Article

2007-11-03 Africa Subsaharan

Deadly HIV-TB co-epidemic sweeps sub-Saharan Africa

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Posted by Nimble Spemble 2007-11-03 04:37|| || Front Page|| [11137 views ] Top

#1 TB is still past its glory days, when it spawned what we now think of as "Gothic". It was so unpredictably murderous that Europe had something of a collective nervous breakdown about it.

Many people wasted away. The "Victorian look" of gaunt and pale was a fashion decision to look like you had TB. But the disease could also cause paralysis, hyper creativity, hyper sexuality, or show almost no symptoms before you dropped dead.

In the US, the West was particularly popular because of its dry air for those afflicted. I live near one of the last hospitals dedicated to TB patients, that eventually closed due to effective antibiotics. It is noteworthy because of its smokestack, where used mattresses and linens were burned.

Posted by Anonymoose 2007-11-03 10:50|| 2007-11-03 10:50|| Front Page Top

#2 Africa wins again!

Posted by Scooter McGruder 2007-11-03 10:59|| 2007-11-03 10:59|| Front Page Top

#3 Anonymoose, my birth mother had TB in the 50s. I got screened every year for my first couple decades.

Posted by lotp 2007-11-03 11:02|| 2007-11-03 11:02|| Front Page Top

#4 Evil western colonial antibiotics, quarantined patients, remotely located medical facilities....? Has a certain apartheid ring to it. It'll never fly.

Posted by Besoeker 2007-11-03 11:06|| 2007-11-03 11:06|| Front Page Top

#5 Do they still give the kiddies mass TB screening tests in elementary school?

Posted by SteveS 2007-11-03 11:10|| 2007-11-03 11:10|| Front Page Top

#6 TB is coming back to the US, courtesy of illegal immigrants

Posted by Frank G">Frank G 2007-11-03 11:26|| 2007-11-03 11:26|| Front Page Top

#7 Africa seems to have shifted from its previous role as a mere incubator over to being the Pressure Cooker O' Death.

Posted by Zenster">Zenster 2007-11-03 12:05|| 2007-11-03 12:05|| Front Page Top

#8 lotp: I've no doubt they watched you very carefully. No sense of humor about these things.

Public health authorities are still very 'up' for TB, as evidenced by that guy who flew over from Europe only to be quickly arrested.

They about had a collective hernia when half the Phoenix Fire Department tested positive for exposure. They discarded all their breathing equipment, even though it was not shared. They never did find out where they all got it.

You get one skin test to see if you have been exposed to it, if positive, a second skin test to confirm you have the disease.

I gather if you are exposed to it, you are placed on one set of drugs for six months; then if you develop the disease, you are on a different set of drugs for a year or two.

Being identified as carrying TB is probably worse than being pointed out as a terrorist.

Posted by Anonymoose 2007-11-03 13:21|| 2007-11-03 13:21|| Front Page Top

#9 It was a good thing when I was finally declared Not Infected. Both to reduce the hassle and because of the effects the disease had on my birth mother. Among other things, although she screened clear for 10 years she was denied a nursing license in 3 stats and finally settled for much lower paid jobs (and nursing itself wasn't all that well paying in the 60s and 70s).

Posted by lotp 2007-11-03 13:24|| 2007-11-03 13:24|| Front Page Top

#10 Let me make a couple of points:

we in the Pulmonary and Infectious Disease areas differentiate between TB infection and tuberculosis. The former means you've inhaled the bacillus and had a primary infection that you then contained. We call this primary TB. Basically, the bacillus causes a localized pneumonia for 4 to 6 weeks. It feels as if you have a lingering cold or flu. Your cell-mediated immune system then kicks in and walls off the infection to some of your pulmonary lymph nodes. You get better. It's at that point your skin test (PPD) turns positive.

90% of the time your primary infection is walled off as noted. If your immune system is compromised (e.g., AIDS), you can't wall it off and the TB infection spreads. We call this primary progressive TB.

If you succeed in walling off the infection, there is about a 1% chance per year after the first year that the infection will re-activate. We call this secondary TB. Reactivation occurs for unclear reasons, but people with weaker immune systems, silicosis, etc are more susceptible. This is the classic TB that most people think of and what is usually described in the popular literature and news.

Primary TB and primary progressive TB usually are found in the lower lung fields and lymph nodes. Secondary TB is found in the upper fields, frequently cavitates, and is the one that allows TB to spread (you have lots of bacilli to cough out from the cavities).

Treatment for a positive PPD (meaning you had a primary infection) is designed to prevent secondary TB years later. That is to say, this is prophylactic treatment. You take isoniazid (INH) for 9 months or INH plus rifampin (RIF) for 4 months. Some people who are much more susceptible to secondary TB (e.g., people with AIDS or silicosis) take this prophylactic treatment for life.

People with primary progressive TB (PPD positive, never got better from their primary infection) or secondary TB (PPD positive, reactivation years later) take INH, RIF, ethambutol (ETH) and pyrazimamide (PZA) for about two months, or until the bacilli no longer are found in the sputum, followed by INH and RIF for another six months. With non-drug resistant TB and a compliant patient, cure rates with this regimen are 97 - 99%.

You have to take multiple drugs as noted in what's called 'directly-observed therapy' (DOT). This is done to prevent the development of resistance. Multiple drugs makes the chance of resistance much lower, and DOT ensures compliance. A public health nurse comes to the home and watches you swallow the pills. Along the way the nurse helps with social issues, etc.

Resistant TB occurs when one drug no longer works. When that happens we drop that drug and add TWO others from a list of 'second-line' drugs (e.g., streptomycin, clarithromycin, PAS, etc). MDR is multi-drug resistance, that is, resistant to two or more drugs. Now you have a problem, because the more resistant the organism is, the farther down on the list of 2nd and 3rd line drugs you go to find drugs that will work. That increases the risk for complications and decreases compliance.

XDR, extremely or extensively drug resistant TB, is the nightmare, because now you have insufficient number of drugs to which the bacilli are susceptible. If XDR catches hold in the developed world, we'll not be able to get any reasonable cure rate, and we'll be back to the 1930s in our treatment approach with surgical procedures and long-term isolation in santoriums.

A slightly more technical explanation as to why we need multiple drugs in treatment: in secondary, cavitary TB the total load of bacill in the body is ~ x 10^12 organisms. The resistance rate in nature for INH, RIF and ETH is about 1 in 10^6 organisms. If you treat someone with only one drug, you're almost guaranteed to see a resistant bacillus develop. As you wipe out the sensitive ones, the resistant ones grow, and after a transient period of improvement the patient again becomes ill. By using three drugs, you make it extremely likely (given good compliance) that a resistant organism would develop (only a 1 x 10^-18 chance). Nowadays we use four drugs because of the concern over native INH resistance in the field.

I can supplement this with more, but there are good open-source reviews of these aspects of TB therapy.

Posted by Steve White">Steve White 2007-11-03 14:56|| 2007-11-03 14:56|| Front Page Top

#11 as I understand it, a big problem is the carrier doesn't stick with the months-long drug treatment

Posted by Frank G">Frank G 2007-11-03 15:02|| 2007-11-03 15:02|| Front Page Top

#12 In the Navy they found a guy in our (Sleeping) Compartment who had TB, everyone was tested, I showed positive, they gave me some little yellow pills to take for a year,(Gave me the shits) and told me "You don't have TB, you'll never have TB, but you'll forever test positive for TB, be sure to tell any doctor who treats you to expect a "False Positive", for TB.

I'm fine, some 40-odd years later.

Posted by Redneck Jim 2007-11-03 16:45|| 2007-11-03 16:45|| Front Page Top

#13 (Gave me the shits)

Probably due to whatever poweful antibiotic they gave you killing off all of your intestinal tract's bacteria and screwing up your digestive system.

Posted by Zenster">Zenster 2007-11-03 17:10|| 2007-11-03 17:10|| Front Page Top

#14 When my brother was in Africa in the early-mid nineties, he and his coworkers said that the anagram 'AIDS' stood for 'Africa is dying slowly'.

Whether for reasons of climate, or critters, or culture, or genetics, or some bits of all of the above, Africa just seems to be a breeding place for human contagion. Perhaps because various species of humans have been living there for millions of years, plasmids, retrovirii, and other evil chunks of DNA lethal to humans have accreted in organisms ffrom bacteria on up.

Posted by no mo uro 2007-11-03 19:22|| 2007-11-03 19:22|| Front Page Top

23:41 SteveS
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21:48 HammerHead
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21:21 Leonard Plynth Garnell
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19:54 Nimble Spemble
19:52 Abdominal Snowman
19:41 Nimble Spemble
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19:16 Frank G