Tuberculosis

by Jo Ruth, Beth El College of Nursing, University of Colorado at Colorado Springs


HISTORY

Evidence of Tuberculosis has been observed in skeletons of early man found in graves from such diverse geographical areas as Germany, Italy, Denmark, Japan and the Pre Columbian Americas. Frank Ryan M.D. (1992) documented the early history of tuberculosis in his book The Forgotten Plague. The earliest human skeletal evidence has been identified from remains of 5,000 to 4,000 BC. At the turn of the nineteenth century it is estimated that half of the world's population had come in contact with tuberculosis. There was fear that the European civilization might be destroyed by the disease.

In March, 1882 Robert Koch announced his sensational discovery of a staining technique which would reveal the bacterium causing tuberculosis, now known as Mycobacterium tuberculosis. This scientific discovery shed light on the ancient and dread disease known as Consumption or White Plague.

The organism causing tuberculosis met the first Europeans as they ventured into the "new" world and, of course, some of the adventures carried the disease with them, in their own bodies. It is estimated that one third of the world's population was and is now infected with Mycobacterium tuberculosis. We have an estimated 10 to 15 million persons infected in the United States.(1)

As the American West was settled, Colorado became known for it's healthy climate. Persons with Consumption who were of the upper and middle classes were encouraged to come to Colorado Springs by Dr. Edwin Solly in his booklet, The Health Resorts of Colorado Springs and Manitou. He boasted of the climate's beneficial effect on many chronic ailments, including tuberculosis.

Dr. Solly's dream was to build a first rate sanitorium for wealthy "lungers" north of Colorado Springs. Cragmor, as it was called, featured wide windows in each room and a sun roof to allow the patients maximum time in the fresh air and sunlight. He also served excellent food for his guests and created a pleasant physical and social environment to enhance their recovery.

There were many sanitoriums and guest homes for consumptives established in Colorado Springs. Dr. Charles Gardiner created individual tents made of heavy canvas for his patients. Eventually he designed small octagonal wooden buildings which provided both the fresh air and greater physical comforts for persons who came for the treatment. An example of these buildings and more information about early health care in Colorado Springs can be found in the Colorado Springs Museum.(2)

DISEASE PROCESS

Tuberculosis is most often spread as an airborne bacillus produced when an infected person may cough, sneeze, talk or sing. Persons sharing the same air space are at risk of inhaling infectious airborne droplets. The tuberculosis bacillus can also transmitted in the milk from infected cows.

In the United States approximately eighty percent of new cases are found in the lungs. The remaining cases are found in the lymphatic system, bone/joint, or disseminated throughout the body. Tuberculosis is a very slow developing disease. After the person is infected the body may be strong enough to fight off the disease by walling off the bacillus where it remains in an inactive state. If the individual is weak and at "high risk" the bacterium is able to develop into active TB. Risk factors include: age, immune status, underlying health conditions or diseases, crowded living conditions, poor diet, high number of contacts with persons who have active tuberculosis.

In 1998 a team of doctors lead by Dr. Stewart T. Cole at the Pasteur Institute in Paris and Dr. Bart B. Barrell from the Sanger Center, Cambridge, England identified and decoded the 4,411,529 chemical letter that make up the genome or DNA sequence of M. tuberculosis. This is an important breakthrough in the process of developing new drugs for treatment and creating vaccines for prevention of the disease.(3)

SYMPTOMS

The symptoms of tuberculosis depend on the site of involvement. The systemic symptoms which frequently occur are fever, night sweats weight loss, and fatigue. This is a very slow developing disease and symptoms may be difficult to identify for a long period of time. If it is found in the lungs the individual will develop a cough which eventually produces white or blood tinged sputum. Symptoms of tuberculosis in other sites may be very subtle at first, depending on the part of the body involved.

The historical name, Consumption, describes the all consuming progression of this disease. The bacillus destroys the tissue of what ever has been infected, it eats into blood vessels resulting in massive hemorrhage in the lungs or if in the bones it produces well known spinal or leg deformities, Death is often the outcome if not treated with medication.

SCREENING

A tuberculin skin test is done to establish suspicion of an infection. A positive responses indicates the individual has come in contact with the tuberculosis bacillus, however, there is no way to tell the status of the infection. Perhaps it has become latent, that is, it has been walled off or it may develop into an active disease process or perhaps it is now reactivated after a long latency or dormant period. The skin test must be given in a standardized fashion to be considered accurate. This simple procedure can be preformed at a Health Department immunization clinic or by other qualified health care providers or clinics. The skin test of Mantoux Purified Protein Derivative (PPD) is injected just under the skin on the inner side of the forearm. The results will be interpreted based on physical status and skin test history of the individual being tested. It is important to return to have the results read 48 to 72 hours following administration of the test or when instructed by the care provider. Mass screening of the total population is not recommended. Persons in high risk occupations such as health care workers are screened annually. Other high risk groups are immigrants from countries which have a high number of persons with tuberculosis such as south eastern Asia. Persons with chronic diseases such as HIV/AIDS, renal disease, diabetes and persons who are being treated for cancer are at a greater risk. Individuals who use IV drugs have a greater risk, as do persons who live in crowded conditions of homeless shelters and migrant camps.(4)

DIAGNOSIS

Diagnosis depends on obtaining samples of sputum or other specimen from the site of involvement. A culture of the organism is positive proof. Tests will also be conducted to identify the specific strain of the organism and identify the best drugs to treat the individual.

TREATMENT

History of Treatment

Until the late 1940's there were no drugs available to treat tuberculosis. Treatment was directed toward lessening the symptoms, identifying environmental factors, and enhancing general physical health by what ever means possible. Many prescribed substances to be taken were actually lethal, such as a kerosene and whiskey concoction. Because of the body wasting, "overeating" or eating unusual foods such as mare's milk were suggested. There were also surgical treatments used to produce an artificial pneumothorax or collapse of the lung to "let it rest" or stop a hemorrhage.

None of these treatments proved effective and many were harmful to the suffers. There were many practitioners who subscribed to the benefit of fresh air. The best known "climatologist" was Dr. Charles Denison of Denver. His writings were instrumental in expanding the national reputation of Colorado's climate.(4)

Current Treatment

Medications now available are INH, Ethambutol (EBB), Streptomycin, Rifampin (RAF) and pyrazinamide (PA). These drugs are given in various combinations and dosage schedules. We now have one tablet, Refuter, which contains rifampin, isoniazid and pyrazinamide together. Currently, the Centers for Disease Control recommends that the selected medications which are effective against the identified strain of bacillus be given twice a week for six to nine months. Each dose MUST be given directly by a health care provider to be sure there are no missed doses. Missed doses contribute to the development of drug-resistance strains of M. tuberculosis.(5)

A 1998 study completed by the World Health Organization showed that of 36 percent of the people who took their prescribed medication for less that a month developed resistance to at least one of the medications. The greatest risk for development of resistance is in the last four months of treatment. Drug resistant bacillus were found in persons with tuberculosis living in 36 different nations throughout the world.(6)

In the state of Colorado medications are given free of charge to person with tuberculosis by the Health Department. This is a cost effective method of preventing a very contagious disease from spreading throughout the community. Individuals who have had recent contact with the infected persons will be screened and treated if they are positive. The motto for tuberculosis control is "treatment is prevention". Success of treatment depends on development of a working partnership between the individual with tuberculosis and health care provider. (7)

If an individual will not accept treatment the Colorado Revised Statutes allow for the quarantine of persons with infectious TB who pose a risk to public health. Persons are considered contagious until they have had 14 days of continuous treatment.(8)

ADDITIONAL INFORMATION

Further information may be obtained from the references and on listed web sites. Communication is welcomed. Please contact J.Ruth, MS, RNC, Senior Clinical Faculty at this web address.

FOOTNOTES

1. Ryan, F. (1992). The Forgotten Plague: How The Battle Against Tuberculosis Was Won - And Lost, New York: Little Brown and Co.

2. Shikes, R.H. (1986) Rocky Mountain Medicine: Doctors, Drugs, and Disease in Early Colorado. Boulder, Johnson Books.

3. Wade, N. (1998 June 11). Scientists Decode the DNA of Germ Responsible for TB. The New York Times Section A; Page 1; Column 1; National Desk.

4. Shikes, R.H. (1986) Rocky Mountain Medicine: Doctors, Drugs, and Disease in Early Colorado. Boulder, Johnson Books.

5. Tuberculosis 2000, (1997, Jan and Feb). Fundamentals of Clinical Tuberculosis and Tuberculosis Control. Atlanta: Centers for Disease Control and Prevention.

6. Pablos-Mendez A. and Others(1998). Global Surveillance for antituberculosis-Drug Resistance 1994-1997. The New England Journal of Medicine.338(23), 1641-1649.

7. Colorado Department of Health and Environment. (1997, Jan 12). Colorado Tuberculosis Manual. Denver: Colorado Department of Health and Environment.

8. Colorado Revised Statutes (25-4-503, 506 and 507)

Web Sites:

Centers for Disease Control and Prevention's Hospital Infections Program