Tuberculosis Control: Think Globally, Act Locally

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Tuberculosis ControlThink Globally, Act Locally

• Sponsored by
• Sen. Richard T. Moore and Rep. Peter J.
  Koutoujian
• and
• American Lung Association of Massachusetts
• Boston University School of Public Health
• Massachusetts Infectious Diseases Society
• Massachusetts Public Health Association
• The Medical Advisory Committee to Eliminate
  Tuberculosis
• Partners in Health
• RESULTS

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TB-Not Gone, but Forgotten?

• Tom Garvey, MD, JD
• Chair, Subcommittee on Government Relations,
  Medical Advisory Committee to Eliminate
  Tuberculosis
• Harvard Clinical Fellow, The Cambridge Hospital

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What is Tuberculosis?

• The white plague
• Consumption
• The English disease
• Pthisis
• Decay
• The captain of all the men of death

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Transmission
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a TB sanitorium in the late 1800s
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(No Transcript)
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The End?
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Tuberculosis II
Multi-Drug Resistant Tuberculosis
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The Cycle of Neglect
US Tuberculosis Case Rates by Year
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MDR TB 1993-1998
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Multidrug-Resistant TB (MDR TB)

• Presents difficult treatment problems
• Treatment must be individualized
• Requires longer courses of more expensive, more
  toxic, less effective medications
• Requires directly observed therapy (DOT) to
  ensure adherence

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Factors Contributing to the Decrease in TB
Morbidity Since 1993

• Increased efforts to strengthen TB control
  programs that
• Promptly identify persons with TB Identify
  contacts to persons with infectious TB evaluate
  and offer therapy
• Test high-risk groups for latent (i.e. not
  active) TB infection offer therapy as
  appropriate
• Initiate appropriate treatment
• Ensure completion of therapy by directly observed
  therapy (DOT)

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Directly Observed Therapy (DOT)

• Patient observed swallowing each dose of
  medication
• Preferred public health practice in therapy of TB
• Partial treatment of infection selects for drug
  resistant surviving TB germs.
• Key to getting patients to take a complicated
  regimen for 6 months.
• In countries where anti-TB drugs taken w/o
  supervision, higher incidence of resistance.
• Thus, the state needs to support the staff needed
  for DOT to protect the public health.

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Cost of the New York Outbreak

1. Human costs (incalculable)
2. Emergence of new, more deadly strains of
   tuberculosis
3. Diversion of health resources away from other
   problems
4. State monetary Ten times x cost savings of
   cutting prevention
5. Total monetary gt1 billion

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The Trend in Massachusetts

• Because of general cuts to public health, local
  health departments are laying off public health
  nurses--the eyes and ears of TB control
• We have shut down 4 out of 23 Tuberculosis
  clinics in the last 2 years, most problematically
  in Framingham and New Bedford, where there are
  high-risk populations
• Proposals have been floated to charge patients
  for secondary TB tests and TB medications

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Conclusions

• Tuberculosis continues to be one of the leading
  threats to human health.
• Although it is preventable and curable,
  relaxation of the effort to fight it has
  disastrous consequences.
• Our TB clinics are an irreplaceable barrier
  against the epidemic through their concentration
  of expertise, their TB tracking and outreach
  resources, and directly observed therapy.

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Recommendations

• That no further cuts be made to the Department of
  Public Health
• That a separate line item for tuberculosis
  clinics be created
• That funding for existing clinics be maintained
• That the clinics be restarted in Framingham and
  New Bedford and a new one be founded in Quincy
  since these are potential breeding grounds for an
  epidemic
• That no barriers, including fees be applied to
  tuberculosis testing and treatment