Fred M. Jacobs, M.D., J.D. CommissionerDepartment of Health and Senior Services

The Evolution of TB Treatment: A Personal Perspective

Northeast TB Controllers MeetingOctober 24, 2006Nassau Inn, Princeton

Medical School • University of Miami School of Medicine

- - 1958 - 1962• Pulmonary Disease as a Specialty:

- - TB or Clinical Physiology• Pulmonary Function @ University of

Miami Jackson Memorial Hospital

Chief Resident in Pulmonary Diseases 7/01/66 - 6/30/67:

• Set up conferences• Pulmonary Grand Rounds:

- - 2 hours: - - 1 guest speaker - - 2 cases presented

• Rounds with House staff • Consulting Rounds; general medical floor

Kings County Hospital Center, BrooklynLate 1960s “E” Building

• Big, high - volume TB , 700 beds, all Chest• 6 to 8 far advanced, active, cavitary cases per day, every day. • MDs from as far as Philippines to observe • Two 58 - bed units for men• One 58 - bed unit for women• One 58 - bed non -TB chest disease floor•. Pediatric TB, Thoracic Surgery, Chronic

Care

The Great White Plague• Mycobacterium tuberculosis isolated by

Robert Koch in 1882 • The great illness of the time• “cheesy white” material in middle of

infection• Doctors were passionate about treatment • NO ICUs

Sanitariums: 1900 - late 1960s• TB was managed by putting people in sanitariums• Naturally Isolated• Fresh, cold mountain air & pure water = therapeutic• Trudeau Sanitarium opened 1918 on shores of

Saranac Lake deep in Adirondack Mountains, NY • National Jewish Hospital near Denver• Glen Gardner pastoral hilltop, Hunterdon County • Deborah Heart & Lung in Browns Mills opened 1922 • Essex Mountain Sanitarium in Verona

Essex Mountain Sanitarium• Opened 1917• 4,000 patients• “Colorado Springs of the East”• Crest of Second Mt.• 50% recovery rate• Dozen buildings• 200 - acre campus• Prisoners of nearby penitentiary worked farm; grew vegetables•1977—last patient released

Essex Mountain Sanitarium

J. N. Adam Memorial Hospital TB Sanitarium Buffalo, NY 192Os

Sanitarium Patient Care Team 1917

Sanitariums Nurses 1930s

First Effective Therapy for TB • Discovery of Streptomycin (SM) in 1944• Para-amino salicylic acid (PAS) in 1946• Isoniazid (INH) in 1952

- - bacterial resistance when used alone• Disease now viewed as treatable, preventable

and eradicable• However, still remains major global threat

Annals of Internal Medicine• U.S. TB death rates decreased from 194 per 100,000

in 1900 to 40 per 100,000 persons in 1945• 1945, 63,000 persons died of TB and 115,000 new

cases• TB drugs, Sanitariums, non-surgical & surgical

collapse therapy, & resectional surgery widely used• Sanitariums closed; TB is mainstream disease• As mortality and morbidity decreased, government

decreased funding for TB & states, cities downgraded programs

TB Morbidity by Decade

Bilateral Plombage Thoracoplasty w lucite spheres

Far Advanced Cavitary TB

Cavitary TB Patient 3 Years after Treatment

Regression after treatment with Viomycin, tetracycline & ethionamide and pyrazinamide

Modified Thoracoplasty

Left apical disease showing first rib left in position and the 2nd, 3rd, & 4th ribs turned inwards to form a solid new roof

14 Months After Treatment w PAS, SM & INH

• 2000 - 565• 2001 - 530• 2002 - 530• 2003 - 495• 2004 - 482• 2005 - 485

TB cases in New Jersey:

DHSS TB Program • DHSS historically used 80 - 85% of total

funding for direct patient care activities• Funding expected to be stable thru June 2007• SFY 2008 funding may decrease $550,000• Clinical consolidation & regionalization will

increase efficiency & improve quality of care• State support only for regional clinic services

DHSS TB Program• To ensure protection of the public health

TB program will provide drug coverage to ensure no patient with TB goes untreated due to financial considerations

• Public health field staff can provide patients under private care with DOT to increase likelihood of adherence of treatment

MDR-TB On The Rise• 2004 – 3 cases in NJ• 2005 – 10 cases in NJ• We are not going to be able to control TB in

U.S. unless we control it overseas• Rate ratio TB in foreign born to U.S.-born

persons increased 6.6 % a year 1993-2002• TB rate in foreign born in 2005 was 8.7

times that of U.S.-born persons (MMWR 3/06)

A cautionary warning:

• If we are not careful—with additional cutbacks and inability to control TB in foreign born—we may experience a rise in TB incidence similar to what we saw in the early 1990s