At the beginning of the twentieth century, “Consumption” plagued humanity. In the 1800s, consumption, or Tuberculosis (TB), was incurable. Those afflicted by the disease suffered the pain of stigmatization along with an early, laborious death. Although its victims were viewed as lepers, no eschelon of society was immune to the effects of TB. At the mercy of this eerie malady, some of the nineteenth centuries’ most reknowned playwrights, artists and actors slipped into early immortality. While animal species and plant lineages are lost forever to extinction, hardy strains of Mycobacterium tuberculosis live on, impervious to the ravages of time. Indeed, stepping backwards to the year 460 BC, Hippocrates classified Pthisis (Tuberculosis) as “the most widespread disease of the times...and it is almost always fatal” (NJMS National Tuberculosis Center,1996).

Amazingly, some 2,458 years later, tuberculosis still commands worldwide efforts aimed at its annhiliation. According to the Massachusetts Department of Public Health, the Bacille-Calmette Guerin (BCG) vaccine for Tuberculosis is “the most common vaccine used in the world” (1995). Despite utilization of this controversial inoculation, the World Health Organization (WHO) estimates that 3 million people die from tuberculosis every year. WHO conjectures that another 8 million people contract the disease annually. Once thought to have been virtually eradicated by the mid-1980’s, TB resurges as a major health threat, trans-continentally.

Even as they died from tuberculosis, some of our most beloved artists captured eternity through the ethereal hourglass of creation. Emblazoned upon canvas or stage, artists affected by TB rendered public awareness of their suffering. Thus, the effects of TB reverberate in the silent frames of 1800s masterpieces. For instance, the otherworldly Aubrey Beardsley urgently amassed a vast body of work before succombing to TB at age 25 in 1898. Diagnosed at age seven with the then fatal illness, it is no suprise that Death inks its subconscious countenance upon his work. At 18 years, Beardsley described himself as having “a vile constitution, a sallow face and sunken eyes, long red hair, a shuffling gait and a stoop*” (Beardsley, Aileen Reed, 1991). John Keats exerted a powerful influence upon the young Beardsley.

One of London’s most outstanding poets, Keats, (1795-1821) worked feverishly, foreboding his early death at age 24. Tuberculosis forewarned Keats of his own demise by first stealing his mother, and then his brother to an early grave. As such, entire families were dismantled by tuberculosis. Tenessee Williams illuminates the effects of TB upon the family structure in his one act play, ‘This Property is Condemned”. Here, Alvah falls prey to the dangers of prostitution, and then dies from “lung affection”. Edvard Munch (1863-1944) witnessed the death of his mother and sister to this dreaded blight(www.angelfire.com). Consequently, tuberculosis casts its greenish hue in the palette of Munch’s other famous painting, ‘The Sick Child’. Lately exhumed to decorate the walls of a local Nursing School, the “Sick Child” is as timely now as it was in the 19th century.

Question: Exactly what is tuberculosis?

Answer: Tuberculosis is a chronic infection caused by the acid-fast bacillus, Mycobacterium tuberculosis. It primarily affects the lungs. For most people, a diagnosis of tuberculosis refers to asymptomatic, disease-free infection with M. tuberculosis. Specific high-risk populations newly diagnosed with TB infection are prescribed prophylactic medications. This preventative therapy insures the continued health of newly converted TB positive people. Anyone not prescribed preventative therapy should learn about the signs and symptoms of tuberculosis disease, and report immediately to their physician should these ensue.

Question: Do a lot of people with TB infection actually get TB disease?

Answer: Approximately 10% of the people infected with M. tuberculosis will progress to TB disease(Monahan etal,1995). In rare cases, TB can spread from the lungs to other organs. Extrapulmonary sites (outside the lungs) include the throat, kidneys, spine, joints, and meninges of the brain. Disseminated, or miliary tuberculosis travels throughout the body in the bloodstream. This can lead to sequalae such as Tuberculosis osteomyelitis.

Question: If tuberculosis travels through the bloodstream, do you catch it like HIV or Hepatitis B? If I wear a condom, does that mean I won’t contract TB?

Answer: Wearing a condom does not prevent TB. TB is transmitted through the air in droplet nuclei. TB transmission occurs when a person who has TB disease sneezes, coughs, sings or laughs and an uninfected, susceptible person inhales the expectorated droplets. Unlike the bloodborne diseases HIV or Hepatitis B, TB is airborne.

Question: If you can catch TB just by breathing it, that must mean that TB is mega-contagious!

Answer: Fortunately, acquisition of TB is dose dependent. One must be repeatedly exposed to TB in order to catch it. So, TB is not “mega-contagious”.

Question: You mentioned a bunch of artists who got sick from TB. I’m an art major at Hampshire College. Does that mean I’m at risk for TB?

Answer: No. Being an artist is not a risk factor for TB. People who are though to be at risk for TB include the poor, the homeless, prisoners, migrant farmers, babies and children exposed to TB, elderly residents of nursing homes, health care workers at long-term care facilities, and denizens of crowded urban areas (American Academy of Pediatrics,1994). Immunocompromised people are at especially high risk for TB.

Question: Do you mean people with AIDS?

Answer: Yes, people with AIDS harbor a special vulnerability to tuberculosis. Moreover, any condition that adversely affects the immune system increases the risk for acquiring TB.

Question: What conditions particularly jeopardize the immune system?

Answer: Factors associated with immunocompromise include anorexia, diabetes, silicosis, alcoholism, leukemia, kidney disease, steroid therapy, intravenous drug use, and cancer of the head or neck. (Center for Disease Control,1993).

Question: I have diabetes and just got hired at a nursing home. That’s already two risk factors for TB! What should I do?

Answer: Protect yourself. Anyone in a high risk group or community should undergo yearly testing for TB utilizing the PPD or mantoux. The mantoux protects you from TB disease through early detection of TB infection.

Question: Are they going to make me drink nasty fluids or stick tubes down my throat for this test?

Answer: Don’t worry - no tubes or repugnant beverages are involved. When you receive the PPD, a tiny amount of testing fluid (tuberculin) will be injected just beneath the skin of your forearm, forming a small bubble. Two to three days later, you will return to the Doctor’s office for interpretation of your test.

Question: What if my mantoux test comes out positive-then what will happen?

Answer: A positive mantoux usually indicates infection with TB. Your physician will likely order a chest x-ray and sputum samples. These tests assay for active TB disease. You may also be required to donate a blood and urine sample(CDC, 1994). Should the determination of active TB result, you may be hospitalized in a private room. Alternately, you may receive medications with instructions to remain home-bound until your practitioner ascertains resolution of contagion.(CDC,1994) Remember, most people with a positive PPD do not have active TB disease.But, if you have active tuberculosis, the importance of completing drug therapy can not be overemphasized Prematurely quitting treatment is very dangerous. When someone with TB abandons treatment, their TB can mutate, evolving to acquire medication-resistant traits. Thereby, early cessation of treatment results in the emergence of multi-drug resistant strains of TB which are extremely difficult to cure.

Question: You said that TB was fatal in the 1800’s. Well, I have a friend in a band who really does have TB disease. Is he going to die?

Answer: Nowadays, TB can be successfully cured. However, it is imperative that your friend faithfully adhere to his treatment program- a strict regimen of several anti-tuberculosis medications for up to one year.

Question: OK, I’ll tell him. Now, when my friend in the band plays out, fans buy him beers. Can he drink beer while he’s on this TB medicine?

Answer: You raise a very important issue here. Alcohol and drugs may have contributed to your friend’s diagnosis of TB. According to the Mobile AIDS Resource Team(MART) of Victory Programs, “drug users and alcoholics are at great risk” for HIV and TB. This is because alcohol and drugs cripple the immune system, impairing the user’s natural defenses. Additionally, drug users unwittingly expose themselves to tuberculosis because “the places where people... go to cop put them at risk for TB” (MART, Victory Programs). Intoxication impairs judgement, which in turn contributes to the transmission of TB, HIV and STDs.

Question: You still didn’t answer my question - can he drink beer or not while he’s taking this medicine?

Answer: If your friend drinks alcohol while on the anti-tuberculosis medications rifampin or pyrazinamide, he runs the risk of serious liver damage. He could even die from drug and alcohol induced hepatic necrosis (Lehne,1994).

Question: Is there anyone who can help him deal with this medication-alcohol mixing problem?

Answer: Yes! He can call Hampshire Health Access through First Call for Help at 413-256-0121. Your friend sounds like a good candidate for DOT.

Question: What is DOT, some new Political Party?

Answer: No, its D.O.T.- Directly Observed Therapy: a health care worker in the community will work with a TB patient for the entire duration of their treatment. DOT helps people with TB to recover quickly. Together, the patient and health care worker schedule where and when to meet. The health care worker insures that the patient receives medication on time, and intervenes to prevent adverse medication side effects. DOT therapies also simplify treatment by enabling the patient to take medication a couple of times a week instead of every day (CDC,1994). For more information about DOT, call the Division of Tuberculosis Prevention and Control at 617-983-6970.

Question: OK, I’ll tell my friend about this. But what if my PPD is positive, and the doctor decides I don’t need preventative medications like DOT. Should I be on the lookout for any particular signs and symptoms?

Answer: Yes. Be aware of and telephone your doctor if you experience one or more of the following : weakness, pallor, fatigue, fever, chills, chest pain, night sweats, poor appetite, weight loss, and coughing with or without bloody sputum. (CDC/ Monahan etal.,1994)

PATHOPHYSIOLOGY - GHON’S LESION, MILIARY TB

Question: I like to know why and how diseases work. What’s happening in the body of someone with active and untreated Tuburculosis?

Answer: There are entire text books written on this one question. A painfully brief depiction of TB’s pathophysiology then: (a) a susceptible individual inhales a droplet nuclei containing mycobacterium tuberculosis (b) the alveoli (air sacs) of the lungs catch the bacillus - if the alveolar macrophages win the contest between host and parasite, no infection will occur. If the alveolar macrophages “lose the fight”, cytotoxic cells are “recruited” to the area. (c) the primary Ghon lesion develops at the alveoli- this is a small grey-white area of inflammation and consolidation; white blood cells called macrophages differentiate - some become fighters (mycobactericidal) and others become trappers (fibroblasts). The mycobactericidal macrophages attempt to kill the TB; the fibroblast macrophages encircle (trap) the primary lesion within a wall of “dense connective tissue”. In this way, the characteristic “granulomatous lesion” is formed. If the person is immunocompetent (has a strong immune system), the lesion hardens (fibroses/calcifies), the person will have a positive mantoux test (infection) but will not have active disease (there is still potential for reactivation and disease in the future). If the person is immunocompromised (has a weak immune system), then there will be several areas of granulomatous consolidations. Liquefication necrosis, in which a lesion spills its contents into a mainstem bronchus- causes the formation of a cavity in the lung. This cavity is uniquely suited to allow the tuberculosis to multiply to the 8th power because “host defenses are ineffectual” here. (Pathogenesis of tuberculosis, Nardell, Harvard Medical School/ Monahan etal) This information is just the tip of the iceberg- but clearly one sees that TB has the potential to incur major damage if left unchecked.

RESURGENCE

Question: You said that TB was practically eradicated by the mid-eighties. How come its back? What happened?

Answer: Several interrelated health threats contributed to TB’s resurgence including HIV, STD’s, drug use, poverty, and homelessness. Airplane travel introduces TB into disease free communities by shrinking the global community. The explosion of newfound poverty with decreasing access to healthcare in the USA contributes to the resurgence of TB. According to the NJMS National TB Center “the highest incidences of TB are seen in those countries with the lowest GNP” (1996). This statement directly correlates squalor to TB. Once TB rates declined drastically in the 1980’s, funding for the control and prevention of this deadly disease was withdrawn. Subsequently, TB rates have steadily increased. (TB- A Deadly Disease Makes a Comeback, The American Nurses Association, 1993)

SIDEBARS

According to Servicenet’s Annual Report, 32 percent of the people who visited the Northampton Cot Shelter (from November 1, 1997-April 30, 1998) listed eviction as their primary reason for homelessness. Another 32 percent of guests at the Cot Shelter state that they are homeless due to loss of income. So for 64% of people visiting the Northampton Cot Shelter at Hawley Street, poverty was the main reason for being homeless. This runs counter to the myth that homelessness is a ‘lifestyle choice’, or that the majority of homeless are mentally ill. Locally, the escalating rates of homelessness with the concomitant risk for acquiring Tuberculosis may be attributed to violent economic disenfranchisement.

TB DISEASE VS. TB INFECTION
(extracted from the “TB Teaching Tool”)
TB Infection vs TB Disease
Inactive TB Active TB
Skin test positive Skin test & culture positive
Chest x-ray normal Chest X-ray abnormal
No symptoms Symptoms
Not contagious Contagious
Give medication Give medication

*In the past, TB was the number one cause of death in the United States (CDC, 1994)