It is mandatory in the immunisation programmes of most countries in the region. Protection against pulmonary TB in adults is less consistent but BCG remains recommended because it prevents the most dangerous complications.

If you live or work with someone who has active TB, ask at your nearest health centre about being screened with a skin test or IGRA. If latent infection is found, your doctor will assess whether a short preventive treatment course is appropriate for you given your health history.

Good ventilation in homes, schools and clinics lowers the concentration of airborne bacteria. If you are being treated for active TB, wear a mask in indoor spaces and avoid crowded environments until your doctor confirms you are no longer contagious, which is usually after two to three weeks of treatment with the correct drugs.

For households with young children, ask your health centre whether the children qualify for IGRA screening or preventive isoniazid. Children under five who are close contacts of a smear-positive case carry a higher risk of progressing to severe forms of TB, and preventive treatment in this group is well established. In many public health programmes in Egypt, Jordan and the Gulf, contact tracing is offered at no cost when a case is notified.

When should you seek urgent medical attention?

Coughing blood requires a same-day medical review. So does worsening breathlessness with fever, or chest pain alongside any respiratory symptoms. These may point to complications such as a pleural effusion (fluid around the lung) or spread of the bacteria through the bloodstream.

If you are already on TB treatment and develop yellowing of the skin or eyes, blurred or reduced vision, ringing or reduced hearing, burning in your feet, or a sudden skin rash, do not stop the medication on your own. Contact your doctor or treatment centre immediately, as a dose or drug adjustment may be needed. These are recognised side effects of TB drugs and are manageable if reported early.

Patients on TB treatment need regular monthly follow-up reviews. These visits include symptom assessment and sputum culture to confirm the treatment is working. Do not wait for your next scheduled appointment if your condition is worsening.

One practical concern in the region is the cost and availability of follow-up sputum cultures. If your nearest laboratory cannot perform culture, a smear microscopy is cheaper and still informative. Ask the TB programme or health centre about the options available locally. The priority is to stay engaged with care rather than drop out because follow-up seems complicated.

Sources

• Abbara A, Almalla M, AlMasri I et al: The challenges of tuberculosis control in protracted conflict: The case of Syria, International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases, 2020
• Proenca R, Mattos Souza F, Lisboa Bastos M et al: Active and latent tuberculosis in refugees and asylum seekers: a systematic review and meta-analysis, BMC public health, 2020
• Hassanain SA, Edwards JK, Venables E et al: Conflict and tuberculosis in Sudan: a 10-year review of the National Tuberculosis Programme, 2004-2014, Conflict and health, 2018
• Brehm TT, Kohler N, Schmiedel S et al: Treatment of tuberculosis: what is new?, Innere Medizin (Heidelberg, Germany), 2023
• Ontario Health: Interferon-Gamma Release Assay Testing for Latent Tuberculosis Infection: A Health Technology Assessment, Ontario health technology assessment series, 2024
• World Health Organization: Tuberculosis fact sheet