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University of Toronto Scarborough

ANTC68 WINTER 2013 Lecture # 9 – Tuberculosis – Social Disease BACKGROUND  Agent: Mycobacterium tuberculosis  Slow rate of reproduction  Can survive outside body in dry state for weeks  Inside the body can stay latent for yars  Only starts producing symptoms when a person is immune-compromised  Up to 1/3 of the world’s population infected with Mycobacterium  Will only lead to active TB in 5-10% of cases  Symptoms: o Active Pulmonary – coughing with blood, fever, night sweats, weight loss o Airborne transmission  Other manifestations o Lungs, central nervous system, lymphatic system, Pott’s disease, Disseminated  Either started with agriculture 10000 YA or even earlier 35 000 YA  Present in both OLD WORLD and NEW WORLD before contact  Not becoming less virulent over time  Other forms: M.bovis, M.africanum, M.canetti, M.microti  Unclear whether human form came from cowas or both have common ancestor CONSUMPTION, “WHITE DEATH”  More prevalent around 1600 due to urbanization  People affected: young, in the prime of life  Peak rates around 1800 – main cause of death in Victorian England  Called White Death because of pallor of victims DECLINE OF TB  Common in all levels of society, but still most prevalent in urban poor  TB declining due to improvmeents in housing, nutrition, hygiene, sanitation, overall standard of living  No matter even if Robert Koch discovered infectious agent in 1882 PUBLIC HEALTH CAMPAIGNS  Public health campaigns to discourage spitting also went a long way toward reducing TB TB VACCINES  Bacillus Calmette-Guerin (BCG vaccine), first used in 1921  Prepared from weakend bovine strain ANTC68 WINTER 2013  Public slow to accept vaccine, rates increased after WW2  BCG vaccine works well in children to prevent TB, meningitis, but not well in preventing pulmonary TB in adults  Confers protection for 10-15 years  Not routinely in most countries  Not used in adults because it leads to false positive for TB skintest which makes detection difficult  Development of other vaccines continues today – 11 in development, may be ready by 2020 Sanatoriums, Heliotherapy  Good air seen as treatment either cold, mountain air of Swiss Alps or hot, dry air of Arizona  Led to development of anatoriums as places to treat TB patients  Heliotherpay: sun therapy commonly used for TB patients up until WW2  Sanatoriums wourld provide palliative care, nutiriton, quiet places to rest and convalesce  Over time they became more medicalized and infantilized patients  TB sufferers blamed for being moraly poor, lacking intelligence, lacking will power, sanatoria exist to correct bad habits US TB Rates 1900-1940  With improvements in housing, nutrition, santiation, TB rates declined overall leading up to WW2  Rates declined in white people but black, infact it went up and went on to spur increased racism, segregation and justification of morally superiority of White people seeing Black people as somehow genetically inferior or susceptible Drug Resistance  Streptomycin = first treatment for TB (1944). Injected. May more followed  Almost as soon as drugs used, problem of antibiotic resistance o 1 line drugs used to treat regular TB ( 1 – 5 drugs) o Second Line Drugs used totreat MDR-TB patients  MDR-TB = Multi resistant Tuberculosis  Resistant to the two most potent first line drugs (Isoniazid and Rifampicin) and requires second-line drugs o XDR-TB = Exensively Drug Resistant Tuberculosis  Resistant to isoniazid, rifamici, fluoroquinolones and at lealst one second line drug  First observed in 2006  XDR-TB present in all regions of the world  Hot spots include China, India, Russia (prison population), Estonia, Latvia, Dominican Republic and Argentina o TDR-TB = Totally drug resistant TB ANTC68 WINTER 2013  Why can’t we give everyone second line drugs? o Expensive – TB = $50 dollars per patient per year vs. $5000-10000 dollars per year o Not as effective o Toxic side effects o Risk of resistance  Diagnosis: Observation, X-rays or sputum culture o Hard to differentiate between regular TB from MDR/XDR-TB o Need to grow sputum sample in sculture, my take months to determine resistance status o Meaniwhile patient with XDR-TB may die if left untreated o Developemtn of rapid testing in the works  Treatment Side Effects – a barrier to completing full course of treatment o Gastrointestinal dist
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