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

Clinic (ECC) by directly observed therapy
(DOT) in his home on Mondays and Thursdays.
Provided he does not miss either of his
twice-weekly intermittent supervised doses
(TWIS) of TB medications, he receives two $5
food coupons on Thursdays to fortify his
nutritional intake. If Mr. C needs to come
into the ECC for a clinician evaluation, his
transportation is provided by BCHD. A nurse
outreach team manages Mr. C’s case. His case
manager is a registered nurse and his DOT
manager is a licensed practical nurse. Mr. C’s
case is reviewed by the nurse team weekly and
by a BCHD clinician monthly. As a result of
contact with Mr. C, his family and friends
have all been offered TB screening evaluations
and follow-up, free of charge. Mr. C is also
participating in a national TB research protocol,
one that is evaluating the efficacy and
safety of a rifabutin-based treatment regimen
for HIV-related TB. His BCHD/ECC clinician
is also his HIV care provider at the Johns
Hopkins Hospital HIV Clinic.
What Mr. C may not know is that the comprehensive
care he is receiving through the
BCHD took years to develop, research, and
refine. He also may not know that as a result
of the once innovative, now national standard
of care he is receiving, the Baltimore TB case
rate is at the lowest level ever recorded, and
that the resurgence of TB that occurred elsewhere
in the US between 1985 - 1992 did not
affect Baltimore (see graph).
TB Control at the Millennium
14
In Baltimore, DOT was the brainchild of the
late Dr. David Glasser, Baltimore City’s
Director of Disease Control/Assistant Commissioner
of Health. Implemented in 1978 for
high-risk clinic TB patients, DOT was expanded
in 1981 to a community-based,
citywide program. As a result, between 1978
and 1992, TB case rates in Baltimore declined
by 81%, and the city’s national rank for TB
dropped from second in 1978 to 28 th in 1992,
despite the emergence of an HIV/AIDS epidemic.
Cases and case rates have continued to
decline to a record low of 84 cases (13 per
100,000) in 1998.
Baltimore’s declining TB case rates are also
attributable, in part, to another of
Dr. Glasser’s novel approaches to TB control.
In the mid 1970s he convinced Baltimore’s
City Council to pass an ordinance mandating
pharmacies to report any issuance of antimycobacterial
drugs to the BCHD. Pharmacy
reporting led to improved TB case reporting,
improved treatment regimens, and an increase
in DOT through BCHD managed cases. These
treatment and management improvements also
explain, in part, Baltimore’s low incidence of
drug resistance (5.9% in 1998), and high incidence
of treatment completion (96.5% in
1997).
Yet another of Dr. Glasser’s foresights was to
develop an outreach and liaison program with
the City’s methadone maintenance clinics.
Recognizing injecting drug use as an important
risk factor for TB, Dr. Glasser implemented a
TB screening and preventive treatment program
at the city’s methadone clinics. By the
mid-1990s, BCHD had bridged TB efforts
with nearly all of the city’s drug treatment
programs.
Dr. Glasser’s ideas laid the foundation for the
hard-working members of Baltimore’s TB
program, who have continued to build upon
his TB control legacy through the years.
Baltimore has implemented additional innovative
TB control strategies in the last two