One in three people around the world have the tuberculosis bacteria already within their body. If you meet and talk with a hundred people in one day, at least thirty-three have TB within them. Fortunately, tuberculosis is not contagious until one contracts the symptoms: coughing, weight loss, fatigue, fever, night sweats, chills, and loss of appetite. Until then, we call this dormant bacteria Latent TB. Once it becomes “active”, usually when our immune system plummets for one reason or another, the mycobacterium tuberculosis will attack our body. In America, we are blessed to have several resources at our disposal to fight this disease. In third world countries, however, resources are rare, and thus tuberculosis takes on a new form. It becomes resistant to many drugs as the bacteria becomes more resilient. Because of this, tuberculosis can no longer be called an epidemic of the past, with recent uncontained outbreaks, unregulated treatments, reports of further mutations, the neglect of needful mental health care, and the lack of safe and affordable drugs for resistant TB. When we hear the word tuberculosis, we automatically tend to think of a plague of the past. “We have cured that disease. We don’t have to worry anymore,” we often say. Yet that is where we do error.
Over the years we have come to better understand how tuberculosis attacks our body. In truth, we are learning about it more and more. So far, we understand that it spreads in the air by either coughing, sneezing, shouting, singing or even talking. However, it cannot be spread by sharing the same food, touching contaminated objects, or even kissing. It only takes a few TB bacteria to infect a body, and it will actually allow itself to be consumed by our white blood cells. In fact, it is within these very “disease fighting” cells that the mycobacterium tuberculosis destroy our body. S. E. Gould says in a 2012 post, "The white blood cells that first ingest the TB bacteria are macrophages, which kill invading particles… by ingesting them into a vacuole, and then breaking them down. The TB gets ingested fine, but once inside the cell it stops the cell from breaking it down. That means that the body now has a white blood cell infected with a TB bacterium." She goes on to explain how, using a certain protein called ESX-1, the tuberculosis bacterium is able to break out of the cell vacuole, and into the cytoplasm where it can destroy it. “ESX-1 gene codes for a secretion system, [is] not surprising seeing as there job [in our body] seems to be to get the bacteria out of the vacuole,” she states. While mainly attacking the lungs, the TB bacteria can also be found in the spine and brain. Other organs it will avoid most often, and "if it does go in other organs it's in bones,” explains Dr. Ruth Wrightsman, an Associate Professor of Biology with a PhD from the University of Irvine, California, in a 2013 interview. With this information, we are able to create drugs to help fight tuberculosis, and restore our white blood cell count.
Unfortunately, this does not stop tuberculosis from spreading, and causing harm worldwide. There are, "an estimated annual caseload of thirteen thousand MDR-TB cases [in South Africa alone], placing it fourth among countries where MDR-TB is highly prevalent,” says Klopper M, et al. in a 2013 article. MDR-TB is also known as multiple drug resistant tuberculosis. Klopper adds, “the cure rate of patients with drug-resistant TB is less than fifty percent for those with MDR-TB." This is only multidrug resistant tuberculosis! Beyond that, through migration, it travels to other places in South Africa, and ultimately around the world. In answer to the question if whether drug resistant tuberculosis can spread the strain as well, Dr. Ruth Wrightsman admits, “Yes. If someone has resistant strains then that is what you are going to get". If one is around someone who has XDR-TB, also known as extensively drug resistant tuberculosis, than that is what one is prone to catching. Whether it be by plane, automobile or old fashioned foot travel, these strains of TB are spreading. More people are getting sick, more are dying, and most without even being diagnosed. In truth, TB is no longer only an affliction of the past, seeing it surrounds those of third world countries today.
There are now rumors of a further mutation of this bacteria, this is known as TDR-TB. Also known to many as XXDR or extremely drug resistant tuberculosis. TDR simply means totally drug resistant, and as it is named: there is no cure. These are “rumors” however, and have yet to be proven. According to Steve Vincent from an article earlier in 2013, he “warned that there was a further threat of Totally Drug Resistant or TDR-TB 'just around the corner'." It goes on to explain how he had lost a young patient to tuberculosis recently, for whom he could find no means of treatment. They had tried everything, and yet to no dismay. This is not the only report of an incurable strain. Europe, Iraq, Iran and India all were affected by this new mutation of TB. All explained that they could not find a cure. According to a 2013 article by Klopper, et al, "the atypical Beijing genotype clone is evolving toward total drug resistance… [because] ninety-three percent of atypical XDR Beijing isolates had mutations that confer resistance to 10 anti-TB drugs and some isolates also were resistant to para-aminosalicylic acid.” When talking with Wrightsman she added that the “vaccination process is not good.” There are not enough people receiving it, and many times the vaccinations are not adequate. People are admitting the very possibility of a new epidemic. People are seeing it coming around the corner. Unfortunately, most medical organizations are not.
Two medical centers that do not admit that there is a possibility of an incurable tuberculosis epidemic are the Center for Disease Control and Prevention (CDC) and the World Health Organization (WHO). Wrightsman reports, "I keep pretty good tabs on the CDC.org website and I haven’t seen anything yet.” Even though there are “continuing mutations of these bacteria,” and it would seem logical we would find ourselves struggling to find new treatments. According to the W.H.O. website, FAQ’s of 2013. “The prognostic relevance of in vitro resistance to drugs without an internationally accepted and standardised drug susceptibility test therefore remains unclear and current WHO recommendations advise against the use of these results to guide treatment. Lastly, new drugs are under development, and their effectiveness against these 'totally drug-resistant' strains has not yet been reported. For these reasons, the term 'totally drug-resistant' tuberculosis is not yet recognised by the WHO. For now, these cases are defined as extensively drug resistant tuberculosis (XDR-TB),” Whether it be indeed for these reasons, or out of determination to keep the general public at ease, W.H.O. does not recognize this type of TB. For them, it must be internationally addressed. It must be tested in the laboratories of several countries. It reminds me of the mother who told her son the burner was hot. Unfortunate for him, he had to discover it for himself, and all his friends, in order to believe the danger. "If 'totally drug-resistant' TB defines a subset of XDR-TB,” W.H.O. goes on to explain, “with different characteristics to other XDR-TB cases, particularly with respect to the outcome of such cases, then an internationally recognised definition may be needed." Yet perhaps it will become too late to control by the time nations acknowledge it universally. The time for action is now. The time to inform the world is today.
As humans, we have been wrong before when it comes to science or medicine. Consider when we thought the earth was flat, when infection came from “bad air”, when rats were birthed from dusty old rags, and when heavier objects fell faster when dropped. We continually are discovering more about our planet, and the way it works. We theorize, we put our trust in explanations we believe we have proven, then we often later find them faulty. The tuberculosis disease is the same. In a book by Wayne Biddle, published in 2002, the theory of an early disease is explained. “For hundreds of years in England, scrofula - now known to be a mycobacterial infection of the glands - was called ‘the king’s evil’ and was treated by divine ‘royal touch’ from the monarch himself until the eighteenth century” (p. 159). TB isn’t any different in that we can’t misunderstand it. Like any other bacteria, TB can mutate and change, giving way to yet another untreatable plague. It isn’t to say there will never be a cure, but that we have yet to find one for certain uncommon strains.
It’s expected for mutations to occur in a disease mismanaged with unregulated treatment. Samuel Loewenberg speaks of Mumbai in an article of 2012, "Government health officials attribute the problems with drug-resistant tuberculosis to the city's unregulated private doctors who prescribe inappropriate drugs. Privately, some senior officials acknowledge that much of the public have a negative perception of government-run health facilities, due to long waiting periods, rude treatment, and the stigma associated with tuberculosis. The result is that many infected people avoid the government tuberculosis program and seek relief from private doctors, only some of whom have medical training.” At the mercy of untrained doctors, the chances of regaining full health fades. He goes on to quote, "There is 'poor infection control at most of these settings', said Mistry [the director of the Foundation for Medical Research in Mumbai], and people with resistant tuberculosis could well be infecting patients with a regular tuberculosis infection." This is not all however, with the cost of treatment about four thousand dollars per patient, it makes it extremely difficult for third world countries to fight these strains of tuberculosis. With inconsistent management of drug prescription and consumption, the body is unable to kill the TB bacteria. Instead, it gives it a sort of vaccine while enabling it to build up an immunity.
Beyond this, we are neglecting mental health care in treating tuberculosis. There have been numerous studies on the correlation between TB and how it causes common mental disorder, better known as CMD. "Mental health is not an integral part of... TB care and treatment services, [however] CMD would have negative impact on the treatment outcome of patients,” writes Deribew, et al. (2013). If addressed, the state of mental health can increase over time in a TB patient. Deribew et al. summarizes a study done recently, "At baseline, 54.4% of TB/HIV co-infected patients had mild to severe mental disorder... At the six month follow up, 18.1% of TB/HIV co-infected patients had mild to severe mental disorder." Unfortunately, it isn’t a concern to attend to the mental health of such patients. Perhaps this too is due to lack of knowledge. Perhaps it is due to lack of funds and resources. While maybe not curing TB, it would certainly strengthen the patient over all.
As much care as is put into creating drugs to fight resistant TB, we have yet to find an affordable, safe and effective cure. "Any new drug has a protocol. You always start with a culture... and then animal models.” Dr. Ruth Wrightsman explains. Once it has passed these extensive tests, it is then applied to normal, healthy individuals on a small scale. If the results are favorable they will take it to the next level with patients who are actually ill with TB. They will divide the patients in two group, averagely fifty to a hundred each, selecting one half to test the new drug, and the other to take a previously established drug. This is done in such a manner, because they must compare the results of the new drug. It is unfair to leave the other group left hanging with no cure, so they find them an already recognized treatment. They compare the results by recovery time, level of side effects, and cost of manufacturing. Once the drug passes this test, they take it a step further in prescribing it to 1,000 TB patients. Fluoroquinolones is a drug which passed these extensive tests. "Fluoroquinolones are known to be safe and well tolerated. They are said to have the widest clinical acceptability when compared with other antibiotics,” E. Adikwu of 2012. “Their reported side effects include gastrointestinal tract, central nervous system effect and blood disorder. Rare side effects include phototoxicity, hypersensitivity, convulsion, psychosis, tendinitis, hypoglycemia, cardiotoxicity and nephrotoxicity." Suddenly these Fluoroquinolones don’t seem so safe. Moreover, this is supposedly the widest clinical acceptable drug. Adikwu goes on, “It was observed that some fluoroquinolones may have hepatotoxic potential. Reported fluoroquinolones induce hepatotoxicity manifested as hepatitis, pancreatitis, jaundice, liver injury and hepatic failure.” Jeffrey C. Pommerville in his book of 2013, illustrates how consequential this drug can be, “Inhibitors of DNA synthesis: Fluoroquinolones” (p.820). Perhaps if we took small doses the side effects would not be as severe, but even “for children, maximum doses are used. These are very important drugs in MDR-TB therapy," Claims IOM in a book of 2011 (p. 78). From an article by Samuel, Zarir F Udwadia has been treating the patients at the P D Hinduja National Hospital and Medical Research Centre, “trying any treatment he thinks might work [to cure TDR-TB]. This includes a double-dose isoniazid, the harsh antibiotic linezolid, the anti-leprosy drug clofazimine, the antipsychotic drug thioridazine, and meropenem and clavulanate, which reportedly had some effect on tuberculosis in mice. ‘We are clutching at straws here’, Udwadia admits.” Though antibiotics can kill most bacteria, it also kills the good bacteria within our bodies, weakening our immune systems to fight off other disease. There are other options to treating TB however, one being surgery. When talking with Wrightsman she explains how these, “procedures can take out the infected part in the lungs”. Only one must ask himself if the TB bacteria can’t spread to the doctors and nurses, despite them wearing protective gloves and a face mask. For many reasons surgery is rare and very dangerous to attempt, but it can be done if necessary.
With all this evidence it becomes clear tuberculosis is not a disease of the past. Maybe it is not spreading as quickly as it might have years before, and maybe we understand it better, but never the less it is mutating and becoming immune to certain drugs and antibiotics. The drugs we do have available are harmful to our bodies, and in many cases seem to be doing more damage than healing. In addition, more attention should be given to the CMDs that parallel with TB, considering that 54.4% of all TB/HIV co infected patients have mild to severe mental disorder. In the interview with Dr. Ruth Wrightsman, she explains how even informing the public and keeping up on vaccines can be a lot of help. If more people took the intuitive in getting the shots and TB testing, while becoming alert and aware to these diseases, the cases of tuberculosis would go down. Not only in America, but worldwide. Beyond taking this epidemic seriously, we must admit that an incurable tuberculosis could very well be spreading.
Reference
Adikwu, E., & Deo, O. (2012). Fluoroquinolones Reported Hepatotoxicity. Pharmacology & Pharmacy, 3(3), 328-336. doi:10.4236/pp.2012.33044
Biddle, W. (2002). Tuberculosis. A field guide to germs (p. 159. New York, NY: Anchor Books.
(Original work published 1995)
Deribew, A., Deribe, K., Reda, A. A., Tesfaye, M., Hailmichael, Y., & Maja, T. (2013). Do
common mental disorders decline over time in TB/HIV co-infected and HIV patients without
TB who are on antiretroviral treatment?. BMC Psychiatry, 13(1), 1-6.
doi:10.1186/1471-244X-13-174
Dias, M. (2012, January 13). Drug-resistant tuberculosis. FAQ’s. Retrieved from
Gould, S. (2012, February 12). How the TB bacteria bursts your cells. Retrieved from
IOM (Institution of Medicine). (2011). Introduction. The Emerging Threat of Drug-Resistant
Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint
Workshop (p. 78). Washington, DC: The National Academies Press.
Jeffrey C. Pommerville. (2013). Airborne Bacterial Diseases. In M. Johnson, M. Bradbury & R. Isaacs
(Eds.), Fundamentals of Microbiology (10th ed.) (p. 820). Burlington, MA: Jones &
Bartlett Publishers.
Klopper, M., Warren, R., Hayes, C., van Pittius, N., Streicher, E., Müller, B., & ... Trollip, A. (2013).
Emergence and Spread of Extensively and Totally Drug-Resistant Tuberculosis, South Africa.
Emerging Infectious Diseases, 19(3), 449-455. doi:10.3201/eid1903.120246
Loewenberg, S. (2012). India reports cases of totally drug-resistant tuberculosis. The Lancet,
PNG girl dies of XDR-TB in Cairns. (2013, March 18). Post-Courier (Papua New Guinea), 17.
http://ehis.ebscohost.com/ehost/detail?vid=9&sid=d264778b-1fcd-47ab-82fa-68ec518d1d08%40sessiongr12&hid=3&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=n5h&AN=201303182017256203
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