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

the greatest contribution of National Jewish is
in education. In addition to the TB course,
the hospital maintains a Mycobacterial Consult
Line, a free service whereby physicians
anywhere in the world can call up and receive
advice from our specialists. Over the past 5
years this service has responded to over 2,000
calls annually.
At the opening of National Jewish back in
1899, the president of the institution, speaking
of TB in the exalted rhetoric of that day,
declared that it was his dream for the hospital
“that its doors may never close again until the
terrible scourge is driven from the earth.”
Now, at the time when the World Health
Organization estimates that one out of every
three people in the world is infected with TB,
those doors are still open.
Earthquakes, Population Growth, and TB
in Los Angeles County
by Paul T. Davidson, MD
Los Angeles TB Controller
In the late 1960s, Los Angeles County built a
state-of-the-art TB hospital. Most of the 1,300
or more persons being diagnosed with new
cases of this disease each year were spending
many months in the hospital before receiving
treatment as outpatients. The Sylmar earthquake
of 1971 essentially destroyed the hospital
and propelled the County into considering
other approaches to managing this disease.
Some patients were transferred to Rancho Los
Amigos Hospital, a long-term rehabilitation
facility. The majority were referred to the
over 40 Public Health Centers then in existence
throughout the county. This began what
has since become a largely outpatient system
for the follow-up and care of TB patients. Six
county hospitals have continued to diagnose
and treat many TB patients. Liaison nurses
assigned by the TB Control Program facilitate
the transfer of these patients to the Public
Health Clinics. Approximately 25% of TB
patients are diagnosed and followed by the
private health sector.
TB Control at the Millennium
20
During the past 30 years there have been
numerous changes in Los Angeles County that
have impacted upon the TB problem. A
dramatic increase in the population has occurred.
Many of the new residents are immigrants
from countries where TB is prevalent
and in many cases increasing in incidence. By
the end of the 20th century nearly 75% of all
the new cases in Los Angeles occurred in the
foreign born. Poverty and homelessness have
been a persistent social and cultural factor
supporting continued spread of TB. By the
late 1980s, the emergence of HIV infection and
disease contributed to the number of TB cases,
reaching a peak of 15% of all the cases being
HIV positive in 1991.
In the 1980s efforts were increased to fight the
TB problem among the homeless. A satellite
clinic in the Skid Row area of downtown Los
Angeles was established. This clinic depended
on outreach workers to find and transport
patients to the clinic for directly observed
medication and medical management. Because
many of the homeless still defaulted on treatment
and spent repeated episodes in the hospitals,
a pilot project funded by the State of
California was instituted. It provided housing
and food incentives to the homeless in Skid
Row in exchange for taking medication and
completing TB treatment. The results were
dramatic, with better than 95% of the participants
completing therapy and the number of
hospital days being much reduced. The program
was eventually funded by the County
and extended to other areas where
homelessness is also a problem. This program
continues, and the number of TB cases among
the homeless is declining more rapidly than
the overall number of cases.
In the late 1980s an HIV/TB program was
established to provide liaison with HIV providers.
Screening guidelines for TB were
established regarding admission of HIV patients
to hospitals, hospices, and other congregate
living facilities. The liaison nurse essen-