Health Experts Fear Possible Tuberculosis Resurgence

June 8, 2005 -- -- Tuberculosis may seem like a disease of a bygone era, but experts are concerned that budget cuts and slackening vigilance now threaten to undermine eradication efforts in the United States.

"Many, many, many states are cutting their tuberculosis programs," warned Ed Nardell, a tuberculosis researcher at Brigham and Women's Hospital in Boston. Nardell said such cutbacks were dangerously short-sighted, given the risks of the disease.

Until the advent of antibiotics, TB -- a bacterial infection that can cause coughing, scarring of the lungs, neurological problems -- was one of the biggest killers in America.

The disease, along with its even more deadly counterpart, Multi-Drug Resistant Tuberculosis, still affects almost 15,000 Americans every year.

But detection and treatment is very labor intensive and expensive, and crucial early intervention is particularly costly.

When a case of TB is identified, all of the people with whom that patient has had contact must be tested for TB and then retested a few months later. Directly Observed Therapy -- the best way to prevent the spread of TB -- requires that a health-care worker watch as a patient takes his or her medication.

Health-care workers must be vigilant about TB flare-ups in at-risk populations such as the homeless, AIDS patients and inmates.

Last year, former U.S. Surgeon General David Satcher described the battle against TB in stark terms.

"We have two choices in the United States. We can continue the path toward neglect and experience another unnecessary, expensive resurgence of tuberculosis. Or we can take the necessary steps to continue progress toward tuberculosis elimination," he said in a 2004 report to Congress.

Drug-Resistant Strain Is Particularly Dangerous

But one of the major problems in the fight against TB is the expensive, lengthy treatment needed for patients who become resistant to the usual medications. Multi-Drug Resistant TB occurs when people have incomplete tuberculosis treatment, allowing resistant TB bacteria to flourish. It is four times more deadly than normal tuberculosis.

Two main drugs, isoniazid and rifampin, become useless in cases of Multi-Drug Resistant TB, said Reuben Granich, of the Office of the U.S. Global AIDS Coordinator and author of one of the JAMA studies.

"Once you lose those two drugs, you're in pretty deep trouble," he said.

Granich's study looked at TB cases in California, where 1 percent to 2 percent of all tuberculosis cases were Multi-Drug Resistant TB.

It costs up to $1 million to treat a single case of Multi-Drug Resistant TB. Treatment costs soar as doctors are forced to use highly toxic "second-line" drugs that require a person to be hospitalized for up to two years.

Many of those treatments are paid for by taxpayers. In 1991, 48 percent of Multi-Drug Resistant TB cases were managed exclusively by the public health department. In 2001, that figure rose to 59 percent.

Granich's study also found that most cases of Multi-Drug Resistant TB occurred in people who had recently arrived from a foreign country.

The Fight Abroad

Granich and other health care experts believe that helping to fight tuberculosis abroad would reduce the burden of TB in the United States.

More than half of the TB cases in this country occurring in foreign-born people, according to Maryam Haddad, a TB researcher at the Centers for Disease Control and Prevention and author of a new study on the illness in this week's Journal of the American Medical Association.

"It's not going to do us any good to just focus on the U.S.," Haddad said.

The global rates of TB are alarming. Currently, about 8 million people worldwide suffer from this disease, and 2 million will die this year. Most of these cases occur in Africa, Asia and the former Soviet Republic.

Tuberculosis remains a large problem for countries in these regions for many reasons, including close living quarters and poor public health systems. However, AIDS has become the biggest driving force behind TB's global rampage.

Where the AIDS virus has spread, tuberculosis moves in, taking advantage of immune systems decimated by the HIV virus. The majority of people with AIDS die of tuberculosis, rather than from the virus itself.

The United Nations' stated goal is to have global tuberculosis under control by 2015, but the studies this week find that meeting this goal will be difficult without increases in health technology and resources.

Haddad shared his concern, noting that programs must be in place to quickly identify and treat new cases that arrive with immigrants from around the world and with Americans returning from exotic vacations.

Reuben Granich, of the Office of the U.S. Global AIDS Coordinator, thinks we should be hopeful, but not complacent.

"We've made a lot of progress," he said. But he cautioned that now is not the time to give up on TB control efforts. "We're not out of the woods yet."