“Medical education does not existto provide students with a way ofmaking a living but to ensurethe health of the community”

Rudolf Virchow Mid 1800s

Tuberculosis hasbeen killing millionsfor centuries

Picture: World Lung Foundation

Symptoms of untreated active TB

Persistent cough andLow grade-fever

Difficulty in breathing

Blood in sputum

Severe weight loss

Night sweats

Cambodian TB patient

Credit: Marsha Miller, the University of Texas at Austin

TB is an ancient human disease!

Recent evidence supports a diagnosis of TBin this 500,000 year old Homo erectus

Bone lesions indicative of TB

TB is an ancient human disease!

TB spinal lesions have also been found in Egyptian mummies

It is estimated that from 1700-1900, TB killed 1 billion people.

The annual death rate in the late 1800swas 7 million.

TB Ward, Ellis Island

"Forgotten Ellis Island,”photographer Stephen Wilkes

Waverly Hills Tuberculosis Sanatorium. Louisville KT 1926

After urbanization up to 25%of all European deaths in the 1800s

may have resulted from TB

TB Ward, Ellis Island

http://www.birdchildsandgoldsmith.com/acatalog/slums.gif

The famous and the infamous died of TB

John Keats Frederic ChopinAnton Chekhov

Emily Bronte

Simon BolivarHenry Thoreau

The famous and the infamous died of TBalong with countless millions known only to their families

Eleanor RooseveltDH LawrenceFranz Kafka

George Orwell

Eugene O’Neill

In 1900 TB was still the second

leading causeof death in the US

CDC

Now infectious diseases aremuch less prominent as causes of death

and TB has dropped off the list

CDC

American Red Cross. "The Next to Go: Fight Tuberculosis." [American Red Cross], 1919.

"'Stamp' Out Tuberculosis: Buy Christmas Seals." National Tuberculosis Association, 1924.

"Prevent Disease: Careless Spitting, Coughing, Sneezing, Spread Influenza and Tuberculosis." Rensselaer County Tuberculosis Association (Troy, N.Y.), [ca. 1925]

In the early to mid 1900s TB remained a major public health challenge in the US

In the US TB is now an almostforgotten disease

US TB deaths in 2010:569

CDC

In the US TB is now an almostforgotten disease

US TB deaths in 2010:569

CDC

US Influenza deaths: 2125 (90% age >60 years)

US deaths due to dog bites: 30

Stats from WHO, 2012

But not in the developing world!

TB KILLS1.3 MILLION PEOPLE EVERY YEAROVER 3500 EVERY DAYONE PERSON EVERY 27 SECONDS

TB is present world-wide but Incidence rates differ dramatically

CDC

Partners in Health and Harvard Medical SchoolDept. of Social Medicine Program in Infectious Disease and Social Changehttp://www.hms.harvard.edu/news/releases/family_cemetery.html

For this Peruvian family mourning a child dead to TBthe disease is certainly not forgotten

Two billion people--one third of the world’s population--

are infected with the bacteria that causes TB

World Lung Foundation (2008)

Stats:NIAID/NIH Pix: World Lung Foundation

Worldwide TB causes:

5% of all deaths

~10% of all adult deaths

Morocco

India

South Africa

China

Left untreated, a person with active TBwill infect 10-15 other people per year

World Lung Foundation (2008) and http://pathport.vbi.vt.edu/pathinfo/pathogens/Tuberculosis_2.html

Left untreated, a person with active TBwill infect 10-15 other people per year

World Lung Foundation (2008) and http://pathport.vbi.vt.edu/pathinfo/pathogens/Tuberculosis_2.html

new infections occur at a rate of one per second!

In most cases TB starts as aninfection of the lungs = pulmonary TB

http://library.med.utah.edu/WebPath/TUTORIAL/DRUG/DRUG022.html

X-rays used to be the primary means of diagnosis

http://library.med.utah.edu/WebPath/TUTORIAL/DRUG/DRUG022.html

Now TB exposure is diagnosed by a skin test

What is an antigen?

What does this test measure?

Tubersol =a cell-free purified protein fraction

obtained from a human strain of Mycobacterium tuberculosis

grown on a protein-free synthetic medium, and inactivated

A positive test result simply means youhave been exposed to TB* at some point

and have developed antibodies to it

*=Active casePreviously “cured”Inactive caseVaccinated with BCG

The next step is aChest X-ray and a sputum culture

The next frontier: DNA testing to identifydifferent strains of TB

and assess drug resistance

Dbtechno.com

The next frontier: DNA testing to identifydifferent strains of TB

and assess drug resistanceJuly 2008: WHO unveils

$26 million program

to create labs in poor nations

that can do DNA tests

Cost: $5 per test

Time frame: 24 hours

Rather than weeks to months!

http://library.med.utah.edu/WebPath/TUTORIAL/DRUG/DRUG022.html

However, the TB bacterium can alsoInfect many other organs,causing distinct “diseases

However, the TB bacterium can alsoInfect many other organs,causing distinct “diseases

Renal TB

www.vetmed.wsu.edu

However, the TB bacterium can alsoInfect many other organs,

causing distinct “diseases”

Renal TB

http://www.ecureme.com/atlas/data/Tuberculosis_of_Skin550_ab.htm

Lupus vulgaris

Pott’s disease = tuberculous spondylitisCredit: Dr Laughlin Dawes www3.shropshire-cc.gov.uk/. ../med/med_i03.htm

TB infecting the spine

“Miliary TB” is disseminated throughout the bodyHere it is presenting in the eye

www.aippg.net/forum/ viewtopic.php?t=11673

Scrofula: TB of the lymph nodes of neck

King Henry IV of France touching sufferers of scrofula. André de Laurens, 1609

As late as the 1800s, causes and cures of TB remained mysterious

www.nlm.nih.gov

www.umdnj.edu/librweb

TB sanitoria were built all around the US

Waverly Hills Tuberculosis Sanatorium. Louisville KT 1926housed over 400 patients, from infants to adults.

Waverly Hills closed in 1961library.louisville.edu

This may seem like ancient history to you

Waverly Hills Tuberculosis Sanatorium. Louisville KT 1926housed over 400 patients, from infants to adults.

Waverly Hills closed in 1961library.louisville.edu

But they remained in operation untilAfter Professor Peifer was born

Gravely Building, now the site of the UNC Cancer Hospital

and only torn down in 2010, was a TB sanitorium

www.med.unc.edu