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TB Notes 1, 2000
Introduction
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This is an archived document. The links are no longer being updated.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

Baltimore at the New Millennium

by Kristina Moore, RN, and
Richard E. Chaisson, MD,
Professor of Medicine, Epidemiology, and International Health
Johns Hopkins University

Mr. C, a Baltimore City resident, knows he was diagnosed with active pulmonary and lymphatic TB in May 1999. He receives his TB treatment through the Baltimore City Health Department (BCHD)/Eastern Chest Clinic (ECC) by directly observed therapy (DOT) in his home on Mondays and Thursdays. Provided he does not miss either of his twice-weekly intermittent supervised doses (TWIS) of TB medications, he receives two $5 food coupons on Thursdays to fortify his nutritional intake. If Mr. C needs to come into the ECC for a clinician evaluation, his transportation is provided by BCHD. A nurse outreach team manages Mr. C's case. His case manager is a registered nurse and his DOT manager is a licensed practical nurse. Mr. C's case is reviewed by the nurse team weekly and by a BCHD clinician monthly. As a result of contact with Mr. C, his family and friends have all been offered TB screening evaluations and follow-up, free of charge. Mr. C is also participating in a national TB research protocol, one that is evaluating the efficacy and safety of a rifabutin-based treatment regimen for HIV-related TB. His BCHD/ECC clinician is also his HIV care provider at the Johns Hopkins Hospital HIV Clinic.

What Mr. C may not know is that the comprehensive care he is receiving through the BCHD took years to develop, research, and refine. He also may not know that as a result of the once innovative, now national standard of care he is receiving, the Baltimore TB case rate is at the lowest level ever recorded, and that the resurgence of TB that occurred elsewhere in the US between 1985 - 1992 did not affect Baltimore (see graph).

Graph 1: Baltimore City's Reported Tuberculosis Cases by Year, 1978 - 1998.

In Baltimore, DOT was the brainchild of the late Dr. David Glasser, Baltimore City's Director of Disease Control/Assistant Commissioner of Health. Implemented in 1978 for high-risk clinic TB patients, DOT was expanded in 1981 to a community-based, citywide program. As a result, between 1978 and 1992, TB case rates in Baltimore declined by 81%, and the city's national rank for TB dropped from second in 1978 to 28th in 1992, despite the emergence of an HIV/AIDS epidemic. Cases and case rates have continued to decline to a record low of 84 cases (13 per 100,000) in 1998.

Baltimore's declining TB case rates are also attributable, in part, to another of Dr. Glasser's novel approaches to TB control. In the mid 1970s he convinced Baltimore's City Council to pass an ordinance mandating pharmacies to report any issuance of anti-mycobacterial drugs to the BCHD. Pharmacy reporting led to improved TB case reporting, improved treatment regimens, and an increase in DOT through BCHD managed cases. These treatment and management improvements also explain, in part, Baltimore's low incidence of drug resistance (5.9% in 1998), and high incidence of treatment completion (96.5% in 1997).

Yet another of Dr. Glasser's foresights was to develop an outreach and liaison program with the City's methadone maintenance clinics. Recognizing injecting drug use as an important risk factor for TB, Dr. Glasser implemented a TB screening and preventive treatment program at the city's methadone clinics. By the mid-1990s, BCHD had bridged TB efforts with nearly all of the city's drug treatment programs.

Dr. Glasser's ideas laid the foundation for the hard-working members of Baltimore's TB program, who have continued to build upon his TB control legacy through the years. Baltimore has implemented additional innovative TB control strategies in the last two decades. The development of liaisons with Maryland Department of Health and Mental Hygiene, Maryland Division of Corrections, and private providers has improved case reporting, case management, case follow-up, and case prevention efforts. Forging a treatment, prevention, and research collaboration with nearby Johns Hopkins University's (JHU) Center for TB Research has also contributed to improved BCHD TB control measures. BCHD/ECC's Medical Director, clinician staffing, and radiology support are all provided through a contractual agreement with JHU. In addition, this cooperative relationship has resulted in several exciting TB research projects, including neighborhood-based TB screening, TB prevention studies in injection drug users, and DNA fingerprinting studies. BCHD and JHU have also collaborated to form a contract site for the TBTC (Tuberculosis Trials Consortium).

The challenges for Baltimore City TB Control in the new millennium will involve continuing the successful case reduction efforts of the past century through new initiatives. A main priority will be focusing efforts on the treatment of latent TB infection (LTBI). Efforts to evaluate the possibilities of even shorter course therapy and additional treatment options for both active cases and LTBI will also be paramount. Another key interest will be participating in the efforts to develop a more efficacious TB vaccine. All of these new initiatives will depend upon the development of national and international collaborative networks in TB research. For TB elimination to finally take its place in history, a global approach is an absolute necessity.

As the new millennium begins, Baltimore City TB Control is ready to join the world in meeting its challenges. Patients like Mr. C will continue to benefit from the dedication of a City Health Department committed to the ultimate goal: treating the last case of TB.

 


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination - http://www.cdc.gov/tb

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