A New Face For An Old Nemesis

Tuberculosis. The word conjures up faded images of 19th-century sanatoriums. Once America's leading cause of death, TB was subdued by potent new drugs during the 1950s and all but forgotten by 1980. Now, thanks to AIDS, poverty and a collapsing health-care system, the old scourge is returning in new attire. The caseload has exploded in some East Coast cities, and recent outbreaks have involved deadly new strains. Last summer health officials reported that drug-resistant TB had swept through four hospitals in New York and Miami, killing many of the 147 patients it struck. And New York prison officials disclosed last week that a new TB strain has caused 14 deaths at two state facilities. Patients and prisoners aren't the only ones in danger. As prison commissioner Thomas Coughlin observes, "Their health problems reflect those faced by the community at large."

TB spreads on airborne droplets. Anyone sharing a poorly ventilated space with a coughing sufferer can contract the culpable microbe (Mycobacterium tuberculosis). Only a small fraction of those infected develop active TB, since the body's defenses keep the bug in check. But when the immune system is compromised by age, illness or immune-suppressing drugs, the germ starts to multiply. And as that happens, the body attacks it with enzymes that are toxic to the lungs and other organs.

Antitubercular drugs can stop the disease in its tracks, or even prevent its onset, by clearing the bug from the body. But success requires taking several drugs for six months or more. When treatment is sporadic or too brief-a common problem among patients who lack jobs, homes or regular access to health care-it kills only the most vulnerable of the invading germs. Resistant specimens survive and get passed along, making the next generation of patients harder to treat. Eventually, the process yields a bacterial strain that some medications can't touch. When a resistant strain infects people already weakened by the AIDS virus-as happened in the recent hospital and prison outbreaks-the death rate can exceed 70 percent. The odds are better when the illness isn't complicated by HIV; 50 to 70 percent of those cases are curable. But the treatment takes years and can cost hundreds of thousands of dollars per patient.

Drugresistant strains still account for only a small fraction of all TB cases, but in New York City that fraction has doubled since the early 1980s. A new study by city and federal health officials shows that 23 percent of this year's new cases were resistant to at least one drug, up from 10 percent in the early '80s. "We knew how to says Dr. Michael Iseman of the National Jewish Center for Immunology and Infectious Diseases. "But we dropped the ball by not ensuring proper treatment. We have squandered a precious legacy."

For health and prison officials, the immediate challenge is to identify and isolate patients who are contagious. Because the same drug-resistant strain has recently turned up in two New York prisons-one in New York City and one near Syracuse officials fear that transferring inmates may have seeded other facilities as well. "We have to determine how it got from point A to point B and who carried it," says prison spokesman James Flateau. To help prevent such outbreaks in the future, officials have ordered the system's 60,000 inmates and 28,000 employees to undergo annual skin tests for TB infection. Prison employees working in high-risk areas such as infirmaries will be retested every six months. Anyone testing positive will be offered treatment and checked regularly for active disease. And those stricken win be quarantined for supervised treatment.

The risk to the general population, though real, is still too small to warrant emergency measures. Some big-city school districts are calling for annual TB skin tests, which are cheap and easily administered. But the American Academy of Pediatrics recommends routine testing only for kids from stricken households or from high-risk demographic groups, such as Native Americans and immigrants from Asia, Africa, the Middle East and the Caribbean.

Experts warn that without prompt action, TB could decimate some segments of society. Unfortunately, America has stopped thinking of the illness as an emergency. Drug companies quit devising new treatments 20 years ago, after the disease became curable. Slow sales have since pushed the antibiotic streptomycin, one of a dozen traditional mainstays, off the market. And because few TB clinics use up-to-the-minute technology to analyze patients' germ samples, the task of identifying a drug-resistant strain often takes weeks rather than hours. At the same time, public funds for infection control remain scarce, even as the TB caseload grows. New York City sought $15 million in federal TB assistance last year and got $600,000. At that rate, experts say, the return of the sanatorium is a real possibility in some cities. Welcome to the 20th century.

PHOTO: Trying to track the contagion: New York prison officers now receive annual TB tests (DAVID CANTOR-AP)

YEAR                  Total Number of TB Cases in N.Y. City      


1960                  5,000

1970                  2,500 

1980                  0

1990                  3,500