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Can Tuberculosis Be Eradicated?
EDITORIAL Can Tuberculosis Be Eradicated?
T
HE
TITLE
OF
THE
PAPER
BY
devoting time and effort to an "already solved problem." Despite obstructions and discouragements sincere tuberculosis workers are now encountering, tuberculosis still can be eradicated. For this accomplishment Dr. Willner calls attention to significant facts such as the importance of the tuberculin reaction since new clinical cases of tuberculosis arise from reactors regardless of their apparent good health or age. It is only through reducing infections with tubercle bacilli that morbidity and mortality rates will decrease. Adequate examination of all tuberculin reactors, community by community, will solve the present problem of unknown cases. He points out that nationally about 33 per cent of the cases of tuberculosis are not diagnosed during life. The fact that these persons were not found while they were only tuberculin reactors and kept under surveillance is chargeable to state and local boards of health, tuberculosis associations, the medical profession, etc. for not having long ago made adequate provisions in the eradication of tuberculosis program. The author emphasizes the fact that predictions to the effect that antituberculosis drugs alone will solve the problem is a forlorn hope; moreover, he points out the serious hazard to present and future tuberculosis work by indiscriminate use of drugs which may be resulting in resistant mutants. The methods which were so effectively practiced before the advent of antituberculosis drugs, must be continued or resumed, and drugs used as an adjunctive treatment for clinical cases with promise of recovery. Dr. Willner calls attention to the fact that in 1961 approximately 2600 new clinical cases of tuberculosis were reported in children under five and 12 per cent of all new cases reported in the United States
DR.
Irving Willner in this issue of Diseases of the Chest is in the form of a question, "Can Tuberculosis Be Eradicated?" This question is definitely answerable in the affirmative. If the title had been "Will Tuberculosis Be Eradicated?" the answer would be "probably not for centuries, if ever." This answer is because humans have never freed themselves from diseases for which much simpler and more specific methods of treatment or prevention have been available, including diphtheria, gonorrhea, malaria, smallpox and syphilis. In numerous activities of life, it has long been observed that many persons work enthusiastically and untiringly on health and other projects until the glamour is gone and the drudgery of the final cleanup begins. The number willing to carry through to complete accomplishment is greatly limited which is one reason so many worthwhile projects are never completed. Soper recently said, "In control one tends to lose interest in a disease at the point where in eradication the greatest difficulties are often encountered." A potent factor which may prevent eradication is complacency which sets in after the goal looms into view and many believe the remainder of the way will be accomplished with lessened or no effort. In some places, significant strides have been made in the control of tuberculosis during the twentieth century. The pioneer workers who labored through the heat of the day and established the foundation for tuberculosis control had in mind ultimate eradication. Many who followed them worked incessantly; however, as the fruits of their labors began to ripen, the glamour was gone and complacence set in. Hence, those who have continued with their shoulders to the wheel are receiving little support and indeed are often frowned upon for 327
J.
ARTHUR MYERS
were under the age of 25 years. Obviously this is because of insufficient effort to protect those in this age period from the tuberculosis "seedbed" among adults. Tuberculosis will make its last stand among persons in the upper age brackets. He states that in some areas approximately 80 per cent of the morbidity and mortality occurs in persons over 40 years. In 1961 in one state 97.9 per cent of the deaths occurred in persons of 45 years or older. In that state, no one died under the age of 35 years. Of the reported cases, 62.5 per cent were 45 years of age or older. The explanation for this situation is clear; namely that among those in the upper age brackets, large numbers, when children and young adults, became invaded with tubercle bacilli because of lack of protection from persons and animals with contagious tuberculosis. Many of these older persons are still harboring tubercle bacilli, some of whom are being reinfected endogenously. On the other hand, the majority of the younger citizens are profiting from protective measures adopted in time to prevent invasions of tubercle bacilli. It is not until protective measures are practiced so that no child's body becomes invaded with tubercle bacilli of any type that the army against tuberculosis can enter and travel the road to eradication. Attention is called to the serious problem remaining in the United States, but from 20 to 40 times higher morbidity and mortality rates obtain in Asia, Africa, South America and some countries of Europe. Emphasis is placed on the fact that tuberculosis still incapacitates and kills more people in the world than all other communicable diseases combined. The procedures necessary to eradicate tuberculosis have been known for decades. Following the recommendation of Laennec with reference to the importance of repetition, attention has frequently been called to them under such titles as "EradicationNot Control," "The Last Tubercle Bacillus" and "Eradicate Tuberculosis-Don't Stop Half Way." Nevertheless, the costly
Diseases of the Chest
time lag between establishment of knowledge and its practical application has operated in tuberculosis as it has in so many other diseases and fields of endeavor. However, the word eradication is now being used more frequently and it appears that the time lag is drawing to a close. No one has been more encouraging with reference to a breakthrough than Dr. Fred L. Soper in the paper he presented at the American Public Health Association Meeting in 1961 and his addresses delivered before several state Tuberculosis Association meetings in 1962. With so much experience in programs designed to eradicate other diseases, his presentations on tuberculosis are so down to earth, logical and convincing as to encourage and promote action of tuberculosis workers. For example, following his presentation before the Wisconsin Association a strong resolution was adopted involving immediate steps toward eradication. Moreover, the greater part of the June, 1962 issue of the official publication, The Crusader, was devoted to this activity. Dr. Soper has not been a tuberculosis worker. He classifies himself as a public health administrator and is now a special consultant, Office of the Surgeon General, Division of International Health, Public Health Service, Washington, D. C. Not having worked in tuberculosis has given Dr. Soper a special advantage in that he has been able to acquire a perspective of the field as a whole without the prejudice that might obtain among those within. Dr. Thomas Parran's selection of the subject of eradication for his keynote address at the 1962 annual meeting of the National Tuberculosis Association was also another step toward bringing an end to the costly time lag. On first thought, the work which remains to be done to eradicate tuberculosis in the United States may seem overwhelming. However, the armamentarium and know-how have long existed. Until some individual, or an organization, develops enough courage to take up the cudgel and direct an all-out battle against the tubercle
Volume 43. No.3 March 1963
CAN TUBERCULOSIS BE ERADICATED?
bacilli, the disease will continue to wreak destruction as it has since prehistoric days. If all armamentarium and presently available information were put into immediate operation so that from this day on no uninfected person would be invaded with tubercle bacilli, this organism could not be eradicated during the remainder of the twentieth century. Indeed, eradication could not possibly be achieved until infants and children now harboring tubercle bacilli have passed through the entire span of life, which could be 100 years or more. Even if a germicidal drug were made generally available throughout the world today and was promptly administered to every person harboring tubercle bacilli, the time required to eradicate this organism would not be short for the simple reason that in the majority of such persons the organisms are so protected by fibrous, calcified and osseous encapsulations and avascular necrotic and caseous material as to be safe from drugs in the blood stream.
Nevertheless, such a drug would be of extreme value in destroying tubercle bacilli (as present antituberculosis drugs are in suppressing them) which may be liberated from their present safe domiciles to vascular areas where they contact the drug. Thus, illness and death from tuberculosis would be prevented, but one could not hope for eradication of tubercle bacilli until the last person now harboring them has died. To point out that beginning immediately with the most intense tuberculosis eradication movement would require a hundred or more years for the eradication of tubercle bacilli may seem discouraging to those who lack courage to gird for such an encounter for the remainder of their lives and then pass it on to other generations for completion. However, 100 years is an exceedingly brief period for such an accomplishment when one considers that the lifetime of the disease extends far back into antiquity.
J.
z.c.c.e., Minneapolis, Minnesota
ARTHUR MYERS, M.D.,
CALCIFIED HEART VALVES Cinefluorography compares favorably with other methods In Its abillty to demonstrate calclfled valves. Its potential Is considered to be superior. Body-section studies Involved less radiation exposure (2.5 r contrasted with 4.0 to 8.0 r) and may be done by supervised technical personnel. The viewing of the ftlms Is easier. and the yield at present Is approximately equal to that of cinefluorography.
Fluoroscopy Is a good. simple and cheap method. but suffers from Inabillty to provide objective confirmation of subjective Impressions. A skilled fluoroscopist Is essential. Spot roentgenography has a relatively low yield compared to other methods. WOODRUFF,
J. H. JR.: "Calcified Heart Valves."
79:384, 1962.
RAdiolog"
CHRONIC FORMS OF INFECTIOUS ALLERGIC MYOCARDITIS The authors observed two patients with chronic Infectious allergic myocarditis. The cl1nlcal picture of the disease In one patient resembled rheumatic endomyocardltls with the development of a combined mitral disease of the heart and manifestations of circulatory disorders. In the second patient. the disease was manifested by pain In the region of the heart and attacks of paroxysmal tachycardia with
electrocardiographic changes pointing to coronary Insuftlclency. Anatomic studies revealed In both cases a typical chronic recurrent myocarditis with a protracted course. SKACHILOVA, N. N. AND REVZIS, M. G.: "Chronic Forms of Infectious Allergic Myocarditis," Cbest M,d. (USSR). 26: 19, 1962.
T
HE
TITLE
OF
THE
PAPER
BY
devoting time and effort to an "already solved problem." Despite obstructions and discouragements sincere tuberculosis workers are now encountering, tuberculosis still can be eradicated. For this accomplishment Dr. Willner calls attention to significant facts such as the importance of the tuberculin reaction since new clinical cases of tuberculosis arise from reactors regardless of their apparent good health or age. It is only through reducing infections with tubercle bacilli that morbidity and mortality rates will decrease. Adequate examination of all tuberculin reactors, community by community, will solve the present problem of unknown cases. He points out that nationally about 33 per cent of the cases of tuberculosis are not diagnosed during life. The fact that these persons were not found while they were only tuberculin reactors and kept under surveillance is chargeable to state and local boards of health, tuberculosis associations, the medical profession, etc. for not having long ago made adequate provisions in the eradication of tuberculosis program. The author emphasizes the fact that predictions to the effect that antituberculosis drugs alone will solve the problem is a forlorn hope; moreover, he points out the serious hazard to present and future tuberculosis work by indiscriminate use of drugs which may be resulting in resistant mutants. The methods which were so effectively practiced before the advent of antituberculosis drugs, must be continued or resumed, and drugs used as an adjunctive treatment for clinical cases with promise of recovery. Dr. Willner calls attention to the fact that in 1961 approximately 2600 new clinical cases of tuberculosis were reported in children under five and 12 per cent of all new cases reported in the United States
DR.
Irving Willner in this issue of Diseases of the Chest is in the form of a question, "Can Tuberculosis Be Eradicated?" This question is definitely answerable in the affirmative. If the title had been "Will Tuberculosis Be Eradicated?" the answer would be "probably not for centuries, if ever." This answer is because humans have never freed themselves from diseases for which much simpler and more specific methods of treatment or prevention have been available, including diphtheria, gonorrhea, malaria, smallpox and syphilis. In numerous activities of life, it has long been observed that many persons work enthusiastically and untiringly on health and other projects until the glamour is gone and the drudgery of the final cleanup begins. The number willing to carry through to complete accomplishment is greatly limited which is one reason so many worthwhile projects are never completed. Soper recently said, "In control one tends to lose interest in a disease at the point where in eradication the greatest difficulties are often encountered." A potent factor which may prevent eradication is complacency which sets in after the goal looms into view and many believe the remainder of the way will be accomplished with lessened or no effort. In some places, significant strides have been made in the control of tuberculosis during the twentieth century. The pioneer workers who labored through the heat of the day and established the foundation for tuberculosis control had in mind ultimate eradication. Many who followed them worked incessantly; however, as the fruits of their labors began to ripen, the glamour was gone and complacence set in. Hence, those who have continued with their shoulders to the wheel are receiving little support and indeed are often frowned upon for 327
J.
ARTHUR MYERS
were under the age of 25 years. Obviously this is because of insufficient effort to protect those in this age period from the tuberculosis "seedbed" among adults. Tuberculosis will make its last stand among persons in the upper age brackets. He states that in some areas approximately 80 per cent of the morbidity and mortality occurs in persons over 40 years. In 1961 in one state 97.9 per cent of the deaths occurred in persons of 45 years or older. In that state, no one died under the age of 35 years. Of the reported cases, 62.5 per cent were 45 years of age or older. The explanation for this situation is clear; namely that among those in the upper age brackets, large numbers, when children and young adults, became invaded with tubercle bacilli because of lack of protection from persons and animals with contagious tuberculosis. Many of these older persons are still harboring tubercle bacilli, some of whom are being reinfected endogenously. On the other hand, the majority of the younger citizens are profiting from protective measures adopted in time to prevent invasions of tubercle bacilli. It is not until protective measures are practiced so that no child's body becomes invaded with tubercle bacilli of any type that the army against tuberculosis can enter and travel the road to eradication. Attention is called to the serious problem remaining in the United States, but from 20 to 40 times higher morbidity and mortality rates obtain in Asia, Africa, South America and some countries of Europe. Emphasis is placed on the fact that tuberculosis still incapacitates and kills more people in the world than all other communicable diseases combined. The procedures necessary to eradicate tuberculosis have been known for decades. Following the recommendation of Laennec with reference to the importance of repetition, attention has frequently been called to them under such titles as "EradicationNot Control," "The Last Tubercle Bacillus" and "Eradicate Tuberculosis-Don't Stop Half Way." Nevertheless, the costly
Diseases of the Chest
time lag between establishment of knowledge and its practical application has operated in tuberculosis as it has in so many other diseases and fields of endeavor. However, the word eradication is now being used more frequently and it appears that the time lag is drawing to a close. No one has been more encouraging with reference to a breakthrough than Dr. Fred L. Soper in the paper he presented at the American Public Health Association Meeting in 1961 and his addresses delivered before several state Tuberculosis Association meetings in 1962. With so much experience in programs designed to eradicate other diseases, his presentations on tuberculosis are so down to earth, logical and convincing as to encourage and promote action of tuberculosis workers. For example, following his presentation before the Wisconsin Association a strong resolution was adopted involving immediate steps toward eradication. Moreover, the greater part of the June, 1962 issue of the official publication, The Crusader, was devoted to this activity. Dr. Soper has not been a tuberculosis worker. He classifies himself as a public health administrator and is now a special consultant, Office of the Surgeon General, Division of International Health, Public Health Service, Washington, D. C. Not having worked in tuberculosis has given Dr. Soper a special advantage in that he has been able to acquire a perspective of the field as a whole without the prejudice that might obtain among those within. Dr. Thomas Parran's selection of the subject of eradication for his keynote address at the 1962 annual meeting of the National Tuberculosis Association was also another step toward bringing an end to the costly time lag. On first thought, the work which remains to be done to eradicate tuberculosis in the United States may seem overwhelming. However, the armamentarium and know-how have long existed. Until some individual, or an organization, develops enough courage to take up the cudgel and direct an all-out battle against the tubercle
Volume 43. No.3 March 1963
CAN TUBERCULOSIS BE ERADICATED?
bacilli, the disease will continue to wreak destruction as it has since prehistoric days. If all armamentarium and presently available information were put into immediate operation so that from this day on no uninfected person would be invaded with tubercle bacilli, this organism could not be eradicated during the remainder of the twentieth century. Indeed, eradication could not possibly be achieved until infants and children now harboring tubercle bacilli have passed through the entire span of life, which could be 100 years or more. Even if a germicidal drug were made generally available throughout the world today and was promptly administered to every person harboring tubercle bacilli, the time required to eradicate this organism would not be short for the simple reason that in the majority of such persons the organisms are so protected by fibrous, calcified and osseous encapsulations and avascular necrotic and caseous material as to be safe from drugs in the blood stream.
Nevertheless, such a drug would be of extreme value in destroying tubercle bacilli (as present antituberculosis drugs are in suppressing them) which may be liberated from their present safe domiciles to vascular areas where they contact the drug. Thus, illness and death from tuberculosis would be prevented, but one could not hope for eradication of tubercle bacilli until the last person now harboring them has died. To point out that beginning immediately with the most intense tuberculosis eradication movement would require a hundred or more years for the eradication of tubercle bacilli may seem discouraging to those who lack courage to gird for such an encounter for the remainder of their lives and then pass it on to other generations for completion. However, 100 years is an exceedingly brief period for such an accomplishment when one considers that the lifetime of the disease extends far back into antiquity.
J.
z.c.c.e., Minneapolis, Minnesota
ARTHUR MYERS, M.D.,
CALCIFIED HEART VALVES Cinefluorography compares favorably with other methods In Its abillty to demonstrate calclfled valves. Its potential Is considered to be superior. Body-section studies Involved less radiation exposure (2.5 r contrasted with 4.0 to 8.0 r) and may be done by supervised technical personnel. The viewing of the ftlms Is easier. and the yield at present Is approximately equal to that of cinefluorography.
Fluoroscopy Is a good. simple and cheap method. but suffers from Inabillty to provide objective confirmation of subjective Impressions. A skilled fluoroscopist Is essential. Spot roentgenography has a relatively low yield compared to other methods. WOODRUFF,
J. H. JR.: "Calcified Heart Valves."
79:384, 1962.
RAdiolog"
CHRONIC FORMS OF INFECTIOUS ALLERGIC MYOCARDITIS The authors observed two patients with chronic Infectious allergic myocarditis. The cl1nlcal picture of the disease In one patient resembled rheumatic endomyocardltls with the development of a combined mitral disease of the heart and manifestations of circulatory disorders. In the second patient. the disease was manifested by pain In the region of the heart and attacks of paroxysmal tachycardia with
electrocardiographic changes pointing to coronary Insuftlclency. Anatomic studies revealed In both cases a typical chronic recurrent myocarditis with a protracted course. SKACHILOVA, N. N. AND REVZIS, M. G.: "Chronic Forms of Infectious Allergic Myocarditis," Cbest M,d. (USSR). 26: 19, 1962.