CDC History of Tuberculosis Control - Medical and Public Health ...

It was not until 1991 that TB got the attention
it warranted. The first alarm was a series of
nosocomial outbreaks of multidrug-resistant
TB (MDR TB) in various hospitals in New
York City. The second alarm was the announcement
of the results of a month-long
citywide drug resistance survey, which revealed
that 19% of all M. tuberculosis cultures
in New York City were resistant to isoniazid
and rifampin. Remarkably, half of all patients
with positive cultures had been treated before,
many of them for months. These patients
represented a failure of the system to ensure
that patients were reliably treated, and fully
one third of these patients had MDR TB. By
comparison, a nationwide survey during the
first quarter of 1991 showed that only 3% of
all cultures were multidrug-resistant (with
New York City accounting for two thirds of
the cases), a proportion similar to that in New
York City just 7 years earlier, in a 1984
survey.
Phase I: the battle
Dr. Karen Brudney, an astute clinician with
international experience in TB control who
had worked with Dr. Karel Styblo in Nicaragua,
called the City Health Department to
report that she suspected that drug resistance
was increasing. Dr. Brudney had written
highly publicized (and accurate) articles highlighting
the dismantling of the TB control
infrastructure in New York City and documenting
that in Central Harlem, only 11% of
patients started on treatment completed the
TB Control at the Millennium
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treatment. In 1991, one of the authors (TF),
then working at the New York City Department
of Health as an Epidemic Intelligence
Service Officer, conducted the citywide survey
of drug resistance mentioned above in response
to Dr. Brudney’s concern. Working in
one of the Department’s chest clinics since
1990, he had seen the TB problem first-hand.
Margaret A. Hamburg, who was the Commissioner
of Health at that time, appointed Dr.
Frieden the Director of the Bureau of TB
Control (changed in September 1999 to the
NYC TB Control Program). At the height of
the epidemic in early 1992, in a meeting with
the entire staff of the Program, Dr. Frieden
surprised staff by stating that he was “proud to
be part of the organization that would control
TB in New York City.” The basic tenets of
the program were developed: the patient is the
VIP, directly observed therapy (DOT) is the
standard of care for TB treatment, laboratories
need to be supported and monitored, completion
of treatment is the report card of how
well the program is performing, and every
staff member is accountable for his or her
performance. Against considerable barriers,
doctors, nurses, outreach workers, and other
staff were hired, chest clinics were opened on
Saturdays and evenings, and the TB Program
became a significant source of income for the
Department of Health through improved
billing practices. TB control doctors and
nurses even performed new employee physicals
so staff could be hired without the typical
months-long delays. The TB program had the
crucial and unwavering support of Commissioner
Hamburg.
At every opportunity, it was emphasized that
outreach workers were “modern public health
heroes.” The TB Program worked on multiple
fronts, simultaneously striving to improve the
medical care of TB patients, promote standardized
treatment guidelines, expand surveillance,
improve laboratories, expand social services
for TB patients, control outbreaks in hospitals
and correctional facilities, encourage and
conduct epidemiologic studies, educate and