country may be in the midst of a terrible outbreak where nearly everyone is TB infected and diseased, while their neighbors have much less or even no disease. The neighbors will have infection, but less disease. Then the pattern will reverse in the next year or century. Environmental factors and living conditions alone cannot account for the huge difference in the number of cases. It is another one of the unknowns about TB.
Physicians and scientists have studied TB for millennia trying to understand the disease in order find effective cures, preventatives, or treatments. Ancient Indian and Chinese texts refer to TB. Hippocrates and Galen, famous physicians of antiquity, were familiar with the disease. Hippocrates did not think that TB was passed from person to person. Galen did think TB was a communicable disease. In 1680, Franciscus Sylvius, a Frenchman living in Germany, described pulmonary tubercles and thought the disease might be hereditary. The specific cause of TB remained unknown until Robert Koch, the Prussian doctor, revealed in 1882 that he had isolated and identified the TB mycobacterium from diseased patients and produced TB in laboratory animals with the organism. Koch also produced tuberculin by killing the TB mycobacteria and filtering the solution of dead organisms. He touted tuberculin as a cure for TB-in which role it failed miserably. However, tuberculin is still used today to test for TB in the host.
Before the advent of modern vaccines and antimicrobials, treatment for TB was very hit and miss. Mostly miss. Galen advocated bleeding, among other things. Bleeding TB patients not only doesn't work, it will make them worse.
In Europe, until the early modern era, it was believed that the touch of a ruling monarch could cure scrofula. Any of the old treatments that decrease further exposure to TB bacilli or that strengthens the body's immune system will have some positive effects. Fresh air and sunshine actually work to some degree. Modern research has shown that a person with vitamin D deficiency is more likely to develop TB disease. Exposure to UV light in sunshine increases the body's stores of vitamin D. Proper rest was also prescribed for TB patients. Rest enhances the immune system, as does the absence of stress factors. Various changes of diet were also advocated. Those changes usually eliminated malnutrition.
In our world, it has proven much easier to significantly decrease the incidence of bovine TB affecting people than the human strain. Once it was discovered in the late 1800s that most bovine TB was caused by ingesting infected milk and meat, control measures were quickly implemented in most American and European countries. Boiling or pasteurizing all milk kills TB bacilli. Sale of meat from TB infected livestock was forbidden. Skin-testing livestock using tuberculin was implemented. TB infected herds were quarantined or destroyed with compensation paid by the government to the owners. Extensive education programs aimed at healthcare workers, farmers, and consumers were initiated. In the UK, there was widespread opposition to control measures by farmer's groups and the MP's that they controlled. So the UK fell decades behind in controlling bovine TB. Once bovine TB control measures were put in place, the rate of TB meningitis in infants and small children was cut in half.
Albert Calmette, a bacteriologist, and Camille Guerin, a veterinarian, developed the first effective and safe vaccine for human TB. Working out of the Pasteur Institute in Lille, France, they attenuated (weakened) a strain of TB using multiple subcultures in a glycerin-bile-potato culture medium. Each subsequent culture in the medium was less virulent than the last. They named the attenuated TB strain Bacillus Calmette-Guerin (BCG). Human tests of the BCG live vaccine began in 1921. BCG is still the only vaccine used to combat TB. It is variably effective. It will prevent some forms of TB more effectively than others. It also works better in northern Europe than it does near the equator. A tuberculin skin test should be done on everyone, except newborns, before they get BCG vaccine. A positive tuberculin test indicates prior exposure to TB or another mycobacterium. BCG should not be given to those who have a positive reaction to a tuberculin skin test. In tuberculin reactors there can be a severe local reaction to vaccine with scarring. BCG vaccine will cause a positive reaction on a tuberculin test given later. So it is important to test before the vaccination to differentiate between natural infection and vaccination positives. People should not take antimicrobials for a few weeks after BCG vaccination. The antimicrobial will very likely kill the live vaccine in the body before it can produce immunity.
Detection of TB uses several methods. Chest x-rays can detect typical pulmonary TB lesions in the lungs. Sputum and other body fluids from those suspected to be infected is stained to find the very typical TB bacilli. The tuberculin skin test, made from killed, filtered, and diluted T. bovis bacilli has been the most common test for TB for many years. A tiny amount of tuberculin is injected intradermally. Three days later the skin reaction, if any, is measured. The size of the reaction is used to determine whether the person is positive or negative for TB infection. Tuberculin testing can detect those with active disease, those with latent (currently inactive) infection, and those that were infected in the past but don't have TB bacilli in their systems now.
The first antimicrobials that were effective against TB were developed in the 1940s in the US, Sweden, and Germany. Streptomycin was developed in the US, PAS in Sweden, and thioacetazone was developed in Germany. At first they were considered miracle drugs because they were so effective in treating all forms of TB. Within a couple of years many patients treated with the drugs were relapsing with TB. Even worse, the TB bacteria in the relapses were now resistant to the drug first used to treat the TB.
In their race to find better drugs, three competing drug companies nearly simultaneously discovered that isoniazid had very strong ant-TB effects. Isoniazid is a coal tar derivative that was discovered by Czech chemists in 1912. It has remained one of the first-line treatments of TB to this day. Treatment is more effective and less drug resistance develops when two or more anti-TB drugs are used together. Ethambutol, thioacetazone, rifamycins, pyrazinamide, and PAS, are other drugs that are used to treat TB.
Chloramphenicol kills mycobacteria in test tubes. I have not found any references to testing the drug in humans for control of TB. Strains of TB that are resistant to multiple drugs are emerging. Most multi-drug resistance stems from improper drug use. Some patients don't comply with the often months-long therapy. When they don't, resistant bacteria are more likely to occur.
What measures can Grantville take to protect their citizens and their neighbors from White Plague? First, start a new fashion trend. Surgical masks for everyone in indoor gathering and work places. It is the single most important step that can be taken for immediate protection from airborne TB bugs. Never ingest a milk product unless you know the milk was boiled or pasteurized. Segregate all people who show obvious signs of TB disease. None of the measures are going to be very popular. Public health education about the danger that TB and other diseases pose is essential. Establish good exhaust ventilation in indoor meeting and work places. Re-circulating air in those places is a very bad idea unless the air is treated with strong UV light.
It is going to take some time to develop tuberculin for testing, BCG for vaccination, and isoniazid for treatment and prevention. The technology is there to begin right away and all can be achieved in a reasonable amount of time.
'Immediately' is the time to spread the word throughout Europe that much about TB is known in Grantville. That many cases of TB can be prevented and treatments are on the way in the near future.
The short-term goal is to protect Grantville and its neighbors with public health measures and education. The medium-term goal is develop tests, vaccine, and treatment. The long-term goals include shortening and eventually eliminating the European TB epidemic. It cannot be allowed to rage unchecked until the twentieth century. Up- timers must find effective ways to disseminate their knowledge of TB to all corners of Europe. The up-timers have centuries of discoveries to build on and share. They can stand on the shoulders of the OTL heroes of the fight against TB. They have a wealth of information from the current TB epidemic in the third world about which programs work and which have failed.
Good ventilation in workplaces, public meeting places, and habitations is essential. TB bacilli can stay aerosolized for several hours in a room after they are coughed into the atmosphere. Evacuating the air to the outside clears the room. The TB germ will be quickly killed by UV light once it is outside. If a recirculating air system is used, the bacilli can be moved to the air in other rooms as well as the first room. Recirculating systems must have a micro filter or UV light filter to prevent the spread of TB. The type of filters needed will probably not be developed right away because of technology and manufacturing limitations. Surgical masks worn by the infected and the uninfected are a cheap, easy way to cut the number of exposures to aerosolized TB mycobacteria.
Preventing and alleviating overcrowded living conditions is essential in controlling TB over the long haul. In all ages, overcrowded people are much more susceptible to TB.
Eliminating malnutrition is absolutely necessary if TB is to be effectively controlled. Low body weight from malnutrition makes a person many times more likely to develop TB disease. Malnourished people's immune system (especially the T-cells) are much less robust than those with a good plane of nutrition. Supplementing with vitamin
