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TB, the quiet killer

This is World Tuberculosis Day, the day in 1882 when Dr. Robert Koch discovered the cause of tuberculosis (TB), an airborne infectious disease that continues to rage around the world, killing 1.4 million people each year. The disease remains a leading infectious disease killer globally. In Africa, TB is the biggest killer of people with HIV/AIDS.

Baltimore once had the highest rates of TB cases and deaths in the U.S., but a heroic effort by the Baltimore City Health Department's TB clinic, led by the late Dr. David Glasser in the 1970s and 1980s, resulted in drastic reductions in our TB rates through the use of directly observed therapy (DOT) and aggressive use of treatment to prevent TB in those at highest risk.

However, TB has not been eliminated in Baltimore — or in any state. Maryland has had TB outbreaks in schools, social clubs, hospitals and among transplant patients in recent years. Los Angeles is currently battling a TB epidemic among a homeless population in which more than 4,600 people have potentially been exposed and 11 have died.

Alarmingly, Maryland ranks as the sixth most highly TB-burdened state in the country, with the majority of cases in Montgomery County and Baltimore City. Baltimore's Tuberculosis Control Program, the model program that introduced DOT to the world, has seen 30 percent to 40 percent cuts in federal funding even before the recent, disastrous sequestration, and as a result the ability of the program to provide medically necessary services to people with TB is stretched thin. With fewer public health staff now available, the core functions of TB control — identifying and treating people at high risk of developing the disease — are severely curtailed. Preventive treatment of latent (inactive) TB is an essential part of TB control because latent cases are the reservoir for future active infectious cases. The cuts in funding are putting the people of Baltimore at risk for deadly outbreaks among vulnerable populations, such as people with HIV/AIDS, cancer patients and others with impaired immunity.

Making matters worse, multi-drug-resistant (MDR) TB is on the rise globally, with more than 650,000 cases per year. In the past, most drug-resistant TB occurred in patients with initially drug-susceptible TB who were improperly treated, but now the majority of cases arise when an individual becomes infected with a resistant strain acquired from another patient. Fewer than one in five people with resistant TB each year receive appropriate treatment; many die, but not before infecting others with these deadly strains. MDR-TB treatment requires a lengthy and toxic drug regimen that patients compare to cancer chemotherapy.

Budget cuts to TB programs in the 1980s resulted in a huge resurgence of the disease between 1985 and 1992 and an unprecedented epidemic of MDR-TB in cities such as New York and Newark, N.J. Reversing that deadly tide cost taxpayers hundreds of millions of dollars. The tragedy of the current decimation of TB control programs here in Baltimore and across the nation is that we know this will result in a lethal comeback of the disease — it happened only 20 years ago, and it will happen again if we don't maintain our public health infrastructure. The continued spread of all forms of TB is something that we have the knowledge to prevent with TB control measures that are highly effective and inexpensive.

So, why are we paying little attention to a disease that spreads through the air and knows no borders?

Despite the devastation that TB wreaks, it still is not a global health priority. U.S. funding for global TB programs is paltry compared to funding for the other two leading infectious diseases, HIV and malaria. TB receives about $250 million versus $4.75 billion for HIV and $650 million for malaria. About two-thirds of TB cases in the U.S. are in people born in other countries, and our efforts to stem TB worldwide are essential for our nation's own health.

Halting the TB pandemic requires a sustained effort. We must stop cutting our domestic TB infrastructure, or more cities and states will be vulnerable to outbreaks. If we fail to address TB, more than 12 million people around the world will die over the next decade. And the U.S. will face many more, and much costlier, outbreaks of TB, including in Baltimore.

Richard E. Chaisson is professor of medicine, epidemiology and international health at the Johns Hopkins University and directs the Hopkins Center for Tuberculosis Research. His email is rchaiss@jhmi.edu.

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