"Easily Cured" or an under-appreciated risk?

Recent media coverage of the Cornish lady (and her dog) who contracted bTB, had the glib and airy observation that "TB is easily cured", implying that an aspirin, an organic carrot and a dose of selenium would do the business. So what are the facts on 'treatment' of this ancient disease - assuming diagnosis allows time to treat at all?

Four years ago, a young man died from 'bovine' TB in the Birmingham area. Several more patients presented with symptoms 2004 - 2006 and much detective work was done to try and find a common source. The BBC carried an overview after the case was published in the Lancet last year.

Bovine TB can spread from human to human, scientists fear after a cluster of six cases, one fatal, in England. All had visited the same Birmingham bar or nightclub, yet only one of the young patients had been in contact with infected unpasteurised milk or cattle. The Health Protection Agency said although rare, the cases emphasised the need for rigorous checks and controls.

Experts told The Lancet that bovine TB was an under-appreciated cause of disease and death in humans.

This 'under-appreciation' may be because an undisclosed proportion of UK tuberculosis cases are not strain typed, but bundled under the all embracing term, 'tuberculosis complex'. And what was also not made plain was that doctor's text books have not kept up with public health measures applied on-farm in that anyone under the age of 50, (the average age of the Birmingham victims was 32)would have been drinking unpasteurised milk, from regularly tested (and slaughtered if they reacted to the test) cattle.

Certainly unpasteurised milk was the driver for transmission of bTB in the 1930s and 1940s, but during the TB eradication programme undertaken in GB, 1952 - 1960, all cattle in the country were tested and slaughtered if they reacted to the test. This brought the instance of TB reactor cattle down from 40 % of the national herd in 1934 to 0.04% in 1965. Thus strains (spoligotypes) of bTB circulating in the environment, are now limited one the one hand to tested sentinel cattle, mainly slaughtered ahead of clinical disease, and an unchallenged, uncontrolled but highly infectious wildlife reservoir of disease in badgers.

The TB infected index case went on to transmit the disease to several other people, in the confines of a Birmingham nightclub. And their treatment? Were they 'easily cured' as the recent press articles have told us? One of the cocktail of several drugs used for months to control or hopefully cure, tuberculosis is Isoniazid. This is the drug information sheet for it:

ISONIAZIDBrand names: , Nydrazid

Isoniazid is an antibiotic. It prevents tuberculous bacteria from multiplying in the body.Isoniazid is used to treat and to prevent tuberculosis (TB).

Avoid alcohol while taking isoniazid. Alcohol may increase the risk of damage to the liver during isoniazid treatment.
Contact your doctor immediately if you experience numbness or tingling in the hands or feet, weakness, fatigue, loss of appetite, nausea and vomiting, yellowing of the skin or eyes, or darkening of the urine. Before taking this medication, tell your doctor if you have ever had an allergic reaction to isoniazid, kidney disease, or liver disease.

It is not known whether isoniazid will be harmful to an unborn baby. Do not take this medication without first talking to your doctor if you are pregnant or could become pregnant during treatment. It is not known whether isoniazid will be harmful to a nursing baby. Do not take this medication without first talking to your doctor if you are breast-feeding a baby.

Your doctor may also want you to take a supplemental vitamin B6 (pyridoxine) tablet daily during treatment to prevent numbness and tingling caused by low levels of this vitamin. Your doctor may want you to have blood tests or other medical evaluations during treatment with isoniazid to monitor progress and side effects.

Seek emergency medical attention if an overdose is suspected.
Symptoms of an isoniazid overdose include nausea, vomiting, dizziness, slurring of speech, blurred vision, visual hallucinations, seizures, coma, and death.

Avoid alcohol while taking isoniazid. Alcohol will increase the risk of damage to the liver during treatment with this medication.
Use caution with the foods listed below. They can interact with isoniazid and cause a reaction that includes a severe headache, large pupils, neck stiffness, nausea, vomiting, diarrhea, flushing, sweating, itching, irregular heartbeats, and chest pain. A reaction will not necessarily occur, but eat these foods with caution until you know if you will react to them. Call your doctor immediately if you experience any of these symptoms.

Eat the following foods with caution:

cheeses, including American, Blue, Boursault, Brick, Brie, Camembert, Cheddar, Emmenthaler, Gruyere, Mozzarella, Parmesan, Romano, Roquefort, Stilton, and Swiss;

sour cream and yogurt;

beef or chicken liver, fish, meats prepared with tenderizer, bologna, pepperoni, salami, summer sausage, game meat, meat extracts, caviar, dried fish, herring, shrimp paste, and tuna;

avocados, bananas, figs, raisins, and sauerkraut;

soy sauce, miso soup, bean curd, and fava beans;

yeast extracts;

ginseng;

chocolate;

caffeine (coffee, tea, cola, etc.); and

beer (alcoholic and nonalcoholic), red wine (especially Chianti), sherry, vermouth, and other distilled spirits.

Not just an aspirin then? The website for trainee doctors run by the BMJ also had some information on m.bovis and m.tuberculosis infections. In particular note the reference to Isonaizid resistant strains.

...a large proportion of those affected [by tuberculosis] are "young, UK born, white, and reasonably affluent. Almost half of the 7000 cases seen nationwide each year being found in the capital: 7.5% of the TB seen in London is isoniazid resistant.

The bacterium responsible for the outbreak is unusual in that it takes patients longer to recover from the illness. Nine months of antibiotic treatment is required to combat the infection, in contrast to the usual six months. Patients suffering from "normal" TB have a relapse rate of around 2-3%, but the rate is 10% in those with the drug resistant strain. [] Both the incubation period and mortality rates of the strain are similar to "normal" TB.

As a commentator in the Birmingham Post pointed out, "bTB has not gone away".

It has been pointed out that while some UK patients with tuberculosis have to be encouraged with payments to complete their course of treatment (so long and horrible it is) sufferers in the US used to have the big stick treatment. We are not sure whether this is still the case, hence the 'used to', rather than 'have'. But for sure, the seriousness with which the disease was taken was reflected in the compulsory attendance of patients to local police stations to take their medication under supervision. Should they default, then they had committed a criminal act and an arrest warrant was served.
In a part of of own 1936 Public Health Act, it is an offence to travel on public transport while infectious with a notifiable disease. Treatment of a notifiable disease is mandatory. Tuberculosis (of any strain) is a notifiable disease.

We will leave you to decide from those snippets whether bTB should be airbrushed into a politically expedient comfort zone, or treated with the seriousness we think it deserves.