Tuberculosis(TB) will develop in about eight million persons worldwide
this year and this number will continue to rise. Three million people will
die of this disease in 1996. More than 95% of these deaths will occur in the
developing countries where TB accounts for more deaths than any other single
pathogen and for 25% of avoidable adult mortality. TB now kills more adults
than any other infectious disease, more than HIV, Malaria,Cholera combined.
    The worsening global trends are further complicated by multi-drug-resistant
TB which has been accelerated by the HIV epidemic. Public health measures in
the past decade were derailed by the false perception that the disease would
be eliminated from industrialized countries and would steadily decline in 
developing countries because of effective chemotherapy.
    The most effective way to fight TB is to use directly observed treatment
with short (for TB therapy) course. Only in this way can one be assured 
that the patient is cured and thus not a threat to others. If the patient
fails to take his medications then drug resistance is more likely to 
develop.  
    In this country the incidence of TB is also on the rise having declined
through the 60's and 70's.  However, with the development of HIV a 
resurgence has occurred.  Also drug resistant strains have been a big
problem in the New York area with it's high number of homeless and high
incidence of HIV.   
    TB is transmitted by aerosol droplets usually from the cough of an 
infected individual.  Usually a prolonged exposure is necessary; however,
cases have occurred on a long plane flight.  Symptoms include fever and 
night sweats and usually chronic cough with sputum production. The first
successful drug therapy occurred in the 1940's. It was standard up until 
the 1980's to take two to three drugs at a time for an eighteen month
period.  Now the treatment has been shortened to about six months but with
multiple drugs.  With treatment (if not drug resistant type) the patient
is cured with virtually no chance of recurrence unless he is re-exposed.
     The screening for TB has been with the combination of skin testing
and chest x-rays. Recently the Tine test has virtually lost it's usefulness
and has been eliminated as seen from this recent report from a Harvard 
pulmonologist Dr. Nardell of Cambridge City Hospital.  
 
In his November 11, 1995, lecture on tuberculosis, Dr. Nardell, Tuberculosis Control Officer for the
Commonwealth of Massachusetts, reminded us of the following important points about the tuberculin
test:
1. The "tine" test is no longer accepted. Only the Mantoux intradermal method is acceptable.
2. Testing of low-risk individuals is to be discouraged. The false positive rate is too high.
3. A 10-15 mm Mantoux reaction is ONLY positive for the high-risk individual. A low-risk individual
only has about a 25% risk that the test reflects infection.
4. A >15 mm Mantoux reaction is positive for all degrees of risk.
5. Watch out for the booster effect: The first test boosts the immune response and makes the
second test seem like a conversion when it is not. To overcome this, when testing individuals WHO
WILL PREDICTABLY BE SUBMITTED TO SERIAL TESTING, do the following: if the test is negative,
give a second test a week later; if the test is now positive, then you know it is a booster effect and
not active infection acquired within the week's interval.
  
    TB is still a serious disease and the risk that  strains which are
resistant to all medications can begin to infect the general public
in ever increasing numbers is scary.  We need a massive effort by US and
world health organizations to stop this disease which for the most part
is treatable at this time. Remember  The Coming Plague  is not 
just a good book which I can recommend to you (by Laurie Garrett) it will
be a reality we must face in the 21st century.

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