PREVENTING RELAPSE Lee B. Reichman, MD, MPH Northeast TB Controllers Meeting October 24, 2006 Princeton, New Jersey

Reported TB Cases United States, 1982–2005 Year No. of Cases

Trends in Tuberculosis – United States, 2005 Deceleration of the decline in the overall national TB rate, the persistent disparities in TB rates between U.S.-born and foreign-born persons and between whites and racial/ethnic minorities, and the increase in MDR TB cases all threaten progress toward the goal of TB elimination in the United States Effective TB control and prevention in the United States require sufficient resources, continued collaborative measures with other countries to reduce TB globally, and interventions targeted to U.S. populations with the highest TB rates

The U-Shaped Curve of Concern

Tuberculosis: No Longer a Problem? CDC TB Related News Items Weekly Update 6 month sample: October 1, March 31, articles from 33 states on all aspects of TB 76 reports of TB outbreaks: (almost 1 every 2-3 days) –Schools and colleges38 –Prisons8 –Hospital/Nursing Home7 –Workplace16 –Homeless7 - J. Seggerson, NCET WIRE, April 2004

Federal News Radio

CNN

NBC 4

Results

TB Onboard

XDRTB 1539 Patients with Isolates sent 544 Culture-Positive for M.Tb –35% of total 221 Resistant to Isoniazid & Rifampin (MDR TB) –40% of M.Tb and 14% of total 53 Resistant to all tested drugs (XDR TB) –24% of MDR TB, 10% MTB and 3% of total -G. Friedland, Int Conf on AIDS, 2006

XDRTB Patients Prior TB Treatment or Hospitalization CharacteristicsXDR TB Patients n (%) Prior TB Treatment: No prior TB treatment26 (51%) Cure or completed treatment14 (28%) Default or Treatment Failure7 (14%) Prior Hospitalization:32 (64%) -G. Friedland, Int Conf on AIDS, 2006

XDRTB Mortality 52 of 53 (98%) of XDR patients have died Median survival from date sputum collected was 16 days (IQR days) –No significant difference by HIV status, previous or use of ARVs -G. Friedland, Int Conf on AIDS, 2006

The New York Times September 14, 2006 EDITORIAL: Extreme Tuberculosis More funding is needed to catch up with new, extensively drug-resistant strains of tuberculosis.

Patient Involvement in Medical Care Patients and their families have become increasingly involved— and influential—in all aspects of medical care In the mid-eighties, as the first anti-viral drugs for treating AIDS were being developed, activists demanded to participate in the design of clinical trials directed by the National Institutes of Health and pharmaceutical companies Inspired by the activists’ example, breast cancer patient- advocacy groups made similar requests The AIDS groups interrupted meetings and staged “die-ins” at the N.I.H. Eventually, the physicians in charge of planning the clinical trials agreed to their demands Laypeople now routinely sit on committees on the N.I.H. and on hospitals’ institutional review boards, which assess the ethicality and scientific merit of clinical trials

The Patient’s Charter for Tuberculosis Care

Initiated and developed by patients from around the world Outlines rights and responsibilities of people with tuberculosis Sets out the ways in which patients, the community, health providers (both private and public), and governments can work as partners in a positive and open relationship Practices principle of Greater Involvement of People with Tuberculosis Affirms that empowerment is catalyst for effective collaboration with health providers and authorities

Patient’s Rights You have the right to: Care; Dignity; Information; Choice; Confidence; Justice; Organization; Security

Patient’s Responsibilities You have the responsibility to: Share information; Follow treatment; Contribute to Community Health Show Solidarity

Deaths Due To: TB (annually)2 - 3,000,000 SARS813 Angola Marburg Hemorrhagic Fever 329 Avian Influenza144 Anthrax5 Mad Cow Disease1 (Cow) Smallpox0

Reichman’s Prediction The continued rise of the TB in the world and the leveling off of tuberculosis in the US portends a significant global resurgence of TB followed by a frightening resurgence of MDRTB still diagnosed and treated with old tools The resurgence will continue unabated followed by subsequent transmission to healthcare workers and through that vector to the community at large Subsequent global re-establishment of control of tuberculosis will then entail more staggering costs, both in cash and hysteria than has ever been contemplated New drugs and New Diagnostics and an effective vaccine will enhance the TB community’s success in turning this around which once again will depend on energizing others to make our case

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