Fred M. Jacobs, M.D., J.D.

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Fred M. Jacobs, M.D., J.D. Commissioner Departmen
t of Health and Senior Services
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The Evolution of TB Treatment A Personal
Perspective
Northeast TB Controllers Meeting October 24,
2006 Nassau Inn, Princeton
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Medical School

• University of Miami School of Medicine
• - - 1958 - 1962
• Pulmonary Disease as a Specialty
• - - TB or Clinical Physiology
• Pulmonary Function _at_ University of Miami Jackson
  Memorial Hospital

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Chief Resident in Pulmonary Diseases 7/01/66 -
6/30/67

• Set up conferences
• Pulmonary Grand Rounds
• - - 2 hours
• - - 1 guest speaker
• - - 2 cases presented
• Rounds with House staff
• Consulting Rounds general medical floor

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Kings County Hospital Center, Brooklyn Late 1960s
E Building

• Big, high - volume TB , 700 beds, all Chest
• 6 to 8 far advanced, active, cavitary cases
  per day, every day.
• MDs from as far as Philippines to observe
• Two 58 - bed units for men
• One 58 - bed unit for women
• One 58 - bed non -TB chest disease floor
• . Pediatric TB, Thoracic Surgery, Chronic
  Care

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The Great White Plague

• Mycobacterium tuberculosis isolated by Robert
  Koch in 1882
• The great illness of the time
• cheesy white material in middle of infection
• Doctors were passionate about treatment
• NO ICUs

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Sanitariums 1900 - late 1960s

• TB was managed by putting people in sanitariums
• Naturally Isolated
• Fresh, cold mountain air pure water
  therapeutic
• Trudeau Sanitarium opened 1918 on shores of
  Saranac Lake deep in Adirondack Mountains, NY
• National Jewish Hospital near Denver
• Glen Gardner pastoral hilltop, Hunterdon County
• Deborah Heart Lung in Browns Mills opened 1922
• Essex Mountain Sanitarium in Verona

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Essex Mountain Sanitarium

• Opened 1917
• 4,000 patients
• Colorado Springs of the East
• Crest of Second Mt.
• 50 recovery rate
• Dozen buildings
• 200 - acre campus
• Prisoners of nearby penitentiary worked
  farm grew vegetables
• 1977last patient released

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(No Transcript)
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Essex Mountain Sanitarium
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J. N. Adam Memorial Hospital TB Sanitarium
Buffalo, NY 192Os
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Sanitarium Patient Care Team 1917
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Sanitariums Nurses 1930s
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First Effective Therapy for TB

• Discovery of Streptomycin (SM) in 1944
• Para-amino salicylic acid (PAS) in 1946
• Isoniazid (INH) in 1952
• - - bacterial resistance when used alone
• Disease now viewed as treatable, preventable
• and eradicable
• However, still remains major global threat

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Annals of Internal Medicine

• U.S. TB death rates decreased from 194 per
  100,000 in 1900 to 40 per 100,000 persons in 1945
• 1945, 63,000 persons died of TB and 115,000 new
  cases
• TB drugs, Sanitariums, non-surgical surgical
  collapse therapy, resectional surgery widely
  used
• Sanitariums closed TB is mainstream disease
• As mortality and morbidity decreased, government
  decreased funding for TB states, cities
  downgraded programs

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TB Morbidity by Decade
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Bilateral Plombage Thoracoplasty w lucite spheres
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Far Advanced Cavitary TB
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Cavitary TB Patient 3 Years after Treatment
Regression after treatment with Viomycin,
tetracycline ethionamide and pyrazinamide
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Modified Thoracoplasty
Left apical disease showing first rib left in
position and the 2nd, 3rd, 4th ribs turned
inwards to form a solid new roof
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14 Months After Treatment w PAS, SM INH
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TB cases in New Jersey

• 2000 - 565
• 2001 - 530
• 2002 - 530
• 2003 - 495
• 2004 - 482
• 2005 - 485

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DHSS TB Program

• DHSS historically used 80 - 85 of total funding
  for direct patient care activities
• Funding expected to be stable thru June 2007
• SFY 2008 funding may decrease 550,000
• Clinical consolidation regionalization will
  increase efficiency improve quality of care
• State support only for regional clinic services

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DHSS TB Program

• To ensure protection of the public health TB
  program will provide drug coverage to ensure no
  patient with TB goes untreated due to financial
  considerations
• Public health field staff can provide patients
  under private care with DOT to increase
  likelihood of adherence of treatment

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MDR-TB On The Rise

• 2004 3 cases in NJ
• 2005 10 cases in NJ
• We are not going to be able to control TB in U.S.
  unless we control it overseas
• Rate ratio TB in foreign born to U.S.-born
  persons increased 6.6 a year 1993-2002
• TB rate in foreign born in 2005 was 8.7 times
  that of U.S.-born persons (MMWR 3/06)

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A cautionary warning

• If we are not carefulwith additional cutbacks
  and inability to control TB in foreign bornwe
  may experience a rise in TB incidence similar to
  what we saw in the early 1990s