By Barbara Tone, RN
November 11, 1999
Photo: Custom Medical Stock Photo, Inc.

There's good news when it comes to TB. After a significant national resurgence of TB in the late 1980s and early '90s, the U.S. TB rate is now in its sixth year of decline. But worldwide, TB continues to be a major public health problem.

Experts say the national resurgence was caused by a combination of factors, including an increase in immigration from TB-endemic countries and a deterioration of funding and services for TB identification and treatment. The development of multi-drug resistant (MDR) TB and the increase in susceptibility among people with HIV have also made control very difficult. From 1953 to 1985, the annual number of TB cases reported in the United States dropped 74 percent, from 84,304 to 22,201. But by 1989, there was a 5 percent increase over the previous year, and the numbers peaked at 26,673 cases in 1992. In Texas, the number of cases per 100,000 climbed from 11 in 1989 to 14.6 in 1992.

Since 1992, the number of cases reported in the United States has fallen each year, reaching a record low of 18,361 in 1998. Texas has seen similar results. "Texas has had a morbidity decline for the last six years. That's an exciting trend," said Charles Edward Wallace, director of the TB Elimination Division of the Texas Department of Health and a member of the Advisory Council for the Elimination of Tuberculosis (ACET) at the national Centers for Disease Control and Prevention (CDC).

Money talks

The decline is a direct result of a substantial increase in funding for TB control, experts say. "The federal government recognized the problem and tripled and quadrupled the funds, and many state and local jurisdictions did likewise," said Charles Nolan, MD, chair of the ACET and director of the tuberculosis control program for the Seattle-King County Department of Health. In 1989, federal support for TB research totaled less than $5 million. Today, the National Institutes of Health spends $60 million annually, and the CDC contributes another $15 million.

The state and local money was used to increase TB surveillance, expand the use of directly observed therapy (DOT), and speed investigation of TB contacts. "The increased funding led to increases in education of physicians and other healthcare providers," said Brenda Ashkar, MSN, RN, nurse manager for the TB control division of the Los Angeles Country Department of Health Services. "Along with the increases also came the resources to implement a lot of innovative programs like DOT."

TB experts say the results of these efforts are a notable public health achievement and clearly demonstrate what can be done with focused attention and resources.

Still, health professionals are working to ensure that there isn't a resurgence of TB. It's especially important to focus on prevention and treatment in low-income groups, they say. "TB continues to be a disease that has a strong correlation with poverty. We don't want those with active TB in shelters spreading the disease, so we try to provide assistance and get them into a hotel in their own private room," said Sasha Cuttler, RN, a nurse manager in TB control for the San Francisco Department of Public Health.

Global 'disaster'

While TB may be on the decline in the United States, the global picture is alarming. "Internationally, TB is a disaster," said Lee Reichman, MD, MPH, executive director of the New Jersey Medical School National Tuberculosis Center and professor of medicine, preventive medicine, and community health at the New Jersey Medical School in Newark.

TB continues to be the leading infectious disease killer of adults worldwide, Cuttler said. In 1998, 8 million people worldwide were infected with TB, and about 2 million died.

Efforts at global TB control are severely hampered by lack of funding in developing countries. The World Health Organization estimates that in 1997 only 32 percent of the world's population was living in areas with effective TB control programs. In addition, MDR-TB is becoming a serious problem, and the expense of its treatment is beyond the resources of most developing nations. Some experts estimate that one case of MDR-TB can cost up to $1 million to treat.

"By any objective criteria, TB has become a minor public health problem here," Nolan said. "Yet, internationally, in many countries it is the leading public health problem."

Many experts caution that the United States might be lulled into complacency and allow TB-control funding to lapse, opening the door for a more serious resurgence.

Eliminating, or even controlling, TB worldwide will require continued attention to identification, treatment, and-experts hope-prevention of the disease.

Need for better tools

TB experts would like to see a major change in current treatment, which requires a minimum six-month course of antibiotics. "Historically, compliance has been a big problem in TB control," Ashkar said. "If you think about how difficult it can be to get parents to give 10 days of antibiotics, and here we are saying people have to take these drugs for six months, or even more."

Nolan, too, would like to see the treatment regimen improved. "We deserve that, " he said. "We need better tools. We're still using a skin test devised in the 1880s."

The best tool, experts say, would be an effective vaccine. BCG (bacille Calmette-Guérin), the only vaccine in existence, is not thought to be effective and is rarely given in the United States. In 1998, the ACET called for a concerted national effort to develop a new vaccine, saying that "without a breakthrough in intervention strategy (i.e., a new TB vaccine), the global toll of TB will not be reduced substantially nor will the disease be eliminated in the United States."

Until a vaccine is found, experts hope that local, state, and national governments will sustain current efforts to control the disease. "Finding people with TB, getting them into the system and through treatment, and protecting their contacts are things we have all been taught and they are truly effective," Nolan said.