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INFECTIOUS DISEASE

“infectious diseases can force enormous, sometimes cataclysmic changes on societies. They can determine not just who lives and who dies, but who wins and who loses, who gets wealthy and who stays poor, which ideas become popular and which ones wither away.” PLAGUES AND PESTILENCE Leanne Schimke MSN, FNP-C, CUNP Lancaster Urology Quote by Bryn Barnard, author of Outbreak Plagues that Changed History. Lancaster, PA

DEFINITIONS DEFINITIONS

• Epidemic: any excessive and related incidence of a • Anything that causes disease is called a pathogen. particular disease in a population. • Vector: an organism such as a flea that serves as an • Pandemic: when an epidemic extends beyond a continent intermediary in the transmission of host-to-host disease. • Endemic: a disease with a normal low to moderate • Fomite: any inanimate object that adheres to or incidence in the population, but intermittent episodes. i.e. transmits infectious material, i.e. bedding. common cold • Zoonotic: transmitted between species, for example • Two major types of infectious disease that can develop into animal to human, sometimes through a vector. epidemics: • Common source: arise from a contaminated source, such as water or food. • Host-to-host: transmitted from one infected individual to another via various, sometimes indirect routes.

BLACK DEATH BLACK DEATH

• Bubonic, Pneumonic, and Septicemic plague • 1st pandemic in 541-543 AD, 2nd 1346-1352, 3rd 1894 • Caused by Yersinia pestis, a rod shaped, Gram negative bacteria. Only 1 bacteria is needed to cause the plague. • Initial symptoms: fevers, painful buboes (from Greek bubo meaning groin) in groins and armpits as lymph • Reservoir is the female Indian rat flea. nodes swelled.

• 3 days later: high fevers 104 or >, delirium, restlessness, staggering gait, skin hemorrhages resulting in black splotches, gangrene, necrotic tissue, • Feeds on rodents: prairie dogs, rats, squirrels, gerbils, field enlarging buboes up to hen’s egg size that caused mice, etc. severe pain when they burst. • Can jump several feet, so when their hosts die they jump to • 5 days later: convulsions, coma and death. If fever a new one broke usually survived, if buboes were lanced possible survival. Some victims died in 1 day.

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BUBONIC PLAGUE BLACK DEATH

• In bubonic and septicemic plague, there is hemorrhagic illness, multiple system failure and death. • Mortality rate now for untreated bubonic plague is 50-70%, septicemic plague is 100% • Can change to pneumonic plague which enters the lungs, causes coughing, blood tinged mucous that changes to pulmonary edema. Death can occur in a matter of hours. Has 100% mortality rate if untreated. • During the pandemics so many people died that their bodies were unable to be buried fast enough, so they were dumped in rivers, streets and docks.

Images from CDC PHIL

SPREAD OF THE BLACK DEATH BLACK DEATH

• People lived in crowded, filthy cities. Sewage was inadequate so rotting garbage and human waste were • No one then knew how the disease was spread. Fear and heaped in streets or dumped in rivers. terror ruled. People deserted cities and towns, work and service disrupted. • People hardly ever bathed. • Theories such as: • The black rats lived in the thatch of the roofs and in the • “bad air” or miasma ships that traveled between cities. Rats were highly • Result of conjunction of Saturn, Jupiter and Mars in the susceptible to the plague, they became infected and died, 40th degrees of Aquarius which forced the earth to exhale so the fleas jumped to humans nearby. a virulent sulfurous miasma. • Plague spread via ships, the rats infected the humans on • Divine punishment for sins of the world. Curse from God the ships and then left the ships to infect the land • Caused by spirits and devils population. • Caused by strangers, xenophobia was the norm. • In Venice, a quarantine was placed on ships. Quarantina is • Jews became targets, rumors of their poisoning the wells the Italian word for 40 days. Unfortunately, the rats were ran rampant. Numerous massacres occurred. able to leave via the ropes tied to the docks.

BLACK DEATH PLAGUE DOCTORS

As may be seen on picture here, • In Germany, a group formed to try to appease God through group mortification; known as the Brotherhood of the In Rome the doctors do appear, When to their patients they are Flagellants. called, • They would march from town to town and in the town square In places by the plague appalled, would form a large circle, strip themselves to the waist and Their hats and cloaks of fashion new, beat themselves with a whip in rhythm to their chanting Are made of oilcloth, dark of hue, hymn. Their caps with glasses are designed, • They would perform this rite three times daily for 33 days, a Their bills with antidotes all lined, day for each year of Jesus Christ’s life. That foulsome air may do no harm, • As time went on instead of just hurting themselves, they Nor cause the doctor man alarm, began to lead in persecution and murder of the Jews The staff in hand must serve to show Their noble trade where 'er they go. Seventeen century poem about Plague Doctors

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BLACK DEATH BLACK PLAGUE HISTORICAL SIGNIFICANCE

 Most famous plague doctor was Michel de • Plague of 541 AD raged in Constantinople, Europe, North Africa and Middle East by 600 AD population was reduced Nostraedame, known more commonly as by 100 million, approximately 50% of the population. Nostradamus. • Marked the end of the Classical World, of Greek and Roman  His advice: drink only boiled water, sleep in Civilization, ushered in the Dark Ages. clean beds, and leave infected towns as • Followed trade routes, how the disease spread from country to country and continent. soon as possible.

BLACK DEATH HISTORICAL SIGNIFICANCE BLACK DEATH EFFECT ON MEDICINE

nd • In 1346, the 2 pandemic hit Europe, was called the Great • Medieval society had 4 kinds of medical practitioners: Mortality, the Pestilence and the Pest. 1. Academic physicians-knew theory but didn’t care for the • In 4 years, it killed a third of Europe’s population. sick. • Before 1346, Europe was ruled by aristocrats and the 2. Surgeons- main caregivers of the sick, Church. They owned all the land, controlled the wealth, 3. Barbers who did bloodletting and minor surgery. determined the laws and were gatekeepers of all 4. Folk medicine practitioners which were mostly women. knowledge. • Academic physicians believed Hippocrates's and Galen theories • The Black Death did not discriminate, wealthy and poor alike were afflicted and died. Religious leaders died along that bad humors in the body caused disease. The four humors with sinners. were blood, phlegm, black and yellow bile. Since this couldn’t be applied to the plague, confidence in these practitioners • So with fewer workers, wages went up. With fewer diminished. consumers, prices went down. • Surgeons who wore the Plague doctor costume died at higher • In the countryside and cities, a rising middle class was able rates than barbers or folk practitioners, so they were not valued. to buy property, businesses and wealth the dead had left behind.

BLACK DEATH BLACK DEATH

• New prestige fell to the barber, which lead to an emphasis • In 1894, Alexander Yersin, a student of Louis Pasteur, was on study of the human anatomy in health and disease. sent to Hong Kong to discover the cause of the plague. He • The Galenic system which had no clear theory of contagion identified Yersinia pestis bacterium, a gram negative declined in importance. bacteria. Originally named Pasteurella pestis, the name was changed in 1970 to reflect the person who identified it. • In the 1500’s Girolamo wrote that infectious disease could be transmitted by semanaria (germs) in 3 ways-by direct • Yersin did not identify how it was spread. contact, through carriers, and through airborne • In 1898, Paul Simond, another student of Pasteur, was sent transmission. Other physicians did not believe him and his to Vietnam and India to follow up on Yersin’ s observations. theory was not followed up until the 19th century by Louis He noted there were large numbers of dead and dying rats Pasteur and Robert Koch and their associates. and from there went to discover the intermediary the rat flea.

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BLACK DEATH TRIVIA THINGS LEARNED FROM THE BUBONIC PLAGUE

• God Bless You: Pope Gregory I in 590 AD ordered unending prayer to fight the plague in Rome. Sneezing was thought to be an early • Quarantine symptom, so God Bless you became a common saying to halt the disease. • Need to understand the pathogen and the • Eau de cologne: invented in Germany, named after the city of Cologne, was used to “purify” the air from the stench of death from the plague. vector of disease to be able to control it. • Pied Piper of Hamlin: Pied piper offered large sum of money to rid the • Protective clothing for caregivers city of rats, played his flute and lead rats to river where they drowned. Officials reneged on payment, so the pied piper played his flute again, • Burning of clothing and bedding this time all the children followed him to the mountain and were never seen again • Burying the dead in shallow graves sprinkled • Ring Around the Rosie: debate whether it was written due to the plague or not. Sung from the 1790s, but didn’t appear in print literature with lye until 1822. • “Ring around the rosies. • A pocket full of posies, • Ashes, ashes!

BUBONIC PLAQUE PLAGUE AS A BIOTERRORISM WEAPON

 Last case of Bubonic plague Aug 2013 in Kyrgyzstan 15 • An aerosolized plague weapon could cause fever, year old boy died before diagnosed. Endemic in region. cough, chest pain, and hemoptysis with signs  1000-2000 cases yearly reported to WHO. consistent with severe pneumonia 1 to 6 days after exposure.

• Rapid evolution of disease would occur in the 2 to 4 days after symptom onset and would lead to septic shock with high mortality without early treatment. • Early treatment and prophylaxis with streptomycin or gentamicin or the tetracycline or fluoroquinolone classes of antimicrobials would be advised.

JAMA. 2000;283(17):2281-2290. doi:10.1001/jama.283.17.2281

SMALLPOX SMALLPOX HISTORY

• At one time the most • Smallpox did not exist among the native people of North devastating of all human and South America until the Europeans came to their diseases, unknown when it shores. began infecting humans. • When exposed, nearly everyone caught the disease and • If survive illness, are immune approximately half died from it. for life. • Native people saw the invaders immunity to smallpox as • Best evidence of smallpox in godlike, so the Europeans talked about the disease as humans is found in 3 Egyptian being sent by God to help them gain control of these mummies, dating from 1570 to lands. 1085 BC. • The Incas and Aztecs were decimated by smallpox and • Pharaoh Ramses V-died in that is how their lands were conquered. 1155 BC, mummified face, • Same thing occurred in North America when the Pilgrims neck and shoulders bear landed and infected the Native Americans. In some the pockmark scars of cases, the Native Americans were infected intentionally smallpox. with blankets contaminated with smallpox

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Progression of Smallpox SMALLPOX

• One of the largest viruses. Variola major and minor. • Outer surface resemble facets of a diamond. • Inner service has a dumbbell shaped core that contains the genetic material. • Not zoonotic transmission • It can exist only as long as there are susceptible humans. Incubation period 10-14 days. • Up to 30% mortality in unvaccinated individuals

Source: Foege, Lane, and Millar, Am J. Epi, 1969

PROGRESSION OF SMALLPOX PRE-ERUPTIVE SYMPTOMS PRE-ERUPTIVE STAGE 6942 CASES OF VARIOLA MAJOR SYMPTOM PERCENT Fever 100 • Sudden onset of fever (38.5-40.5C or Headache 90 101.3 -104.9F) and malaise. Chills 60 • Headache, muscle pain, nausea, vomiting Backache 90 and backache Pharyngitis 15 • Toxic during first two days. Vomiting 50 • Fever drops and patient feels better by Diarrhea 10 days 2-4. Delirium 15 Abdominal Pain 13 Convulsions 7

Rao, Smallpox in Bombay, Kothari, Bombay, 1972

SMALLPOX SMALLPOX PROGRESSION OF RASH

• The first visible lesions appear in the mouth as minute red • A major diagnostic characteristic of smallpox is that spots on the tongue and oral and pharyngeal mucosa, about lesions in a given area are similar in appearance 24 hours before the appearance of rash on the skin. and feel. • Lesions in the mouth and pharynx enlarge and ulcerate quickly, releasing large amounts of virus into the saliva. • Progression occurs, however, from area to area: • The skin rash usually appears first as a few macules, known • Pharynx, Palate. as “herald spots” on the face, particularly the forehead. • Face. • Lesions then appear on the proximal portions of the • Proximal Extremities. extremities, then spread to the trunk and distal portions of • Hands and Feet. the limbs. • Usually, the rash appears on all parts of the body within 24 hours.

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TYPICAL PROGRESSION OF SMALLPOX BIRTH OF VACCINES • Theory of inoculation dates back to 1000 BC when people in India rubbed pus into skin lesions and the Chinese blew • Incubation Period powdered smallpox scabs up their noses. They would develop mild cases of smallpox, recover and be immune • Pre-eruptive Stage from it. However, 1 out of 50 would die. • Macules • Lady Mary Wortley Montague survived smallpox and • Papules traveled with her Ambassador husband to East Asia, Africa and India where she observed the smallpox inoculation. She • Vesicles had her son inoculated and he survived. She brought the • Pustules knowledge back to England, where a smallpox epidemic had developed. • Scabs • Princess Caroline heard of it and had the theory tested on 6 • Scars prisoners and orphans, when they all survived, she had her daughters inoculated. Then high society in England followed suit.

BIRTH OF VACCINES SMALLPOX

• Lady Montague set the stage for Edward Jenner to develop • Anyone born before the 1970’s has been immunized the smallpox vaccine in 1796. against smallpox. • Edward Jenner observed that people who had cowpox were • The scar is a dime-size depression etched on the immune from smallpox. upper arm. • On May 14, 1796 a milkmaid got cowpox. Jenner took a quill • In 1980, WHO declared smallpox was eliminated full of pus and slipped it into a scratch on a young boy, who from the planet. The only disease we have ever then grew cowpox pustules, then on July 1, 1796 Jenner eliminated. inoculated the same arm with smallpox. Nothing happened, • Officially, the only smallpox virus available exist in no illness. two laboratory deep freezers, one in Atlanta and one • Birth of the smallpox vaccine. in Siberia • Concern now is may be used as bioterrorism weapon

MODELING POTENTIAL RESPONSES TO SMALLPOX ISOLATION SMALLPOX AS A BIOTERRORIST WEAPON

Strategy Days to Required Number of • Airborne, droplet and contact isolation Contain Strategy Targets Cases Quarantine Alone 240 50% removal 2,300 • Negative pressure isolation room rate • HEPA filters do trap the smallpox virus Vaccination Alone 365 Reduce 2,857 • transmission to Use of fitted N95 respirators 0.85 • Only assign personnel who have been infected/case vaccinated to care for individual. Quarantine and 365 25% removal 4,200 Vaccination rate; • Use disposable gloves, gowns, and shoe covers transmission • reduced 33% by Reusable bedding and clothing should be vaccination autoclaved or laundered in hot water with bleach

Meltzer M, Damon I, Le Duc J. Millar J. EID 2001 (Nov-Dec);7(6)

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SMALLPOX TREATMENT BURIAL ISSUES

• All patients may require supportive care. • Contain and seal remains • Vaccinia Immune Globulin is not effective against smallpox infection and should not be used. • No open funeral • Flat / Hemorrhagic: Treat as for shock. • Cremate, if possible: • Semi confluent/confluent: Treat as for a burn. • If not, bury, but no embalming • All types: Bacterial superinfection likely. • Put in ground, not “on surface.” • Always consider: • If you can’t bury in ground, move remains • Dehydration, renal failure. • Malnutrition. • Role of antiviral medications uncertain.

WHAT WE GAINED FROM SMALLPOX CHOLERA

• Development of vaccines to prevent illness • In 1817, a new disease called Cholera swept out of India. • First and only disease eradicated worldwide • Caused violent gushing diarrhea and vomiting, dehydration causing shriveling of face, hands and feet that turned blue-black. • Could cause death within a few hours. • 7 pandemics since that time. • Last epidemic occurred in Haiti in 2010.

CHOLERA CHOLERA

• Caused by Vibrio cholerae: • In London, the third cholera outbreak in 1853, beliefs of the • Dehydrating diarrheal gram-negative, curved rod cause of the disease: illness, can have up to 1 with a single polar flagellum • Miasmists blamed the disease on mysterious emanations, liter per hour. that makes it highly mobile rotting garbage, foul smelling sewers, swamp vapors. • Causes rapid profound • Transmitted through Worked to clean up the environment. loss of fluids and contaminated water/food. • Contagionists believed it was spread by contact with electrolytes in diarrhea and infectious agent: bad beer, cucumbers, foreign food, vomiting. shellfish, phosphorus, copper. • After initial purge, diarrhea has fleck of mucous, called “rice stool”. • Leg cramps from hypokalemia

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CHOLERA- HISTORICAL CHOLERA-BIRTH OF EPIDEMIOLOGY • 1835, Max von Pettenkofer, considered the first sanitary scientist, said that sanitation, specifically disposal of waste • John Snow, born in England in 1813, began to study cholera and sewage in a manner that it could not contaminate food in 1850. and water was the key to improving health in Germany. • Digestive symptoms started immediately, felt was caused by • Edwin Chadwick, in England, led the movement to improve something people ate or drank. sanitary conditions of the poor. His board of health produced • Poor in cities had difficulty getting enough water to wash “sanitary maps” showing relationship to disease to thoroughly so contamination easy. But not confined to the overcrowding, lack of drainage and defective water supply. poor. He introduced paved streets, piped water and efficient • ? possible for river water and from pumps in town to be sewage drains, unfortunately the outflow was to the river. contaminated Beginning of flush toilets. First Public Health Act of 1848 • Tested his theory by examining in minute detail a single • Chadwick was not being altruistic to the poor, he believed outbreak of cholera in London. The area was within 250 that a healthier population could work harder and would be yards of Cambridge and Broad Street. Upwards of 500 less of a burden. cases daily for 10 days.

CHOLERA CHOLERA • Focused on the Broad Street water pump, the water looked • Quarantines didn’t work, but were frequently used especially clear and clean. Germs wouldn’t with immigrants. be identified for another 19 years. • Doctors prescribed various treatments that were ineffective • Got the names and addresses of including: all the people who had died in • Hot poultices of salt, mustard, roasted black peppers, that area and found they all powdered ginger, horseradish or burnt cork. used the Broad Street pump for • Ice water baths their water. • Tobacco enemas • Had the handle of the pump removed so no one could use it. • Opium suppositories The outbreak stopped. • Phlebotomy • Beginning of epidemiology, unfortunately he was not taken seriously at this point.

CHOLERA- BIRTH OF HANDWASHING CHOLERA

• Pasteur, Koch and Hansen had all accumulated evidence • In 1846, Ognaz Semmelweis, an obstetrician in Vienna, supporting the germ theory of disease. pointed out that women who gave birth at home or in the • 1873-Leprosy street had a better survival rate than those delivered in the • 1876-Anthrax hospital. • 1880-Typhoid fever • He felt that doctors who worked ungloved and wore the • 1881-Bacterial pneumonia same attire throughout the day including an apron for surgeons that was considered the redder the better, were • 1882-Tuberculosis contagious. • 1883-Diptheria • In 1883, Cholera outbreak in Egypt. Koch was sent to • Semmelweis ordered his subordinates to wash their hands identify the microbe responsible. in chlorinated water before entering the wards. The maternal death rate dropped from 30% to 1%. • Saw bacteria swimming in the feces of those infected and called it Vibrio because of its vibrating wiggles. • Washing hands then spread from the hospital to business to homes as a cheap effective way to stop illness.

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CHOLERA-OUR FAILURE CHOLERA TREATMENT TODAY

• Cause of cholera is known • Oral Hydration Therapy is the main treatment. If moderate • It is preventable and curable or severely dehydrated then IV therapy with Ringer’s • Prevention is simple-access to sanitary water. CDC has a Lactate. safe water system- a cheap water purification system. • Antibiotics used in severely dehydrated. • Root cause is global poverty. • Zinc supplementation significantly reduces the severity and • Example is Iraq, industrial nation that was modern and duration of cholera in children and other childhood diarrheal prosperous with a large middle class. In the 1990’s UN illnesses. sanctions, caused decreased ability to purchase food, and medications along with disruptions of water supplies caused • A recommended dosage of 10–20 mg zinc per day by mouth deterioration of Iraqi health. Along with Saddam’s regimen’s should be started immediately if available, and continued as indifference to his country’s suffering lead to increase in long as the diarrhea lasts infectious diseases, Cholera outbreaks, infant mortality rose • . sharply and approximately 1/2 million children died. (exact www.cdc.gov/cholera number unknown, WHO estimate).

CHOLERA-WHAT WE LEARNED TUBERCULOSIS

• Public health measures of sanitary drinking water, • Kills more individuals than any other germ besides HIV appropriate disposal of sewage, hand washing. • Single largest cause of death from infectious disease in the • Knowledge of health care workers causing nosocomial US infections • Worldwide over 9 million become infected each year and 1.4 • Quarantine is not always the answer. million die from it yearly. • Birth of epidemiology • An estimated 2 billion people are infected with it. • On average 1 person dies of TB every 15 seconds. • Caused by mycobacterium tuberculosis. A rod shaped bacilli.

www.cdc.gov

TUBERCULOSIS TUBERCULOSIS Symptoms of pulmonary TB General symptoms of TB • Reported in almost every state and disease: disease: is actually increasing in some areas • Cough lasting 3 or more • Fever weeks • Affects racial and ethnic minorities • Chills • Chest pain • disproportionately. • Night sweats • Coughing up blood or sputum • Drug-resistant TB is increasingly challenging to treat • Weight loss Symptoms of extrapulmonary TB • Management of patients with comorbidities, such as HIV, • Appetite loss disease depend on the part of the diabetes, and other immune compromising conditions, is body that is affected. • Fatigue difficult • TB disease in spine may cause • More than half of all persons in the United States who have • Malaise back pain TB disease are foreign-born residents • TB disease in kidneys may cause blood in urine • TB disease in lymph nodes may www.cdc.gov cause swelling in the neck

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TUBERCULOSIS TUBERCULOSIS-HISTORY

• Called consumption, white plague or graveyard cough in • Skeletal remains show prehistoric humans as early as 4000 the 19th century BC had TB. • In 1853 medical text it was described as having the • Tubercular decay has been found in the spines of Egyptian following features: nostalgia, depression, and excessive mummies from 3000-2400 BC. sexual indulgence. • In 460 BC, Hippocrates described TB as the most • It was believed that mental activity and artistic talent were widespread disease of the time, involving coughing up blood stimulated by the poisons of this wasting disease. and fever, which was almost always fatal. • In the 1800s persons with TB were considered beautiful and erotic: extreme thinness, long neck and hands, shining eyes, pale skin and red cheeks • The operas La Boheme and La Traviata heroines had TB. • At that time TB was not recognized as an infectious disease

TUBERCULOSIS-HISTORY TUBERCULOSIS-HISTORY

• Stealthy disease, after it enters the body it will wait 10 days to 50 years until the host’s immune system is weak enough • Ancient Greeks developed tests to analyze what the TB patient coughed up: in one test, the patient spit in a copper to attack vessel filled with seawater, if the sputum sank death was • Because it seemed to occur in families it was thought to be near. In another, the sputum was dripped on hot coals-if it hereditary. smelled like rotten meat, then death was near. • Gives no outward sign of its presence until it is too late. • In 1761, the idea of percussion of the lungs was started by Leopold Auenbrugger, who was the doctor son of an • Before x-rays and skin tests, the first sign was coughed up innkeeper. Just as his father rapped on the side of casks of blood. wine or beer to tell how much was in them, you could do the • It is estimated that in the 19th century, 25% of all Europeans same with the chest to tell how fluid filled the lungs were. died young from the disease. • In 1820, Dr. Rene Laennec, suffering from TB himself, • Risk highest in densely crowded areas, inadequate invented the stethoscope ventilation

TUBERCULOSIS-SANATORIUMS TUBERCULOSIS-SANATORIUMS

• Toward the end of the 19th century, people who could afford • Sanatorium Drs. Experimented with an array of therapies it began to go to sanatoriums for treatment. including; • • For the rich, these were lavish places, with good food and Bedrest the latest fads to treat the disease. For the poor, little better • Lung collapse than prisons. • Rib removal • Became places to isolate the sick as much as they were • Exposure to heat or cold places to heal. Voluntarily or mandatory. • Gold, calcium or iodine therapy • People could spend five years to life in a sanatorium, which • Cod liver oil brought out people’s prejudice so there were separate • Horse riding. hospitals built to house the Native Americans and blacks. • Dietary therapies ranged from starving a person to stuffing • By 1950, there were over 100,000 sanatoriums in the US them with nutritious food. alone.

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TUBERCULOSIS-DISCOVERY OF CAUSE TUBERCULOSIS-DISCOVERY OF CAUSE

• In 1822, Robert Koch discovered the rod shaped • Once Koch grew the bacterium, the next step was to see if mycobacterium tuberculosis that caused TB. what he grew caused TB- he injected a guinea pig that • Even with a microscope it is difficult to see, so he tried promptly developed TB and died. He repeated the staining bits of a TB infected lung with an old bottle of experiment again and again with different animals with the methylene blue he had and then washed it a second time same results. with a brown stain. Tiny bright blue rods appeared. • In 8 months of study, he had discovered the cause of TB • But was this what caused TB- he went to the next step to try to grow the bacteria-he considered the merits of growing it that had been killing people for centuries. on a potato, then decided a solid liquid bacteria food would • After he discovered the bacterium, he went on to develop be perfect. the TB skin test that is still used today. • Turned out, Frau Hesse, the wife of one of his coworkers, • Koch also identified that milk from infected cows could infect used agar-agar, a gelatin-like substance derived from humans, pasteurization of milk immerged and was able to seaweed to harden jams. Koch used it and was able to grow kill the disease. TB on it. • It is still used today to grow bacteria.

TUBERCULOSIS TUBERCULOSIS

• Once it was discovered how TB was contagious: • Testing for TB Infection • Spitting in public was forbidden, • Cows with TB were slaughtered before milk pasteurization • Diagnostic tests that can be used to detect TB infection was developed, include: • Handwashing, • Mantoux tuberculin skin test (TST) • Higher standards of hygiene • Interferon-gamma release assays (IGRAs) • Better nutrition • • Compulsory reporting of the disease • A positive TST or IGRA result only indicates if someone has • Isolation been infected with M. tuberculosis. These tests cannot identify if a person has TB disease. • All of these helped contribute to control TB

TUBERCULOSIS-TESTING TUBERCULOSIS

• Mantoux Tuberculin Skin Test An induration of 5 or more mm is considered positive for: • Forearm site read within 48 to 72 • People living with HIV hours. • Recent contacts of persons with infectious TB disease • To determine whether a TST reaction should be considered positive, a • Persons with chest x-ray findings suggestive of previous health care worker needs to interpret TB disease the reaction based on: • Patients with organ transplants and other • 1. Size of induration (measured in millimeters [mm]) immunosuppressed patients • 2. Patient’s risk factors for TB Redness around the injection site is not An induration of 15 or more mm is considered positive in measured. This is because the presence of redness does not indicate that a anyone, including persons with no known risk factors for TB. person has TB infection.

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TUBERCULOSIS TUBERCULOSIS

• An induration of 10 or more mm is considered positive for: Testing for TB in BCG-Vaccinated People • People who have come to the United States within the last 5 years from areas of the world where TB is common: Asia, • People who were previously vaccinated with BCG may Africa, Eastern Europe, Latin America, and Russia receive a TB skin test to test for TB infection. Vaccination with BCG may cause a positive reaction to a TB skin test. A • Injection drug users positive reaction to a TB skin test may be due to the BCG • Residents and employees of high-risk congregate settings vaccine itself or due to infection with TB bacteria. • Myco-bacteriology laboratory personnel • TB blood tests (IGRAs), unlike the TB skin test, are not • Persons with conditions that increase risk for progressing to affected by prior BCG vaccination and are not expected to TB disease give a false-positive result in people who have received • Children less than 4 years of age BCG. • Infants, children, and adolescents exposed to adults in high- risk categories

TUBERCULOSIS-TREATMENT TUBERCULOSIS

• With the advent of antibiotics, the sanatoriums closed. • In the US, TB cases declined by 73% between 1953 and 1987. • Unfortunately for some, streptomycin stopped working- antimicrobial resistance was occurring. • Lead to decreased money being spent on treating TB. • TB cases started rising again for 3 reasons: sharp rise in • Drs. then used 3 antibiotic drugs at a time for periods of 6 homelessness, worldwide spread of HIV, and poverty that months to a year which seemed to be the solution. made it especially difficult to follow the complicated drug • However, the problem became people stopped taking the regimen. drugs too soon, so the TB that survived was now developing • In New York City, in 1993 started a program known as resistance. Directly Observed Therapy Short-Course or DOTS, they • This has happened so many times, that there are now some track down everyone with TB and watch them take their pills strains of TB that are resistant to 7 drugs. daily. • In Africa, DOTS as been able to cure more than 80% of the cases • In 1998, the DNA sequence of the tuberculosis bacillus was identified.

TUBERCULOSIS-HISTORY TUBERCULOSIS-WHAT DID WE LEARN

Famous persons who died from TB: • Use of percussion of the lungs Harriet Webster • Invention of the stethoscope Frederic Chopin • Use of agar-agar to grow bacteria Edgar Allan Poe • Development of TB skin test John Keats-both his mother and younger brother died before him • Pasteurization of milk to kill bacteria Henry David Thoreau • Use of antibiotics to treat illness John Henry “Doc” Holliday • Multi-drug antibiotic resistance Elizabeth Barrett Browning • Poverty still places people at high risk for disease George Orwell Eleanor Roosevelt- had contracted the disease at age 12 Vivien Leigh

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REFERENCES

Barnard, B. (2005). Outbreak Plagues That Changed History. New York: Crown Publishers. Bugl, P. (2001). History of Epidemics and Plagues. Retrieved 9/16/12 from uhavax.hartford.edu/bugl/histepi.htm. “Those that cannot remember the past are Centers for Disease Control and Prevention Website. www.cdc.gov Farrell, J. (2005). Invisible Enemies Stories of Infectious Disease. 2nd condemned to repeat it”. edition. Harrisonburg, Virginia: RR Donnelley & Sons George Santayana 1905 Foege, Lane, and Millar, Am J. Epi, 1969 Heysell, S, et al. (2103). Epidemiology of extensively drug resistant tuberculosis. Retrieved 8/2/13 from www.uptodate.com. JAMA. 2000;283(17):2281-2290. doi:10.1001/jama.283.17.2281 Meltzer M, Damon I, Le Duc J. Millar J. EID 2001 (Nov-Dec);7(6) Public Health Library Images through www.cdc.gov Rao, Smallpox in Bombay, Kothari, Bombay, 1972 Sherman, I. (2006). The Power of Plagues. Wash DC: ASM Press.

Thank you.

Any questions.

LEANNE SCHIMKE EMAIL: [email protected]

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