Big cities credit drops to HIV drugs, DOT
Centers with lots of foreign-born to plateau?
Across the nation, many big cities saw their TB caseloads continue to fall last year. Some cities with larger proportions of cases among the foreign-born saw less impressive declines than their counterparts with more cases of the "home-grown" variety, an informal survey of big cities conducted by TB Monitor found.
New York City saw its cases fall by about 10% last year, says Paula Fujiwara, MD, the city’s TB controller. Better treatment for HIV-infected patients has diminished the number of TB cases among the co-infected, she adds. "But the percentage of cases among the foreign-born is higher than ever, with not as much TB related to HIV. The face of TB is changing."
In Los Angeles, the drop was a more modest 3.6% — from 1,347 in 1997 to 1,299 in 1998. Though blessed with relatively small numbers of patients co-infected with HIV and TB, the city has a big pool of foreign-born residents latently infected with TB, thousands of whom receive preventive therapy at community-based organizations.
"We pay 10 places to screen foreign-born, and boy, can they yield the numbers," says Gayle Gutierrez, RN, MPH, lead nurse manager for the city’s TB and HIV programs. "We find that even people who are scared of the health department will still go to their culturally sensitive neighborhood clinics — and that’s been great."
In San Francisco, cases were down 14.5%. "That’s the biggest drop we’ve ever recorded," says Masai Kawamura, MD, who heads the city’s TB control division. "But I think we’ve probably hit rock bottom, and will plateau after this." Like its bigger neighbor to the south, San Francisco has many foreign-born residents, Kawamura adds. "Unless we build a high wall around the city, don’t let any planes fly in, and put every foreign-born person with a positive skin test on isoniazid — well, I predict we’ll continue to have TB in San Francisco," she says. "We could come down some more — but it’ll take resources."
Houston likewise saw a drop, from 623 cases in 1997 to 462 cases in 1998, says Kathy Penrose, RN, MPH, program services coordinator for TB control. "We always thought we’d get this drop," says Penrose. "We just didn’t think we’d get it all at once." A variety of factors helped bring it about, Penrose adds, including having 89% of all patients on directly observed therapy (DOT); starting initial contact investigations promptly within three to seven days; and the fact that TB controllers have finally completed a massive project that delivered 1,000 doses a week of preventive therapy to Houston’s tuberculin-reactive school children.
Big gains for Chicago
In Chicago, TB controller William Paul, MD, also cited a broad mix of reasons to account for his city’s impressive drop in cases — from 599 in 1997 to 470 in 1998. "We don’t have a dramatic story to tell like New York City, with massive infusions of funds overnight," says Paul. Instead, it’s been a long, steady haul for the Windy City, starting in 1993, when Chicago instituted DOT as the standard of care in its public health clinics.
The year afterward, Cook County Hospital also implemented DOT. Paul also credits a county program that provides special services to homeless TB patients. By providing temporary housing during treatment, the program result has helped boost completion rates among the city’s homeless to 95%, he adds.
A drop in TB among patients co-infected with HIV also has helped, Paul says. Cooperation and training sessions with HIV/AIDS programs have meant lots of little changes that have a big impact — for example, the city’s public health clinic staff are now capable of doing HIV testing themselves, so TB patients don’t get sent somewhere else for HIV testing.
Other cities reporting drops in last year’s TB caseloads include Atlanta, Miami, Detroit, and Baltimore.
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