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

train doctors and other staff, and delineate the
proper use of increasingly restrictive measures
against TB patients, including detention.
After a visit by Dr. Karel Styblo to New York
City, the TB Program implemented a cohort
review process, in which the Director personally
reviewed every one of the thousands of
cases for treatment details and completion.
The outcome was a steep increase in completion
rates and, beginning in 1993, a steep
decline in the number of reported TB cases.
More impressive was the even sharper decline
in the number of reported cases of MDR TB,
from 441 cases in 1992 to just 38 cases in 1998.
Cases of TB in US-born persons decreased
from 2,939 in 1992 to 700 in 1998.
Phase II: new frontiers
After completion rates increased, cohort
review meetings began to include information
on contact evaluation and preventive treatment.
The efficacy of this process was recognized
when, in 1998, the NYC TB Control
Program was honored as one of 25 finalists,
out of a field of more than 1,300 nominees, for
the prestigious Innovations in American
Government Award, given by the Ford Foundation
and the Harvard School of Government.
After TB case completion rates improved,
program staff began to concentrate on treatment
of patients with latent TB infection
(LTBI), especially those at high risk of developing
TB disease, such as the HIV-infected,
close contacts, recent immigrants from TBendemic
countries, and persons with evidence
of “old” TB. A unit to monitor treatment of
immigrants and refugees was created, and an
expanded contact investigation unit evaluated
cases of TB in workplace as well as congregate
and school settings. Treating those who “only”
have TB infection rather than disease has been
in many ways even more difficult than treating
those with TB disease. It has been difficult
to convince people to take medications when
they do not feel sick. The City’s health code
does not allow (nor should it) the TB program
Notable Events in TB Control
11
the same powers to use increasingly restrictive
measures against the patients who do not take
treatment for LTBI. Some physicians in New
York City, including many trained outside of
the country, do not believe that treatment for
LTBI is important, and pass this belief on to
their patients.
Facing the next century, one of the program’s
biggest challenges is to improve completion of
treatment for LTBI while at the same time
effectively treating the more than 100 new
cases of TB that arise every month.
Phase III: New York City in the context of
global TB control
During the late 1980s and early 1990s, HIV
fueled New York City’s TB epidemic. This
masked the slower rise in the number of cases
in persons born outside of the United States.
In 1997, the percentage of cases in foreign-born
persons in New York City exceeded the
number of cases in United States-born persons
for the first time in recent history. The rise in
cases in the foreign-born has created new
challenges. Bicultural and bilingual staff have
been hired. People’s fears that the TB control
program is connected to the Immigration and
Naturalization Service must be quelled. People
from Ecuador, the Dominican Republic,
Puerto Rico, and Mexico may share a common
language, but have disparate beliefs about TB
transmission and risk. It is not possible to have
a one-size-fits-all approach to identifying
patients, encouraging them to present for
evaluation and treatment of TB disease or
infection, and helping them adhere to treatment.
TB control activities must be specifically
tailored not only to the patients, but also
to those who provide their care. When patients
move back to their country of origin,
New York City’s program staff communicate
with patients’ health care providers to ensure
that adequate treatment continues. It is not
unusual for staff to call Costa Rica, Pakistan,
Mexico, or the Ivory Coast to glean information
on treatment completion in order to
“close the loop” for cohort reporting!