Tuberculosis

When it comes to diseases that have shaped world history you cannot go past Tuberculosis (TB).  Its footprint lingers in literature, it is found in ancient Neolithic remains and Egyptian mummies and we can even link the development of Kellogg’s Cornflakes with the health crazes that it triggered over the previous two centuries.

Cause

TB is caused by the bacterium Mycobacterium tuberculosis, in the same genus as the bacteria that cause leprosy, another scourge of the ancient world.  M. tuberculosis bacteria invade the body then concentrate in tubercles otherwise known as granulomatous lesions, cysts which are formed around infected tissue by the immune system.  While these halt the immediate invasion and minimise tissue damage they do prevent the immune system or certain antibiotics from destroying the bacteria within allowing it to maintain chronic infection.  Its slow growth and aberrant cell wall structure allow the bacteria to be further resistant to treatment.  Antibiotics find the cell wall, a cross between gram negative and positive structures, difficult to permeate, and many, including penicillin, target the cell replication process.  Treatment required a mix of multiple hard hitting antibiotics over at least six months, a schedule that is often not maintained by patients.

Infection

M. tuberculosis shows a preference for the lungs but can invade any body tissue including the brain. Military Tuberculosis is when it gets into the blood stream to cause a systemic infection and is often rapidly fatal.  Once a rare complication of Tuberculosis, seen mostly in young children, co-morbidity (infection of two or more pathogens) with AIDS results in a 3-6 fold increase in the risk of developing Military Tuberculosis if infected with the bacteria.  More commonly the chronic infection causes scarring of the lungs, leading to a slow death from lung failure.

The 1800s

By the start of the 1800s, it was estimated one in four deaths in England was caused by Tuberculosis.  The Victorian’s love of tragedy introduced the consumptive beauty into literature, the heroine who slowly succumbed to a disease that made her pale, thin and ethereally lovely. Diseases were considered the result of miasma (bad air) and health resorts became the rage across Europe and America.  In Germany and Switzerland health spa tourism was born.  In England, it was Bath and the seaside resorts of Brighton and Hampton that benefited.  In America, Dr Kellogg’s health sanatorium focused on nutrition, exercise and strangely enemas.  The breakfast cereal he developed was wildly successful.  His enema treatments not so much.

By the end of this century, the microscope had revealed the cause of infectious disease.  This was the age of Koch and Pasteur, the fathers of microbiology and two of the most bitter rivals in scientific history.  It was German Robert Koch who identified the M. tuberculosis, a discovery that won him the Nobel prize in medicine in 1905 and lead to M. tuberculosis being commonly called Koch’s bacillus.  Public health campaigns started up to prevent the spread the results of that we can still see today.  Laws prohibiting public spitting can be traced to anti-tuberculosis campaigns and the signs from the 1920’s campaign prohibiting spitting are still in place at Melbourne’s famous Flinders St train station.  Frenchman Louis Pasteur put his own mark on the history of tuberculosis by developing the method of pasteurisation by which milk could be sterilised prior to sale.  Pasteurisation stopped the transmission of the closely related bacteria M. bovis from cows to humans, a common cause of TB in the 1900s.

Arrival of Antibiotics

By the 1940s to 1950s antibiotics had come onto the scene and were successful in causing a rapid decrease in the rates of TB.  However, M. tuberculosis was quick to fight back and due to its unique cellular quirks was one of the first bacteria in which antibiotic resistance was seen.  The emergence of antibiotic resistant TB strains coincided with the sexual revolution and the explosion of AIDS onto the world, first in Africa in between 1950-1970 then into Asia and the western world.

The Link Between HIV and TB

So why should AIDS and TB be linked?  After all of the 1.45 million deaths caused by TB in 2013 (second only to AIDS as the leading cause of infectious disease-related deaths worldwide) only 0.34 million were HIV positive.  Yet HIV is listed as a risk factor for TB.

Shared Risk Factors

Firstly there are the shared risk factors.  Poverty and drug use, which are risk factors for contracting HIV, are also risk factors for many other diseases including TB.  TB, like most respiratory diseases, is spread through close personal contact and kissing during sex, like a cold.  Secondly, bacteria are primarily opportunistic pathogens.  They cause disease for the most part in sick people where the immune system is not so strong and you can’t get all that much more immunocompromised than AIDS.  People with compromised immune systems are also more likely to have asymptomatic TB and so spread the disease more readily as they will not take measures to protect their partner.  Then there are the drugs, medical drugs I mean.  I spoke in an earlier blog piece about how the recent development of one pill HIV PEP combination therapy for HIV was a godsend for doctors as it make people far more likely to take their medication.  The same is true for TB.

The Cocktail of Confusion

Imagine that you have AIDS.  You are taking three drugs for the HIV, another two to counter side effects, one for the thrush in your mouth, one that you are not sure what it does but your doctor says you have to take it.  Then you are told, “Oh and by the way, you have TB.  You need to take isoniazid for six months so here are some vitamin B tablets as well and I will also put you on rifampicin.  Two months on pyrazinamide, it may cause some joint pain, and ethambutol, now that may cause red-green colour blindness, unlikely, but let me know if you have any trouble with your eyes, ok.  Here are some tablets for the diarrhoea this is likely to cause and now I should let you know all of these can cause your liver to shut down, only sometimes, but I will need to you come in for a liver test next month.  These need to be taken with food, this one can’t be taken with food, this one twice a day, only take that one in the evening” and so on.  I suspect like me you would have trouble keeping them all in order let alone taking them all.

The Problem With Non-compliance

The problem is that non-compliance with the treatment is what causes resistance.  There are some superbug strains of M. tuberculosis which nothing will cure, and with a fatality rate of around 50%, that is a scary thought.  Compliance programs, where a nurse comes to your house and watches over you while you take your drugs, have been very effective. However, such programs are very expensive and when the highest incidence of TB is in the third world, such programs are just not feasible.  You can see why combination therapy for HIV is a wonder.  Reducing that list by two drugs makes everything seem far more manageable.

A Problem That Affects Everyone

HIV and TB are both diseases of poverty.  They occur most often in the marginalised and those who court risk.  But their impacts are felt by all.   The AIDS 2031 Cost and Financing Working Group, as part of the Joint United Nations Programme on HIV/AIDS (UNAIDS) Global Resource Needs, estimates that by 2031 HIV may be costing the global economy $35 billion dollars US.  TB while less in incidence has not had the global research on reducing costs and is estimated to cost $1-3 trillion a year and can rob a country of up to 7% of its GDP.  For both diseases are seen primarily in people of working age, resulting in not only direct costs to the health care services but in the reduction of effective workforce.

The good news is that as they are both seen in the same demographic, resources can be targeted to that demographic for both diseases and share the costs.  The chronic condition of TB makes it economically viable for drug companies to research and manufacture combination therapies for TB, whereas they are not for other bacteria diseases.  Less arduous treatment options mean that compliance going forward is less costly and more likely without a nurse to hover over the patient’s shoulder.

Conclusion

A vaccine, the bacille Calmette-Guerin (BCG), exists, however causes the patient to give a false positive for blood tests for TB.  For this reason, the vaccine was not introduced into the childhood immunisation programs in the USA, though it has been used and still is used in many countries including Singapore and Australia.  Australia discontinued immunisation against TB in the 1980s except for children less than six months who would be living in or travelling through a country with high TB incidence.  TB incidence has been on the rise in Australia since 2007 as with many first world countries, thought to be a result of increased global migration.

Singapore discontinued the second vaccination for BCG in 2001 following a highly successful campaign with the Singapore TB Elimination Programme (STEP) which saw a 15% reduction in new cases of TB in three years.  Infants are still vaccinated and this protects them during the most vulnerable years and the second vaccination is deemed unnecessary save in specific high-risk circumstances.  Vaccination of children under six months of age does not cause them to show a false positive in TB tests, leaving the current TB detection tests effective. Research is ongoing for a workable adult vaccine.

Co-morbidity is rare for infectious disease except in STDs.  Unfortunately if you have one STD it is likely you also have another, and that list is not just limited to STDs.  Singapore is fortunate to have a relatively low incidence of both AIDS and TB.  If you are travelling be aware that other countries are not so fortunate and activities that may be fairly low risk in Singapore or Australia may be high risk in China or Africa.  Make your doctor aware of any other symptoms you may have as well as regions you have recently visited.  These things can be treated if you catch them early.  Don’t become a statistic.

Syphilis is forever linked in my mind with Elizabethan times. It may even be responsible for them, as Henry the Eight was allegedly infected. Syphilis may have been responsible for the high incidence of miscarriage seen in his first wife, leading to his divorce, the creation of the Church of England and his infamous marriage to Anne Boylan. As the new world opened up to explorers and spread the diseases of medieval Europe across two continents, one disease moved the other way.

Making A Comeback

Treponema pallidum, a spiral shaped bacteria that under the microscope almost looks cute as it corkscrews its way across the slide. The symptoms, however, are terrible. In the year 2000 it looked as if it was on its way out, reaching the lowest incidence in the USA since reporting began in 1941. Since then however the disease has made a comeback, doubling in incidence between 2005 and 2013. Control has been less successful in the developing world with an estimated 12 million new cases in 1999 and notable recent outbreaks in Russian and China.

Symptoms

Syphilis is a disease for the long term and has three distinct stages. The first stage (primary syphilis) consists of highly infectious skin lesions. These commonly occur on or around the genitals or mouth but can appear on any part of the body. The sores usually last about 3 weeks but can be present for as long as 90 days. They are painless, sometimes go unnoticed by the patient and will resolve even without treatment.

If untreated, however, secondary syphilis may occur one to six months later with a rash around the groin and commonly on the palm of the hand. The rash is often described as a rosy “copper penny” rash and is easily identifiable as syphilis, but can occur as a nondescript rash that may be misdiagnosed. Other symptoms include possible warts around the genitals, sores in the mouth, fever and weight loss. Like primary syphilis, secondary syphilis will appear to resolve without treatment within a few months.

The bacteria can then lay dormant in your system for years, a period known as latent syphilis without causing any symptoms.

The Final Stages

Tertiary syphilis is the reason that Treponema pallidum should be feared. Following the latent period, the bacteria can then re-emerge to cause systemic disease, infecting essential organs such as the heart, nervous system and brain. Symptoms can include heart disease, blindness, deafness, arthritis and brain damage leading to dementia. If untreated the disease will eventually prove fatal.

Treatment

Treatment with penicillin once proved exceptionally effective and resulted in almost wiping out the disease. In most cases the bacteria are still highly susceptible to a single dose of intramuscular Penicillin, but there has been a rise in macrolide (erythromycin), tetracycline and rifampicin resistance in Treponema pallidum making treatment of penicillin-sensitive people difficult. Even with treatment if the syphilis bacteria have invaded the cerebral spinal area (brain and spinal column) many antibiotics struggle to reach this area and may not reach levels fatal to the bacteria. Relapse can occur and patients should be monitored following treatment.

What To Do

People diagnosed with syphilis will need to notify sexual partners. Condoms provide limited protection against the spread of syphilis as sores are often not covered so anyone with Syphilis must abstain from sex while sores are present to prevent infecting others. Incidence in of syphilis in Singapore is low compared to most countries but care should always be taken. Remember the best protection against any STD is abstinence or to be in a monogamous relationship where both partners are known to be STD free.

“We have received feedback from those with close links to HIV/AIDS patients, that some HIV positive persons deliberately spread the disease as a form of revenge on society.” Dr Balaji Sadasivan, Senior Minister of State for Information, Communications and The Arts, and Health, 4^th Singapore AIDS conference 2004.

You would think that being diagnosed with a horrible disease that your instinct would be to protect other people from the same fate. So often you see people who are affected with a devastating disease or who have lost a family member to that disease, supporting campaigns to find a cure, or educate others to avoid it. But with AIDS we see a nastier side to humanity, those who feel cheated by life, used by those who infected them. Who either ignore the risk to others or continue with their promiscuous lifestyle uncaring of who they infect, or worse, who deliberately infect others in order to get their own back, or share their pain.

If cancer was infectious would we see the same pattern, cancer patients infecting others to share the misery or is it to do with the social stigma? If AIDS was not linked to prostitution and homosexuality would we see the same reaction? Is it a person already stigmatised for their lifestyle lashing out at the world for this new indignity?

Then there is a new trend in the USA known as bug seeking, where young homeless men are intentionally contracting the disease in order to receive assistance from the state.

Gaétan Dugas, a Canadian flight attendant is rightly or wrongly credited with spreading the HIV virus through the gay community of the USA, at a rate estimated at 250 partners a year and linking the AIDS epidemic in the USA forever with homosexuality. Sources vary as to whether Gaétan spread the virus knowingly or not.

Hans-Otto Schiemann, a German man living in Thailand, allegedly offered young women large sums of money to sleep with him despite being HIV positive. According to The Age (October 13, 2004) between 400-500 girls were at risk of infection from his actions from when he was first diagnosed in 2001 to being jailed in 2004.

David Mannum in the USA was jailed in 2013 for deliberately infecting up to 300 people. According to CBS New (September 5, 2013) he did not disclose his HIV status due to fear of rejection.

It is not just men, German pop star Nadja Benaissa was convicted in 2010 of infecting her partner with HIV. English hairdresser Sarah Jane Porter was jailed in 2006 for having unprotected sex with multiple partners following her HIV diagnosis. While it is harder for men to contract the virus than women during sexual intercourse it is still a high risk to take.

Few cases however get darker than that reported in the New York Times (January 9, 1999) of Brian Stewart, who in 1992 infected his 11 month old son with contaminated blood when the boy was recovering in hospital following an asthma attack. The reason behind the attack was that he did not want to pay child support. In 1999 he was sentenced to life in prison.

Rumours abound of men and women who recklessly and deliberately spread the HIV to multiple partners, but the cases of HIV sociopaths are rare. More often they are terrified and unable to face the truth about their condition. They do not tell others for fear of being rejected. Unfortunately, it is not a problem that goes away if ignored and many people can be hurt from non-disclosure.

In some countries, it is against the law to transmit the disease to another once you know you are HIV positive. Other countries use existing laws to prosecute those who deliberately infect others. In Singapore, the law is very clear. “It is an offence for persons who know that they are infected with HIV not to inform their sex partners of their HIV status before sexual intercourse,” under the Infectious Disease Act. There have been no cases of large-scale deliberate infections with HIV in Singapore. The first conviction under the act was in 2008 and since then there have been two more. None passed the disease to more than two people.

Most people are honest and will do the right things. Those who are out to deliberately infect people are looking for the act themselves. Beware one night stands. Get to know the person before you get into bed and ask the hard questions. Not asking can be much harder in the end.

If you are HIV positive or suspect you may be, please consult your healthcare professional. There is support available. If you suspect you have been deliberately infected, consult your doctor and mention that it may have been deliberate, they will be able to give you support in approaching law enforcement agencies.

We live in troubled times, medically speaking. The antibiotics that seemed so close to conquering the world of bacterial disease are failing. There is a very real possibility of a gonococcal superbug, resistant to all forms of antibiotic. As early as 2012 Dr. Gail Bolan, director of the Division of STD Prevention at the CDC advised that “Untreatable gonorrhea is a real possibility” and this is not the only STD that is powering its way through genetic mutation to apparent invincibility.

The post-antibiotic age is fraught with uncertainty, but things could be worse. We have a scientific powerhouse to fall back on, with a solution more likely than not. But what was it like to live in pre-antibiotic times?

Gonorrhea, herpes and genital warts are mentioned in historical documents going back to Ancient Egypt and Ancient Greece. There is a plethora of social and medical solutions to the sexually transmitted poxes that followed armies across the ancient world.

Have cankers or warts on the genitals? No problem for a Greek surgeon. The obvious solution is to cut them off. Anaesthetic? Not really but here is some hemlock that might dull the pain, possibly permanently.

Herpes on the rise in your city? A ban on kissing is an easy, if unpopular, solution. Even less popular I suspect was the cure for  lesions. Application of a red-hot poker will solve that problem.

The clap cutting a swath through the population? The English have the solution. Yes, youth clubs for the peasantry. Get the young men out rowing, bell ringing, playing at archery or learning to swim is sure to “distract them from moral carelessness.” Should you be unfortunate enough to contract it, a urinary blockage is easily cleared by insertion of a metal catheter into the urethra.

Syphilis introduced by sailors from the new world was so feared that the French King banished suffers from the city. King Henry VIII of England ordered an immediate, and as it turned out temporary, closure of brothels in London and a ban on mixed-sex bathing. But a cure was on its way, fresh from the Islamic scholars. The miraculous cure of mercury injected into the infected urethra or vagina. Sure to prevent the progression to tertiary syphilis with its accompanying lesions and madness (side effects may cause lesions and madness). If mercury failed, why not add lead to the heavy metal treatment with a lead infusion in almond oil?

If the problem persists, bloodletting was commonly used as well as arsenic, more mercury (ingested this time), and when all else fails, a prayer to the god(s) will most definitely work (most effective when combined with a generous donation to your local monastery).

Can’t perform in the bedroom? No Viagra as yet, but why not try the new craze on the block. Yes, it is the early 1800s and a new age has dawned. Lightning has been tamed and for a one-time special offer you can purchase an electrifying belt, sure to give you a jolt in just the right place. Warning: electrification may result in burns or death (no refund).

Mercury injection was a common treatment for syphilis up until the late 1800s despite its hideous side effects, in the absence of a better treatment. It was gradually replaced by silver nitrate, potassium iodine and into the 1900s with the sulphonamides and penicillin in 1943.

So not matter the outcome of any test. No matter the tedious instructions to take with food, or before eating, after eating, at night, one 5^th of a tablet five times a day, the threat of an intramuscular injection or even a suppository. Give a small prayer of thanks that you will never see the words injection of mercury solution or application of heated iron on the doctor’s prescription pad.

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SEXUALLY TRANSMITTED DISEASES: AN HISTORICAL RETROSPECT by Brian Plumb

There was a time, when lice were so much a part of daily life that a good infestation was considered a sign of good health. Bill Bryon in his masterpiece of domestic history “At Home” tells of people forming this idea due to body lice fleeing the heat of a feverish body and poets imagining a lecherous louse crawling on the body of a beautiful woman and reaching places they could not. In modern times, the increase in hygiene has removed lice as a daily infestation. Most of us will have a passing experience with head lice as a child (or a parent) but few with think of checking for pubic lice.

Lice are small insects, the pubic lice are a different genus and smaller size than the body or hair lice we are more familiar with. There are three stages in the life cycle of a louse, nits (eggs) which show as white dots on the hair, three stages of nymphs and the adult louse or crab.

Pubic lice are human specific and cannot live more than 24hrs off the body. The nymph and louse both feed solely on human blood and cause bites that vary from 0.2 to 3 mm initially red turning to blue spots. The bites and droppings of the louse can cause itching and irritation that tends to be worse at night.

Pubic lice show a preference for secondary sexual hair. They will not live on head hair or other body hair, but, as well as pubic hair, they will happily dwell in armpit hair, coarser leg hair and, disturbingly, moustaches or beards and, in very rare cases, the eyelashes.

Infestations are most commonly seen in teenagers and are spread mostly via sexual contact. They can be spread by sharing clothing or sheets but this is not a common form of transmission due to their short life span once off the body. They do not adhere to toilet seats and cannot be passed by use of public facilities. It is thought that about 2% of the global population is infected, though many scholars believe that the popularity of the Brazilian wax may be causing a reduction in lice populations.

Unlike body lice, pubic lice have not been known to carry dangerous bacteria in their stomachs. Long-term infection can result chronic dermatitis and scratching can cause a secondary infection through broken skin.

Treatment involves washing with special body wash and using a nit comb to remove any remaining nits. Clothing and bedding should be treated with a hot wash of clothing. Family members and sexual partners should be advised to get themselves checked. Infection with lice often occurs in conjunction with other STD infection so it is a good idea to get tested for the most common STDs if crabs are seen.