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

disappeared into the private sector, while the
poor and those from the street continued to be
housed for months upon months on a forgotten
floor of the public hospital.
In 1965, Denver was awarded a CDC TB
Branch grant, which included the assignment
of one of the CDC’s first six TB medical
officers. The project award was designed to
enhance the city’s decimated TB clinic. However,
the standard of treatment, 24 months of
daily INH and PAS, presented a daunting
obstacle to the ambulatory treatment of a large
population of chronic alcoholics and disadvantaged,
socially isolated inpatients. How to
treat effectively yet compassionately was the
question.
A little-noticed report in a foreign journal
provided an answer. In Madras, India, the
British Medical Research Council (BMRC)
appeared to have successfully treated patients
with high doses of INH and streptomycin
given intermittently over one year. The
regimen made sense scientifically and programmatically.
If directly administered
throughout treatment, the opportunity for
cure would be maximized and a concerned
public assured that these ambulatory patients
did not place the community at risk because
they were receiving adequate treatment
(“chemical isolation”). Fortunately, at that
moment there was no local health department
authority to say “no” and the regimen was
implemented, although modified to include a
three-drug intensive phase and an 18-month
two-drug continuation phase.
The uniqueness of this treatment approach
spawned widespread changes in Denver’s
ambulatory TB program. The resultant emergence
of one-to-one relationships between
nurses and patients led to a major role expansion,
with nurses encouraged to function more
independently, including reading x-rays and
determining which standing treatment orders
Notable Events in TB Control
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to implement. By early 1966, both DOT and
the nurse-directed TB clinic had indeed arrived
in the US. And what nurses do, they document
— every action and every outcome —
and with that documentation, Denver’s ongoing
research program was established. Innovation,
when measured, becomes meaningful
clinical research. A long list of skilled TB
nurse specialists such as B.J. Catlin, Jan Tapy,
and Maribeth O’Neill not only provided care
to thousands of patients but served as the
cornerstone for Denver’s contributions to the
scientific and social understanding of TB
control.
However, organizations either continue to
grow or they die, and growth requires change.
As new knowledge emerged and new drugs
became available, so did new opportunities.
Fortunately, the arrival of Mike Iseman early
in the program and subsequently of Dave
Cohn ensured that no opportunity would pass
unnoticed. Program components were evaluated
for cost-effectiveness and community
impact. Denver was amongst the first to
eliminate the mobile chest x-ray in favor of
selected population skin testing; to focus on
the effect of inducements and enforcement on
patient compliance; and to create a meaningful
role for community outreach workers. New
short-course DOT regimens were developed
and tested; screening programs were evaluated;
the effect of TB drugs in infected human
macrophages documented; and “molecular
epidemiology” was applied to a long-standing
database and a freezer stored with isolates of
mycobacteria.
The emergence of HIV stimulated new questions,
new initiatives, and an opportunity to
further build upon 30 years of close working
relationships with, and support from, the
CDC. Denver’s long history of integrating
federal, state, and private grants into a single
local program encouraged its early inclusion in
multicenter national studies sponsored by
CDC and the National Institutes of Health