Tuberculosis: a timeless challenge for medicine

This overview shows how tuberculosis has represented and still represents a continuous challenge for Medicine. Starting from the dawn of medicine, when tuberculosis was called “phthisis” by Hippocrates, passing through the discovery of the tubercles and the creation of the word “tuberculosis”, following the application of the anatomo-clinical method, until the discovery of a microscopic enemy: Mycobacterium tuberculosis. The progressive discovery of the pathological basis of tuberculosis has allowed to devise important therapeutic strategies in Pre-Antibiotic and Post-Antibiotic Era. In particular, “antibiotic therapy” had to be the end of the challenge between man and tuberculosis. However it was only an illusion. Despite progress in care and prevention, tuberculosis remains one of the world’s leading causes of ill-health and the first cause of death from infectious disease. Nowadays, the drug resistance, individuals with immune deficiencies, the ageing and globalization are just some of the causes responsible for the increasing of the challenge between man and tuberculosis.

Tuberculosis in Iran: a historical overview from al-Tabari, Rhazes, Avicenna and Jorjani to Abolhassan Ziyā-Zarifi. Old and new pioneers in the fight against tuberculosis: challenges, pitfalls and hopes

Tuberculosis is a serious respiratory infectious disease, caused by Mycobacterium tuberculosis bacteria. It has always represented a permanent, serious public health challenge over the course of human history, because of its severe epidemiological, clinical and societal implications. The present review aims at over-viewing the contributions of the Iranian medicine to the control, management and treatment of tuberculosis, from the glorious past of the eighth-ninth centuries to the present, from Ali Abu al-Hasan Ahmad ibn Sahl-e Rabban al-Tabari to Rhazes, Avicenna, Jorjani and Abolhassan Ziyā-Zarifi. However, despite the efforts, tuberculosis and, in particular, multidrug-resistant tuberculosis still represent a great public health concern in Iran. On the other hand, this country can capitalize on its millennial, incredibly rich story of major achievements in the battle against tuberculosis to develop and implement ad hoc public health programs for the control of the disorder, including targeted and specialized interventions.

The evolution of a neglected disease: tuberculosis discoveries in the centuries

Tuberculosis (TB) and humans have coexisted for more than 40,000 years. The word “tuberculosis” derives from “tubercle”, the histological lesion which appears in the organs, described by Pott in the late Eighteenth century and found, by molecular biology, in human skeletons dating back to 5000 BC. Early description of TB can be found in the writings of ancient India and China and in the Bible.

In ancient Greece tuberculosis was not considered contagious, but Aristotle recognized the contagious nature of the pig’s and ox’s scrofula. The suspicion that phthisis is a contagious disease and that isolation can reduce the risk of transmission was expressed for the first time by the Arabian Avicenna, in his work “The canon of medicine”. In 1699, the Health Council of the Republic of Lucca founded the “sanatorium” concept as place of care and isolation. In 1865 Villemain inoculated tubercular material from a human lymph node into a rabbit, obtaining for the first time the typical tubercular lesions. Some years later, on March 24, 1882, Robert Koch announced to the Berlin Society of Physiology the discovery of Mycobacterium tuberculosis. In the same period Virchow improved awareness of risk factors and correct behaviours among the general population.

In 1952 Waksman won the Nobel Prize for the discovery of the first active drug against TB: streptomycin. Nevertheless, drug resistance appeared rapidly some years later and it is still a great challenge in TB fight nowadays.

Social determinants, ethical issues and future challenge of tuberculosis in a pluralistic society: the example of Israel

Tuberculosis is a very serious respiratory infectious disease, caused by the bacillus Mycobacterium tuberculosis, which generates a relevant societal and clinical burden. It has always represented a permanent concern and a public health challenge over the course of human history, because of its severe epidemiological, and economic-financial implications. The present review aims at over-viewing the impact of tuberculosis on the Israeli healthcare system, its temporal trend and evolution, stratified according to ethnicities and minorities, the need of establishing new facilities and implementing screening techniques, public health strategies and diagnostic tests, following massive immigration waves from countries characterized by a high incidence rate of tuberculosis during the fifties-sixties until the nineties, and the policies implemented by the Israeli government in the control, management and treatment of tuberculosis, as well as the role played by Israeli prominent scientists in discovering new druggable targets and finding bioactive compounds and bio-molecules in the fight against tuberculosis. Israel represents a unique, living laboratory in which features of developed and developing countries mix together. This country as a case-study of immigrant, pluralistic society underlines the importance of adopting a culturally-sensitive community intervention approach. The understanding of the subtle interplay between race/ethnic host and pathogen factors, including the role of gene variations and polymorphisms can pave the way for a personalized treatment and management of tuberculosis patients, contributing to the development of new tools for targeted tuberculosis therapeutics, immunodiagnostics and vaccination products.

The hepatitis C virus in Iran: health policy, historical, ethical issues and future challenges

Background

Hepatitis C infection (HCV) can have a harmful effect on the health of people and can impose relevant healthcare costs. The World Health Organization has identified the elimination of Hepatitis C by 2030 as an important goal for all countries. This study aimed to identify the HCV-related policies in Iran.

Methods

A qualitative approach was used for this study. Data was collected through a comprehensive search of documents and interviews with different stakeholders related to the HCV program. Data was analyzed and validated using content analysis based on the policy triangle framework.

Results

Our findings highlighted that certain social and cultural issues related to stigma can impact on awareness-raising processes. It is also necessary to consider HCV directly in the context of government policies. All relevant stakeholders should be included. Continued talks and interactions need to be made between them for the active participation of all actors.

Conclusion

The findings of this study can provide useful information for improving, supporting and developing policy processes. Healthcare providers should address all aspects of the disease by 2030 in order to achieve the goal of HCV elimination. Evidence-based planning, support for up-to-date policies and resource mobilization are needed to achieve this ambitious goal.

Anti-rabies vaccination between the 18th and 19th centuries and its pioneer Eusebio Giacinto Valli (1755-1816)

An eclectic, versatile Tuscan doctor, Eusebio Giacinto Valli (1755-1816) was a scholar of several branches of medicine, particularly public health, preventive medicine and epidemiology. His brilliant and wide-ranging education, and his intense passion for physics and chemistry, as applied to the human body, enabled him to conduct numerous studies in the field of vaccinology. He travelled to the Middle East in order to study the epidemiology of the plague and carried out experiments aimed at discovering a cure and a prophylaxis for rabies, succeeding in attenuating the rabies virus by inoculating a mixture of saliva from rabid dogs and gastric juice from frogs. Having travelled to Spain and then to Cuba, where he undertook the study of yellow fever, he died in Havana in September 1816, after injecting attenuated germs of the disease into his own body. He was buried in the great Monumental Cemetery "Cristobal Colon", where his tomb bears the epigraph: "victima de su amor à la humanidad ("a victim of his love for humanity").

The Spanish Influenza Pandemic: a lesson from history 100 years after 1918

In Europe in 1918, influenza spread through Spain, France, Great Britain and Italy, causing havoc with military operations during the First World War. The influenza pandemic of 1918 killed more than 50 million people worldwide. In addition, its socioeconomic consequences were huge.

“Spanish flu”, as the infection was dubbed, hit different age-groups, displaying a so-called “W-trend”, typically with two spikes in children and the elderly. However, healthy young adults were also affected.

In order to avoid alarming the public, several local health authorities refused to reveal the numbers of people affected and deaths. Consequently, it was very difficult to assess the impact of the disease at the time.

Although official communications issued by health authorities worldwide expressed certainty about the etiology of the infection, in laboratories it was not always possible to isolate the famous Pfeiffer’s bacillus, which was, at that time, deemed to be the cause of influenza.

The first official preventive actions were implemented in August 1918; these included the obligatory notification of suspected cases and the surveillance of communities such as day-schools, boarding schools and barracks.

Identifying suspected cases through surveillance, and voluntary and/or mandatory quarantine or isolation, enabled the spread of Spanish flu to be curbed. At that time, these public health measures were the only effective weapons against the disease, as no vaccines or antivirals were available.

Virological and bacteriological analysis of preserved samples from infected soldiers and other young people who died during the pandemic period is a major step toward a better understanding of this pandemic and of how to prepare for future pandemics.

The history of tuberculosis: the social role of sanatoria for the treatment of tuberculosis in Italy between the end of the 19th century and the middle of the 20th

Since ancient times, the most frequently prescribed remedy for the treatment of tuberculosis was a stay in a temperate climate. From the middle of the 19th century to the middle of the 20th, Europe saw the development of sanatoria, where patients were able to benefit from outdoor walks, physical exercise and a balanced diet. Moreover, the institutionalisation and isolation of patients deemed to be contagious remains one of the most efficacious measures for the control of this type of infection. The first sanatorium opened in Germany in 1854, while in Italy the earliest experiments were conducted at the beginning of the 20th century. At that time, it was widely believed in Italy that pulmonary tuberculosis could improve in a marine climate. By contrast, the scholar Biagio Castaldi described the salubrious effects of mountain air and documented a lower incidence of tuberculosis among mountain populations, which supported the hypothesis of a hereditary predisposition to the disease. In 1898, several local committees (Siena, Pisa, Padua) were founded to fight tuberculosis. The following year, these gave rise to the Lega Italiana (Italian League) under the patronage of the King of Italy, which helped to promote state intervention in the building of sanatoria.

The pioneer of the institution of dedicated facilities for the treatment of tuberculosis was Edoardo Maragliano in Genoa in 1896. A few years later, in 1900, the first specialised hospital, with a capacity of 100 beds, was built in Budrio in a non-mountainous area, the aim being to treat patients within their habitual climatic environment. In the following years, institutes were built in Bologna, Livorno, Rome, Turin and Venice. A large sanatorium for the treatment of working-class patients was constructed in Valtellina by the fascist government at the beginning of the century, in the wake of studies by Eugenio Morelli on the climatic conditions of the pine woods in Sortenna di Sondalo, which he deemed to be ideal. In December 1916, the Italian Red Cross inaugurated the first military sanatorium in the “Luigi Merello” maritime hospice in Bergeggi (SV) to treat soldiers affected by curable tuberculosis. In 1919, a specific law mandated a 10-fold increase in funding for the construction of dispensaries and sanatoria. As a result, the Provincial Anti-tuberculosis Committees were transformed into Consortiums of municipal and provincial authorities and anti-TB associations, with the aim of coordinating the action to be undertaken. In 1927, the constitution of an Anti-tuberculosis Consortium in every province became a legal obligation.

Despite this growth in social and healthcare measures, tuberculosis in Italy continued to constitute a major public health problem until the advent of antibiotics in the 1950s. Until that time, the sanatorium played a leading role in the treatment of tuberculosis in Italy, as in the rest of Europe.

The never-ending story of the fight against tuberculosis: from Koch's bacillus to global control programs

Tuberculosis (TB) is one of the oldest diseases known to affect humanity, and is still a major public health problem. It is caused by the bacillus Mycobacterium tuberculosis (MT), isolated in 1882 by Robert Koch. Until the 1950s, X rays were used as a cheap method of diagnostic screening together with the tuberculin skin sensitivity test. In the diagnosis and treatment of TB, an important role was also played by surgery. The late Nineteenth century saw the introduction of the tuberculosis sanatorium, which proved to be one of the first useful measures against TB. Subsequently, Albert Calmette and Camille Guérin used a non-virulent MT strain to produce a live attenuated vaccine. In the 1980s and 1990s, the incidence of tuberculosis surged as a major opportunistic infection in people with HIV infection and AIDS; for this reason, a combined strategy based on improving drug treatment, diagnostic instruments and prevention was needed.

History and evolution of influenza control through vaccination: from the first monovalent vaccine to universal vaccines

Influenza is a highly infectious airborne disease with an important epidemiological and societal burden; annual epidemics and pandemics have occurred since ancient times, causing tens of millions of deaths. A hundred years after this virus was first isolated, influenza vaccines are an important influenza prevention strategy and the preparations used display good safety and tolerability profiles. Innovative tools, such as recombinant technologies and intra-dermal devices, are currently being investigated in order to improve the immunological response. The recurring mutations of influenza strains has prompted the recent introduction of a quadrivalent inactivated vaccine. In the near future, scientific research will strive to produce a long-lasting universal vaccine containing an antigen that will offer protection against all influenza virus strains.