When it comes to diseases that have shaped world history you cannot go past Tuberculosis (TB).\u00a0 Its footprint lingers in literature, it is found in ancient Neolithic remains and Egyptian mummies and we can even link the development of Kellogg\u2019s Cornflakes with the health crazes that it triggered over the previous two centuries.<\/p>\n
TB is caused by the bacterium Mycobacterium tuberculosis<\/em>, in the same genus as the bacteria that cause leprosy, another scourge of the ancient world.\u00a0 M. tuberculosis<\/em> bacteria invade the body then concentrate in tubercles otherwise known as granulomatous lesions, cysts which are formed around infected tissue by the immune system.\u00a0 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.\u00a0 Its slow growth and aberrant cell wall structure allow\u00a0the bacteria to be further resistant to treatment.\u00a0 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.\u00a0 Treatment required a mix of multiple hard hitting antibiotics over at least six months, a schedule that is often not maintained by patients.<\/p>\n M. tuberculosis<\/em> shows a preference for the lungs but can invade <\/span>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.\u00a0 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.\u00a0 More commonly the chronic infection causes scarring of the lungs, leading to a slow death from lung failure.<\/span><\/p>\n By the start of the 1800s, it was estimated one in four deaths in England was caused by Tuberculosis.\u00a0 The Victorian\u2019s 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.\u00a0Diseases were considered the result of miasma (bad air) and health resorts became the rage across Europe and America.\u00a0 In Germany and Switzerland health spa tourism was born.\u00a0 In England, it was Bath and the seaside resorts of Brighton and Hampton that benefited.\u00a0 In America, Dr Kellogg\u2019s health sanatorium focused on nutrition, exercise and strangely enemas.\u00a0 The breakfast cereal he developed was wildly successful.\u00a0 His enema treatments not so much.<\/p>\n By the end of this century, the microscope had revealed the cause of infectious disease.\u00a0 This was the age of Koch and Pasteur, the fathers of microbiology and two of the most bitter rivals in scientific history.\u00a0 It was German Robert Koch who identified the M. tuberculosis<\/em>, a discovery that won him the Nobel prize in medicine in 1905 and lead to M. tuberculosis <\/em>being commonly called Koch\u2019s bacillus.\u00a0 Public health campaigns started up to prevent the spread the results of that we can still see today.\u00a0 Laws prohibiting public spitting can be traced to anti-tuberculosis campaigns and the signs from the 1920\u2019s campaign prohibiting spitting are still in place at Melbourne\u2019s famous Flinders St train station.\u00a0 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.\u00a0 Pasteurisation stopped the transmission of the closely related bacteria M. bovis<\/em> from cows to humans, a common cause of TB in the 1900s.<\/p>\n By the 1940s to 1950s antibiotics had come onto the scene and were successful in causing a rapid decrease in the rates of TB.\u00a0 However, M. tuberculosis <\/em>was quick to fight back and due to its unique cellular quirks was one of the first bacteria in which antibiotic resistance was seen.\u00a0 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.<\/p>\n So why should AIDS and TB be linked?\u00a0 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<\/a> positive.\u00a0 Yet HIV is listed as a risk factor for TB.<\/p>\n Firstly there are the shared risk factors.\u00a0 Poverty and drug use, which are risk factors for contracting HIV, are also risk factors for many other diseases including TB.\u00a0 TB, like most respiratory diseases, is spread through close personal contact and kissing during sex, like a cold.\u00a0 Secondly, bacteria are primarily opportunistic pathogens.\u00a0 They cause disease for the most part in sick people where the immune system is not so strong and you can\u2019t get all that much more immunocompromised than AIDS.\u00a0 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.\u00a0 Then there are the drugs, medical drugs I mean.\u00a0 I spoke in an earlier blog piece<\/a> about how the recent development of one pill HIV PEP<\/a> combination therapy for HIV was a godsend for doctors as it make people far more likely to take their medication.\u00a0 The same is true for TB.<\/p>\n Imagine that you have AIDS.\u00a0 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.\u00a0 Then you are told, \u201cOh and by the way, you have TB.\u00a0 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.\u00a0 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.\u00a0 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.\u00a0 These need to be taken with food, this one can\u2019t be taken with food, this one twice a day, only take that one in the evening\u201d and so on.\u00a0 I suspect like me you would have trouble keeping them all in order let alone taking them all.<\/p>\n The problem is that non-compliance with the treatment is what causes resistance.\u00a0 There are some superbug strains of M. tuberculosis<\/em> which nothing will cure, and with a fatality rate of around 50%, that is a scary thought.\u00a0 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.\u00a0 You can see why combination therapy for HIV is a wonder.\u00a0 Reducing that list by two drugs makes everything seem far more manageable.<\/p>\n HIV and TB are both diseases of poverty.\u00a0 They occur most often in the marginalised and those who court risk.\u00a0 But their impacts are felt by all.\u00a0\u00a0 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.\u00a0 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.\u00a0 For both diseases are seen primarily in people of working age, resulting in not only direct costs to the health care services\u00a0but in the reduction of effective workforce.<\/p>\n 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.\u00a0 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.\u00a0 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.<\/p>\n A vaccine, the bacille Calmette-Guerin (BCG), exists, however causes the patient to give a false positive for blood tests for TB.\u00a0 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.\u00a0 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.\u00a0 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.<\/p>\n 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.\u00a0 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.\u00a0 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.<\/p>\n Co-morbidity is rare for infectious disease except in STDs<\/a>.\u00a0 Unfortunately if you have one STD it is likely you also have another, and that list is not just limited to STDs.\u00a0 Singapore is fortunate to have a relatively low incidence of both AIDS and TB.\u00a0 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.\u00a0 Make your doctor aware of any other symptoms you may have as well as regions you have recently visited.\u00a0 These things can be treated if you catch them early.\u00a0 Don\u2019t become a statistic.<\/p>\n","protected":false},"excerpt":{"rendered":" Tuberculosis When it comes to diseases that have shaped world history you cannot go past Tuberculosis (TB).\u00a0 Its footprint lingers in literature, it is found in ancient Neolithic remains and Egyptian mummies and we can even link the development of Kellogg\u2019s Cornflakes with the health crazes that it triggered over the previous two centuries. Cause… Continue reading Infection<\/h3>\n
The 1800s<\/h3>\n
Arrival of Antibiotics<\/h3>\n
The Link Between HIV and TB<\/h2>\n
Shared Risk Factors<\/h3>\n
The\u00a0Cocktail of Confusion<\/h3>\n
The Problem With Non-compliance<\/h3>\n
A Problem That Affects Everyone<\/h3>\n
Conclusion<\/h2>\n