TB Rears Its Head in the City. Should We Worry?

“With most diseases, we’d say ‘that’s your problem.' With TB, it’s everybody’s problem.”

A report released Saturday by the New York City Department of Health indicates the number of citywide confirmed tuberculosis cases increased by 10 percent in 2017—the largest uptick in 25 years. How much should we be worried?

 

Are New Yorkers at risk?

Public health experts say the rise in TB is not so much a cause for panic and as it is a reminder that TB—an airborne infection, usually in the lungs, that can be fatal if left untreated—could return to the city without enough funding and infrastructure to fend it off.

The 2017 rise in active tuberculosis cases to 613 pales in comparison with 1992 rates, when there were 3,811 cases in the city. Although TB is up 10 percent this year from last, it is down 85 percent from that modern peak in 1992. And the current spike is not a result of the disease being transmitted from person to person, health experts say, so the city is far from being en route to an epidemic like the one that began to threaten the city in the late 1980s.

Source: NYC Bureau of Tuberculosis Control

Source: NYC Bureau of Tuberculosis Control

Dr. Neil Schluger, an epidemiology professor at the Mailman School of Public Health at Columbia University, said current research shows tuberculosis is only transmitted after a prolonged period of sharing the same air with someone who has the active form of the disease. So homes and other confined indoor spaces, like homeless shelters and prisons, are the places where the disease is most likely to spread.

“People always ask me if they can contract tuberculosis on the subway,” Schluger said. “I always say there are about 100 things I’m more worried about than getting TB.”

 

What accounts for the new cases of TB?

Schluger said most of the new cases in the city and in the country as a whole result from an activation of latent tuberculosis, a dormant form of the disease. When TB is dormant, the patient is neither contagious nor exhibiting symptoms, and the disease can go undetected. Though there is no official count, surveys show that about 1.5 percent of U.S.-born individuals and about 15 to 20 percent of immigrants in the U.S. have latent TB.

About 10 percent of those individuals will eventually get the disease in its active form. Schluger said there isn’t really a rhyme or reason to who develops active TB, but those with weakened immune systems—from HIV, out-of-control diabetes, or the result of suppression by medical treatments—are more susceptible. People younger than 5 or older than 85 are also at a greater risk.

But anyone can get it. “It’s just sort of bad luck,” Schluger said.

Experts also blame the continuing decline of TB funding as a factor in the increase. The city received a huge influx of money at the height of the city’s tuberculosis epidemic in 1992, but funding was reallocated as the caseload decreased. Schluger said the city used to have 11 clinics open five or six days per week, but only four remain—two are open six days per week and two are open two or three days a week. Clinics that are free to the public treat more than half of the city’s patients diagnosed with TB.

“The increase is a real warning shot across our bow,” Schluger said. “Let’s not cut anymore and restore the budget.”

 

Is immigration a factor in the rise of TB?

In 2017, immigrants made up 86 percent of tuberculosis cases in the city, but experts are quick to say they are not to blame. Schluger said all who come to the U.S. legally are screened for symptoms of tuberculosis before they emigrate, and those who test positive cannot travel here. But the screen does not detect latent TB, so some with that form of the disease do immigrate. On average, they live in New York City for about seven years before developing signs of active TB.

“It’s certainly not a reason to build a wall or close the border,” Schluger said.

Tuberculosis is the leading cause of death by infectious disease worldwide, accounting for more than 1.6 million deaths in 2016, according to the World Health Organization. More than a quarter of the world’s population has TB in its latent form. The disease, which is both preventable and treatable, surpasses the fatality rates for malaria and HIV. While the U.S. sees very few cases—especially compared to countries like China, India, and South Africa where TB is endemic—the incidence rate in New York City is more than twice the national average.

The report released by the city’s Bureau of Tuberculosis Control found that China, followed by the U.S., Mexico, and India, are responsible for the highest number of cases in the city in 2017. Immigrant populations account for higher rates of TB in neighborhoods like Western Queens. Sunset Park in Brooklyn has the highest rate, with 19 patients born in China, five in Mexico, and two in the U.S.

Source: NYC Bureau of Tuberculosis Control

Source: NYC Bureau of Tuberculosis Control

The vaccine for tuberculosis, first developed in the 1920s, is not used in the U.S. because researchers saw mixed results during testing. Barun Mathema, a Mailman professor who researches the transmission of tuberculosis, said the vaccine is believed to prevent the most extreme cases of tuberculosis in children, so it’s commonly used in countries where that’s a major concern.

 

What does TB funding pay for?

Mathema said the disease is costly to treat. Thus, funding fluctuations impact both the availability and depth of care patients with TB receive. Studies indicate the response to the city’s worst outbreak in the late 1980s and early 1990s cost about $1 billion. City, state, and federal resources brought in $40 million in 1992 alone. Since then, the total funding has been cut to about $14.5 million. It was easily double that about a decade ago, Schluger said.

The money is used for a variety of programs—city clinics, house visits, what is called contact tracing and directly observed therapy, and more. Anyone who is diagnosed with TB must be reported to the city, which will dispatch an employee to the hospital for an interview to find out who the patient has been in regular contact with. Employees from the Bureau of Tuberculosis Control then follow up with visits to the patient’s home and workplace to understand who else may have been infected—a process called contact tracing. After being discharged from the hospital, patients are closely followed, including in directly observed therapy, which in which city employees ensure patients continue to take their medication.

Mathema said directly observed therapy is crucial to tuberculosis control because patients who stop taking medication when symptoms wear off instead of staying the course may fall ill again, develop drug resistance, or transmit the disease to others. But it’s a hard sell, because treatment involves antibiotic therapy that can range anywhere from six to 24 months. And the pills make you feel lousy, Mathema said.

But it’s important. “With most diseases, we’d say ‘that’s your problem,’” he said. “With TB, it’s everybody’s problem.”

 

What led to the epidemic that peaked in 1992?

Studies show the tuberculosis epidemic that devastated the city in the late 1980s was largely homegrown rather than immigration-related. Schluger said the AIDS epidemic, social chaos, prison overcrowding, and a large homeless population contributed to the rapid transmission of disease. By 1992, the city had 3,811 confirmed cases of tuberculosis, disproportionately affecting young black children and black men between 35 and 44.

X-rays from a tuberculosis patient at A. G. Holley Hospital in Lantana, Fla. (Photo via AP)

X-rays from a tuberculosis patient at A. G. Holley Hospital in Lantana, Fla. (Photo via AP)

Where there’s poverty, there’s a higher risk of infection. Mathema said poverty can often be used as a stand-in for overcrowding, bad air quality due to poor ventilation, lack of housing, diabetes, and substance-abuse habits that negatively impact immune regulation—all of which increase the risk of getting TB. These are the same issues that explain today’s cases of tuberculosis in patients who are American-born, Schluger said.

Schluger, who ran the tuberculosis clinic in Bellevue Hospital from 1992 to 1998, called the height of the epidemic “really overwhelming.” Bellevue alone was treating 500 patients with TB at the time, and Schluger saw upwards of 50 every day. But the effort went beyond medicine. Nurses, social workers, and housing service employees all worked to get patients the help they needed so they could stay on medication and keep from spreading the disease.

Despite the immense financial and human cost, the city’s response to the epidemic is lauded as one of nation’s greatest public health victories. Schluger said a “public health army” descended on New York City, and Mathema called the efforts “absolutely remarkable.”

“The health department was a phoenix rising from the ashes,” Mathema said.

Since then, cases have dropped by 85 percent and the city’s tuberculosis control program is one of the best in the world, Schluger said. “A child born today in New York City should never get TB,” he said.

 

What will the city do now?

In a statement released Monday, the city’s Department of Health said officials are concerned about the rise of TB cases in the city, and would work to ensure fast, equitable access in the disease’s diagnosis and treatment. “It will require a coordinated public health response, coupled with the city’s robust health care infrastructure,” said Dr. Joseph Burzynski, assistant commissioner for the Health Department’s Bureau of Tuberculosis Control.

When asked about specific measures the health department planned to implement, a spokesperson passed along a copy of the original report.

 

What else can be done?

Schluger said restoring funding to the city’s tuberculosis control efforts is integral to the elimination of the disease. But he added that the city should also work with health care centers in communities with large immigrant populations to increase awareness of the issue.

As a precaution, doctors recommend screenings for those who have been in contact with infected individuals and people who come from a country where TB is prevalent, to detect not only active TB but also the latent form of the disease. Those who are aware they have latent TB tend to more quickly seek care for symptoms—like fever, cough, and weight loss—that may indicate an activation of the infection.

Experts say that city clinics should also assuage any concerns of undocumented individuals worried that seeking medical help could result in a report to Immigrations and Customs Enforcement. Schluger emphasized that facilities will not ask about an individual’s status in the U.S. and will offer care to anyone who needs it, free of charge.

To address the remaining cases of homegrown tuberculosis, the city needs to address poverty. Mathema said better drugs would certainly help, but improving social conditions is the best thing officials can do.

“Tuberculosis is very intricate,” Mathema said. “It’s woven into the fabric of society.”

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