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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
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.