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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
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.