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April 1, 2002


University Physicians At Grady On Cutting Edge of Infection Control and Research for Tuberculosis

Physicians at Grady Health System have developed a cutting-edge tuberculosis control and research program to fight the disease burden of TB in Atlanta, which in some areas rivals the rate of incidence found in developing countries.

"We care for a lot of patients with TB, so we really have to be prepared and we must have excellent TB infection control, which we do have at Grady," said Henry M. Blumberg, M.D., associate professor of medicine with the Emory University School of Medicine, Division of Infectious Diseases, and hospital epidemiologist at Grady Memorial Hospital. "Our program has been recognized nationally to be a leader in TB infection control."

With regards to research, Emory is leading the way. In October 2001, the Emory University School of Medicine received funding for a new, 10-year, $4 million study as part of the Centers for Disease Control and Prevention (CDC) Tuberculosis Epidemiology Studies Consortium. The Emory-Georgia Department of Health and Human Resources partnership is one of 22 sites across the country to receive funding for the CDC-sponsored epidemiology studies. The partnership also involves Fulton and DeKalb county health departments and Grady Health System.

Emory physicians, including Sophie Lukashok, M.D. and collaborators Mark Feinberg, M.D., and Jon Altman, M.D. at the Emory Vaccine Center, are also working on efforts to develop new diagnostic tests for tuberculosis to replace the tuberculin skin test for the diagnosis of tuberculosis infection. Other applied research studies being carried out by Emory investigators include molecular epidemiologic (DNA fingerprinting) studies of TB isolates, or TB strains, recovered from patients in Atlanta. The Emory University School of Medicine is also collaborating with the former Soviet Republic of Georgia to examine TB rates and drug resistance as well as transmission dynamics in that country.

Controlling tuberculosis infection remains a major priority among Emory University physicians at Grady Hospital. In an effort to prevent TB transmission in healthcare facilities, Grady employs a hierarchy of TB infection control measures including administrative, engineering and respiratory protection. The most important include administrative controls, by which physicians and other health care workers perform careful screening and early identification of patients with TB. Patients with or at risk for TB are isolated upon admission, and all health care employees are given TB skin tests annually. Grady isolates between 1,200 to 1,500 patients each year with only about 10 percent of the patients who are isolated at Grady are diagnosed with TB. This approach, however, results in the early identification of the vast majority of patients seen at Grady who are subsequently diagnosed with active TB.

Grady also has a 26-bed respiratory isolation ward, which has increased efficiency in evaluating patients admitted to respiratory isolation to "rule out" TB, and in treating patients. There also are specially engineered, negative pressure rooms, where air is passed through a filter before being re-circulated or exhausted to the outside of the hospital.

Tuberculosis is especially problematic among the patient population served at Grady with very high rates of TB in the communities surrounding the hospital, which cared for about 130 patients with active TB cases in 2001. In 2000, Georgia TB cases increased to 703 cases from 665 in 1999 and Georgia was one of only three states where the numbers of reported cases increased. In 2001, however, TB rates in Georgia decreased by 18 percent, to a total of 575 cases.

"TB remains a problem in certain areas," Dr. Blumberg said. "There are very high rates of TB in the inner city, and we're seeing as much TB as almost half of the states in the U.S. at Grady."

Tuberculosis is a treatable, communicable disease that has two general states: latent infection and active disease. Only those who develop active tuberculosis in the lungs or larynx can infect others, usually by coughing, sneezing, or otherwise expelling tiny infectious particles that someone else inhales. Symptoms of TB can include weight loss, fever, night sweats, and occasionally blood in the sputum.

The southern United States has the highest rates of TB in the U.S. and continues to have rates of TB higher than the national average. In 2000, Georgia had the fifth highest rate of tuberculosis in the country; by 2001, it had fallen to seventh highest.

"The reasons for the high rates of TB in Georgia and the south are mixed some that we know and some that need further investigation and elucidation," Dr. Blumberg said. "Demographics, economics, and access to health care are key factors making the rates of TB higher in African Americans. Other causes include poverty and links to HIV, and a variety of other reasons as well."

In Atlanta, the facts are startling. If Grady Memorial Hospital were a state, for example, it would rank 28th in the country for the number of tuberculosis cases reported. The epidemiology of TB is different in Atlanta and many southeastern states compared to other parts of the nation with rates of tuberculosis that are higher than the national average and, with most cases occurring among U.S.-born persons who are African Americans, according to Dr. Blumberg and Carlos del Rio, M.D., chief of medicine at Grady Hospital.

In a Nov. 15, 2001 letter to the New England Journal of Medicine, Dr. del Rio and Dr. Blumberg point out that the number of tuberculosis cases in Georgia increased between 1998 and 2000 despite decreasing in the United States and most states. The rates of disease in some areas of Atlanta, for example, exceed 100 cases per 100,000 persons per year, similar to the rates in developing countries. Tuberculosis also is not a Medicaid-eligible disease in Georgia (as it is in all of the other high-incidence states), thus Grady Health System has annually provided more than $1.5 million of uncompensated care to patients with tuberculosis.

Patients with active TB are initially treated with a four-drug regimen (Isoniazid, Rifampin, Pyranizamide, Ethambutol) and therapy takes a minimum of six months. In addition, directly observed therapy (DOT), which involves health department staff directly observing a patient take medication, is typically considered for all patients with active disease, since it is difficult to predict a patient's adherence to therapy and data shows that DOT is the most effective way to ensure patients are rendered non-infectious and cured of the disease.

The best way to measure the effectiveness of therapy for pulmonary TB is monitoring patients bacteriologically through sputum examination at least monthly until conversion to negative culture. If a patient's sputum cultures remain positive beyond two months of therapy, there is a possibility of drug-resistance disease. When multidrug resistant (MDR) disease is present, it is much more difficult to treat patients and therapy has to be continued for up to two years. Grady and the state of Georgia, fortunately, have relatively low rates of MDR-TB; at Grady this is in the range of 1 percent.

Blumberg said Georgia is starting to see more cases of foreign-born TB, but unlike many states, the large majority of cases of TB still occur in U.S.-born persons. In 2000, for example, 46 percent of tuberculosis cases in the United States occurred among foreign-born individuals and by 2001, half of the TB cases in the U.S. occurred among foreign-born persons. In Georgia, however, the proportion of TB cases occurring among the foreign-born was less than 25 percent.

"Within the next year, the majority of the TB cases in the U.S. will be among the foreign born," Blumberg noted. "This just reflects the huge, global public health problem associated with tuberculosis."

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