Tuberculosis

Health Alert

Tuberculosis Henry Wouk

TUBERCULOSIS

Health Alert

TUBERCULOSIS

Henry Wouk

With thanks to Adam J. Adler, PhD, Associate Professor, Center for Immunotherapy of Cancer and Infectious Diseases and Department of Immunology, University of Connecticut Health Center, for his expert review of the manuscript. Marshall Cavendish Benchmark 99 White Plains Road Tarrytown, New York 10591-5502 www.marshallcavendish.us Text copyright © 2010 by Marshall Cavendish Corporation All rights reserved. No part of this book may be reproduced or utilized in any form or by any means electronic or mechanical including photocopying, recording, or by any information storage and retrieval system, without permission from the copyright holders. This book is not intended for use as a substitute for advice, consultation, or treatment by a licensed medical practitioner. The reader is advised that no action of a medical nature should be taken without consultation with a licensed medical practitioner, including action that may seem to be indicated by the contents of this work, since individual circumstances vary and medical standards, knowledge, and practices change with time. The publisher, author, and medical consultants disclaim all liability and cannot be held responsible for any problems that may arise from the use of this book. Library of Congress Cataloging-in-Publication Data Wouk, Henry. Tuberculosis / by Henry Wouk. p. cm. — (Health alert) Includes index. Summary: “Provides comprehensive information on the causes, treatment, and history of tuberculosis”—Provided by publisher. ISBN 978-0-7614-4611-8 (e-book) 1. Tuberculosis—Juvenile literature. 2. Tuberculosis—History—Juvenile literature. I. Title. RC311.W94 2010 616.9’95—dc22 2008021369 Front cover: An X-ray showing extensive tuberculosis in both lungs (in red). Title page: Tuberculosis bacteria Photo Research by Candlepants Incorporated Cover Photo: SPL / Photo Researchers Inc. The photographs in this book are used by permission and through the courtesy of: Peter Arnold Inc.: Manfred Kage, 3, 54. Corbis: CDC/PHIL, 5, 11; Anna Kern/Etsa, 21; Bettmann, 38, 39, 30; Seattle Post-Intelligencer Collection; Museum of History and Industry, 41; Hulton-Deutsch Collection, 42; Gideon Mendel for The International HIV/AIDS Alliance, 44; 45. Photo Researchers Inc.: Deni McIntyre, 8; Véronique Estiot, 12; Innerspace Imaging, 14; Adam Gault, 18; SPL, 19, 28; Andy Crump, TDR, WHO, 26, 47. Getty Images: 3D4Medical.com, 13. Alamy Images: Nick Gregory, 16; Bubbles Photolibrary, 24. PhotoTakeUSA.com: ISM, 22; Bart's Medical Library, 25. Art Resource, NY: HIP, 31. The Image Works: Print Collector / HIP, 33; Jacques Boyer / Roger-Viollet, 37. The Bridgeman Art Library: Barry, Jonathan (Contemporary Artist) / Private Collection, 34. AP Images: Ric Francis, 49; Greg Baker, 52; Marcio Jose Sanchez, 56 Editor: Joy Bean Publisher: Michelle Bisson Art Director: Anahid Hamparian Printed in Malaysia 654321

Contents

Chapter 1

What Is It Like to Have Tuberculosis?

6

Chapter 2

What Is Tuberculosis?

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Chapter 3

The History of Tuberculosis

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Chapter 4

Treating and Living with Tuberculosis

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Glossary

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Find Out More

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Index

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[1]

WHAT IS IT LIKE TO HAVE TUBERCULOSIS?

F

or a couple of weeks, ten-year-old Jeremy had a cough that would not quit. At first it was a nuisance. His parents thought it was just a bad cold and it eventually would go away. Then other things started to happen in his body. Sometimes Jeremy coughed so hard that his chest hurt. His body shook with chills. He began waking up in the middle of the night to find his pajamas drenched with sweat. During the day, Jeremy felt tired and did not have the energy to play with his friends or even to go fishing with his grandfather. Because the cough hung on for so long, Jeremy’s parents thought he might have the flu. His doctor agreed—at first. Then the doctor asked about other family members, including Jeremy’s grandfather. Grandpa Madden had been going to his doctor with the same complaint about a bad cough and

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WHAT IS IT LIKE TO HAVE TUBERCULOSIS?

trouble breathing. The cough got worse. Mr. Madden began to lose weight. He had chills and night sweats. None of the doctor’s recommendations helped. During one of his doctor visits, Grandpa Madden remembered something. When he was about Jeremy’s age, he had tuberculosis (TB), a serious lung disease. Fortunately Grandpa Madden was treated for the disease, and he recovered. Even so, he knew that a person who had TB once could get it again. He asked his doctor if he should get a chest X-ray to see if there was anything wrong with his lungs. If he did have tuberculosis, he worried he might have spread the disease to his grandson. That summer Jeremy and Grandpa Madden had been sharing a bedroom at the family summer cottage for weeks at a time. At first Grandpa Madden’s doctor thought there was no need for an X-ray. He said that people rarely get TB these days. The doctor had good reason to think that. Fewer and fewer people come down with the disease because of special medicines and public health laws. The number of TB victims is shrinking so fast that some experts predict the disease will soon be wiped from the face of the earth. But TB is still around, as Jeremy’s grandfather found out after an X-ray. The image showed white shadows, which are possible signs of TB infection. When examined under a microscope, a tiny sample of fluid from his lungs showed he had the TB germs. The doctors immediately ordered the same tests for

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Tuberculosis

A doctor points to an X-ray of lungs stricken with tuberculosis showing the damaged portions as white areas. Healthy lungs, on the right, appear as clear dark images.

Jeremy and the rest of the family. Grandpa Madden’s hunch was right. Although other family members were fine, Jeremy had TB.

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WHAT IS IT LIKE TO HAVE TUBERCULOSIS?

Fortunately there is a treatment for tuberculosis. Every day for six months, Jeremy and his grandfather had to take pills containing antibiotics, which killed the bacteria. Within three weeks, both grandfather and grandson felt better. After six months, Jeremy and his grandfather completely recovered. Before long it was spring and they were having fun fishing together again.

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[2]

WHAT IS TUBERCULOSIS?

T

uberculosis is a disease in which bacteria may invade many parts of the body, such as the brain, the kidneys, and the spine. TB’s most common target is the lungs. The TB bacteria damage the lungs so much that it is difficult for a person to breathe. There are two main types of TB. One is latent TB, which means a person carries the TB germ but is not sick and cannot pass the germ on to other people. The other type is active TB. People with this form of the disease do get sick, and they can make other people ill as well. When someone who is sick with TB coughs or sneezes, he or she exhales clouds of tiny droplets. Inside each droplet are TB bacteria. A person who repeatedly breathes the germ-loaded air can catch tuberculosis. Once inside the body, TB bacteria can work their way to the lungs. If the disease goes untreated, the TB germs will spread and eat away at lung tissue. This damage

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WHAT IS TUBERCULOSIS?

A microscopic snapshot shows the distinctive rod shapes of tuberculosis bacteria.

shows up on a chest X-ray. Soon the infected person will develop a cough and may have trouble breathing. For healthy people, breathing takes place automatically. Sit quietly, close your eyes, and listen to your breathing. Each time you breathe in, your body takes in oxygen that it needs to survive. Each time you exhale, you breathe out things that the body needs to get rid of—germs, gases such as carbon dioxide, and excess body heat. The lungs are organs that

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Tuberculosis

exchange bad air for good air as you breathe. Tuberculosis germs destroy lung tissue. This destruction weakens a person’s ability to take in oxygen and to rid the body of carbon dioxide. To understand how important this is, you need to know a little bit about how these amazing organs work. HOW THE LUNGS WORK A special part of the brain called the respiratory center controls the process of breathing. Whether you are running, watching Blood cells carry carbon dioxide from the body to the lungs, which expel the gas from the body. television, or sleeping, your brain makes sure your body is breathing every second of every day. Your brain also keeps track of how much oxygen your body needs. Your respiratory center automatically adjusts the rate of breathing when you run faster or work harder. But you can also override this system.

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WHAT IS TUBERCULOSIS?

For example, you can take a deep breath when you are getting ready to shout or to sing. Or you can choose to stop breathing completely for a few seconds when you are swimming underwater. All the air that comes into the body goes into the lungs. Every healthy person has two of them. They sit on either side of the heart and are protected by the ribs. The left lung is a little smaller than the right lung because it leaves a pocket for the heart to nestle in. Lungs cannot take in Lungs cannot take in air on their own. They need the air by themselves. They diaphragm muscle (in red, below lungs) to expand and need the help of a muscle contract them. called the diaphragm. This muscle fits like a dome under both lungs and lies between them and the ribs. The front of the diaphragm is attached to the sternum, the bone in the center of the chest. The back of the diaphragm is attached to the spine.

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To see how respiration works, take a deep breath. Notice how your chest expands. The diaphragm is making your chest cavity bigger. This draws in air. Now breathe out. Watch your chest relax. The diaphragm is squeezing out air from your lungs. When you inhale, air comes in through your nose and mouth. It flows down through the windpipe, or trachea. The trachea splits into two tubes called This colored X-ray shows how the body’s breathing bronchial tubes. The trachea system is a series of smaller and smaller branches, and bronchial tubes form an eventually ending with tiny air sacs. upside-down Y. Each bronchial tube leads to a lung. Inside the lungs each bronchial tube subdivides, like branches on a tree, into smaller and smaller tubes called bronchioles. These tubes are about as thick as a human hair. At the tips of the bronchioles are alveoli, which look like tiny balloons. Under a microscope, they resemble grapes at the end of a branch.

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WHAT IS TUBERCULOSIS?

The thin walls of the alveoli are lined with blood vessels. When a person inhales, the air travels all the way down to the end of the bronchioles. It seeps through the alveoli walls into the blood vessels. These vessels circulate oxygen to the rest of the body. At the same time, carbon dioxide seeps into the alveoli as a waste product. THE INVADER WITH TWO INITIALS: TB Every time a person exhales, sneezes, coughs, sings, or even talks, he or she sends out clouds of thousands of tiny drops of moisture. When someone talks for five minutes, sings for only a minute, or coughs once, that individual sprays about three thousand droplets into the air. And if the

Lung Power From the outside, the lungs look like two large pink sponges. If you could take a microscopic peek inside, you would see that they are packed with about six hundred million tiny bubbles, or air sacs. A pair of lungs has so many bubbles that if they all were flattened, they would cover a football field. The lungs are so good at their job that a person can still survive with just one. On average, the human body breathes in and out about every fifteen seconds. That equals 4 times a minute, 5,760 times a day, or 2,102,400 times a year. The lungs usually do their job smoothly. That is because they are covered with pleural membranes. These are super-slippery layers of tissue, which let the lungs slide easily against the diaphragm as they are squeezed with each breath.

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Tuberculosis

individual sneezes just one time without covering his or her mouth, approximately 40,000 droplets may spread as far as 3 feet (0.91 meters) away. After a sneeze, these tiny drops can hang in the air like fog. The bacteria in the coughs or sneezes of a person infected with active TB hang in the air in the same way. A TB infection can start when someone inhales the germ Mycobacterium tuberculosis (MTB) into his or her lungs. Each droplet from a sneeze or cough contains about three MTB germs. The resulting

This is what a sneeze looks like—a fog of tiny droplets, each a potential germ carrier.

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WHAT IS TUBERCULOSIS?

infection is called pulmonary tuberculosis. The word pulmonary means “related to the lungs.” TB typically spreads when an uninfected person inhales the infected droplets that the sick person exhales. This can happen to family members who spend a lot of time together. It can also happen to anyone who spends a lot of time in enclosed areas with groups of people. People at a high risk of catching TB include medical workers in hospitals or clinics, students in dormitories, convicts in a prison, and soldiers in military barracks. Fortunately, TB is not as infectious as the common cold. You cannot catch TB by handling an infected person’s clothes, bedding, or eating utensils. You will not get the disease if an infected person sneezes near you once or twice. You have to be exposed to a lot of germs over a long period of time in order for tuberculosis to develop. According to some scientists, if a healthy person stays with someone who has active TB twentyfour hours a day for sixty days, he or she has only a 50 percent chance of catching the disease. A healthy person’s body has many ways of protecting itself. The body’s first line of protection comes from stiff hairs called olfactory cilia, which line the inside of the nose. Olfactory cilia trap dust, tiny particles, and microorganisms that people inhale from the surrounding air. Any swallowed germs travel to the stomach, where stomach acid kills them. Another germ barrier is mucus, the sticky fluid that lines the inside of the nose and the

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Tuberculosis

People in enclosed spaces can breathe in someone else’s germs.

back of the throat. Mucus traps and collects bacteria. Mucus can build up in the lungs, where it becomes a slimy substance called sputum. Mycobacteria that do make it past these defenses—nose hairs, stomach acid, and mucus—can be breathed into the lungs. From there, they can travel down the bronchioles all the way to the alveoli. Even then, the body continues to protect itself. The immune system, the body’s natural defense against disease, sends out white blood cells to attack bacteria

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WHAT IS TUBERCULOSIS?

and other harmful invaders. The white blood cells that go after MTB are called macrophages. When TB bacteria invade, macrophages pile onto the invading germs like tacklers jumping on a runner with a football. These cells swallow TB germs, but they do not kill them all. Tuberculosis bacteria are hard to kill. Under the microscope they look like tiny sticks. They have a tough, waxy outer shell that protects them even when they are swallowed.

This microscopic photo shows a macrophage engulfing tuberculosis bacteria.

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Tuberculosis

However, the macrophages isolate the bacteria from the rest of the body. The pile of cells forms a lump called a tubercule. Tuberculosis got its name from the Latin word tubercule, which means “little swelling.” Tubercules have hard walls made of scar tissue. Inside the walls is a mixture of dead TB germs, live TB germs, and white blood cells. The TB germs are sealed in the tubercules like money locked in a safe. They are not destroyed, but they are isolated from the rest of the body. They can live sealed up like this for years. When TB bacteria are alive inside the body but are under control, the person has latent TB. Although people with latent TB carry the germs, they do not get sick or experience symptoms of the disease. They could cough and sneeze forever without infecting anyone else. Only about one of every ten people with a TB infection has active TB. This means they do get sick and can infect others. Usually this happens because a person’s immune system is not strong enough to keep the TB bacteria sealed off and under control. People who have weak immune systems include babies and very young children, the elderly, and people who have a disease that weakens the immune system, such as acquired immunodeficiency syndrome (AIDS), which weakens the immune system. Doctors also have discovered that African Americans and Native Americans are a little more likely to get TB than people of other cultural backgrounds.

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WHAT IS TUBERCULOSIS?

People get active TB because their immune systems cannot hold back the MTB in their bodies. The germs continue growing while sealed inside the tubercule. After a time, there are so many germs that they ooze out of the tubercules. More macrophages arrive to fight the MTB, but the bacteria spread into the lungs. There, the germs eat away at tissue, and infected parts of the lungs turn into a soft, crumbly substance. This substance eventually becomes a liquid that seeps into the breathing tubes. That is Babies have underdeveloped immune when the victim develops a systems, which makes them vulnerable to wet, suffocating cough—one all kinds of diseases. of the early symptoms of TB. As this germ-filled liquid oozes into other healthy areas of the lungs, it leaves holes behind. The more holes in the lungs, the less lung tissue there is to take in air, and the more

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Tuberculosis

difficult it is to breathe. TB germs collect in these holes, which become collection areas for other types of germs. When the TB victim coughs or sneezes, the germs in his lungs spray out into the air and infect other people. As tuberculosis continues to spread, it can cause serious damage throughout the body. In the lungs, one especially

An X-ray shows what lungs with miliary tuberculosis looks like—tissue punctured by thousands of tiny holes.

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WHAT IS TUBERCULOSIS?

deadly form of the disease is called miliary TB. An X-ray of heavily infected lungs ravaged by this type of TB shows countless little flecks where the disease has made tiny holes. One scientist thought the marks resembled little millet seeds, so he called it miliary tuberculosis after the Latin word for “millet.” TB germs can also spread into the bloodstream. At that point, TB can attack almost any part of the body. Tuberculosis germs can travel to and infect the lymph nodes. These bean-shaped masses of tissue near the neck, collarbone, and armpit trap bacteria carried in the bloodstream. MTB can also attack a person’s kidneys, bones, joints, and the tissues that cover the brain and the heart. The two most dangerous forms of TB are miliary tuberculosis and tuberculosis meningitis. DETECTING Tuberculosis At first, a doctor cannot always tell whether a person has tuberculosis. The disease’s symptoms are fairly common. One is a persistent cough. People cough for all kinds of ordinary reasons, and they usually do not worry about it. Doctors usually do not suspect anything is seriously wrong with a patient who has a bad cough. However, if the patient also complains about feeling tired all the time, losing appetite and weight, constantly running a fever, and having night sweats, that patient needs further medical tests.

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Tuberculosis

One of the early symptoms of tuberculosis is a cough that will not go away.

Once doctors suspect that tuberculosis is a possibility, they may do different tests. One is called the Mantoux test, named after a French doctor named Charles Mantoux, who devised it over a hundred years ago. The test takes only a second and is no more painful than a pinprick. It is an attempt to provoke a reaction from the body’s immune system. A health care worker injects a tiny amount of fluid containing tuberculin, or dead TB cells, just under the skin of the forearm.

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WHAT IS TUBERCULOSIS?

A few days after a pinprick, or Mantoux, test, a patient may show a distinct bump like this on his or her forearm, a sign the patient may have tuberculosis.

Two or three days later, the patient returns to the doctor’s office. The doctor inspects the spot where the injection was made. If there is a reddish bump, the doctor measures it with a ruler. The wider the bump, the greater the possibility a patient has TB. The Mantoux test is not 100 percent accurate. One out of five tests is false. Even if the test is accurate, it only tells doctors that a person carries TB germs. It cannot determine the form of the disease—latent or active. Therefore, doctors may also decide to take an X-ray of the lungs. If there are

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Tuberculosis

lesions, or holes, in the lungs, they may show up as bright spots on the X-ray. Finally, if someone has a bad cough, the doctor will want to test the phlegm, or mucus, inside the lungs. Technicians might examine the phlegm under a microscope to detect TB bacteria. Or they may send a sample to a laboratory to test whether bacteria grow inside the phlegm. This lab test is very accurate, but it also takes a lot of time. TB bacteria grow very slowly—as

Examining samples of a patient’s lung fluid, or sputum, smeared on glass slides is one way to test for tuberculosis.

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WHAT IS TUBERCULOSIS?

long as six weeks—before doctors can identify the infectious bacteria and make a diagnosis. Diagnosing TB in children can be difficult. Even when children are infected, they may not have enough TB bacteria in their systems to show up on some of the laboratory tests. In the end, a doctor’s most useful diagnosis strategy is talking to the patient. Knowing that someone has spent signficant time near a person with infectious tuberculosis can be the most valuable piece of medical information of all. Active tuberculosis used to be a death sentence. Today, that is no longer true. Today the disease can be completely cured. A variety of medicines and treatments help a patient recover and lead a healthy life.

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[3]

THE HISTORY OF Tuberculosis

T

uberculosis has been around for a long, long time. Scientists have found traces of the disease in the lung tissue of a three-thousand-year-old Egyptian mummy and in the remains of a woman buried one thousand years ago in Chile. Wherever people lived together in a crowded environment, tuberculosis often spread throughout a community. Almost 2,500 years ago, the famous Greek doctor Hippocrates said that tuberculosis was the most common disease of his time. It was so deadly that he

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Tuberculosis has been around so long that this ancient drawing from an Egyptian tomb shows a man thought to have suffered from the disease.

THE HISTORY OF TUBERCULOSIS

told doctors not to try to treat it. The ancient Greek philosopher Aristotle believed TB spread from one person to another, but it would take thousands of years to prove this. Drawings on the walls of Egyptian tombs show hunchbacked people who may have had tuberculosis of the spine, which causes the upper back to curve over. Some experts even think that the fictional character the Hunchback of Notre Dame was based on a person who had tuberculosis of the spine. TB has gone by many different names. The ancient Greeks called it phthisis, from a word meaning “to waste away.” They probably chose this word because TB victims lose their appetites and become weak and pale. TB was once called consumption because it devoured, or consumed, a person from within. It was also known as the white plague because victims were so pale from loss of blood. TB also has been called scrofula, the Latin word for female pig. (Sometimes TB bacteria infected glands in the neck, which swelled up like a pig’s neck.) Another name was Prosector’s wart, a tuberculosis of the skin that coroners, butchers, and surgeons caught from contaminated dead bodies. For a long time, TB was called Koch’s disease after Robert Koch, the man who discovered MTB. For centuries, the origin of TB was a great mystery. TB was not a major health problem in prehistoric times, when people lived by hunting and did not settle in one place. However, when people began to live in settlements and began to raise

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Tuberculosis

cattle, the disease spread. Many medical historians now believe that tuberculosis developed from bacteria in the soil, which spread to cattle grazing near the bacteria. The disease then spread from the cows to people who drank milk. Experts once thought TB began in Europe, and explorers brought the disease to the New World—what is now North, South, and Central America. That theory was disproved, however, when researchers found a woman who died of TB in Chile one thousand years ago. She had At first, tuberculosis was called Koch’s the disease centuries before disease, named after this man, Robert any Europeans arrived in the Koch, who discovered the TB germ. New World. For centuries, most people lived in villages or small towns. If someone got sick with tuberculosis, there were fewer people around to catch it. Since most people spent their time

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THE HISTORY OF TUBERCULOSIS

outdoors, the germs did not linger in the air. In addition, the ultraviolet rays of sunlight killed the germs. Even today, doctors use ultraviolet light in homeless shelters, hospitals, and prisons to combat tuberculosis germs. Tuberculosis became a very serious health problem when people started moving from the country into cities and began to live in crowded conditions.

In eighteenth-century London, tuberculosis was the cause of one in every three deaths.

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THE EIGHTEENTH CENTURY

The Royal Touch A common form of TB in medieval times was called scrofula, a TB infection that caused lymph nodes in the neck to swell up. In those days, some people in England and France believed they would be cured if their king or queen merely touched them. They would gather around their king on special days for a ceremony called the king’s touch or the king’s evil. On Easter Sunday afternoon in 1686, King Louis XIV of France individually touched more than a thousand people.

In the early 1700s in England, an era called the Industrial Revolution began. More and more people moved to the cities to work in factories. As the cities grew, so did the number of tuberculosis victims. People worked in dark, damp buildings. They lived crammed together in rooms with little or no fresh air. To make matters worse, landlords had to pay the government a window tax. The more windows a building had, the higher the taxes. Landlords began bricking up or boarding over windows to avoid paying the window tax. They rented out these dark, windowless places to people who were forced to breathe stuffy, infected air. TB spread quickly. One of every three people who died in England in those days died of tuberculosis.

THE HISTORY OF TUBERCULOSIS

THE NINETEENTH CENTURY By the 1800s, tuberculosis was one of the deadliest diseases known to humans. It was then the leading cause of death in the United States. People were terrified of getting TB. At the same time, doctors were frustrated. They knew little about what caused TB and had no way to treat it. There were all kinds of ideas about how and why people got the disease. Some people believed that TB attacked only creative and sensitive people like artists. Famous writers such as John Keats and George English poet John Keats died in his twenties Orwell, as well as composer of tuberculosis. Frederic Chopin, all died of tuberculosis. In a famous opera, La Bohème, the sensitive heroine dies tragically from TB. A more likely explanation is that starving artists died of TB because they lived in unhealthy spaces. 33

Tuberculosis

Another theory was that victims inherited tuberculosis. People who believed this theory often mentioned authors Charlotte and Emily Brontë, sisters who wrote the classic novels Jane Eyre and Wuthering Heights. Both women died of TB, as did their brother and two other sisters. A more logical explanation is that a person with active TB is likely to pass it on to people who live in the same house. Because TB was so feared and so mysterious, people Superstitious people once thought the developed many superstitions pale white appearance of tuberculosis about it. In New England, some victims meant they were vampires. people thought a person with tuberculosis was the victim of a vampire and would become a vampire himself. This was because TB victims had the pale, bloodless look of the undead. In advanced stages of the disease, the victim might also cough up blood, which was another suspicious sign. Another superstition was that a TB victim might return from the grave to attack the rest of his family.

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The Strange Case of the Two Skulls In 1990, two boys made their way down a muddy slope near Griswold, Connecticut, and came upon human skulls. Workmen digging a gravel pit had accidentally disturbed a family cemetery on an abandoned farm. Archaeologists found the remains of twenty-nine people who had been buried there in the 1700s and 1800s. Among them was one mysterious grave. The initials J.B. appeared on the coffin lid. Inside was a man’s skeleton, which had been taken apart and rearranged as a skull and crossbones. Historical detective work revealed that there had been a tuberculosis epidemic in the area during the 1800s. Scientists examined J.B.’s bones and discovered that he had suffered from tuberculosis. Because local people believed that TB victims were vampires, scientists speculated that superstitious people had reopened J.B.’s coffin and had rearranged his bones so he could not rise from the grave and attack other people.

Tuberculosis

This seemed to explain why other people in the same family got mysteriously pale, became weaker, and died. A more logical theory about TB was that it had environmental causes. Some doctors thought that a damp area was a breeding ground for the disease. They recommended that people build their houses on dry ground and in areas with no shade. Other doctors said moving to a drier climate would help cure the disease. For that reason, many people with TB moved from New England to warmer, drier areas like the Southwest and California. During the late 1800s, one of every three settlers in Arizona said they moved to the state for their health. They were known as “lungers.” Other doctors suggested building special TB hospitals in places believed to be healthy for people with tuberculosis. In Europe, the development of sanatoriums began. Sanatorium is from the Latin word meaning “to cure.” Each sanatorium was a special clinic where people with TB would go to get better. The first sanatoriums were built in the mountains of Switzerland and Germany, where the air was clean and clear. An American doctor, Edward Trudeau, adopted this idea in the United States. Trudeau became interested in TB after he discovered he had the disease in 1873. Believing he would die soon, Trudeau moved to the Adirondack Mountains in New York State to spend what was left of his life. Instead of getting sicker, however, Trudeau started to feel better. He decided

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In the 1930s, it was common practice to send sickly children to sanitoriums like this one.

that all the fresh air was curing him. He had read about the European sanatoriums, and he decided to open one on the shore of Saranac Lake in upstate New York. Doctors there encouraged TB patients to exercise in the chilly air and to eat a healthy diet. Some patients even slept outside in the winter. This idea was so popular that hundreds of sanatoriums were built all over the country by the 1920s. Sanatoriums did not actually cure people, but they did have some benefits. They removed infectious patients from the rest

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of the population, and they raised awareness about diseases of the lung. Dr. Trudeau, who eventually died of TB, was the first president of what is known today as the American Lung Association. The causes of the disease continued to be a mystery. Some people thought there must be a TB germ. In 1865, a French army doctor named Jean Antoine Villemin took fluids from humans who had TB and injected them into rabbits. The rabbits got tuberculosis as well. This proved that the disease was contagious, but it still did not explain how the infection took hold. A few years later, in 1882, a German Patients at sanitoriums took special sun baths in both doctor named Robert Koch made summer and winter to build medical history when he announced up their strength. he had found the germ that causes tuberculosis. He studied samples from eleven people with severe TB. Each sample contained bacteria that he called the tubercle bacillus—the rod-shaped germ that causes TB. His discovery proved not only that tuberculosis can be passed from one person to another, but also that bacteria cause the disease.

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A Simple Country Doctor Before he announced his discovery, Robert Koch was not a famous scientist with a large staff of assistants. He was a country doctor who worked by himself. He did much of his early research in his living room, where he stretched a sheet across the room to mark his homemade laboratory. His lab equipment consisted of a microscope that his wife had given him as a birthday gift. With this simple setup, Koch solved one of the great medical mysteries of his time. After he found the cause of tuberculosis, Koch spent the rest of his life looking for a cure. He never found it, but he did discover tuberculin, the substance made from dead TB bacteria that is still used for tuberculosis tests today. In 1905, Koch won the Nobel Prize for Medicine for his achievements.

This is the simple laboratory where Dr. Koch made his historic discovery of the tuberculosis germ.

Tuberculosis

THE TWENTIETH CENTURY After Koch proved there was a tuberculosis germ, governments passed laws and issued health regulations to keep people from catching it. It became illegal to spit in public places in the United States. Health regulations required that milk be pasteurized, or heated, to kill the germs from infected cows. Building codes required better ventilation to keep TB germs from lingering in crowded apartments. Some cities, such as New York, required TB victims to register with the city’s department of health so the government could keep track of them and prevent them from infecting others. Doctors and researchers invented new tools to diagnose the disease. The invention of the X-ray, discovered in 1895, let doctors peer inside a person’s lungs. In 1908, researchers developed the skin test for TB still used today. Despite these advances, people continued to get TB. Doctors attempted all sorts of treatments for curing tuberculosis patients. One drastic treatment was an operation in which surgeons collapsed an infected lung. This gave the lung time to rest and recover, some said. It was a painful and complicated procedure. Doctors sometimes had to remove a couple of ribs to get to the lungs. Another method was to crush something called the phrenic nerve. This paralyzed the diaphragm and supposedly helped infected lungs to relax. Neither method was very effective. By the 1900s, there was still no sign of a cure. 40

THE HISTORY OF TUBERCULOSIS

Once the X-ray was invented, doctors could look inside the body and detect lung damage.

At that time, tuberculosis was the most common cause of death in the United States. By the late 1930s, more than seven hundred American hospitals specialized in TB treatment. Finally, in 1943, sixty-one years after Robert Koch discovered the TB bacterium, researchers came up with a cure. Microbiologist Dr. Selman Waxman at Rutgers University in New Jersey discovered a wonder drug called streptomycin. This antibiotic stopped the growth of bacteria like MTB. Doctors began injecting streptomycin into tuberculosis patients. The first person to get the drug, a twenty-one-year-old woman, recovered in a matter 41

Tuberculosis

of weeks and went on to live a long, healthy life. Antibiotics seemed to work miracles. The victory was not that simple. Not every TB patient was cured, and some people appeared to recover but got the disease again. The reason was that some types of TB were resistant to streptomycin. The drug did not destroy all of the bacteria. In the 1950s, scientists came up with another antibiotic called isoniazid (INH). In the years following, they devised other drugs that could kill various other kinds of TB bacteria. After some experimentation, scientists discovered that by giving a person streptomycin with one or two other antibiotics, they could eliminate any kind of TB a person was likely A drug technician mixes large batches of the to have. anti-tuberculosis drug streptomycin. The results were impressive. In 1953, the United States had over 84,000 cases of TB. By 1985, that number dropped to a little over 22,000, the lowest in 42

THE HISTORY OF TUBERCULOSIS

recorded history. By the early 1980s, TB was an almost forgotten disease all over the world. The health minister of England announced that tuberculosis was practically eliminated in his country. Health experts predicted that the disease would be wiped out by 2010 in the United States and all over the world by 2025. EPIDEMIC In the late 1980s, doctors in New York City noticed something disturbing. More people, not fewer people, began to get tuberculosis. Doctors faced a new TB epidemic for several reasons. More infectious people were coming to the United States from countries where TB was both common and untreated. Another cause was AIDS. This disease is spread from person to person through sexual contact, blood transfusions, and sharing hypodermic needles among drug users. The organism responsible for AIDS, the human immunodeficiency virus (HIV), weakens a victim’s immune system so that it has trouble fighting off the TB germ. People with AIDS were at risk for catching TB as well. Health officials started to see tuberculosis cases increasing in prisons. These were the perfect places for TB to develop and spread. People were living in crowded conditions, and there were significant numbers of prisoners with AIDS. New kinds of tuberculosis began to appear. One was called multi drug-resistant (MDR) TB, a form of TB that is resistant 43

Tuberculosis

This health care worker in India uses one of the best weapons against tuberculosis: public education.

to the two most powerful TB drugs, isoniazid and rifampicin. The other TB type, XDR-TB, was an even tougher form. Newer, more powerful drugs did not always work on it. By the early 1990s, health officials realized TB had not gone away. Experts renewed their attack on the disease. They opened up special health clinics to treat TB patients. They installed special isolation rooms in hospitals and prisons so they could keep infectious patients away from everyone else.

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THE HISTORY OF TUBERCULOSIS

They carefully watched TB patients to make sure they took all their antibiotics. The strategy worked. The number of cases of tuberculosis in the United States began to shrink. By 2005 there were 14,085 cases of TB, and by 2006 the number had dropped to 13,767, the lowest it has been since 1953. Today TB is still not conquered. It remains a serious health problem in some parts of the world. According to the World Health Organization, someone is infected with TB Isolating patients in special wards helped germs every second. An estikeep the disease from spreading. mated 1.6 million people died from the disease in 2005. After the epidemic of the 1980s, however, modern medicine is fighting back hard. Once again we are starting to beat an old enemy.

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[4]

TREATING AND LIVING WITH TUBERCULOSIS

B

ecause there is more than one form of tuberculosis, there is no single treatment. Doctors have had to devise different ways of fighting the disease. Fortunately, these methods work very well. Most of the people who get tuberculosis can be cured. Doctors sort patients with tuberculosis into two general groups: those who have latent TB and those who have active TB. Each group is treated with different medications. LATENT Tuberculosis If tests show that a person is infected with MTB but has no symptoms of tuberculosis, he or she may be one of the lucky 90 percent of the people infected with TB who get the latent form. He or she can live a long and healthy life, never suffer from the

46

TREATING AND LIVING WITH TUBERCULOSIS

Isoniazid (lower left) is only one of the many drugs now used against the various kinds of tuberculosis.

disease, and never pass it on to anyone. Someone with latent TB who has a healthy immune system does not have to worry about it. As a precaution, however, a doctor may prescribe the drug isoniazid. INH is an antibiotic discovered in 1952. Doctors usually give it to patients with latent TB. They take the medicine every day for at least six months. Except for checkups, patients with latent TB never have to do anything special after that.

47

Tuberculosis

ACTIVE TB Treatment is more complicated for people with active (infectious) TB. Active TB is potentially dangerous not only for the patients themselves, but also for people around them. Experts estimate that one person with active TB who is not treated can spread the disease to as many as fifteen people in a year. Treating an infectious person is a bit tricky. Different kinds of TB bacteria can infect people, and no single antibiotic can kill them all. For most people, a four-drug combination works best. Patients take the antibiotics isoniazid, rifampin, ethambutol, and pyrazinamide. The entire treatment period lasts six months. For the first two months, patients take all four drugs every day. For the last four months, they take only two of the drugs—isoniazid and rifampin—every day. Usually people recover if they follow doctors’ orders. However, not everyone does recover. As people with infectious TB quickly learn, they have to take a lot of pills—up to six per day. Another problem occurs when a TB patient starts feeling better—usually after only about two weeks. Some TB patients start to think they are cured, so they stop taking the drugs before the six-month deadline. Still others may stop taking the drugs because they do not like the side effects—feeling tired or sick to their stomachs. There are two problems with stopping treatment too soon.

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TREATING AND LIVING WITH TUBERCULOSIS

Having a patient take all his medicine under the watchful eye of a health professional can prevent him from getting tuberculosis again.

First, a patient might get sick again. Second, the remaining bacteria may become drug resistant—harder to kill with standard drugs. This is when the disease turns into MDR-TB. Patients with MDR-TB can still be cured, but the two most powerful TB medications—isonaizid and rifampin—are useless. Doctors have to use newer drugs, which are more expensive than older ones. Treatment of MDR-TB can last as long as two years. In addition, even this second group of drugs will not help a small number of patients. They turn out to have what is called extensively drug-resistant TB (XDR-TB). This is even

49

Prisoner of Tuberculosis In 2006, public health officials in Phoenix, Arizona, had an unusual and scary problem. A young man named Robert Daniels showed up in their city with a highly infectious form of tuberculosis. Daniels grew up in Arizona, but when he was older he decided to return to Russia, where he was born. While living in Russia, Daniels became ill and started coughing up blood. Doctors diagnosed him with tuberculosis and gave him some medicine. He did not take it for as long as they recommended because he began to feel better. Shortly thereafter, Daniels returned to Phoenix. He began to feel sick again. American doctors found that he had a more resistant kind of TB and gave him more powerful drugs. They worried he might infect others with his dangerous type of TB. They told him to wear a face mask when he was out in public. Once again, Daniels stopped taking the drugs too soon. His tuberculosis changed into the more deadly XDR-TB. He stopped wearing his face mask, and health officials worried that he would infect others. They had him picked up and isolated him in a special unit for prisoners in a Phoenix hospital until he recovered from his disease.

TREATING AND LIVING WITH TUBERCULOSIS

more difficult to treat than MDR-TB. These patients need very special, very expensive drugs and may not be completely cured. To make sure their patients take all their pills and do not develop the harder-to-cure types of tuberculosis, some hospitals and clinics have a program called directly observed therapy (DOT). In this program, a health care worker sits with a tuberculosis patient every day and watches him or her take the prescribed pills. This program is for high-risk patients, such as people with HIV, homeless people, prisoners, and people who have been careless about taking their drugs in the past. This simple method has been very effective in helping people get better. WHAT IS A Tuberculosis PATIENT TO DO? It is crucial that people who have active TB follow their doctors’ treatment instructions. Patients are told to do the following: • • • •

take all their medications for a prescribed period of time cover their mouths when they cough, sneeze, or laugh use disposable tissues and throw them away in a closed bag air out their bedrooms as much as possible to keep the germs from getting concentrated in the room • avoid going to work or school for at least three weeks after they have begun taking their medication (after this period they should no longer be infectious)

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Tuberculosis

Face masks help prevent patients and doctors from spreading tuberculosis germs.

Patients may have to do more than take drugs. Their doctors may require them to go to a hospital and stay in a special isolation room with special air vents to filter out the germs. Hospitals workers who treat these patients have to wear face masks to avoid catching the disease.

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TREATING AND LIVING WITH TUBERCULOSIS

OLD ENEMY, NEW WEAPONS Tuberculosis has not been wiped out, as some experts predicted. After the epidemic of the 1980s, however, researchers have been fighting back with a new set of medical weapons and tactics. Keeping better track of TB cases helps stop the spread of the disease before it starts. And something as simple as watching a person take the proper TB medicine has made a huge difference in the disease’s cure rate. As result, the numbers of people who get infected continue to drop in developed countries like the United States. Doctors are now adopting some of the same tactics in less-developed areas such as South Africa, where TB is a bigger health problem. Today the World Health Organization says that eight out of ten people who are infected with TB can be cured. Researchers are also trying to improve on old remedies. For example, the diagnostic skin-prick test for tuberculosis has not changed much since the days of Robert Koch back in the 1880s. Today, researchers in New Jersey and California have developed a simpler and more accurate test. They put a sample of a person’s sputum in a test tube, treat it with certain chemicals, and put it under special lights. If they see certain colors, they know a person has a special drug-resistant TB. This test leads to a diagnosis in hours rather than weeks. Some of the standard drugs that have been used for years to

53

Tuberculosis

treat TB are not as effective against newer types of tuberculosis. Researchers are working to create more powerful ones. It is not easy. One group of researchers started with a list of more than 100,000 possible drugs. They narrowed the list down to seventy. After much experimentation, they shortened the drug list to twenty-six, then to six, and finally to one. The result of all this work is a drug that goes directly to the lungs, where TB germs live, and kills them quickly.

Looking at the enemy within, here is a microscopic sample of tuberculosis germs in lung fluid.

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TREATING AND LIVING WITH TUBERCULOSIS

Other drugs are even more specific. One reason TB bacteria are hard to destroy is that they have a tough, waxy coating. Now there is a new drug that keeps germs from building this coating. This makes it easier for cells produced by the immune system to fight off and eliminate MTB. The World Health Organization predicts that doctors will have a whole new group of more effective anti-tuberculosis drugs within decades. By 2015, for example, TB researchers hope to have a new vaccine against the disease. Vaccines work by exposing the body’s immune system to a weak version of a disease. The body’s immune cells learn how to recognize those germs and fight them off before they have a chance to make someone sick. Many people think a vaccine will be the best way to fight tuberculosis. A TB vaccine already exists, but it is old and does not work that well. It is called the BCG vaccine. Two French scientists, Albert Calmette and Camille Guérin, developed it in 1921. The BCG vaccine helps protect children from the kind of TB that attacks the brain, but it doesn’t prevent the more common type that attacks the lungs. In addition, its effects wear off over time, it does not seem to work on adults, and it interferes with TB tests. People who have had the vaccine sometimes mistakenly register positive for the disease when they are actually negative. Although the vaccine has been used in Europe, doctors have not used it in the United States because of its limitations. 55

Tuberculosis

A new, more effective vaccine is the current dream of medical researchers.

56

TREATING AND LIVING WITH TUBERCULOSIS

Scientists think they will have better vaccines soon. In 2004, U.S. government researchers at the University of Colorado announced that they had been testing a TB vaccine in humans. At the University of Missouri, a doctor is working on a vaccine that a person administers as a nasal spray. Once again, humans will have new, effective medical weapons to fight an old enemy.

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Tuberculosis

Glossary active TB—The type of tuberculosis in which an infected person develops symptoms and can spread the disease to others. alveoli—Tiny air sacs in the lungs where the body exchanges oxygen for carbon dioxide. antibiotics—Medications that either kill bacteria or stop them from spreading. bacteria—One-celled organisms that can infect other organisms and make them sick. bronchioles—Small tubes that transport air inside the lungs. contagious—Able to spread from one organism to another. diagnosis—A doctor’s determination about the condition of a patient. diaphragm—A dome-shaped muscle that protects the lungs and aids in breathing. directly observed therapy (DOT)—A program by which a health care worker makes sure that tuberculosis patients take their medications. epidemic—A situation in which many people have the same illness simultaneously and are infecting each other. extensively drug-resistant TB (XDR-TB)—A form of TB that cannot be treated with many of the common TB drugs. immune system—The body’s natural defense against infectious diseases. latent TB—A condition in which a person has the TB bacteria 58

Glossary

but experiences no symptoms, does not feel sick, and is not contagious. lesions—Abnormalities, such as wounds, scars, or holes, in an infected part of the body. lymph nodes—Bean-shaped masses of tissue near the neck, collarbone, and armpits. macrophages—White blood cells that attack and swallow tuberculosis germs. miliary tuberculosis—A dangerous form of TB in which the bacteria spread throughout the body and look like tiny seeds on X-rays. mucus—A slimy substance produced in the nose and mouth to protect against harmful germs and viruses. multi drug-resistant (MDR) TB—A form of active TB whose bacteria cannot be killed by two of the more powerful antiTB drugs, isoniazid and rifampsicin. Mycobacterium tuberculosis—The name of the organism that causes TB. resistant—Unaffected by, or immune to, something. sputum—A slimy substance coughed up from deep in the lungs. trachea—The windpipe leading from the throat to the lungs. tubercule—A small swelling caused by immune system cells that trap tuberculosis bacteria. tuberculin—A liquid containing a small amount of TB bacteria.

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Tuberculosis

FIND OUT MORE Organizations The American Lung Association 61 Broadway, 6th Floor New York, NY 10006 1-800-LUNG-USA (1-800-586-4872) www.lungusa.org Books Silverstein, Alvin and Virginia. The Tuberculosis Update. Berkeley Heights, NJ: Enslow Publishers, 2006. World Health Organization. Global Tuberculosis Control: Surveillance, Planning, Financing. Geneva, Switzerland: World Health Organization, 2006. Yancey, Diane. Tuberculosis. Minneapolis, MN.: Twenty-First Century Medical Books, 2007.

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find out more

Web Sites Centers for Disease Control and Prevention (CDC) Questions and Answers about Tuberculosis www.cdc.gov/tb/faqs/default.htm The TB Alliance www.tballiance.org MedlinePlus: Tuberculosis www.nlm.nih.gov/medlineplus/tuberculosis.html National Institute of Allergy and Infectious Diseases (National Institutes of Health): Tuberculosis www3.niaid.nih.gov/topics/tuberculosis/default.htm University of Virginia Health System Health Sciences Library: Tuberculosis www.healthsystem.virginia.edu/uvahealth/adult_infectious/ tuberc.cfm World Health Organization: Tuberculosis www.who.int/mediacentre/factsheets/fs104/en/index.html

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INDEX Page numbers in bold are illustrations. active TB, 10, 20–21, 34, 46, 48–51 AIDS (acquired immunodeficiency syndrome), 20, 43 air sacs, 14, 15 alveoli, 14, 14–15, 18 antibiotics, 9, 41–42, 44–45, 47, 47, 48–49, 51, 53–55 Aristotle, 29 babies, TB in, 20, 21 bacteria, TB, 10, 11, 12, 16, 21–22, 26–27, 54 discovery of, 38, 39, 39, 40, 41 fighting against, 9, 17–20, 19, 23, 31, 44, 48–49, 54–57 See also tuberculosis (TB) blood cells, 12 blood vessels, 15 brain, 10, 12, 23, 55 breathing, 7, 10, 11–15, 14, 21–22 bronchial tubes, 14, 14 bronchioles, 14, 14–15, 18

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drugs. See antibiotics Egypt, TB in, 28, 28, 29 England, TB in, 31, 32, 43 epidemics, 35, 43, 45, 53 extensively drug-resistant TB (XDR-TB), 44, 49–51 face masks, 50, 52, 52 germs. See bacteria, TB Greece, TB in, 28–29 Guérin, Camille, 55 Hippocrates, 28–29 history, 28–45 HIV (human immunodeficiency virus), 43 Hunchback of Notre Dame, 29 immune system, 18–21, 21, 24, 43, 47, 55 isolation rooms, 44, 45, 50, 52 isoniazid (INH), 42, 44, 47, 47, 48, 49 Keats, John, 33, 33 king’s touch, 32 Koch, Robert, 29, 30, 38, 39, 39, 41, 53

Calmette, Albert, 55 cattle, TB in, 30, 40 causes, 29–34, 36, 38–39, 43 children, TB in, 20, 21, 27 Chile, TB in, 28, 30 consumption, 29 coughing, 15, 16, 20 as TB symptom, 6–7, 10–11, 21–22, 23, 24, 26, 34, 50

latent TB, 10, 20, 46–47 laws, 40 lesions, 23, 26 lungers, 36 lungs, 11–15, 13, 17 TB in, 7, 8, 10–11, 18, 21–23, 22, 26, 54, 54, 55 lymph nodes, 23, 32

Daniels, Robert, 50 deaths, 31, 32, 33, 41 diaphragm, 13, 13–14, 15, 40 directly observed therapy (DOT), 45, 49, 51, 53

macrophages, 19, 19–20, 21 Mantoux tests, 24–25, 25, 40, 53 miliary TB, 22, 23 milk, bacteria in, 30, 40 mucus, 17–18, 26

INDEX

multi drug-resistant TB (MDR-TB), 43–44, 49, 51 Mycobacterium TB (MTB), 16–19, 21, 23, 29, 41, 46, 55 olfactory cilia, 17–18 phlegm, 26 phrenic nerve, 40 phthisis, 29 pleural membranes, 15 prevention, 40, 44, 50, 52, 55–57 prisons, TB in, 43, 44 Prosector’s wart, 29 pulmonary TB, 17 respiratory center, 12 rifampicin/rifampin, 44, 48, 49 sanatoriums, 36–38, 37, 38 scrofula, 29, 32 skin tests, 24–25, 25, 40, 53 sneezing, 10, 16, 16, 17, 20, 22 soil, bacteria in, 30 South Africa, TB in, 53 spine, 10, 13, 29 sputum, 18, 26, 53 statistics, 31, 32, 42–43, 45, 53 sternum, 13 stomach acid, 17, 18 streptomycin, 41–42, 42 symptoms, 6–7, 11, 21–22, 23, 24

description of, 10–11 diagnosing, 7, 8, 11, 14, 23–27, 39, 40, 41, 53, 55 spreading, 18, 22–23, 29–36, 38, 45, 48, 52 See also bacteria, TB; and specific types of tuberculosis ultraviolet light, 31 United States, TB in, 33, 36–37, 42–43, 45, 53 vaccines, 55–57, 56 vampires, 34, 34, 35 victims, appearance of, 29, 34, 34, 35, 36 Villemin, Jean Antoine, 38 Waxman, Selman, 41 white blood cells, 18–20 white plague, 29 window tax, 32 X-rays, 7, 8, 11, 14, 25–26, 40, 41

trachea, 14 treatments, 9, 31, 36, 40–55 Trudeau, Edward, 36–37, 38 tubercle bacillus. See bacteria, TB tubercules, 20, 21 tuberculin, 24, 39 tuberculosis meningitis, 23 tuberculosis (TB) catching, 16–17, 20–21, 40, 43

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ABOUT THE AUTHOR Henry Wouk is a writer who lives in the Hudson Valley in New York. He has authored more than a dozen books on health and science and has written articles for a variety of magazines.

Titles in this series ADD and ADHD

Headaches

Allergies

Heart Disease

Alzheimer’s Disease

Juvenile Diabetes

Arthritis

Leukemia

Asthma

Lung Cancer

Autism

Meningitis

Cerebral Palsy

Mononucleosis

Chickenpox

Mosquito-Borne Illnesses

The Common Cold

Multiple Sclerosis

Cystic Fibrosis

Obesity

Depression

Osteoporosis

Down Syndrome

Rabies

Drug Resistant Super Bugs

Skin Cancer

Eating Disorders

Sleep Disorders

Epilepsy

Tick-Borne Illnesses

Fever

Tourette Syndrome

The Flu

Tuberculosis

Food-Borne Illnesses

Vision Disorders