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PLAGUES AND PESTILENCE

Leanne Schimke MSN, FNP-C, CUNP

Lancaster Urology

Lancaster, PA

INFECTIOUS DISEASE

“infectious diseases can force enormous, sometimes cataclysmic changes on societies. They can determine not just who lives and who dies, but who wins and who loses, who gets wealthy and who stays poor, which ideas become popular and which ones wither away.”

Quote by Bryn Barnard, author of Outbreak Plagues that Changed History.

DEFINITIONS

• Epidemic: any excessive and related incidence of a

particular disease in a population.

• Pandemic: when an epidemic extends beyond a continent

• Endemic: a disease with a normal low to moderate

incidence in the population, but intermittent episodes. i.e.

common cold

• Two major types of infectious disease that can develop into

epidemics:

• Common source: arise from a contaminated source,

such as water or food.

• Host-to-host: transmitted from one infected individual to

another via various, sometimes indirect routes.

DEFINITIONS

• Anything that causes disease is called a pathogen.

• Vector: an organism such as a flea that serves as an

intermediary in the transmission of host-to-host disease.

• Fomite: any inanimate object that adheres to or

transmits infectious material, i.e. bedding.

• Zoonotic: transmitted between species, for example

animal to human, sometimes through a vector.

BLACK DEATH

• Bubonic, Pneumonic, and Septicemic plague

• Caused by Yersinia pestis, a rod shaped, Gram negative

bacteria. Only 1 bacteria is needed to cause the plague.

• Reservoir is the female Indian rat flea.

• Feeds on rodents: prairie dogs, rats, squirrels, gerbils, field

mice, etc.

• Can jump several feet, so when their hosts die they jump to

a new one

BLACK DEATH

• 1st pandemic in 541-543 AD, 2nd 1346-1352, 3rd 1894

• Initial symptoms: fevers, painful buboes (from Greek bubo meaning groin) in groins and armpits as lymph nodes swelled.

• 3 days later: high fevers 104 or >, delirium, restlessness, staggering gait, skin hemorrhages resulting in black splotches, gangrene, necrotic tissue, enlarging buboes up to hen’s egg size that caused severe pain when they burst.

• 5 days later: convulsions, coma and death. If fever broke usually survived, if buboes were lanced possible survival. Some victims died in 1 day.

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BUBONIC PLAGUE

Images from CDC PHIL

BLACK DEATH

• In bubonic and septicemic plague, there is hemorrhagic

illness, multiple system failure and death.

• Mortality rate now for untreated bubonic plague is 50-70%,

septicemic plague is 100%

• Can change to pneumonic plague which enters the lungs,

causes coughing, blood tinged mucous that changes to

pulmonary edema. Death can occur in a matter of hours.

Has 100% mortality rate if untreated.

• During the pandemics so many people died that their bodies

were unable to be buried fast enough, so they were dumped

in rivers, streets and docks.

SPREAD OF THE BLACK DEATH

• People lived in crowded, filthy cities. Sewage was

inadequate so rotting garbage and human waste were

heaped in streets or dumped in rivers.

• People hardly ever bathed.

• The black rats lived in the thatch of the roofs and in the

ships that traveled between cities. Rats were highly

susceptible to the plague, they became infected and died,

so the fleas jumped to humans nearby.

• Plague spread via ships, the rats infected the humans on

the ships and then left the ships to infect the land

population.

• In Venice, a quarantine was placed on ships. Quarantina is

the Italian word for 40 days. Unfortunately, the rats were

able to leave via the ropes tied to the docks.

BLACK DEATH

• No one then knew how the disease was spread. Fear and terror ruled. People deserted cities and towns, work and service disrupted.

• Theories such as:

• “bad air” or miasma

• Result of conjunction of Saturn, Jupiter and Mars in the 40th degrees of Aquarius which forced the earth to exhale a virulent sulfurous miasma.

• Divine punishment for sins of the world. Curse from God

• Caused by spirits and devils

• Caused by strangers, xenophobia was the norm.

• Jews became targets, rumors of their poisoning the wells ran rampant. Numerous massacres occurred.

BLACK DEATH

• In Germany, a group formed to try to appease God through

group mortification; known as the Brotherhood of the

Flagellants.

• They would march from town to town and in the town square

would form a large circle, strip themselves to the waist and

beat themselves with a whip in rhythm to their chanting

hymn.

• They would perform this rite three times daily for 33 days, a

day for each year of Jesus Christ’s life.

• As time went on instead of just hurting themselves, they

began to lead in persecution and murder of the Jews

PLAGUE DOCTORS

As may be seen on picture here,

In Rome the doctors do appear,

When to their patients they are called,

In places by the plague appalled,

Their hats and cloaks of fashion new,

Are made of oilcloth, dark of hue,

Their caps with glasses are designed,

Their bills with antidotes all lined,

That foulsome air may do no harm,

Nor cause the doctor man alarm,

The staff in hand must serve to show

Their noble trade where 'er they go.

Seventeen century poem about Plague Doctors

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BLACK DEATH

Most famous plague doctor was Michel de

Nostraedame, known more commonly as

Nostradamus.

His advice: drink only boiled water, sleep in

clean beds, and leave infected towns as

soon as possible.

BLACK PLAGUE HISTORICAL SIGNIFICANCE

• Plague of 541 AD raged in Constantinople, Europe, North

Africa and Middle East by 600 AD population was reduced

by 100 million, approximately 50% of the population.

• Marked the end of the Classical World, of Greek and Roman

Civilization, ushered in the Dark Ages.

• Followed trade routes, how the disease spread from country

to country and continent.

BLACK DEATH HISTORICAL SIGNIFICANCE

• In 1346, the 2nd pandemic hit Europe, was called the Great Mortality, the Pestilence and the Pest.

• In 4 years, it killed a third of Europe’s population.

• Before 1346, Europe was ruled by aristocrats and the Church. They owned all the land, controlled the wealth, determined the laws and were gatekeepers of all knowledge.

• The Black Death did not discriminate, wealthy and poor alike were afflicted and died. Religious leaders died along with sinners.

• So with fewer workers, wages went up. With fewer consumers, prices went down.

• In the countryside and cities, a rising middle class was able to buy property, businesses and wealth the dead had left behind.

BLACK DEATH EFFECT ON MEDICINE

• Medieval society had 4 kinds of medical practitioners:

1. Academic physicians-knew theory but didn’t care for the

sick.

2. Surgeons- main caregivers of the sick,

3. Barbers who did bloodletting and minor surgery.

4. Folk medicine practitioners which were mostly women.

• Academic physicians believed Hippocrates's and Galen theories

that bad humors in the body caused disease. The four humors

were blood, phlegm, black and yellow bile. Since this couldn’t be

applied to the plague, confidence in these practitioners

diminished.

• Surgeons who wore the Plague doctor costume died at higher

rates than barbers or folk practitioners, so they were not valued.

BLACK DEATH

• New prestige fell to the barber, which lead to an emphasis

on study of the human anatomy in health and disease.

• The Galenic system which had no clear theory of contagion

declined in importance.

• In the 1500’s Girolamo wrote that infectious disease could

be transmitted by semanaria (germs) in 3 ways-by direct

contact, through carriers, and through airborne

transmission. Other physicians did not believe him and his

theory was not followed up until the 19th century by Louis

Pasteur and Robert Koch and their associates.

BLACK DEATH

• In 1894, Alexander Yersin, a student of Louis Pasteur, was

sent to Hong Kong to discover the cause of the plague. He

identified Yersinia pestis bacterium, a gram negative

bacteria. Originally named Pasteurella pestis, the name was

changed in 1970 to reflect the person who identified it.

• Yersin did not identify how it was spread.

• In 1898, Paul Simond, another student of Pasteur, was sent

to Vietnam and India to follow up on Yersin’ s observations.

He noted there were large numbers of dead and dying rats

and from there went to discover the intermediary the rat flea.

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BLACK DEATH TRIVIA

• God Bless You: Pope Gregory I in 590 AD ordered unending prayer to

fight the plague in Rome. Sneezing was thought to be an early

symptom, so God Bless you became a common saying to halt the

disease.

• Eau de cologne: invented in Germany, named after the city of Cologne,

was used to “purify” the air from the stench of death from the plague.

• Pied Piper of Hamlin: Pied piper offered large sum of money to rid the

city of rats, played his flute and lead rats to river where they drowned.

Officials reneged on payment, so the pied piper played his flute again,

this time all the children followed him to the mountain and were never

seen again

• Ring Around the Rosie: debate whether it was written due to the

plague or not. Sung from the 1790s, but didn’t appear in print literature

until 1822.

• “Ring around the rosies.

• A pocket full of posies,

• Ashes, ashes!

THINGS LEARNED FROM THE BUBONIC PLAGUE

• Quarantine

• Need to understand the pathogen and the

vector of disease to be able to control it.

• Protective clothing for caregivers

• Burning of clothing and bedding

• Burying the dead in shallow graves sprinkled

with lye

BUBONIC PLAQUE

Last case of Bubonic plague Aug 2013 in Kyrgyzstan 15

year old boy died before diagnosed. Endemic in region.

1000-2000 cases yearly reported to WHO.

PLAGUE AS A BIOTERRORISM WEAPON

• An aerosolized plague weapon could cause fever, cough, chest pain, and hemoptysis with signs consistent with severe pneumonia 1 to 6 days after exposure.

• Rapid evolution of disease would occur in the 2 to 4 days after symptom onset and would lead to septic shock with high mortality without early treatment.

• Early treatment and prophylaxis with streptomycin or gentamicin or the tetracycline or fluoroquinolone classes of antimicrobials would be advised.

JAMA. 2000;283(17):2281-2290. doi:10.1001/jama.283.17.2281

SMALLPOX

• At one time the most devastating of all human diseases, unknown when it began infecting humans.

• If survive illness, are immune for life.

• Best evidence of smallpox in humans is found in 3 Egyptian mummies, dating from 1570 to 1085 BC.

• Pharaoh Ramses V-died in 1155 BC, mummified face, neck and shoulders bear the pockmark scars of smallpox.

SMALLPOX HISTORY

• Smallpox did not exist among the native people of North and South America until the Europeans came to their shores.

• When exposed, nearly everyone caught the disease and approximately half died from it.

• Native people saw the invaders immunity to smallpox as godlike, so the Europeans talked about the disease as being sent by God to help them gain control of these lands.

• The Incas and Aztecs were decimated by smallpox and that is how their lands were conquered.

• Same thing occurred in North America when the Pilgrims landed and infected the Native Americans. In some cases, the Native Americans were infected intentionally with blankets contaminated with smallpox

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SMALLPOX

• One of the largest viruses. Variola major and minor.

• Outer surface resemble facets of a diamond.

• Inner service has a dumbbell shaped core that contains the genetic material.

• Not zoonotic transmission

• It can exist only as long as there are susceptible humans. Incubation period 10-14 days.

• Up to 30% mortality in unvaccinated individuals

Progression of Smallpox

Source: Foege, Lane, and Millar, Am J. Epi, 1969

• Sudden onset of fever (38.5-40.5C or 101.3 -104.9F) and malaise.

• Headache, muscle pain, nausea, vomiting and backache

• Toxic during first two days.

• Fever drops and patient feels better by days 2-4.

PROGRESSION OF SMALLPOX PRE-ERUPTIVE STAGE

PRE-ERUPTIVE SYMPTOMS 6942 CASES OF VARIOLA MAJOR

SYMPTOM PERCENT

Fever 100

Headache 90

Chills 60

Backache 90

Pharyngitis 15

Vomiting 50

Diarrhea 10

Delirium 15

Abdominal Pain 13

Convulsions 7

Rao, Smallpox in Bombay, Kothari, Bombay, 1972

SMALLPOX

• A major diagnostic characteristic of smallpox is that

lesions in a given area are similar in appearance

and feel.

• Progression occurs, however, from area to area:

• Pharynx, Palate.

• Face.

• Proximal Extremities.

• Hands and Feet.

SMALLPOX PROGRESSION OF RASH

• The first visible lesions appear in the mouth as minute red

spots on the tongue and oral and pharyngeal mucosa, about

24 hours before the appearance of rash on the skin.

• Lesions in the mouth and pharynx enlarge and ulcerate

quickly, releasing large amounts of virus into the saliva.

• The skin rash usually appears first as a few macules, known

as “herald spots” on the face, particularly the forehead.

• Lesions then appear on the proximal portions of the

extremities, then spread to the trunk and distal portions of

the limbs.

• Usually, the rash appears on all parts of the body within 24

hours.

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TYPICAL PROGRESSION OF SMALLPOX

• Incubation Period

• Pre-eruptive Stage

• Macules

• Papules

• Vesicles

• Pustules

• Scabs

• Scars

BIRTH OF VACCINES

• Theory of inoculation dates back to 1000 BC when people in India rubbed pus into skin lesions and the Chinese blew powdered smallpox scabs up their noses. They would develop mild cases of smallpox, recover and be immune from it. However, 1 out of 50 would die.

• Lady Mary Wortley Montague survived smallpox and traveled with her Ambassador husband to East Asia, Africa and India where she observed the smallpox inoculation. She had her son inoculated and he survived. She brought the knowledge back to England, where a smallpox epidemic had developed.

• Princess Caroline heard of it and had the theory tested on 6 prisoners and orphans, when they all survived, she had her daughters inoculated. Then high society in England followed suit.

BIRTH OF VACCINES

• Lady Montague set the stage for Edward Jenner to develop

the smallpox vaccine in 1796.

• Edward Jenner observed that people who had cowpox were

immune from smallpox.

• On May 14, 1796 a milkmaid got cowpox. Jenner took a quill

full of pus and slipped it into a scratch on a young boy, who

then grew cowpox pustules, then on July 1, 1796 Jenner

inoculated the same arm with smallpox. Nothing happened,

no illness.

• Birth of the smallpox vaccine.

SMALLPOX

• Anyone born before the 1970’s has been immunized against smallpox.

• The scar is a dime-size depression etched on the upper arm.

• In 1980, WHO declared smallpox was eliminated from the planet. The only disease we have ever eliminated.

• Officially, the only smallpox virus available exist in two laboratory deep freezers, one in Atlanta and one in Siberia

• Concern now is may be used as bioterrorism weapon

Strategy Days to

Contain

Required

Strategy Targets

Number of

Cases

Quarantine Alone 240 50% removal

rate

2,300

Vaccination Alone 365 Reduce

transmission to

0.85

infected/case

2,857

Quarantine and

Vaccination

365 25% removal

rate;

transmission

reduced 33% by

vaccination

4,200

Meltzer M, Damon I, Le Duc J. Millar J. EID 2001 (Nov-Dec);7(6)

MODELING POTENTIAL RESPONSES TO

SMALLPOX AS A BIOTERRORIST WEAPON SMALLPOX ISOLATION

• Airborne, droplet and contact isolation

• Negative pressure isolation room

• HEPA filters do trap the smallpox virus

• Use of fitted N95 respirators

• Only assign personnel who have been vaccinated to care for individual.

• Use disposable gloves, gowns, and shoe covers

• Reusable bedding and clothing should be autoclaved or laundered in hot water with bleach

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SMALLPOX TREATMENT

• All patients may require supportive care.

• Vaccinia Immune Globulin is not effective against smallpox infection and should not be used.

• Flat / Hemorrhagic: Treat as for shock.

• Semi confluent/confluent: Treat as for a burn.

• All types: Bacterial superinfection likely.

• Always consider:

• Dehydration, renal failure.

• Malnutrition.

• Role of antiviral medications uncertain.

BURIAL ISSUES

• Contain and seal remains

• No open funeral

• Cremate, if possible:

• If not, bury, but no embalming

• Put in ground, not “on surface.”

• If you can’t bury in ground, move remains

WHAT WE GAINED FROM SMALLPOX

• Development of vaccines to prevent illness

• First and only disease eradicated worldwide

CHOLERA

• In 1817, a new disease called

Cholera swept out of India.

• Caused violent gushing

diarrhea and vomiting,

dehydration causing shriveling

of face, hands and feet that

turned blue-black.

• Could cause death within a

few hours.

• 7 pandemics since that time.

• Last epidemic occurred in Haiti

in 2010.

CHOLERA

• Dehydrating diarrheal

illness, can have up to 1

liter per hour.

• Causes rapid profound

loss of fluids and

electrolytes in diarrhea and

vomiting.

• After initial purge, diarrhea

has fleck of mucous, called

“rice stool”.

• Leg cramps from

hypokalemia

• Caused by Vibrio cholerae:

gram-negative, curved rod

with a single polar flagellum

that makes it highly mobile

• Transmitted through

contaminated water/food.

CHOLERA

• In London, the third cholera outbreak in 1853, beliefs of the

cause of the disease:

• Miasmists blamed the disease on mysterious emanations,

rotting garbage, foul smelling sewers, swamp vapors.

Worked to clean up the environment.

• Contagionists believed it was spread by contact with

infectious agent: bad beer, cucumbers, foreign food,

shellfish, phosphorus, copper.

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CHOLERA- HISTORICAL • 1835, Max von Pettenkofer, considered the first sanitary

scientist, said that sanitation, specifically disposal of waste and sewage in a manner that it could not contaminate food and water was the key to improving health in Germany.

• Edwin Chadwick, in England, led the movement to improve sanitary conditions of the poor. His board of health produced “sanitary maps” showing relationship to disease to overcrowding, lack of drainage and defective water supply. He introduced paved streets, piped water and efficient sewage drains, unfortunately the outflow was to the river. Beginning of flush toilets. First Public Health Act of 1848

• Chadwick was not being altruistic to the poor, he believed that a healthier population could work harder and would be less of a burden.

CHOLERA-BIRTH OF EPIDEMIOLOGY

• John Snow, born in England in 1813, began to study cholera in 1850.

• Digestive symptoms started immediately, felt was caused by something people ate or drank.

• Poor in cities had difficulty getting enough water to wash thoroughly so contamination easy. But not confined to the poor.

• ? possible for river water and from pumps in town to be contaminated

• Tested his theory by examining in minute detail a single outbreak of cholera in London. The area was within 250 yards of Cambridge and Broad Street. Upwards of 500 cases daily for 10 days.

CHOLERA • Focused on the Broad Street

water pump, the water looked clear and clean. Germs wouldn’t be identified for another 19 years.

• Got the names and addresses of all the people who had died in that area and found they all used the Broad Street pump for their water.

• Had the handle of the pump removed so no one could use it. The outbreak stopped.

• Beginning of epidemiology, unfortunately he was not taken seriously at this point.

CHOLERA

• Quarantines didn’t work, but were frequently used especially

with immigrants.

• Doctors prescribed various treatments that were ineffective

including:

• Hot poultices of salt, mustard, roasted black peppers,

powdered ginger, horseradish or burnt cork.

• Ice water baths

• Tobacco enemas

• Opium suppositories

• Phlebotomy

CHOLERA- BIRTH OF HANDWASHING

• In 1846, Ognaz Semmelweis, an obstetrician in Vienna,

pointed out that women who gave birth at home or in the

street had a better survival rate than those delivered in the

hospital.

• He felt that doctors who worked ungloved and wore the

same attire throughout the day including an apron for

surgeons that was considered the redder the better, were

contagious.

• Semmelweis ordered his subordinates to wash their hands

in chlorinated water before entering the wards. The maternal

death rate dropped from 30% to 1%.

• Washing hands then spread from the hospital to business to

homes as a cheap effective way to stop illness.

CHOLERA

• Pasteur, Koch and Hansen had all accumulated evidence supporting the germ theory of disease.

• 1873-Leprosy

• 1876-Anthrax

• 1880-Typhoid fever

• 1881-Bacterial pneumonia

• 1882-Tuberculosis

• 1883-Diptheria

• In 1883, Cholera outbreak in Egypt. Koch was sent to identify the microbe responsible.

• Saw bacteria swimming in the feces of those infected and called it Vibrio because of its vibrating wiggles.

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CHOLERA-OUR FAILURE

• Cause of cholera is known

• It is preventable and curable

• Prevention is simple-access to sanitary water. CDC has a safe water system- a cheap water purification system.

• Root cause is global poverty.

• Example is Iraq, industrial nation that was modern and prosperous with a large middle class. In the 1990’s UN sanctions, caused decreased ability to purchase food, and medications along with disruptions of water supplies caused deterioration of Iraqi health. Along with Saddam’s regimen’s indifference to his country’s suffering lead to increase in infectious diseases, Cholera outbreaks, infant mortality rose sharply and approximately 1/2 million children died. (exact number unknown, WHO estimate).

CHOLERA TREATMENT TODAY

• Oral Hydration Therapy is the main treatment. If moderate

or severely dehydrated then IV therapy with Ringer’s

Lactate.

• Antibiotics used in severely dehydrated.

• Zinc supplementation significantly reduces the severity and

duration of cholera in children and other childhood diarrheal

illnesses.

• A recommended dosage of 10–20 mg zinc per day by mouth

should be started immediately if available, and continued as

long as the diarrhea lasts

• .

www.cdc.gov/cholera

CHOLERA-WHAT WE LEARNED

• Public health measures of sanitary drinking water,

appropriate disposal of sewage, hand washing.

• Knowledge of health care workers causing nosocomial

infections

• Quarantine is not always the answer.

• Birth of epidemiology

TUBERCULOSIS

• Kills more individuals than any other germ besides HIV

• Single largest cause of death from infectious disease in the

US

• Worldwide over 9 million become infected each year and 1.4

million die from it yearly.

• An estimated 2 billion people are infected with it.

• On average 1 person dies of TB every 15 seconds.

• Caused by mycobacterium tuberculosis. A rod shaped

bacilli.

www.cdc.gov

TUBERCULOSIS

• Reported in almost every state and

is actually increasing in some areas

• Affects racial and ethnic minorities

• disproportionately.

• Drug-resistant TB is increasingly challenging to treat

• Management of patients with comorbidities, such as HIV,

diabetes, and other immune compromising conditions, is

difficult

• More than half of all persons in the United States who have

TB disease are foreign-born residents

www.cdc.gov

TUBERCULOSIS

General symptoms of TB

disease:

• Fever

• Chills

• Night sweats

• Weight loss

• Appetite loss

• Fatigue

• Malaise

Symptoms of pulmonary TB

disease:

• Cough lasting 3 or more

weeks

• Chest pain

• Coughing up blood or sputum

Symptoms of extrapulmonary TB

disease depend on the part of the

body that is affected.

• TB disease in spine may cause

back pain

• TB disease in kidneys may cause

blood in urine

• TB disease in lymph nodes may

cause swelling in the neck

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TUBERCULOSIS

• Skeletal remains show prehistoric humans as early as 4000

BC had TB.

• Tubercular decay has been found in the spines of Egyptian

mummies from 3000-2400 BC.

• In 460 BC, Hippocrates described TB as the most

widespread disease of the time, involving coughing up blood

and fever, which was almost always fatal.

TUBERCULOSIS-HISTORY

• Called consumption, white plague or graveyard cough in the 19th century

• In 1853 medical text it was described as having the following features: nostalgia, depression, and excessive sexual indulgence.

• It was believed that mental activity and artistic talent were stimulated by the poisons of this wasting disease.

• In the 1800s persons with TB were considered beautiful and erotic: extreme thinness, long neck and hands, shining eyes, pale skin and red cheeks

• The operas La Boheme and La Traviata heroines had TB.

• At that time TB was not recognized as an infectious disease

TUBERCULOSIS-HISTORY

• Stealthy disease, after it enters the body it will wait 10 days

to 50 years until the host’s immune system is weak enough

to attack

• Because it seemed to occur in families it was thought to be

hereditary.

• Gives no outward sign of its presence until it is too late.

• Before x-rays and skin tests, the first sign was coughed up

blood.

• It is estimated that in the 19th century, 25% of all Europeans

died young from the disease.

• Risk highest in densely crowded areas, inadequate

ventilation

TUBERCULOSIS-HISTORY

• Ancient Greeks developed tests to analyze what the TB patient coughed up: in one test, the patient spit in a copper vessel filled with seawater, if the sputum sank death was near. In another, the sputum was dripped on hot coals-if it smelled like rotten meat, then death was near.

• In 1761, the idea of percussion of the lungs was started by Leopold Auenbrugger, who was the doctor son of an innkeeper. Just as his father rapped on the side of casks of wine or beer to tell how much was in them, you could do the same with the chest to tell how fluid filled the lungs were.

• In 1820, Dr. Rene Laennec, suffering from TB himself, invented the stethoscope

TUBERCULOSIS-SANATORIUMS

• Toward the end of the 19th century, people who could afford

it began to go to sanatoriums for treatment.

• For the rich, these were lavish places, with good food and

the latest fads to treat the disease. For the poor, little better

than prisons.

• Became places to isolate the sick as much as they were

places to heal. Voluntarily or mandatory.

• People could spend five years to life in a sanatorium, which

brought out people’s prejudice so there were separate

hospitals built to house the Native Americans and blacks.

• By 1950, there were over 100,000 sanatoriums in the US

alone.

TUBERCULOSIS-SANATORIUMS

• Sanatorium Drs. Experimented with an array of therapies including;

• Bedrest

• Lung collapse

• Rib removal

• Exposure to heat or cold

• Gold, calcium or iodine therapy

• Cod liver oil

• Horse riding.

• Dietary therapies ranged from starving a person to stuffing them with nutritious food.

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TUBERCULOSIS-DISCOVERY OF CAUSE

• In 1822, Robert Koch discovered the rod shaped mycobacterium tuberculosis that caused TB.

• Even with a microscope it is difficult to see, so he tried staining bits of a TB infected lung with an old bottle of methylene blue he had and then washed it a second time with a brown stain. Tiny bright blue rods appeared.

• But was this what caused TB- he went to the next step to try to grow the bacteria-he considered the merits of growing it on a potato, then decided a solid liquid bacteria food would be perfect.

• Turned out, Frau Hesse, the wife of one of his coworkers, used agar-agar, a gelatin-like substance derived from seaweed to harden jams. Koch used it and was able to grow TB on it.

• It is still used today to grow bacteria.

TUBERCULOSIS-DISCOVERY OF CAUSE

• Once Koch grew the bacterium, the next step was to see if

what he grew caused TB- he injected a guinea pig that

promptly developed TB and died. He repeated the

experiment again and again with different animals with the

same results.

• In 8 months of study, he had discovered the cause of TB

that had been killing people for centuries.

• After he discovered the bacterium, he went on to develop

the TB skin test that is still used today.

• Koch also identified that milk from infected cows could infect

humans, pasteurization of milk immerged and was able to

kill the disease.

TUBERCULOSIS

• Once it was discovered how TB was contagious:

• Spitting in public was forbidden,

• Cows with TB were slaughtered before milk pasteurization

was developed,

• Handwashing,

• Higher standards of hygiene

• Better nutrition

• Compulsory reporting of the disease

• Isolation

• All of these helped contribute to control TB

TUBERCULOSIS

• Testing for TB Infection

• Diagnostic tests that can be used to detect TB infection

include:

• Mantoux tuberculin skin test (TST)

• Interferon-gamma release assays (IGRAs)

•

• A positive TST or IGRA result only indicates if someone has

been infected with M. tuberculosis. These tests cannot

identify if a person has TB disease.

TUBERCULOSIS-TESTING

• Mantoux Tuberculin Skin Test

• Forearm site read within 48 to 72 hours.

• To determine whether a TST reaction should be considered positive, a health care worker needs to interpret the reaction based on:

• 1. Size of induration (measured in millimeters [mm])

• 2. Patient’s risk factors for TB

Redness around the injection site is not measured. This is because the presence of redness does not indicate that a person has TB infection.

TUBERCULOSIS

An induration of 5 or more mm is considered positive for:

• People living with HIV

• Recent contacts of persons with infectious TB disease

• Persons with chest x-ray findings suggestive of previous

TB disease

• Patients with organ transplants and other

immunosuppressed patients

An induration of 15 or more mm is considered positive in

anyone, including persons with no known risk factors for TB.

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TUBERCULOSIS

• An induration of 10 or more mm is considered positive for:

• People who have come to the United States within the last 5

years from areas of the world where TB is common: Asia,

Africa, Eastern Europe, Latin America, and Russia

• Injection drug users

• Residents and employees of high-risk congregate settings

• Myco-bacteriology laboratory personnel

• Persons with conditions that increase risk for progressing to

TB disease

• Children less than 4 years of age

• Infants, children, and adolescents exposed to adults in high-

risk categories

TUBERCULOSIS

Testing for TB in BCG-Vaccinated People

• People who were previously vaccinated with BCG may

receive a TB skin test to test for TB infection. Vaccination

with BCG may cause a positive reaction to a TB skin test. A

positive reaction to a TB skin test may be due to the BCG

vaccine itself or due to infection with TB bacteria.

• TB blood tests (IGRAs), unlike the TB skin test, are not

affected by prior BCG vaccination and are not expected to

give a false-positive result in people who have received

BCG.

TUBERCULOSIS-TREATMENT

• With the advent of antibiotics, the sanatoriums closed.

• Unfortunately for some, streptomycin stopped working-

antimicrobial resistance was occurring.

• Drs. then used 3 antibiotic drugs at a time for periods of 6

months to a year which seemed to be the solution.

• However, the problem became people stopped taking the

drugs too soon, so the TB that survived was now developing

resistance.

• This has happened so many times, that there are now some

strains of TB that are resistant to 7 drugs.

TUBERCULOSIS

• In the US, TB cases declined by 73% between 1953 and 1987.

• Lead to decreased money being spent on treating TB.

• TB cases started rising again for 3 reasons: sharp rise in homelessness, worldwide spread of HIV, and poverty that made it especially difficult to follow the complicated drug regimen.

• In New York City, in 1993 started a program known as Directly Observed Therapy Short-Course or DOTS, they track down everyone with TB and watch them take their pills daily.

• In Africa, DOTS as been able to cure more than 80% of the cases

• In 1998, the DNA sequence of the tuberculosis bacillus was identified.

TUBERCULOSIS-HISTORY

Famous persons who died from TB:

Harriet Webster

Frederic Chopin

Edgar Allan Poe

John Keats-both his mother and younger brother died before him

Henry David Thoreau

John Henry “Doc” Holliday

Elizabeth Barrett Browning

George Orwell

Eleanor Roosevelt- had contracted the disease at age 12

Vivien Leigh

TUBERCULOSIS-WHAT DID WE LEARN

• Use of percussion of the lungs

• Invention of the stethoscope

• Use of agar-agar to grow bacteria

• Development of TB skin test

• Pasteurization of milk to kill bacteria

• Use of antibiotics to treat illness

• Multi-drug antibiotic resistance

• Poverty still places people at high risk for disease

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“Those that cannot remember the past are

condemned to repeat it”. George Santayana 1905

REFERENCES

Barnard, B. (2005). Outbreak Plagues That Changed History.

New York: Crown Publishers.

Bugl, P. (2001). History of Epidemics and Plagues. Retrieved 9/16/12 from uhavax.hartford.edu/bugl/histepi.htm.

Centers for Disease Control and Prevention Website. www.cdc.gov

Farrell, J. (2005). Invisible Enemies Stories of Infectious Disease. 2nd edition. Harrisonburg, Virginia: RR Donnelley & Sons

Foege, Lane, and Millar, Am J. Epi, 1969

Heysell, S, et al. (2103). Epidemiology of extensively drug resistant tuberculosis. Retrieved 8/2/13 from www.uptodate.com.

JAMA. 2000;283(17):2281-2290. doi:10.1001/jama.283.17.2281

Meltzer M, Damon I, Le Duc J. Millar J. EID 2001 (Nov-Dec);7(6)

Public Health Library Images through www.cdc.gov

Rao, Smallpox in Bombay, Kothari, Bombay, 1972

Sherman, I. (2006). The Power of Plagues. Wash DC: ASM Press.

LEANNE SCHIMKE

EMAIL: FNPPROUD@GMAIL.COM

Thank you.

Any questions.