My pregnant 25-year-old patient was understandably concerned when her tuberculosis (TB) skin test came back positive. Her brother had died of lung problems in Mexico after being sick for several months. It was probably TB, but the family didn't know for sure. Her illness was the first TB case diagnosed in a major outbreak in our rural Illinois community recently, but not the last. Between the public health department and my office staff, we discovered 12 cases requiring TB treatment in the surrounding area -- by far the largest breakout since I started practicing here about eight years ago. Several relatives and friends of the patient have tested positive, as well as some people with no apparent connection to her.
At first, my patient didn't understand what being exposed to this contagious condition meant. Already nauseous from her pregnancy, she had trouble sticking with the medication, which made her even more nauseous. She came down with an active case of the disease.
As her symptoms -- coughing, along with fever and chills -- worsened, the TB soon affected many aspects of her life. Her friends stopped visiting out of fear of contracting the infection. Her children were no longer welcome playmates at their friends' houses.
Many people in the U.S. think of tuberculosis as a disease of the last century that was eradicated, like smallpox and polio. Unfortunately, TB is still very much with us.
It's estimated that 1.75 million people died as a result of TB in 2003, with southeast Asia and Africa hardest hit, according to the World Health Organization. The disease is less lethal in the U.S., where the government has the money to provide life-saving drugs. In 2003 there were 14,852 cases with 704 deaths, according to data -- including some preliminary -- on the Centers for Disease Control's Web site (www.cdc.gov).
At my office, we see some TB patients who are recent immigrants, but they haven't accounted for all of the recent cases. A 65-year-old white man who has lived most of his life in central Illinois turned up positive recently. He wasn't feeling bad, but needed a test so that he could volunteer in the prison ministry for his church.
TB preys upon the sick and those weakened by malnutrition or other infections such as HIV/AIDS. Not counting people with HIV/AIDS, about 5-10% of infected people will become sick or infectious at some time in their lives, according to the WHO. Nine months of daily medication is often recommended to prevent this more serious form of TB from developing. It is estimated that only 25% of patients complete the full course due to side effects and the difficulty of taking medication every day.
In my patient's case, we didn't realize during her pregnancy that she had stopped following the regimen. Staff at the hospital noticed her coughing, but only after she delivered. The delivery-room nurses and I were all tested for TB. No one came up positive that I know of.
When someone has TB, the county public health department takes over their treatment and case management, but that's not always easy to do. Sometimes the person isn't home when they're supposed to be. The logistics of tracking down someone who doesn't speak English is tough. Engaging patients in the importance of treatment and follow up is another challenge.
Patients have to trust the government for the system to work. Some who need treatment the most avoid the scrutiny of the authorities because they have entered the country illegally or don't wish to draw attention to themselves.
The health department sends nurses out to homes to directly observe patients taking their medication. My patient is now on this observed-therapy regimen. Patients who won't take their medication can be ordered to by a judge, but we haven't had to take that step.
The cost of preventing a patient from developing active TB is not prohibitive by Western standards, at $10-$40 per treatment course. Drug-resistant TB treatment can be 100 times more expensive to treat. One way a patient can get resistant TB is if they fail to take the original course of medication as prescribed. A shorter, better drug regimen for TB is needed. My patient had to give up nursing her baby because the medications were causing jaundice and liver blood test abnormalities.
The developed world should take a greater interest in eradicating TB. As an affluent society, we are really only concerned about diseases that our money and status don't protect us against. Tuberculosis happens largely to poor, undernourished people, living in crowded conditions in the third world. Bird flu has the potential to kill anybody so there's money to be made off the fear of it. While we anxiously await the supposedly inevitable outbreak of bird flu, someone in the world is newly infected with TB every second, according to the WHO.
The market for TB drugs is large but not potentially lucrative. The TB Alliance, a global non-profit public-private partnership, started a Phase I trial of a new TB drug, PA-824, four months ago. If it becomes approved for generalized use, it would be the first new TB drug in 40 years.
For now, my patient waits for her long course of treatment to be completed and the world waits for safer, faster medications. Forty years has been too long.