It is arguably the most devastating disease in human history. It was found in the mummies of ancient Egypt; it was common in the time of Plato and Caesar; and it has taken the lives of the poor, the rich, the unknown and the famous for centuries. When the poet John Keats contracted tuberculosis in 1820, he knew there was no cure and called it his “death warrant,” dying at the age of 25.
Since then, antibiotics have largely tamed tuberculosis (TB) in the developed world. Over the past hundred years, consumption, as it was once known, has steadily declined. TB is now at an all-time low in the U.S., with fewer than 10,000 new cases reported in 2012. But in recent months, outbreaks have been reported among the poor, homeless and immigrant populations of several communities, including Jacksonville, Fla.; Sheboygan, Wis.; and Los Angeles County. A confluence of factors has public health officials worried that these outbreaks may become more widespread and harder to contain.
Could TB be coming back?
Federal support for health security research is heavily weighted toward preparing for bioterrorism and other unnatural biological threats, leaving significantly less funding for epidemics. “After 2001, a bunch of money went to bioterrorism,” wrote Shoshana R. Shelton, senior project associate with the Rand Corp. “I believe the money that goes toward bioterrorism should be used for more all-hazards performance.” While bioterrorism is an undeniable threat, she wrote, “naturally occurring disease outbreaks happen every day.”
What’s more, budget cuts and staff reductions continue to plague state and local health departments, making it harder for them to provide basic services and prepare for and respond to these everyday emergencies. Controlling a disease like TB depends significantly on rapid identification and reporting of active cases, but, Shelton wrote, “decreased staffing means decreased capacity to conduct disease investigations and fewer astute clinicians trained in TB.”
Dr. Jonathan Fielding, director of the Los Angeles County Department of Public Health, admits that a 37 percent reduction in funding since 1996 and about a 55 percent cut in staffing have been “problematic.” The county has answered the recent outbreak there with new TB guidelines for homeless shelters, including designating TB liaisons, creating “cough alert” logs for tracking patients with persistent coughs, and recommending that shelters screen incoming clients and refer them to health providers.
Will that be enough? “We are very concerned about drug-resistant TB,” Fielding says. “It is really important to treat people fully or there will be strains that are much more difficult to treat. We are still doing a good job as indicated by the overall declining number of cases, but I must admit I am concerned that we still have a number of suspects that have not declined. I hope state and federal government will realize that and contribute [more money].”
Ohio recognized the lurking TB problem back in 2009 and added a TB module to its disease reporting system. “We expanded beyond just the required data elements to include note and case management sections,” says Maureen Murphy-Weiss, TB controller with the Ohio Department of Health. “As TB has declined nationally, so has the lack of expertise. A large number of workers are retiring and that is where our knowledge base has been. TB requires a very specific skill set and knowledge base.” By building in real-time surveillance and case management, Ohio’s state health office will be able to monitor for TB and intervene early, mitigating the potential for further transmission of TB in the community.
Because overall TB control has been successful, “our guard is down,” says Murphy-Weiss. “We have to become creative in maintaining the infrastructure because history has shown us that when we believe we have conquered this disease, it comes back—and it comes back with a vengeance.”
Source of Infographic: National Tuberculosis Controllers Association survey of state and local public health TB staff between December 2012 and January 2013.