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The return of tuberculosis Once thought to be disappearing, its' back and it's stronger

It's more than 30 years since the tuberculosis sanitarium made its exit from the American landscape, and about as long since public health authorities talked confidently about the "white plague's" disappearing once and for all.

Antibiotics, the miracle of the 1950s, seemed likely to make that possible. It would have been the ultimate triumph of modern medicine: eradicating from this country an illness that, at the turn of the century, killed more people than heart disease, cancer or any other disease.

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Not so fast.

As tuberculosis rates in the United States seemed headed toward the vanishing point, they made a surprising about-face. In 1989, TB rates increased 4.7 percent over the previous year. In 1990, the rate jumped another 9.4 percent.

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The 25,700 people diagnosed with tuberculosis in the United States last year are one-tenth the numbers reported in the 1930s. But TB's sudden resurgence, in Maryland as elsewhere -- and the fertile breeding ground it has found among AIDS patients, immigrants and the poor -- have authorities concerned.

Particularly worrisome is the appearance of strains that have proved resistant to standard medications. This has some physicians fuming over what they consider the U.S. government's failure to anticipate the problem by funding research into new drugs when the disease was at its low point.

"We honestly thought TB was solved," says Dr. Lee Reichman, president of the American Lung Association, who accuses the federal government of forgetting about TB once it no longer seemed a crisis. "There was no need to develop new medicines when other diseases were pre-eminent."

Tuberculosis is caused by an airborne bacteria that infects the lungs and other organs. The infection usually lies dormant, held in check by the immune system. But it can erupt into a potentially deadly disease marked by intense coughing, chest pain, shortness of breath, fever and sweating.

Antibiotics are highly effective against TB, although the infection is more difficult to treat when it strikes people with immune system disorders such as AIDS.

Several forces are behind the re-emergence of tuberculosis:

* The disease is infecting large numbers of AIDS patients, people whose shattered immune systems are nearly defenseless against the TB bacteria.

* AIDS patients who catch TB are in the position to infect other people: family members, health care workers and friends who are regularly exposed to the characteristic coughing that comes with the disease. This stands in stark contrast to the myriad other infections that strike AIDS patients -- infections that people with healthy immune systems are quite capable of defeating.

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* Many immigrants from Latin America, Asia and Africa -- continents where tuberculosis remains a colossal threat -- have been bringing the bacteria with them. Many of them lived with a silent infection for years, only to have their infection blossom into full-blown disease once they were subjected to the rigors of living in a new land.

* The infection is spreading rapidly among drug addicts, homeless people and others living in desperate poverty. The infection has always thrived in crowded, substandard conditions and among people with poor nutrition.

The epidemic has hit New York, Hawaii, California and Florida the hardest -- states with large numbers of foreign-born residents, AIDS patients or both. Although Maryland's TB cases remain below the national average, the trend here is decidedly upward. The number of cases jumped from 384 to 450 between 1990 and 1991 -- a 17 percent increase.

Most of the cases have been concentrated in Baltimore City, Prince George's and Montgomery counties. Dr. Diane L. Matuszak, who has overseen TB control programs in Maryland, attributes this to the AIDS epidemic in Baltimore; AIDS and the swelling immigrant population in Prince George's, and immigration in Montgomery.

Resistant strains have not arrived in force in Maryland, as they have elsewhere. Such strains have spread across populations of AIDS patients, drug addicts and prison inmates in New York, California and other states that have been hard-hit by tuberculosis in general.

Last November, a resistant strain killed 12 prison inmates and a guard in New York, and infected dozens of health care workers who were taking care of them in a Syracuse hospital. Last year, physicians diagnosed only 13 cases of "multiply drug resistant" TB in Maryland, but experts said the problem is bound to emerge in Maryland.

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"It's just inevitable," said Dr. Richard Chaisson, director of AIDS patient care at Johns Hopkins Hospital. "New York City is just a view of the future for the rest of the United States. All factors that produced this epidemic in New York will produce it elsewhere. All it takes is one person from New York coming to Baltimore and transmitting it to someone else."

Resistant tuberculosis is a vexing problem because it thrives among people who do not religiously take their medicine.

Typically, patients are asked to take three drugs. Each drug covers the possibility that the bacteria inside a patient's lungs will mutate into strains that are resistant to one of the other drugs. But if a patient fails to take all his medication -- or any medication -- he becomes an incubator for resistant strains.

Getting patients to take their medicine can be a terrible problem, especially among people who are busy looking for their next fix or have no place to live. At Harlem Hospital in New York, doctors found that 90 percent of patients released for outpatient treatment of tuberculosis failed to return for further treatment.

Last weekend, Dr. John Lewis of the Baltimore Health Department said he was hopeful that the city's much-praised TB control program will keep that scenario from appearing here. The city's tuberculosis clinic cares for 55 percent of all diagnosed patients in Baltimore. Nurses literally watch each patient take his or her medicine -- even if it means visiting the person's home or shelter.

Amid all the gloom about TB, there is some good news:

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First, about 95 percent of the people with healthy immune systems are cured if they take their medicine.

Medicine is also fairly effective for people with immune disorders such as AIDS. "If it's garden-variety tuberculosis, they respond very well," said Dr. Matuszak. "TB responds very well to treatment."

The "multiply drug resistant" strains are much harder to defeat, although assaults of more expensive drugs are sometimes effective. Those drugs are "slower, more toxic, more expensive and nowhere near as effective as standard therapy," notes Dr. Reichman.

The American Lung Association suggests skin tests for people who suspect they have been exposed to someone with tuberculosis. In this test, a nurse injects a small amount of tuberculin -- harmless protein from the TB bacterium -- into the skin. A raised, reddish area that develops within a few days is a sign of exposure.

Exposure doesn't mean the person has active tuberculosis. Doctors, however, may prescribe antibiotics to prevent the disease from developing.

For people with AIDS, the chances are much higher -- about 50 percent -- that TB will develop.

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You and tuberculosis what to do

You should get a skin test if there's any chance you've been exposed to someone with tuberculosis.

* In this test, a small dose of tuberculin, a harmless protein from the TB bacteria, is injected into the skin.

* A dime-sized area that turns red and hard means you have been exposed. (If your skin doesn't change in appearance, you have not been exposed.)

* A positive reaction doesn't mean you have TB. Your doctor may recommend a chest X-ray and sputum tests for a fuller diagnosis.

* Your doctor may prescribe drugs to prevent sickness. Whether you are sick with TB or taking drugs to prevent the disease, take all medications as prescribed.

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Other TB facts:

* Tuberculosis cases have only recently begun to increase in this country after many years of decline. But in developing nations, it remains the largest cause of death of any infectious disease.

* Infection is passed from person to person in airborne droplets produced by coughing and sneezing.

* Today, TB patients are usually treated outside the hospital. Most patients can stay on the job and remain with family and friends if they take medication regularly, as prescribed. Medication keeps the infection in check and keeps it from spreading to others.


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