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-- Saturday -- July 31 2010
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TB Then and Now
Carolyn Grimes, MS, RHIT, CMT, AHDI-F
Tuberculosis is caused by Mycobacterium tuberculosis, a gram-negative bacterium. This is usually the acid-fast bacilli that are positive that you hear on some lab results. The four medications usually used together to treat TB are: isoniazid (INH), rifampin (Rifadin, Rimactane), ethambutol (Myambutol) and pyrazinamide. Rifater combine 3 drugs (isoniazid, rifampin and pyrazinamide) into a single pill. Once-a-week dosage during the last 4 months of therapy is possible with rifapentine (Priftin). Medication must be taken for 6-12 months in order to completely clear the infection.
When I was growing up, a diagnosis of tuberculosis was the next thing to a death sentence. Schools required annual chest x-rays, and waiting for the results, especially if you were pale and thin, was indeed suspenseful. We were fortunate, but not everyone was. Quarantine laws were strictly enforced, and spitting on the sidewalk wasn’t just a gross, distasteful habit but a real threat to public health and fines and jail sentences enforced this.
My mother worked in an office with a man who was diagnosed with TB by x-ray. Everyone he worked with or associated with had to have an x-ray then, but he was the only case. He had to quit his job immediately and make preparations to go to the sanitarium. He and his wife sold their home, and she and the children moved in with his parents on their farm. Two weeks later, the sanitarium made some other tests. He did not have TB. He had histoplasmosis, a fungal infection associated with birds, frequently chickens, and his family did have some chickens. His home was gone, he had been replaced at work, and he and his family had to start over. The only satisfaction he could get was knowing that from then on, each person having a positive chest x-ray would receive the laboratory tests immediately so no one else would go through what he did.
If TB was so contagious, why didn’t the people who worked in the sanitariums develop the disease themselves? Some did, including some of the physicians and interns who performed bronchoscopies on the patients.
Tuberculosis was spread by unpasteurized milk as well as airborne droplets, so it was frequently a problem among children. Transmission of TB from children is possible but not as common as that from adults. In children under 4, TB usually spreads through the body via the blood stream, making central nervous system complications much more likely.
Drugs to treat TB made separate, isolated establishments to treat TB patients obsolete. In the early 60s, the Centers for Disease Control closed its Tuberculosis Branch. TB wasn’t a problem any more, and the only transfers available for the employees of that section were in the Hansen’s disease facility in Carville, LA. Hansen’s disease is caused by Mycobacterium leprae, so it might be considered a logical choice.
In the 70s, I was working at a facility that treated a lot of furrier employees, and they were coming up positive for TB. I wondered why—was there an epidemic of TB in the animal population; did it have something to do with their occupation or something else? I had to ask one of the doctors who told me that it was contracted in their home country. All the patients had to do was take their medicine, and they could go to work every day and get about their lives as they always did. Living at home with their families was no problem. (Still today, anyone who refuses treatment is supposed to be confined and treated. It is still very much a public health threat.)
I also remember when all new arrivals had to pass physical exams, including chest x-rays, and were deported if they did not pass. A bit draconian, perhaps, but this was in the days of sanitariums. Growing up, we always had a house full of displaced persons, and organizations such as the Red Cross were performing exams and giving out health certificates in the refugee camps to speed up the process.
The resurgence of TB was a cover story on Time Magazine when this “obsolete” disease found a new population with AIDS patients.
TB, like many other disease organisms, adapted to changing conditions. Now we have drug-resistant strains. The most notorious example of this is Andrew Speaker, the Atlanta attorney who went to Europe via commercial air for his wedding and honeymoon, taking his tuberculosis with him. According to news accounts, upon his return, he decided to have lung surgery to remove any damaged tissue as well as the organism. It was reported that he had multidrug-resistant tuberculosis (MDR TB), instead of extensively drug-resistant tuberculosis (XDR TB) as was first believed. The procedure was minimally invasive, video-assisted thoracic surgery (VATS).
After this incident, enforcement of treatment of diagnosed cases seemed to have become a priority. A teenager refusing treatment for positive TB found himself a guest in a secure ward in North Georgia where he could receive treatment under direct observation by order of the court.
TB is another example of a disease that is best diagnosed and treated early. Taking care of yourself is always a good idea. So if you are one of the few MTs working in a hospital environment or a student completing an externship on site, when the employee health division sends you a notice that it’s time for a TB skin test, please don’t put it off. This is a disease that can affect not just you but everyone around you.
To review, the name of the disease organism is Mycobacterium tuberculosis, a gram-negative, acid-fast organism. The drugs usually used to treat it are isoniazid (INH), rifampin (Rifadin, Rimactane); ethambutol (Myambutol) and pyrazinamide. Rifater is one pill containing isoniazid, rifampin and pyrazinamide. And rifapentine (Priftin) is a once-a-week dosage for the last 4 months of therapy.
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