Tuesday, September 09, 2008

"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;



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.


Anonymous said...

Not just an Aspirin then?

here is some info

Drug Information - Aspirin

Generic Name: aspirin (AS-pir-in)
Brand Names: Examples include Aspiritab® and Bayer®
Classification: Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Issue Date: October 3, 2006

Aspirin is used for treating pain including: headache, muscle aches, sprains, tooth extraction and toothache, menstrual cramps, arthritis and rheumatism, and pain and fever of the common cold. It also may be used to reduce the risk of death and lessen the damaging effects of an acute heart attack. It is also used to reduce the risk of heart attacks and strokes in certain men and women who have already had a heart attack or ischemic stroke. It may also be used to treat certain conditions as determined by your doctor which may not be listed in the professional package insert.

Aspirin is a nonsteroidal anti-inflammatory drug (NSAID). It works by inhibiting several different chemical processes within the body that cause pain, inflammation, and fever. It also reduces the tendency for blood to clot.
# Before Using This Medicine
# Precautions
# How to use Aspirin
# Safety Information
# Side Effects
# Drug Interactions
Before Using This Medicine

Some medical conditions may interact with Aspirin. Tell your doctor or pharmacist if you have any medical conditions, especially if any of the following apply to you:

* if you are pregnant, plan to become pregnant, or are breast-feeding
* if you are taking any prescription
* if you are taking any nonprescription medicine
* if you are taking any herbal preparation
* if you are taking any dietary supplement
* if you have allergies to medicines or other substances
* if you have alcoholism or if you consume 3 or more alcohol-containing drinks every day
* if you have asthma
* if you have bleeding or clotting problems
* if you have growths in the nose (nasal polyps)
* if you have kidney or liver problems
* if you have stomach or peptic ulcers (bleeding ulcers)
* if you have heartburn
* if you have upset stomach, stomach pain
* if you have influenza (flu)
* if you havechicken pox
* if you have vitamin K deficiency
* if you are a child with a stroke
* if you are a child with a weakened blood vessel (cerebral aneurysm)
* if you are a child with bleeding in the brain
* if you are a child with Kawasaki syndrome (a rare inflammation causing heart problems in children)

[ Top Return to top of page ]


Do NOT use Aspirin if:

* you are allergic to any ingredient in Aspirin
* you are a child or teenager with influenza (flu)
* you are a child or teenager with chicken pox
* you have bleeding problems such as hemophilia
* you have bleeding problems such as von Willebrand disease
* you have low blood platelets
* you have had a severe allergic reaction (eg, severe rash, hives, breathing difficulties, dizziness) to aspirin, tartrazine, or an NSAID (eg, ibuprofen®, naproxen®, celecoxib)
* you are taking anticoagulants (eg, heparin, warfarin) or methotrexate

Contact your doctor or health care provider right away if any of these apply to you.
[ Top Return to top of page ]

How to use Aspirin

Use Aspirin as directed by your doctor. Check the label on the medicine for exact dosing instructions. Aspirin may be taken with or without food. If stomach upset occurs, take with food to reduce stomach irritation. Take Aspirin with a full glass of water (8 oz/240 mL). Do not lie down for 30 minutes after taking Aspirin.

Use Aspirin exactly as directed on the package, unless instructed differently by your doctor. If you are taking Aspirin without a prescription, follow any warnings and precautions on the label.

If you miss a dose of Aspirin and you are taking it regularly, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once.
[ Top Return to top of page ]

Safety Information About Aspirin

Aspirin contains aspirin. Before you begin taking any new prescription or over-the-counter medicine, read the ingredients to see if it also contains an aspirin-like medicine. If it does or if you are uncertain, contact your doctor or pharmacist.

If you consume 3 or more alcohol-containing drinks every day, ask your doctor whether you should take Aspirin or other pain relievers/fever reducers. Aspirin may cause stomach bleeding. Alcohol use combined with Aspirin may increase your risk for stomach bleeding.

Aspirin may reduce the number of blood cells that are needed for clotting. To prevent bleeding, avoid situations where bruising or injury may occur. Report any unusual bleeding, bruising, blood in stools, or dark tarry stools to your doctor.

Aspirin has been linked to Reye syndrome. Do not give Aspirin to children or teenagers during or after chicken pox, flu, or other viral infections without checking with your doctor, nurse, or pharmacist for more information.

If Aspirin has a strong vinegar-like smell upon opening, do not use. It means the medicine is breaking down. Throw the bottle away safely and out of the reach of children; contact your pharmacist and replace.

Before you have any medical or dental treatments, emergency care, or surgery, tell the doctor or dentist that you are using Aspirin.

Do not take Aspirin for at least 7 days after any surgery unless directed by your health care provider. Do not take Aspirin for more than 10 days for pain or for more than 3 days for fever unless directed to do so by your health care provider.

Safety in CHILDREN
Talk to you doctor or pharmacist if you have any questions about the brand you are using.

If you plan on becoming pregnant, discuss with your doctor the benefits and risks of using Aspirin during pregnancy. Aspirin is not recommended during the last 3 months (third trimester) of pregnancy due to the potential for fetal harm or complications during delivery. Aspirin is excreted in breast milk. If you are or will be breast-feeding while you are using Aspirin, check with your doctor or pharmacist to discuss the risks to your baby.
[ Top Return to top of page ]

Side Effects

Get emergency medical help if you have any of these signs of an allergic reaction:

* Hives
* Difficulty breathing
* Swelling of your face, lips, tongue, or throat

Seek medical attention right away if any of these SEVERE side effects occur:

* bloody or black, tarry stools
* confusion
* diarrhea
* dizziness
* drowsiness
* hearing loss
* ringing in the ears
* severe stomach pain
* vomiting

Check with your doctor if any of these most COMMON side effects persist or become bothersome:

* heartburn
* nausea
* stomach upset

This is not a complete list of all side effects that may occur. If you have questions or need medical advice about side effects, contact your doctor or health care provider. You may report side effects to the FDA at 1-800-FDA-1088 (1-800-332-1088) or at http://www.fda.gov/medwatch.
[ Top Return to top of page ]

Drug Interactions

Some medicines MAY INTERACT with Aspirin. Tell your health care provider if you are taking any other medicines, especially any of the following:

* Carbonic anhydrase inhibitors (acetazolamide®)
* Anticoagulants (heparin®, warfarin®)
* NSAIDs (ibuprofen®, celecoxib)
* Insulin and oral antidiabetics (glyburide, nateglinide)
* Methotrexate or valproic acid
* Angiotensin-converting enzyme inhibitors (enalapril®)
* probenecid
* sulfinpyrazone

There may be other drugs not listed that can affect Aspirin. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor.

Matthew said...

Anon 11.32
Don't try and minmise the seriouness of this disease. You insult those unfortunate enough to have contracted it from 'environmental' sources, and who have to take this cocktail of drugs for so long. The side effects are such that patients have to be 'encouraged' - as in paid - to complete their courses. (That from a TB nurse in London)

We prefer aspirin.

Anonymous said...

Matthew thinks that I "insult those unfortunate enough to have contracted it from 'environmental' sources"

I wonder what those 'environmental' sources are?

Oh yes -

milk - unpasteurised


beef - not cooked properly.

The point is Matthew that in the past you have accused others of 'cherry picking' information, whilst you are quite happy to do the same yourself. Perhaps this is unintentional, but for instance quoting a drug info sheet isn't really helpful is it? Just about any drug - even aspirin - has possible down sides.

Your choice of words also does little to further your cause - what do you mean by 'environmental sources' - could argue that everything is environmental as that's what we live in - our environment. Or is this another jibe at badgers I wonder.

Matthew said...

Anon 8.45.
'Environmental' sources are tuberculosis contracted not from the usual suspects: foreign travel, contact with a clinical sufferer or consumption of unpasteurised milk derived from cattle with udder lesions.

Now, please do catch up. After the 'Accreditation' sweep through GB cattle herds 1952-1960, the incidence of reacter cattle dropped to 0.04% - in other words very, very samll numbers. Less than 700 cattle slaughtered in 1986. And, regularly tested cattle are unlikely to have developed TB enough to become a candidate for onwards transmission - to anything. In fact even with open lesions they are surprisingly non-infectious. (Pathman project) So tenuous links with 'unpasteurised milk' owes more to old text books, than the more up to date problems now flagging up with over spill into many other species, from, yes you got that bit right - badgers.

The spoligotype identified in two recent UK outbreaks of TB in humans was identical to that recovered from postmortemed badgers and reactor cattle in the area.

The cattle are tested - every 60 days if there is a breakdown - and slaughtered, in most cases way ahead of identifiable or culturable infection.
Comparing the cattle and badger TB pathology, the disease is very much better adapted to badgers than cattle, in that badgers can be highly infectious and yet show few symptoms until the end of disease progression. (That from a veterinary pathologist)

So, what is done about the increasing amount of tuberculosis infection spread within the environment by badgers?

Answers on a postcard.