- The Washington Times - Monday, March 6, 2006

Dr. Shmule Shoham says the District provides a “perfect storm” of circumstances for the potentially deadly disease tuberculosis to thrive.

The city’s high number of HIV-infected residents, combined with impoverished persons without access to consistent medical care makes an ideal climate for contracting the disease.

“We are very concerned about TB in the city,” says Dr. Shoham, an infectious disease specialist with the Washington Hospital Center.

Tuberculosis, a respiratory infection marked by incessant coughing and fevers, once ranked first in causes of death in the United States. The bacteria that causes tuberculosis typically hits the lungs hardest, but it also can spread to the kidney, spine and brain, according to the Centers for Disease Control and Prevention.

Nationwide, TB is at an all-time low, the CDC says, based on a 2004 report. Yet progress in fighting the disease may be slipping. Between 2003 and 2004, the rate of TB declined by just 2.3 percent, the smallest such slip in more than a decade.

Closer to home, the news is more grim.

The District, Dr. Shoham says, has one of the highest HIV rates in the country, which is like “adding gasoline to the fire” when it comes to TB.

“The cells which are the most important to keeping TB cells under control are the ones most affected by HIV,” he says. “If they’re on HIV therapy, their ability to control it is better.”

The CDC says the District reported 81 cases of TB in 2004, its most recent survey, and that the city’s population had a rate of 14.6 cases of TB per every 100,000 persons in the population. (In 2003, the rate was 14.2 cases.) Nationwide, the rate was 4.9 cases per 100,000 in 2004, or 14,517 total cases.

A person’s immune system is critical to keeping TB at bay. Many people exposed to the disease never develop it or have it in its “latent” stage. That means it could flare up if untreated, especially if the person’s immune system is compromised later by illness. Someone with a latent form of TB can’t spread the disease.

Dr. Mary Young, an infectious disease specialist at Georgetown University Department of Medicine, says tuberculosis is one of the few organisms that is “truly airborne.”

“It can suspend in the air for a period of time after a cough,” Dr. Young says.

Yet doctors still work with “archaic” methods for detection and treatment, she says, despite the ease with which it is inhaled and its inherent dangers.

No new drugs have been developed over the past 20 years, Dr. Young says. The existing medicines work, but they require significant treatment time, which, if not kept up, can hamper the patient’s recovery.

The initial test is equally antiquated, she says.

The PPD test, which stands for purified protein derivative, is a skin test that requires patients to wait up to 72 hours for a diagnosis. That gap can be crucial when District doctors are trying to treat lower-income patients who may not be able to return right away for diagnosis and treatment options, she says.

Once diagnosed, the patient with latent TB must take a single medication for months or start with a combination of four drugs for an extended period if he or she has active TB, she says.

If the medications aren’t taken as recommended, the particular TB strain can become resistant to the treatment.

“It can be eradicated. It’s a treatable disease. It’s just that this requires a much longer treatment course [than other illnesses],” Dr. Young says.

Dr. Gigi El-Bayoumi, associate professor of medicine at George Washington University Medical Center, says another factor putting the District at risk for TB is its international population.

Developing countries often have higher TB rates than other nations, and a percentage of immigrants from those lands end up in the nation’s capital.

A bigger concern stems from the very nature of how scientists duel with various bacteria. Eventually, doctors fear, tuberculosis strains may become immune to the current modes of treatment.

“There’s always that fear. If you look at more common bacteria, you see alarming rates of resistance,” she says.

Instances of multidrug resistance have cropped up in New York City, she adds, but it hasn’t happened yet locally.

“We’re keeping our fingers crossed,” she says.

The TB news isn’t as fragile in neighboring Baltimore.

Dr. Albert Polito, director of the Lung Center at Mercy Hospital in Baltimore, says the city hasn’t had the same intensity of TB outbreaks as its neighboring city has in recent years.

That’s despite the fact that Baltimore suffers from some of the same conditions as the District and other urban centers — poverty, crowded living conditions and patients with HIV.

Tuberculosis rates in Baltimore have been sinking consistently over the past 10 years, Dr. Polito says. He credits the city’s health department for dealing aggressively with the disease, particularly with its directly observed therapy programs in which patients are monitored closely.

Baltimore reflects the nationwide trend that stands opposite to the District’s TB woes.

“As a whole, the country is in better stead than we were 15 years ago [with TB],” Dr. Polito says.

Tuberculosis cases flared nationwide during the early 1990s when the AIDS crisis was at its peak. Back then, multidrug-resistant strains of TB gripped the country, a problem long since eradicated.

Dr. Polito worked at Bellevue Hospital in New York City at the time, “and the number of cases we had was astounding compared to five years before,” he recalls.

With early, consistent treatment, the majority of patients will have the bacteria eradicated from their systems.

While society continues to follow breakthroughs in cancer treatments and heart-healthy diets, tuberculosis remains a stubborn disease that shouldn’t be ignored.

“People in this day and age still can die from tuberculosis,” Dr. Polito says, adding that the disease has a nasty way of roaring back after periods of relative inactivity. “Never say never with TB.”

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