Fighting drug-resistant TB in New York City

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(This article is part of a series of articles on tuberculosis that I wrote for the Summer 2008 issue of NYU Physician.)

For a few weeks last summer, Americans were riveted by news that Andrew Speaker, then a 31-year-old Atlanta native, may have been flying on commercial airplanes, exposing hundreds of people to a virtually untreatable type of tuberculosis (TB).

They could be forgiven for having thought of TB as strictly a third-world disease. In 2006, 13,767 people in the U.S. had TB — the lowest prevalence in the country recorded since 1953 — while elsewhere 1.5 million people died of the disease.

Speaker was diagnosed in early May 2007, but against medical advice he flew to Greece for his wedding later that month. Tracked down in Rome on his honeymoon, he was told he had extensively drug-resistant tuberculosis (XDR-TB) and was asked to stay put.

Instead he and his wife, Sarah, flew to Prague and Montreal and then drove to New York City. On May 24, officials from the Centers for Disease Control and Prevention directed Speaker to report to Bellevue Hospital, where he was served with a federal warrant that isolated him for medical evaluation, the first such order issued in 44 years.

Bellevue is no stranger to TB. The hospital’s Chest Service, established in 1903 to treat the disease, has contributed a great deal of knowledge about its pathophysiology, clinical behavior, and treatment. In the late 1980s and early 1990s, Bellevue endured a long bout with this familiar foe, grappling with nearly 4,000 cases in New York City, many of them homeless people addicted to drugs and infected with HIV.

“I came here and I found everything was all TB and AIDS,” recalls William Rom, M.D., M.P.H., director of the Chest Service. He came to NYU in 1989 after a long stint at the Rocky Mountain Center for Occupational and Environmental Health, where his primary experience had been with coal miners and asbestos workers. Dr. Rom,
the Sol and Judith Bergstein Professor of Medicine and professor of environmental medicine, quickly discovered that TB treatment and care had barely changed since the 1960s, and that the available drugs were powerless against some new strains of M.Tb.

Multi-drug resistant (MDR) TB develops when patients don’t complete the prescribed six-month course of isoniazid and rifampicin. About one in 20 new cases of TB worldwide is resistant to first-line drugs, accounting for nearly 500,000 of the 9 million new TB cases reported each year, according to the World Health Organization.

Treating these strains is even more grueling and expensive: at least four drugs taken daily for up to two years. Not surprisingly, many patients miss doses 
or abandon treatment entirely, putting themselves and others at risk of developing the deadlier XDR-TB. It can take weeks to identify the few drugs to which a particular strain is still sensitive. “These have to be drugs the patient has never taken before,” explains Dr. Rom, “so you can be sure that they’re not resistant.”

Bellevue was one of only two hospitals in New York City with facilities to isolate those who failed to take their medicines regularly. Between 1993 and 1998, the city’s courts allowed Bellevue and Goldwater Memorial Hospital, which closed its TB ward in 2001, to detain more than 250 patients for the duration of their treatment. Dr. Rom took the important step of modernizing Bellevue’s TB facilities, outfitting the isolation rooms with HEPA air filters, negative air pressure, and UV lights to kill airborne bacteria.

Bellevue also instituted hospital-based Directly Observed Therapy (DOT), in which patients took their TB drugs in
the presence of a hospital worker. DOT is credited with turning the tide, slashing the number of cases from 3,800 in 1992 to roughly one-third that number today.

Ironically, the city’s epidemic afforded doctors the opportunity to apply advanced technology to an age-old disease.

Dr. Rom and his colleagues quickly became TB experts, leading rigorous stud- ies on the epidemiology of the disease and the treatment of drug-resistant strains. Of the 173 patients with MDR-TB admitted
by Bellevue between 1983 and 1994, 72 percent were cured with second-line drugs. In those also infected with HIV, however, the cure rate was only 20 percent.

More recently, researchers have made inroads into understanding the immune system’s response to M. tb, the effectiveness of linelazid and aerosolized interferon-gamma on XDR-TB patients, and the interaction between HIV and TB.

After only 72 hours at Bellevue, Andrew Speaker was flown to National Jewish Medical Center in Denver. His diagnosis, based on tests conducted there and at Bellevue, was later downgraded to MDR-TB. The city he left behind is home to nearly 1,300 people infected with TB, and Bellevue sees more than its fair share, including some with MDR-TB. “TB is a disease of poverty and immigrants,” says Dr. Rom. “There’s plenty of both in New York City.”

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