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INT J TUBERC LUNG DIS 11(7):722–732
©
2007 The Union
Historical statistics support a hypothesis linkingtuberculosis and air pollution caused by coal
G. A. Tremblay
SUMMARYPhoresia Biotechnology Inc., Laval, Québec, Canada
Tuberculosis (TB) is generally considered to be linked toindustrialisation and urbanisation. Peaking in the 1800sand receding slowly after, the disease declined sharply inthe West after World War II. TB has made a comeback inthe last 20 years in developing countries such as Chinaand India. Because socio-economic conditions alone can-not explain the connection between industrialisation andTB, factors remain to be determined in the aetiology of the disease. Historical statistics on coal consumption andTB disease in Canada, USA and China are correlated.A hypothesis linking TB and air pollution is developedin the context of industrialisation. A model is proposedwhereby triggering of the interleukin-10 (IL-10) cascade by carbon monoxide in lung macrophages promotes thereactivation of
Mycobacterium tuberculosis.
KEY WORDS:
tuberculosis; coal; air pollution; carbonmonoxide; IL-10
THE INVENTION of the blast furnace and the steamengine were key developments that led to industriali-sation. From that point on, fossil fuel has driven theevolution of the world as we know it today; withprogress and technical innovations, changes in life-style ensued promptly. However, as humans unlockedtheir creative potential in mechanics, they may alsohave unleashed the avatar of progress.A century-old belief blamed foul air or miasmasfor diseases such as tuberculosis (TB), malaria, rheu-matism and cholera. A number of scientists, includingFlorence Nightingale and William Farr, supported thetheory. Nevertheless, miasmas fell into disgrace whenLouis Pasteur discarded spontaneous generation andit became clear that micro-organisms were largely re-sponsible for mankind’s ills.
Mycobacterium tuberculosis
, the agent responsiblefor TB—also called phthisis or consumption—wasidentified in 1882 by the German physician RobertKoch. At the time, TB claimed about one death in sixin Europe.TB has made a comeback in the last 20 years, mostlyin parts of the developing world. In 2004, 9 millionnew TB cases were diagnosed and approximately 2million persons died of TB around the world. Morethan 80% of all TB patients live in sub-Saharan Africaand Asia. People infected with the human immunode-ficiency virus (HIV) are more susceptible to TB.
1
In Af-rica, for example, HIV is said to drive the TB epidemic.
2
TB has been termed a ‘social disease’ because it islinked to poverty, overcrowding and unsanitary con-ditions. Improvements in living conditions are there-fore likely to affect TB incidence.There is general agreement that the TB epidemicincreased dramatically in Europe in the eighteenthand nineteenth centuries and began to decline there-after.
3
TB is intrinsically linked to industrialisation.For example, both industrialisation and TB occurredlater in Japan.
4
As there is no obvious reason to be-lieve that there was less poverty before industrialisa-tion, and considering that overcrowding is relevant toall communicable diseases, one is forced to questionwhy industrialisation and TB go together.Another unresolved issue concerns the decline of TB in the West. For example, between 1850 and 1910,TB death rates declined in England and Wales muchfaster than indicators of social deprivation.
5
It seemstherefore that social factors alone cannot explain thedecline in TB incidence.There may in fact have been some degree of confu-sion between social and environmental factors. Forexample, in a 1911 study,
6
Marie-Davy compared TBmortality and the average number of windows perhousehold (Figure 1) in Paris
arrondissements
(urbandistricts) between 1858 and 1902. Scientists of thetime were aware that inadequate aeration of houseswas related to the development of TB in residents;Figure 1 may also indicate high levels of indoor airpollution in urban households.In recent years, air pollution has been identified asa risk factor for TB. Mishra et al. linked biomasscooking fuels and TB:
7
based on a 1992–1993 survey
Correspondence to: Guy A Tremblay, 3126, 5ième Rue, Laval, Québec H7V 1M1, Canada. Tel: (
1) 514 436 9272. e-mail:guy.tremblay@gmail.com
Article submitted 24 September 2006. Final version accepted 26 January 2007.
REVIEW ARTICLE
Air pollution caused by coal impacts on tuberculosis
723on 90000 households, the study provides evidencethat women in biomass-using households are threetimes more likely to report TB than those in householdsusing cleaner fuels. Another Indian study found thathouseholds using wood or dung cakes as fuel had 2.5times more clinically confirmed TB.
8
Cigarette smokingis now recognised as a risk factor for TB infection.
9
Miners in coal and gold mines are also prone to TB, al-though it is considered an effect of silicosis.
10,11
Based on the observation that industrialisation andTB coincide, and on the assumption that a determi-nant factor remains to be identified in the TB epi-demic, historical statistics of disease and energy werecompared to assess the impact of environmental fac-tors on TB.The present hypothesis suggests that pollutioncaused by combustion of coal and possibly town gasduring industrialisation aggravated the historical TBepidemic in the West and the present epidemic in de-veloping parts of the world. The possibility that car-bon monoxide (CO) and particulate matter (PM) ac-tivate the interleukin-10 (IL-10) anti-inflammatorycascade is discussed. The observations shed new lighton TB biology and epidemiology and emphasise theimportance of environmental health.
METHODS
Historical statistics of disease in Canada, as incidenceper 100000 population, are gathered from StatisticsCanada Historical Statistics on ‘Annual rates of notifi-able diseases, Canada, 1926 to 1975’ (series B517–525).
12
For electricity production, ‘Electric utilities—number of customers by class, 1920 to 1975’ (seriesQ97–101) is used.
12
Electricity production is ex-pressed as percentage of maximum customers over theperiod interval. ‘Principal statistics of the Canadian coalmining industry, 1918 to 1976’ (series Q137–142) isused for the numbers of employees in the coal indus-try.
12
Number of coal employees is expressed as per-centage of maximum over the period. Bacille Calmette-Guérin (BCG) vaccination in Canada, expressed as totalnumber of vaccine shots, was compiled by Malissard.
13
US Department of Energy Official Energy Statisticsprovides historical statistics on coal consumption bysector in million short tons from 1949 to 2005,
14
andthe Centers for Disease Control and Prevention (CDC)Division on Tuberculosis Elimination Statistics dataon historical TB in the US (incidence/100000 between1953 and 2005).
15
Data on coal consumption (exajoules) in China aretaken from the China Statistical Yearbook 2003,
16
and TB notification rate (/100000) from the WHO TBreport 2005.
17
The poverty headcount index repre-sents the percentage of the population living in house-holds with income per person below the poverty line.The headcount index is provided by the World BankPolicy Research Working Paper Series.
18
Pearson correlation coefficients,
R
2
and
P
numberwere calculated using Microsoft Excel mathematicalfunctions. Pearson correlation is carried out with datafrom the corresponding figure for the given time period
Figure 1
TB mortality rate as related to the average number ofwindows per household in Paris urban districts or
arrondisse-ments
between 1858 and 1902. pop
population.
Table
Pearson partial correlation coefficients relating disease incidence or notification rate(China), electrification and indicators of coal consumption in Canada, USA and China
Disease incidenceper 100000populationCanadaUSAChinaEmployees inthe coalindustry(1940–1975)Electricity,total numberof customers(1940–1975)Residential coalconsumption,million short tons(1953–1990)Total coalconsumptionin exajoules(1982–2002)TB 0.97
0.950.99*0.95
†
Typhoid fever0.87
0.86Whooping cough0.85
0.87Diphtheria0.77
0.76Scarlet fever0.55
0.55Poliomyelitis
‡
0.31
0.21
*Correlation in the US for residential coal is done with TB incidence/100000 population. When using TB death rate/ 100000 in the US, the correlation was also 0.99.
†
In China, TB notification rate/100000 is used.
‡
Correlations for the period 1940–1964.TB
tuberculosis.
724
The International Journal of Tuberculosis and Lung Disease
in the Table. Steel industry numbers, population dataand electric drive figures for Norway are from Statis-tike Centralbyrå,
19,20
whereas TB mortality figures(/100000) are taken from Wood.
21
The progress of urban gas lighting (total number of gas lights installed)in Paris is from Bouteville,
22
whereas TB mortalityfigures (/1000) in Paris are derived from Barnes.
23
Waldron provides the number of notified workplaceaccidents during World War II,
24
and TB historicalstatistics (total number of cases) for England andWales are from the United Kingdom’s Statutory Noti-fications of Infectious Diseases (NOID).
25
RESULTS
TB decline in twentieth century North America
Figure 2 shows the incidence of notified diseases andBCG vaccination in Canada between 1926 and 1975.There was a global downward trend of all diseases overthe period. TB incidence rose after 1930 (Figure 2A),increased further with the advent of WWII to peak in1944, and declined steadily after the war. In contrast,whooping cough increased around 1935, but not atthe onset of the war (Figure 2C). Scarlet fever showscyclic behaviour every 8 years or so (Figure 2D). An
Figure 2
Incidence of notified disease (
A
,
C–F
) in Canada during the twentieth century. Vertical dottedlines highlight WW II. In
B
, BCG vaccination in the province of Quebec (solid line), in the province of New-foundland (dotted line) and in the rest of Canada (dashed line) are shown. pop
population.
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