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Tuberculosis: P revious and Present Millennium .

Tuberculosis: P revious and Present Millennium. TB before advent of chemotherapy TB in 1950 - 2000 Morbidity, Mortality & Elimination of TB . Censina R. Apap, Pulmonologist. Introducing Myself. Respiratory specialist since 1983 Working in the Netherlands since 1977

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Tuberculosis: P revious and Present Millennium .

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  1. Tuberculosis: Previous and Present Millennium. • TB before advent of chemotherapy • TB in 1950 - 2000 • Morbidity, Mortality & Elimination of TB. Censina R. Apap, Pulmonologist.

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

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

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

  5. TB R/ in the pre-antibiotica era. Conservative, directed at relief of symptoms. Sanatorium R/ introduced in Germany by Brehmer resulted in 25% sputum conversion within 6 mo. 50% of smear positive cases died of disease within 5 years.

  6. How was TB treated in 1937? • “Upon the permanence of closure of a tuberculous cavity depends the future development of the disease.The tuberculous cavity is the disease itself, the one feature which controls and regulates the course and outcome of the pulmonary lesion andthe fate of the patient.” Coryllos.

  7. SanatoriumHospital Home R/ Total patients 1026 152 347 No of deaths 565 131 288 From W.A. Griep

  8. Deaths (fall off rate) due to TB.

  9. Results of active R/ Active treatment gives an additional sputum conversion of 6%. N.B. Lung resection only possible with required appropriate intratracheal anaesthetic techniques. Active R/ of TB. • Collapse R/ • Artificial pneumothorax, Forlanini in 1888; • Phrenicus paralysis; • Thoracoplasty; • Closed suction of lung cavities (Monaldi); • Lung resection.

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

  11. Natural course of TB infection • Mycobacteria inhaled -> phagocytosis by alveolar macrophages-> 2 possibilities: • No infection • Infection (early / late)

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

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

  14. TB R/ in the antibiotic era. • Role of chemotherapy: permanent cure without development of resistance • Lack of success herein due to various factors: • Improper use of antibiotics • Increased transmission • Priority of disease control less imminent  Risk -> outbreak

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

  16. Terminology • Bacterial resistance = 1% of TB bacilli population insensitive to chemotherapy • Resistance: mono / multiple INH = 5-10%, RMP rare • Resistance: primary / secondary • MDR-TB -> resistant to both INH + RMP

  17. Blessing or threat? • TB is rare in industrialized countries • If undetected, increased morbidity follows • Outbreak to the general population may be the result

  18. Current situation in the Netherlands (NL). • Mortality rate = 2 / 100,000 • Morbidity rate = 20 – 50 / 100,000 • 1n 1987, 1229 cases recorded • Current problems -> emergence of drug resistance and HIV-infection.

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

  20. TB in the year 2000 • TB -> still a leading cause of death in developing countries • TB -> kills 3 million people a year worldwide • 3 current epidemics -> HIV, resurgence of TB, MDR-TB • AIDS + MDR-TB (super bug) -> alliance of error

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

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

  23. TB variance in HIV + and HIV - subjects.

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

  25. Prevention and control of TB • 2 basic strategies of paramount importance: • Timely identification and effective treatment • Effective and timely screening of close contacts

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

  27. Summary (1) • Past R/ ineffective -> high morbidity and mortality • Chemotherapy and improved socio-economic conditions -> a radical change in R/ -> ambulant and in out-patient setting • Result -> TB, a rare disease in industrialized countries

  28. Summary (2) • In 1980+ : relaxation / dismantling of TB control network • HIV epidemic causes TB resurgence • Drug resistance leads to MDR-TB in • Sub-Saharan Africa and South East Asia • Some states of the USA • Might become a problem in W. Europe • A 3rd epidemic with MDR-TB should be avoided at all costs

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

  30. Recommended sites • New York’s Health department • Global netwerk TB control • Centers for disease control & prevention • John Hopkin’s • National Institute of Allergy & Infectious Diseases • Tuberculosis testing • Discuss global TB program

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

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