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TB Notes 1, 2000
Where We've Been and Where We're Going: Perspectives from CDC's Partners in TB Control
Changes I've Seen
TB Control in New York City: A Recent History
Not by DOT Alone
Baltimore at the New Millennium
From Crickets to Condoms and Beyond
The Denver TB Program: Opportunity, Creativity, Persistence, and Luck
National Jewish: The 100-Year War Against TB
Earthquakes, Population Growth, and TB in Los Angeles County
TB in Alaska
CDC and the American Lung Association/ American Thoracic Society: an Enduring Public/Private Partnership
The Unusual Suspects
The Model TB Prevention and Control Centers: History and Purpose
My Perspective on TB Control over the Past Two to Three Decades
History of the IUATLD
Thoughts about the Future of TB Control in the United States
Where We've Been and Where We're Going: Perspectives from CDC
Early History of the CDC TB Division, 1944-1985
CDC Funding for TB Prevention and Control
Managed Care and TB Control - A New Era
Early Research Activities of the TB Control Division
The First TB Drug Clinical Trials
Current TB Drug Trials: The Tuberculosis Trials Consortium (TBTC)
TB Communications and Education
TB Control in the Information Age
Field Services Activities
TB's Public Health Heroes
Infection Control Issues
A Decade of Notable TB Outbreaks: A Selected Review
International Activities
The Role of CDC's Division of Quarantine in the Fight Against TB in the U.S.
The STOP TB Initiative, A Global Partnership
Seize the Moment - Personal Reflections
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This is an archived document. The links are no longer being updated.

TB Notes 1, 2000

TB Control in New York City: A Recent History

by Paula I. Fujiwara, MD, and Thomas R. Frieden, MD, MPH
Current and former Directors of the NYC TB Control Program

Many of the tenets of modern TB control were developed more than a century ago in New York City by Dr. Hermann Biggs, a physician working for the Department of Health. These included the policies of free, high-quality sputum examination, the mandatory reporting of cases, health department supervision of isolation and treatment, education of the public regarding TB, and the fostering of a social movement for control of the disease. The City's TB control program waxed and waned over the next 100 years, with the lowest number of reported TB cases in the city occurring in 1978.

During the 1980s, the rapid rise in TB was fueled by the human immunodeficiency virus (HIV) epidemic; growing poverty, homelessness, and incarceration rates; and immigration from countries with high TB prevalence. In this context, the infrastructure of TB control had been dismantled, the victim of a one-two knockout punch of a fiscal crisis in the City and a change to a system of block grants for federal funding. One long-time employee, when asked how it felt to see the increase in cases year after year, said, "We thought that's just the way it was." Staff were trapped in a cycle of reporting cases, starting treatment on those they could locate, but losing many of them. Staff knew they should be searching for the lost patients but were distracted by the overwhelming number of new infectious cases. Citywide, less than half of the patients completed treatment. Repeated warnings from experts and panels did not lead to increased concern or funding.

Image 1: Queuing up: Men from the TB wing of Bellevue's homeless shelter line up in the morning to receive their medication.

It was not until 1991 that TB got the attention it warranted. The first alarm was a series of nosocomial outbreaks of multidrug-resistant TB (MDR TB) in various hospitals in New York City. The second alarm was the announcement of the results of a month-long citywide drug resistance survey, which revealed that 19% of all M. tuberculosis cultures in New York City were resistant to isoniazid and rifampin. Remarkably, half of all patients with positive cultures had been treated before, many of them for months. These patients represented a failure of the system to ensure that patients were reliably treated, and fully one third of these patients had MDR TB. By comparison, a nationwide survey during the first quarter of 1991 showed that only 3% of all cultures were multidrug-resistant (with New York City accounting for two thirds of the cases), a proportion similar to that in New York City just 7 years earlier, in a 1984 survey.

Phase I: the battle

Dr. Karen Brudney, an astute clinician with international experience in TB control who had worked with Dr. Karel Styblo in Nicaragua, called the City Health Department to report that she suspected that drug resistance was increasing. Dr. Brudney had written highly publicized (and accurate) articles highlighting the dismantling of the TB control infrastructure in New York City and documenting that in Central Harlem, only 11% of patients started on treatment completed the treatment. In 1991, one of the authors (TF), then working at the New York City Department of Health as an Epidemic Intelligence Service Officer, conducted the citywide survey of drug resistance mentioned above in response to Dr. Brudney's concern. Working in one of the Department's chest clinics since 1990, he had seen the TB problem first-hand. Margaret A. Hamburg, who was the Commissioner of Health at that time, appointed Dr. Frieden the Director of the Bureau of TB Control (changed in September 1999 to the NYC TB Control Program). At the height of the epidemic in early 1992, in a meeting with the entire staff of the Program, Dr. Frieden surprised staff by stating that he was "proud to be part of the organization that would control TB in New York City." The basic tenets of the program were developed: the patient is the VIP, directly observed therapy (DOT) is the standard of care for TB treatment, laboratories need to be supported and monitored, completion of treatment is the report card of how well the program is performing, and every staff member is accountable for his or her performance. Against considerable barriers, doctors, nurses, outreach workers, and other staff were hired, chest clinics were opened on Saturdays and evenings, and the TB Program became a significant source of income for the Department of Health through improved billing practices. TB control doctors and nurses even performed new employee physicals so staff could be hired without the typical months-long delays. The TB program had the crucial and unwavering support of Commissioner Hamburg.

At every opportunity, it was emphasized that outreach workers were "modern public health heroes." The TB Program worked on multiple fronts, simultaneously striving to improve the medical care of TB patients, promote standardized treatment guidelines, expand surveillance, improve laboratories, expand social services for TB patients, control outbreaks in hospitals and correctional facilities, encourage and conduct epidemiologic studies, educate and train doctors and other staff, and delineate the proper use of increasingly restrictive measures against TB patients, including detention. After a visit by Dr. Karel Styblo to New York City, the TB Program implemented a cohort review process, in which the Director personally reviewed every one of the thousands of cases for treatment details and completion. The outcome was a steep increase in completion rates and, beginning in 1993, a steep decline in the number of reported TB cases. More impressive was the even sharper decline in the number of reported cases of MDR TB, from 441 cases in 1992 to just 38 cases in 1998. Cases of TB in US-born persons decreased from 2,939 in 1992 to 700 in 1998.

Phase II: new frontiers

After completion rates increased, cohort review meetings began to include information on contact evaluation and preventive treatment. The efficacy of this process was recognized when, in 1998, the NYC TB Control Program was honored as one of 25 finalists, out of a field of more than 1,300 nominees, for the prestigious Innovations in American Government Award, given by the Ford Foundation and the Harvard School of Government.

After TB case completion rates improved, program staff began to concentrate on treatment of patients with latent TB infection (LTBI), especially those at high risk of developing TB disease, such as the HIV-infected, close contacts, recent immigrants from TB-endemic countries, and persons with evidence of "old" TB. A unit to monitor treatment of immigrants and refugees was created, and an expanded contact investigation unit evaluated cases of TB in workplace as well as congregate and school settings. Treating those who "only" have TB infection rather than disease has been in many ways even more difficult than treating those with TB disease. It has been difficult to convince people to take medications when they do not feel sick. The City's health code does not allow (nor should it) the TB program the same powers to use increasingly restrictive measures against the patients who do not take treatment for LTBI. Some physicians in New York City, including many trained outside of the country, do not believe that treatment for LTBI is important, and pass this belief on to their patients.

Facing the next century, one of the program's biggest challenges is to improve completion of treatment for LTBI while at the same time effectively treating the more than 100 new cases of TB that arise every month.

Phase III: New York City in the context of global TB control

During the late 1980s and early 1990s, HIV fueled New York City's TB epidemic. This masked the slower rise in the number of cases in persons born outside of the United States. In 1997, the percentage of cases in foreign-born persons in New York City exceeded the number of cases in United States-born persons for the first time in recent history. The rise in cases in the foreign-born has created new challenges. Bicultural and bilingual staff have been hired. People's fears that the TB control program is connected to the Immigration and Naturalization Service must be quelled. People from Ecuador, the Dominican Republic, Puerto Rico, and Mexico may share a common language, but have disparate beliefs about TB transmission and risk. It is not possible to have a one-size-fits-all approach to identifying patients, encouraging them to present for evaluation and treatment of TB disease or infection, and helping them adhere to treatment. TB control activities must be specifically tailored not only to the patients, but also to those who provide their care. When patients move back to their country of origin, New York City's program staff communicate with patients' health care providers to ensure that adequate treatment continues. It is not unusual for staff to call Costa Rica, Pakistan, Mexico, or the Ivory Coast to glean information on treatment completion in order to "close the loop" for cohort reporting!

What is the role of New York City in the global fight against TB? Many people migrate to places such as New York City to better their economic lot, and many of these people come from areas of the world where TB is endemic. New York City's TB cases represent a microcosm of TB around the world; in 1998, these cases came from 91 countries, led by China, the Dominican Republic, Haiti, Ecuador, India, and Mexico. In some instances, people (including those with MDR TB) come to New York City specifically to be treated, having heard of the program's success.

Image 2: New York City's TB cases represent a microcosm of TB around the world.

One of New York City's contributions to the global battle against TB is to support international colleagues' TB control efforts, to advocate for more funding for these programs, and to be gracious hosts and teachers when officials from different countries visit to learn about New York City's success. In 1900, the TB control program of the New York City Department of Health, under the leadership of Herman Biggs, was an international model. Today, New York City's experience provides global hope and evidence that even in the context of an HIV epidemic and a high rate of multidrug resistance, the battle against TB can be won and the disease can be controlled.


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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