TUBERCULOSIS IS BACK: A CALL TO ACTION Edward E. Mays, MD, FACP Oakland, California
Following decades of decline, the incidence of tuberculosis in the United States has been slowly rising since 1984. During 1986 and 1987, there were 9226 more cases than expected, and projections suggested a continuing increase unless something was done. Toward this end, in 1987 the Secretary of the Department of Health and Human Services established the Advisory Committee for Elimination of Tuberculosis. After review and feedback from numerous health organizations and experts, a strategy has been published by the Centers for Disease Control, with a goal not only of halting the disturbing increase in incidence, but also of eliminating tuberculosis from the United States over the next 20 years.' The problem should have special relevance to NMA physicians for several reasons. Those over age 45-50 can still recall the devastation produced by tuberculosis (TB) in our communities, friends, and families. Nearly two-thirds of present tuberculosis cases now occur among the socioeconomically disadvantaged: blacks, Hispanics, Asians, and Asian Americans. Furthermore, over 80% of childhood cases occur in minority groups. Other groups at high risk include people infected by the human immunodeficiency virus (HIV), but also the homeless, intravenous drug abusers, the elderly, and residents of nursing homes and correctional institutions. Thus, the groups at increased risk are identifiable by From Providence Hospital, Oakland, California. Requests for reprints should be addressed to Dr Edward E. Mays, 411 30th St, Ste 410, Oakland, CA 94609. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 12
circumstance, time, and place, and efforts toward more effective prevention and control can be focused. There is the ever present risk that TB can break out of these enclaves and again spread widely in the population. Tuberculosis is a bacterial disease (Mycobacterium tuberculosis) usually spread by the inhalation of airborne particles produced by the coughs of infected persons. People who become infected develop a positive reaction to the tuberculin skin test, but 90% do not develop clinical respiratory illness. An estimated 10 to 15 million people in the United States are thus infected, with about 5% developing active disease soon after infection, and about 5% who may develop active disease at any time during life. About 5% of all cases are first reported at death. The HIV virus, which weakens the body's immune system and causes the acquired immunodeficiency syndrome (AIDS), is the strongest known risk factor associated with the transformation of subclinical TB infection to active disease. Murray3 calculates that HIV positive, tuberculin positive patients develop active TB at a six times greater rate than those without HIV infection. Therefore, it deserves special emphasis. In some geographic areas, as many as 25% of TB patients are infected with HIV, although they have not yet progressed to AIDS. An estimated 1 to 1.5 million persons in the United States are infected with HIV. Clinicians must consider the diagnosis of TB and other mycobacterial disease in all patients at high risk for HIV infection.2 In several East Coast studies, 80-100% of patients with both TB and AIDS were black, 829
Hispanic, or Haitian. It is strongly suggested that the majority of the active excess TB cases in the United States since 1985 are HIV-related.3
THE PLAN Briefly, three action steps have been proposed by the Centers for Disease Control (CDC) to implement the goal of TB elimination. In consideration that existing strategies have not been fully used, the first step is for more effective use of present prevention and control measures in high-risk populations. For example, the identification and reporting of new TB cases, suspects, and contacts is often slow and incomplete, delaying treatment and preventive intervention. Also, many TB patients do not complete recommended courses of treatment. These are special problems among the poor, elderly, homeless, drug abusers, and prisoners. The recommendations call for innovative ideas at the state, community, and individual levels toward new methods of surveillance, prevention of new infection and disease, containment of known disease, and follow-up program evaluation. Secondly, it is recommended that new technologies be developed and evaluated for the prevention, diagnosis, and treatment of TB. Both basic and applied research have atrophied after decades of decline. Training and treatment centers for TB have long since closed, and many new doctors have never seen the disease. A drug more effective and less toxic than isoniazid should be developed. Mechanisms of action of drugs should be better understood. Postinfection vaccines to boost immunity, methods to kill dormant mycobacteria, studies of genetic differences between those skin test positive persons who develop the disease and those who do not should be continued. The vast majority of new cases of active TB arise from skin test positive individuals, and it is critical to detect and treat these persons before the emergence of active disease and its spread. Finally, recent developments in biotechnology must be applied to tuberculosis, as with other revolutionary approaches to the management of infectious diseases. Various agencies, societies, professional schools, and minority advocacy groups must play major roles in the transfer of technology to clinical and public health practice. There is a need for new investigations in the area of technology transfer. Control measures should be designed and instituted with the cooperation of those at high risk, and with those health care providers who have historically served those populations.
THE NATIONAL TUBERCULOSIS TRAINING INITIATIVE CONFERENCE The American Thoracic Society and the Division of TB Control at the CDC conjointly conducted a conference in March 1989, at San Antonio, Texas, to introduce the National Tuberculosis Training Initiative. Attendees represented 22 national medical and nursing organizations whose members were believed to have potential impact in the care of patients with TB. I was honored to have represented the NMA. The objective of the initiative is to increase TB knowledge and awareness among health care workers, in order to implement the defined goals. A "core curriculum" on TB was introduced consisting of an up-to-date review of the present state of TB control in the United States, intended for use as an aid in preparing educational activities, and possibly as a guide for the practicing clinician. The CDC intends to widely distribute a revision of the curriculum. Most importantly, attendees developed specific plans for continuing educational activities to be recommended to their individual organizations. Already many organizations have produced and implemented new ideas in public and private TB control, and several medical journals have published articles promoting re-awareness of the problem. The initiative is comprehensive, and requires active promotion to insure implementation at the level of the infected populations. Toward this end, a National TB Conference, held in May 1989, in conjunction with the annual ALA/ATS meeting in Cincinnati, focused largely on concurrent small group discussions and workshops dealing with problems and strategies of tuberculosis in minority populations, the HIV positive, foreign born, substance abusers, homeless, and those in jails and prisons. It is clear that the populations at greatest risk are individuals most likely to slip through the established health care networks. Many are uninsured and reside in inner cities, migrant labor camps, or prisons, or have lifestyles which resist both surveillance and active participation.
OUTLOOK In my opinion, the TB initiative is most ambitious for several reasons. As mentioned above, the target populations can only be reached with sustained effort. Additionally, there are 10 to 15 million infected TB persons in the general population, with an estimated 5% who will eventually develop active disease. The reservoir for propagation of the disease remains huge,
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indeed. Foreign born individuals continually invade our borders, bringing triple problems of language barrier, high prevalence of TB infection, and anti-TB drug resistant organisms. Finally, the magnitude of the problem of HIV-infected TB cases has not yet been fully determined. It is clear that the annual incidence of smear-positive tuberculosis remains high in Africa, Asia, and Latin America. HIV seroprevalance rates are high in subSaharan Africa and in Latin America, and early published data already suggest that the consequences of coexistent diseases are devastating and growing,2 as in enclaves in this country.2'3 The problems of TB eradication are many; solutions require much work sustained over time. Such groups and individuals require far greater use of resources than those to whom traditional TB control agencies are accustomed or funded. Medicare and Medicaid may not currently reimburse for TB control services outside those established: directly observed therapy, translator services, transportation, halfway housing, and certain nursing and other paramedical personnel services. Resources to provide care for the uninsured should also be enacted.
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To achieve the stated goals of TB elimination, it will be necessary to form coalitions among many established groups and to foster some new, specialized groups, with each agency contributing what it does best. Efforts should be made to enlist the support of existing local health-related programs to which TB concerns may be attached. Minority health care professionals are very close to the problem, and can be of immense help in its solution. The NMA can also do a number of things toward the initiative goals, limited only by its imagination and resources. Its leadership recognizes the importance of the NMA's zealous and persistent response to the problem. Literature Cited 1. Centers for Disease Control. A Strategic Plan for the Elimination of Tuberculosis in the United States. Morbidity and Mortality Weekly Report. 1 989;38(suppl.S-3):1-25. 2. Murray JF. The white plague: down and out, or up and coming? Amer Rev Respir Dis. 1 989; 1 40:1788-1795. 3. TB/HIV. The Connection. What Health Care Workers Should Know. US Dept of Health and Human Services. PHS, CDC, Division of TB control. Atlanta, Georgia.