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New York, NY
Dr. Schachter is Professor, Mt. Sinai School of Medicine.
Correspondence to: E. Neil Schachter, MD, FCCP, Department of Medicine, Mt. Sinai School of Medicine, One Gustave L. Levy Place, Box 1232, New York, NY 10029; e-mail: neils{at}msnyuhealth.org
Tuberculosis (TB) is an ancient disease that remains one of the most serious infections in the world. In 1990, the World Health Organization estimated that approximately 8 million new cases were active worldwide, the vast majority of which were in developing countries.1 Nearly three million people die annually from this disease.
The tubercle bacillus discovered in 1882 by Koch is currently considered the number one cause of death in developing countries.2 In the United States, TB was initially recorded as increasing as early as the 18th century, accounting for 300 deaths/100,000 in 1786 when statistics were first gathered in Massachusetts and climbing to 1,600/100,000 in 1800. The disease first appeared in the Northeast and spread to the Midwest, Southwest, and West. African Americans and native Americans experienced epidemics only later, in the wake of the spread of this disease. By the end of the last century, the prevalence of TB had peaked and mortality fell to 113/100,000 by the year 1920. At that time, it was still the second most common cause of death in the United States.3
The incidence of TB in the United States declined steadily until 1985, when the rate of newly reported cases was 9/100,000. The decline was seen as the beginning of the end for this disease in the United States; enthusiasm for research and resources allocated for the control of the disease dropped dramatically. As a result of this decline in vigilance, the country was ill prepared for the recrudescence of the disease as well as the more ominous emergence of drug-resistant organisms that began in the 1980s. Nearly a decade passed before the downward trend in new cases began once again.
LoBue and coworkers in this issue of CHEST (see page 1777) report on a 2-year experience with recent immigrants and refugees in the San Diego area, identified as persons possibly infected with TB in their country of departure. Ninety percent of those immigrants considered by the Centers for Disease Control and Prevention (CDC) as being high risk by a panel in the country of departure were rescreened in San Diego. Seven percent of these individuals had active TB, and 76% had latent TB (many of these with abnormal chest radiographic findings). Thus, the screening program had a very high yield of identifying active infections and of equal importance identified those at-risk individuals. Those with active TB were at a relatively early stage of their disease, usually noncavitary.
That is the good news. The bad news is that only a minority of foreign-born persons with active TB were identified by this program (12%). The program appeared much more efficient for Asian immigrants than immigrants from Mexico. What explains these deficiencies in the screening program? The authors point out that a significant number of immigrants do not complete the screening process even though they are initially identified as high risk. Secondly, they postulate that the screening program in the country of departure may be flawed either through error or through intent.
Unlike the situation for most of the people of the world, the TB problem in the United States is declining and has fallen steadily to its lowest level since 1992, with 5.2/100,000 cases newly reported cases annually.4 Complacency, however, should not lower awareness or decrease our respect for this formidable opponent. The experiences of New York City, as retold by John Murray,5 show that premature declarations of victory can be harmful to the health of the public. The relaxation of vigilance that occurred in the 1970s with a concurrent decrease in funding, led New York City, home to 3% of the nation’s population, to be a harbor for 14% of all those with registered active cases of TB. The same trends that resulted in this disproportionate concentration of TB led to an even more incredible statistic: 61% of all TB patients with drug-resistant TB were found in New York City.
A reservoir of TB is increasing in the United States. As documented by the CDC6 from 1986 to 1997, the number of TB cases among foreign-born persons in the United States increased by 56%, from 4,925 (22% of the national total) to 7,702 (39% of the national total). In their summary, they state, "The elimination of TB in the United States will depend increasingly on the elimination of TB among foreign born persons."6 The same may be true for drug-resistant TB. In resource-poor countries, inconsistent drug supplies for the treatment of TB, as well as a weak TB-control infrastructure, leads to inadequate treatment regimens and the selection of drug-resistant strains that become prevalent.7
The report of the CDC6 makes many recommendations. The issues are not simple and require attention to detail on both large and small scales.
The two findings that have been highlighted by the report of LoBue and coworkers should be given urgent attention. First, inadequacies of screening programs in the countries of departure that underreport TB should be reviewed and recommendations proposed. Second, a remedy should be sought for the long delay (median of 5 months) between the identification of high-risk immigrants in the country of departure and the rescreening here in the United States. As a country founded and defined by its immigrant populations, we need to ensure that this generation of new Americans enjoys the health benefits derived from the knowledge that their counterparts in earlier generations helped to develop.
References
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