Tuberculosis: Previous and Present Millennium.

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Tuberculosis Previous and Present Millennium.

• TB before advent of chemotherapy
• TB in 1950 - 2000
• Morbidity, Mortality Elimination of TB.
• Censina R. Apap,
• Pulmonologist.

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Introducing Myself

• Respiratory specialist since 1983
• Working in the Netherlands since 1977
• Special interests include Tuberculosis, Asthma,
  COPD, and Oncology.
• Tuberculosis, a fascinating topic.

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Introduction to the lecture

• Natural history of TB
• Much morbidity and mortality before the advent
  of antibiotics
• HIV, MDR-TB and relaxation of TB control programs
  present new public health problems

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Tuberculosis in the past Phtisis

• Phtisis renamed Tuberculosis in 1837
• Congenital / infectious disease?
• Known to be infectious in 1865
• Cause of TB discovered by Koch in 1882
• Subdivision open / closed TB

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TB R/ in the pre-antibiotica era.

• Conservative, directed at relief of symptoms.
• Sanatorium R/ introduced in Germany by Brehmer
  resulted in 25 sputum conversion within 6 mo.
  50 of smear positive cases died of disease
  within 5 years.

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How was TB treated in 1937?

• Upon the permanence of closure of a tuberculous
  cavity depends the future development of the
  disease.The tuberculous cavity is the disease
  itself, the one feature which controls and
  regulates the course and outcome of the pulmonary
  lesion and the fate of the patient.
• Coryllos.

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Sanatorium Hospital Home
R/ Total patients 1026 152
347 No of deaths 565
131 288
From W.A. Griep
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Deaths (fall off rate) due to TB.
of deaths Infectious TB Non-infectious TB
After 1 year 23.8 0.9
After 5 years 66.5 11.2
After 10 years 74 16.5
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Active R/ of TB.

• Collapse R/
• Artificial pneumothorax, Forlanini in 1888
• Phrenicus paralysis
• Thoracoplasty
• Closed suction of lung cavities (Monaldi)
• Lung resection.

• Results of active R/
• Active treatment gives an additional sputum
  conversion of 6.
• N.B.
• Lung resection only possible with required
  appropriate intratracheal anaesthetic techniques.

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Complications of Thoracoplasty

• Thorax cage instability with paravertebral
  thoracoplasty
• Empyema and wound infections with plombage
• In the case of selective thoracoplasty and
  resection of first rib
• Air emboli
• Trauma to the brachial plexus and thoracic duct
• Postoperative complications included
• Shock
• Aspiration pneumonia, atelectasis
• Cardiac complications

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Natural course of TB infection

• Mycobacteria inhaled -gt phagocytosis by alveolar
  macrophages-gt 2 possibilities
• No infection
• Infection (early / late)

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Transmission of TB

• Source case with open TB of lungs / larynx
• -gt transmission through cough /sneeze -gt
  infection early 5-10, late in 5.
• -gt result recovery (possible morbidity) / death.
• Positive tuberculin test reflects infected
  contacts.
• Progression to early / late infection
• Possible new source cases provided

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Introduction of Antibiotics 1944

• In 1944, Waksman makes Streptomycin.
• PAS is available in 1946, INH in 1952 and
  Rifampicin in 1965.
• Improved socio-economic factors and availability
  of effective chemotherapy-gt radical change in R/
• Ambulant and in outpatient setting,
• unless otherwise indicated.

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TB R/ in the antibiotic era.

• Role of chemotherapy permanent cure without
  development of resistance
• Lack of success herein due to various factors
• Improper use of antibiotics
• Increased transmission
• Priority of disease control less imminent
• ? Risk -gt outbreak

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Terminology

• Rates are expressed per 100,000 inhabitants
• TB mortality number of deaths from TB
• TB lethality deaths from TB at a certain point
  of time expressed as of incidence
• TB prevalence number of TB cases at a point in
  time
• Infection prevalence of population infected
  with TB
• TB incidence number of TB cases infected in a
  defined year
• Infection incidence number of new cases (re-)
  infected with TB in a certain year
• Tuberculin index of a defined age-group of a
  defined population developing a positive
  tuberculin test at a given point in time

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Terminology

• Bacterial resistance 1 of TB bacilli
  population insensitive to chemotherapy
• Resistance mono / multiple
• INH 5-10, RMP rare
• Resistance primary / secondary
• MDR-TB -gt resistant to both INH RMP

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Blessing or threat?

• TB is rare in industrialized countries
• If undetected, increased morbidity follows
• Outbreak to the general population may be the
  result

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Current situation in the Netherlands (NL).

• Mortality rate 2 / 100,000
• Morbidity rate 20 50 / 100,000
• 1n 1987, 1229 cases recorded
• Current problems -gt emergence of drug resistance
  and HIV-infection.

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Prognostic factors.

• Extent of the disease
• Cavernous lung disease
• Family history of tuberculosis
• Social factors
• Nutrition status
• Immune state
• R/

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TB in the year 2000

• TB -gt still a leading cause of death in
  developing countries
• TB -gt kills 3 million people a year worldwide
• 3 current epidemics -gt HIV, resurgence of TB,
  MDR-TB
• AIDS MDR-TB (super bug) -gt alliance of error

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HIV attributable TB

• In 1990 -gt 4
• In 2000 -gt 14, of which 40 in sub-Saharan
  Africa, another 40 in South East Asia
• Global mortality from TB associated with HIV in
  1990 -gt 116,000

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TB in HIV-positive subjects

• M. Tuberculosis
• Prevalence is higher than in HIV-negative
  subjects
• Often preceeds the diagnosis of AIDS, is
  commonly a reactivation of a latent infection
• Other mode of presentation than in HIV-negative
  individuals.

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TB variance in HIV and HIV - subjects.
Features Age incidence Fever Caseation AFBs Tuberculin test Calcification Hilaradenopathy Cavitation Extrapulmonary sites HIV 20 50 years Common Minimal Present, often extracellular Negative in 60 Absent Bilateral Rare In 50 HIV 50 years Common Present Present, usually intracellular Positive in most Present Unilateral Common Rare
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Atypical TB in HIV-postives.

• Atypical TB
• MAIS- complex, exposure difficult to escape
• Late manifestation of HIV disease, an expression
  of severe immuno-suppression
• Is usually widely disseminated, lung is not the
  primary organ affected
• Heaps of intracellular AFBs
• Is to be seen as a harbinger of death.

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Prevention and control of TB

• 2 basic strategies of paramount importance
• Timely identification and effective treatment
• Effective and timely screening of close contacts

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Contact tracing

• Ring 1 high contact, 20 risk of infection
• Ring 2 moderate contact, 4 risk
• Ring 3 little contact, 0,3 risk
• Positive case finding in an inner ring,
  influences testing in an outer ring

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Summary (1)

• Past R/ ineffective -gt high morbidity and
  mortality
• Chemotherapy and improved socio-economic
  conditions -gt a radical change in R/ -gt ambulant
  and in out-patient setting
• Result -gt TB, a rare disease in industrialized
  countries

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Summary (2)

• In 1980 relaxation / dismantling of TB control
  network
• HIV epidemic causes TB resurgence
• Drug resistance leads to MDR-TB in
• Sub-Saharan Africa and South East Asia
• Some states of the USA
• Might become a problem in W. Europe
• A 3rd epidemic with MDR-TB should be avoided at
  all costs

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Recommended literature

• Styblo K.
• Brudney et al
• Ryan Fr.
• Dolin PJ et al
• Gyselen A.

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Recommended sites

• New Yorks Health department
• Global netwerk TB control
• Centers for disease control prevention
• John Hopkins
• National Institute of Allergy Infectious
  Diseases
• Tuberculosis testing
• Discuss global TB program

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Further links

• Search for TB articles
• Personal stories, support groups
• National Library of Medicine
• World Health Organization
• Tuberculosis control in NL
• Tuberculosis control in Belgium