This lecture from John Green is a great full summary on the history of TB https://www.youtube.com/watch?v=7D-gxaie6UI
He's also publishing a book about it https://www.penguinrandomhouse.com/books/312472/everything-i...
Recently, John Green lobbied to get certain pharma companies to lower the price of tests and vaccines
https://www.scientificamerican.com/article/how-advocates-pus...
Tuberculosis is not a medical problem, it's an inequality and access problem. Tuberculosis is fully solved in advanced countries yet less developed countries still suffer from it. Pakistan has 260 death per 100k capita, the US has 2.6. The highest 5 countries have at least 600 per 100k capita.
Oh hey, I had TB. It sucked. I had to be proper quarantined for 3 months, felt like shit for a whole year and a half, and nearly died because I didn't realize I had any symptoms. I thought I was just tired and depressed all the time because I hated my job, and then one day I collapsed from what I thought was a heart attack.
I was/am otherwise healthy and must have just drawn the short straw (or it was a very long dwelling infection from a trip abroad years earlier). I really wish we vaccinated for it like Europe. I'd have taken the little scar on my arm for reducing the already small chance of dealing with that shit.
BCG doesn't really do much beyond childhood, and even then, just reduces the impact of the disease if you do get it.
I'm assuming you're mistaken, given it provided herd immunity. It definitely reduces your chances of getting it. Reducing the impact also means you spread it less.
There is no herd immunity to TB. USA eliminated most of it back in the mid 20th century with a single antibiotic before the resistant strands started spreading, which now requires a 4 drug cocktail for standard non-resistant strands now. We've just done a really good job of controlling it since then, it's not the fastest spreading disease out there. That said, the current volume of border crossings is probably going to cause an uptick here.
In countries with widespread BCG vaccination, substantial percentages of population are latently infected, and a smaller percentage of those will still become actively infected one day.
(Citing my sources
https://en.wikipedia.org/wiki/BCG_vaccine
https://thispodcastwillkillyou.com/2018/02/10/episode-9-tube...)
I would have accepted reduced impact.
Were you able to completely recover? Any symptoms from it still? In the case I was helping care for, the infection ended up leaving a lot of unusual autoimmune conditions in its wake.
Fully recovered. Felt like shit for about a year after from losing so much weight, and being stuck in a room alone for 3 months probably didn’t help much.
Wouldn’t be surprised if it broke something that shows up later but so far everything is fine 8 years on.
Only chronic symptom so far is I got into functional programming while quarantined and it stuck, so maybe it’s a sign of mental illness.
Hah! Good man. Appreciate the sense of humor.
As I mentioned elsewhere in this thread, I've got a nonzero chance of getting it one day. I'm not afraid, just hoping I'd be able to contribute to eradicating it from the world in some way.
There's some work in looking at alternative ways of administering the BCG vaccine (iv injection, inhalation). The IV numbers are pretty promising -- if the monkey numbers hold. I hope that someone, somewhere pushes it into human trials soon.
There's also the nebulous but very nice-sounding "non-specific effect" with it. Who knows.
Interesting, it was my understanding that you don’t actually gain immunity to TB after an infection (as the treatment itself eliminates the bacteria; not your body, mycobacteria stay alive within microphages) so curious what about alternative injection approaches works
I almost lost a former partner to this disease. Totally changed my life.
One of my first projects at my development consulting job was a site build for an org working on vaccine candidates, which a decade later, unfortunately haven't crossed the finish line.
So with a fairly personal connection with the disease, and the nonzero chance I could one day develop it myself, I have a personal interest in seeing progress in the space.
I saw an IAVI update the other day stating TB research is currently only funded to the tune of 1 billion a year when they need 6. 10.5 million infections a year reported. Remember the countries where the disease have the biggest impact have limited diagnostic abilities outside of cities and politically, these countries are very quick to pretend the problem is solved when the reality is that TB started speeding up again in the covid days because the care programs for patients then was put on pause.
If you wanna change the world and aren't just out for VC cash, go design a mobile X-Ray unit to take into villages, work on an AI model to diagnose from imagery, and work on figuring out how to speed up the testing because a MGIT machine needing power 24/7 is not the type of equipment you can always get in the places the disease impacts.
Figure out how to get those little mycobacteria suckers to divide quicker in agar (my limited biology education tells me mess up the mycoic acid synthesis without killing it?) and then get people a positive result in 3 days instead of 3 weeks. Remember: the very good blood test (quantiferon gold) is banned in the largest country in the world because it comes back positive for the 1/3 of the population latently infected.
Why not just teach people to read the x-ray
So this New Yorker article is wrong? https://www.newyorker.com/news/news-desk/how-banning-a-tb-te...
IMO the mistake was using the test in isolation without considering other criteria. Let’s say you have somebody in a village who travels to visit a clinic. Chest xray positive so sputum samples taken. They don’t convert for 3 weeks, but contact is lost with patient. Maybe in this scenario the blood test adds the additional factor needed to start treatment sooner.
There’s a lot of other diseases there a blood test can diagnose immediately, and I don’t blame health workers for the confusion, quantiferon is a unique test, but a countrywide education campaign could have worked to keep it as part of the diagnostic tools.
A mystery not mentioned in the article: why is TB so unusual in places like the US? The US does almost nothing to control TB. We don’t vaccinate. We don’t routinely test (except in special cases, but those cover very little of the population). We don’t treat latent cases unless they somehow get noticed. And yet the incidence of symptomatic TB is low, and there’s no sign of TB developing resistance to whatever the US is accidentally doing right.
TB is almost the archetypal disease of poverty.
Living on top of each other, especially in childhood & adolescence, combined with other environmental and health factors explains almost all of it. If you’re malnourished and your immune system is in bad shape, you’re at risk. If you have HIV, you’re at risk and so on.
That’s still not an explanation. Kids in the US spend a lot of time with other kids at daycare and school. It’s a transmittable bacterial disease. Why aren’t people in the US getting it more? Are you saying you have to be mal/undernourished to get it?
https://bmcpublichealth.biomedcentral.com/articles/10.1186/s...
Unhealthy people are more vulnerable to TB, absolutely. Infections in general are more prevalent in people who are underfed, or living in bad conditions. Other risk factors are exactly what you would expect: smoking, drinking, bad fitness level, and being young or old.
TB rates are basically a function of 1. how immune compromised your population is, and 2. How much access to healthcare there is in the country (poverty, basically).
The majority of healthy people develop a latent infection, and won't manifest symptoms in their lifetimes. The bacteria are encapsulated into nodules by the immune system, which weaken if the immune system weakens. The bacteria escape and active symptomatic infection occurs.
Yeah but the US has very low levels of latent TB in the population at only 4%. Compared that to places like Brazil where 40% of the population has latent TB. It’s not the climate because in Russia 80% of the population has latent TB.
In order to get latent TB, you need exposure to someone with active TB. If someone with active TB meets the healthcare system, you get a rapid response from health departments. In May 2024, the Long Beach, CA declared a public health emergency [1] based on a cluster of 14 cases. This kind of reaction is typical and makes it difficult to spread to others, and keeps the levels of latent TB low.
[1] https://www.longbeach.gov/press-releases/official-city-of-lo...
Yes, and it's a self-perpetuating cycle. If so few people have latent TB, fewer people develop active TB that will go on to infect others. As other comments have mentioned, poverty and its resultant poor health is the biggest correlation for developing active TB. I wonder if most of the Russian latent infections happened during the Soviet/Post Soviet collapse era, with newer latent infections falling off as quality of life improved over time?
quality of life improving in Russia is a very risky statement. Soviets manipulated statistics and so does current Russian government.
80% sounds like a BS number. It's cited on Wikipedia, but references are either "opinions" or do not contain such information at all.
A proper study [1] shows mean infection rate of ~20% in the worst regions (Far East and North) with the highest rate up to 47%. The situation should be better in the western regions. For comparison, in the US studies show ~4% infection rate [2], so situation in Russia is relatively bad, but improves steadily since 90s and it's far from being catastrophic as the 80% number paints it.
[1]: https://www.tibl-journal.com/jour/article/view/1706
[2]: https://www.cdc.gov/tb/hcp/clinical-overview/latent-tubercul...
I guess it depends on what’s considered trustworthy. I wouldn’t trust a Russian paper as far as you could throw it unless it was in math or physics.
But you will trust any unsubstantiated slander disseminated in mass media by interested parties as long as it paints Russia in a bad light. Got it.
Russia actually spent quite a lot of resources on TB, especially during the late Soviet and the early Russian history.
All children and professionals working with children are receiving yearly TB testing ("Mantoux test"). Prisons used to be a major vector, but that was reduced by doing TB prevention (antibiotics).
Nobody likes getting TB.
Malnourishment is a big part according to the WHO [1]
I’m no expert but I also suspect access to medical care is also a big part, as typically only active cases spread the disease. If you are symptomatic and get some antibiotics, you might not spread it to very many people. If you’re symptomatic and go without treatment for ages, then you might spread it to loads of other people.
As we learned during covid, small differences in R value massively change the prevalence over time.
I was exposed to TB at Children's Hospital in Washington DC and it was only because I was seeking a part-time job at another hospital while in grad school that I became aware. Got the bubble at the public health department and by the time I drove 40 minutes home, I was clearly positive, so off to Children's I went to have the test read. Because I was a volunteer, I was able to be xrayed immediately and prescribed drugs to take for 9 months. And then, of course, the hospital came after me for the cost of the xray, arguing that I could have been exposed shopping at Talbot's.
I was not surprised to have been exposed. I volunteered a lot of hours in the Children's ED so I had much greater exposure than other people my age who were doing whatever you do when you're 30. I think the doctors and nurses were surprised that I did not freak out and docs to this day are a little surprised I didn't. It was inactive and I was diligent taking the meds.
All this said, the point is that more needs to be done in the US, particularly when we know where the greatest exposure happens.
Spitting has become socially unacceptable in the US. This is due to large scale "anti-spitting" campaigns in the early 1900.
In the 19th century when spittoons were a thing in the US, TB ran rampant.
There's also the widespread antibiotic use. The widespread prescription of Doxycycline for everything inadvertently does a lot.
Overlay TB with poverty (or more accurately, per capita GDP) on the map.
There are number of correlations with unhealthy activities like smoking, drinking, fitness, etc... but the best indicator is if you live in poverty, and/or if you're country is poor. Poor areas of rich countries have higher TB, and poor countries in general have higher incidences of poverty. Basically, less access to healthcare and bad living conditions.
This is a good study here that explain the individual risk factors, but the available maps also show a pretty clear pattern: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s...
My first job as a teen in 1982 was at a restaurant. I had to get a "food handler's permit" from the local health department, which was mainly a TB test, maybe also a hepatitis test. Those permits are no longer required.
My understanding is that TB doesn't spread while latent, it needs to develop into active TB to spread.
The US healthcare system is tuned into TB cases and will alert local health officials to do contact tracing, outreach, and follow up with confirmed cases when they pop up.
Healthcare and childcare workers are routinely tested for TB in areas with recent spread.
Doing screening on the general population doesn't seem necessary, given the low estimated % of people with latent infections and the low estimated % of latent infections that will develop into active infections. It may make sense to screen more people that have a higher risk if they develop active TB or are at a higher risk of exposure.
Certainly, increased screening or vaccination would result in improved outcomes for people whose TB infection was averted. But those have to be weighed against the negative outcomes from side effects of screening/treatment and vaccination.
While I can't deny the argument that US national anti-TB efforts have become fragmented, possibly as a result of lower incidence, BCG isn't an especially protective vaccine against pulmonary disease and can interfere with TB skin testing, which even in this age of generally available blood QuantiFERON testing is still not uncommon. BCG does have greater value in high-risk countries, and it may be most useful for kids in those regions where TB meningitis is a bigger threat. It doesn't make a lot of sense in a low-burden country, but perhaps one day we'll have a better one.
- working in TB control since 2006
Less public transport perhaps? I remember studies showing strong correlation even though causation can be questionable (less protected member of society in the first place). And anecdotally the only person I know with TB never had known cases neither at home nor at work, which basically leaves the public transportation (which he was using 2-4 times a day at the time) as the most likely source.
Another idea could be "better climate" but it's not obvious when I look on the world map of TB incidence.
Elections have consequences, I just hope the incoming administration isn't actually going to roll things back on vaccines, etc. Otherwise, we may end up with upticks of diseases previously mostly eradicated (at least here in the US).
I wouldn’t be surprised if states like Idaho and Florida that don’t have functioning public health departments start having TB outbreaks to go with their measles outbreaks once the CDC is decimated and can’t provide a backstop anymore.
I see no evidence that Trump is anti-vaccine. He promoted the development and apporval of the first COVID vaccines. He called them "wonderful" or whatever similar words he likes to use.
If he appoints RFK jr as head of anything health - he is antivax. Maybe he doesn’t get appointed.
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It’s relieving that at least other branches of vaccine development are not under the information regime as with COVID.
“However, environmental bacteria complicate the picture. If present before vaccination, memory immune cells primed to destroy the environmental relatives might cross-react with and neutralize the BCG strain before it has a chance to set up an immune response against itself and M. tuberculosis.”
Nobody cared if one already had covid before administering the vaccine and since the vaccine came late many have had a previous infection already. The new mRNA vaccine utilities the body to produce the actual pathogen and with already existing immunity from a previous infection one’s immune system starts to attack the mRNA modified cells and pathogen product.
Previous COVID infection enhances immunity, creating what we call hybrid immunity. This happens because current vaccines mainly target the spike protein, while natural infection exposes the immune system to other parts of the virus.
New vaccines in development aim to include multiple proteins and improved delivery methods, which could lead to longer-lasting immunity. For now, hybrid immunity (infection plus vaccination) offers broader protection, while vaccines safely boost antibody levels without the risks of infection.
An infection exposes the immune system to the whole virus while the mRNA vaccine triggers the synthesis of the viral spike protein which would be a specific part of the virus. It can be called hybrid since it is a combination of a original and novel technique but the underlying immune system still deals with the invaders the same way and creates immunity against them. Naturally an infection would be temporary but with the mRNA technique it's a constant stream of spikes which the immune system attacks to the source. One of the issues here are the byproducts from the immune activity, especially dangerous if the mRNA dosen't stay around the injection area. Hybrid immunity without looking at the cons is not the full picture and seeing some counterpoints about vaccines was refreshing.
I would really love to see your peer reviewed study! Where was it published?
> One of the issues here are the byproducts from the immune activity, especially dangerous if the mRNA dosen't stay around the injection area.
mRNA doesn't stay in the injection area. Most of it ends up in the liver, and that was known since before the mRNA vaccine development.
That's also why the first mRNA gene therapies are targeting inheritable liver diseases.
I tried to hint at the issue of the jab getting into the bloodstream directly instead of the muscle, which can happen when no aspiration is applied.
Defending the jab in a Stockholm syndrome manner is getting quite boring by now.
> TB remains the deadliest infectious disease on Earth, killing about 1.2 million people every year.
I would guess, in 2024 Covid killed more than 1.2 million people. I guess many people are assuming that Covid was a temporary disturbance, and will attenuate in the coming years. But what if it doesn't but will keep at about the current levels from year to year for a long time.
The WHO [0] reports 60 thousand Covid deaths this year so far, and around 250 thousand deaths in 2023.
US CDC has about 40k deaths for 2024 so far [1] for United States, and 76k for the year 2023 [2]. Maybe the WHO dashboard is left unmaintained, or maybe many countries have stopped reporting Covid deaths to WHO.
[1] https://covid.cdc.gov/covid-data-tracker/#trends_totaldeaths...
[2] https://jamanetwork.com/journals/jama/article-abstract/28235...
Or it’s accurate.
How is the cause of death determined for 250k people?
EDIT: I got curious and looked up the CDC guidelines https://www.cdc.gov/nchs/data/nvss/vsrg/vsrg03-508.pdf
> based on sound medical judgment drawn from clinical training and experience, as well as knowledge of current disease states and local trends
> the disease or injury which initiated the train of morbid events leading directly to death
It goes on to suggest that if Covid was present they strongly recommend including it. And even if you did not diagnose Covid it can be a good assumption to make.
There were upper and lower bound stats that accounted for many discrepancies. The high numbers were "death with covid", which means the covid might not've done it, and the low numbers were "death by covid" where we were (fairly) sure Covid did it due to lack of other factors, but missed things where Covid tipped someone over the edge.
That sounds right. Based on my reading the CDC numbers are basically death with Covid test or symptoms, with the exception of an obvious distinct cause.
Which honestly I can’t think of a better way for mass data collection.
The difference is that TB kills young people. Old people have to die from something it's irrelevant what eventually knocks them out.
But with TB it was laying waste to people who were supposed to be in their prime. That's why it was so insidious.
young people have to die from something also, even if it's just getting old. So it's irrelevant what eventually knocks them out as well I guess.
Years of life lost from mortality (YLL) is a concrete and reasonable metric, not just some hand-waiving about everyone dying anyway.
Something which can be applied to old people as well, not just some hand-waiving about old people dying anyway.
Covid turns young people into disabled people. Then we can say "well they had preexisting conditions, it's irrelevant what eventually knocks them out."
Based on the percentage of young people who got Covid (very high) and were disabled (very few), this doesn’t seem significant.
The difference with TB being that COVID infects 95% of the population several times per year, turning those low relative rates into higher and higher absolute numbers...
"Death by a thousand cuts"
For reference, recent figures seem to be around 5% of younger adults currently experiencing long COVID: https://data.cdc.gov/NCHS/Post-COVID-Conditions/gsea-w83j/da... (need to filter on the columns quite a bit to reach the figures : "currently experiencing long COVID, all adults" + "time period end date" set to the latest)
But this figure also includes cases without significant activity limitation. Significant activity limitations from long COVID across all adults for younger adults is slightly above 1%. Which is not negligible I think.
It's certainly much bigger, given diagnosis is still fairly vague (no standardized test).
Here is a chilling possibility it may be closer to 25% already: https://neurosciencenews.com/ai-long-covid-28003/
Can you estimate those absolute numbers for us?
The CDC has measurements: https://data.cdc.gov/NCHS/Post-COVID-Conditions/gsea-w83j/da...
Answer is a bit more of 1% young adults have significant limitations caused by long COVID if I read it well. 2024 data.
Can you? You were the first to bring in a concrete claim about them, that they are "very small."
I’m not the one claiming Covid is as impactful or dangerous as TB, a very unusual claim. Please make your case.
Me neither, despite your flagrant attempt at putting a strawman.
Maybe, you know, there is a middle ground between "as impactful or dangerous as TB" and "negligible"? Especially when so much is unknown about the SARS-CoV-2, a virus that infects the whole body (not just the lungs)?
For reference, almost all the victims of SARS-CoV-1 are still suffering from complications almost two decades later, between permanent fatigue, pulmonary damage, osteoporosis and bone necrosis, immune system deregulation, cognition impairment... Which is, you know, less worse than death and therefore TB, but still
We know that infection with COVID causes permanent changes to the body, and that those changes are damaging to health. There have been studies that indicate this damage might be cumulative.
We do not yet know what the long term impacts of acquiring COVID repeatedly will be, but we're going to find out.
It's my suspicion that those healthy young people will have lungs like chain smokers, higher rates of certain cancers, and a much higher propensity for certain cardiovascular ailments in a few decades.
This isn’t even considering the latest being found about Covid either for long term illness/disability, virus on tumors making certain cancers grow faster, and sudden stroke/cardiac events.
We are heavily undercounting until we can definitively link it. That requires families to consent to an autopsy and for biomarkers to be finalized and used to confirm.
Researchers are pretty close to that nowadays though with micro clots, viral rna persistence assays, and even pathology studies which are all showing results this year and will be for years to come.
> I would guess, in 2024 Covid killed more than 1.2 million people
Why? Seems extremely speculative.
COVID-19 appears to act similarly to the other coronaviruses that are endemic in humans. There are two key properties.
1. You don't develop an immunity to infection by them, but you do become less likely to be made severely ill from subsequent infections.
2. The severity of illness from the first infection is generally less if you are very young.
With the others it is thought that they probably did cause deadly pandemics when they first crossed over to humans, but did not cause much harm to babies or very young children, and so by the next generation they were no longer a big deal.
Nowadays we don't even bother to have a name for infection by them. We just lump them in with around 200 other viruses and call what happens when we get sickened by any of them a "common cold".
Pretty much everybody alive now was exposed to those viruses as a baby, got mildly ill and got that first infection out of the way, and then it is just a routine common cold to them when they get older.
I don't think it is yet known if COVID-19 will fully follow that path of those others. It still does cause severe illness far more often than the common cold viruses even in people who have been infected multiple times.
We probably won't know for sure until we see what happens over several years with people who were very young during the pandemic or were born after it.
For people older than that is is probably going to be something that is more like a severe flu, where we'll have a vaccine each year for the strains expected to be most common that year, and while the vaccine won't stop you from getting sick it will greatly increase you chances of not getting severely sick.
We are already seeing that. COVID-19 fell from the 4th highest cause of death in the US in 2022 to the 10th highest in 2023, with 76000 deaths. Compare to 246000 deaths in 2022 and 462000 in 2021.