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Boston dodged a bullet with tuberculosis in the 1990s — might we do the same with COVID-19 today?
Short answer: Probably not.
COVID-19 case numbers are rising, we’ve transformed our entire health-care system and hospitals in preparation for a further surge, and we are watching the experience in other cities with great concern. We must prepare for the worst.
But it’s worth going back to the major TB outbreaks in the early 90s, which occurred predominantly in large urban areas — especially New York — yet remarkably spared Boston.
Why were we so lucky? Is there anything we can learn from our response to help us with the current pandemic?
I believe the answer is yes. What that experience taught us was the critical importance of a robust and coordinated public health response.
First, some TB history: Starting in the early 1950s, the United States reported a steady decline in annual tuberculosis cases due to effective treatment and coordinated public health measures such state-provided medications, community-based nursing support, and contact tracing. This downward trend, however, stopped in the mid-1980s — and then cases increased in the early 1990s, startling everyone.
As noted in this excellent review, several factors contributed to this disturbing reversal: the arrival and spread of HIV infection; immigration of people from high-prevalence countries; the development of “hot spots” (such as hospitals, shelters, and prisons) where tuberculosis flourished; and the deterioration of tuberculosis control.
It’s that last one where Boston separated itself from several other urban sites, which is why I put it in bold. Reduced federal funding decimated many tuberculosis control programs, especially in New York. The timing could not have been worse, as this occurred right as the incidence of HIV peaked.
With staffing and support at an all-time low, many outpatient TB control programs closed, leaving patients without support or oversight. Since TB treatment consists of six months of complex multi-drug therapy, patients often took partial doses that not only were ineffective but provided the perfect context for selecting drug-resistant strains — strains that then could be transmitted to others in hot spots.
Meanwhile, up here in Boston, we infectious diseases specialists expected these TB cases to make their way north on the highways — it seemed only a matter of time. I recall seeing a woman with HIV and TB admitted to our hospital in 1992 and thinking it was the beginning of the surge.
But it never happened. Our annual TB case numbers remained about the same through the early 1990s, then started declining again. And my experience with this young woman gave me a clue about why.
Once we discharged her from the hospital, Boston’s TB control program kicked into high gear. Perhaps motivated by a bad TB outbreak among homeless individuals in the mid-1980s, the public health officials responsible for TB control in Boston have the same determination and focus as a dog sniffing a steak on a grill. You cannot distract them.
The public health nurse tracked her — and me! — relentlessly. She made absolutely sure my patient never missed a dose of her TB drugs, often doing home visits to watch her take her medicines. She paged me so frequently with updates that I memorized her office phone number during the first month of treatment.
My patient was a relatively “easy” case. For the most challenging TB patients — those with homelessness, psychiatric illness or substance use disorder — Boston offered voluntary long-term hospitalization to complete TB treatment. A small fraction of individuals were kept in the hospital against their will, but only after demonstrating a clear threat to public health. This aggressive program achieved remarkable success in controlling TB in our city.
Yes, COVID-19 poses additional infection control challenges that TB doesn’t — it’s contagious even from people with few symptoms, can be spread by both the respiratory tract and contaminated surfaces, and of course it is spreading far faster than TB ever has. Massachusetts already has nearly 8,000 cases, with hospitalizations increasing rapidly. This will not be an easy task for us, and some have argued that it's too late for the contract tracing proposed by Governor Baker.
However, some of the lessons from our successful TB control programs should not be forgotten. It will be the low-tech personal and public health interventions that will get us through this epidemic in the short term, not antiviral therapies or vaccines. Perhaps — only perhaps — the data are early — we are seeing some of the first hopeful signals that our efforts are working.
Examples include rehabilitation facilities specifically for those recovering from COVID-19, opening more beds for homeless people, and creating heated tents for those under evaluation so they can be isolated from others. Self-quarantine advisories for visitors arriving from out of state is another, as are designated respiratory illness clinics, staffed by health-care providers with sufficient protection and who have ready access to testing.
And yes, ongoing social and physical distancing for a while — the marathon part of our response. Boston has impressive public health talents. Now is the time to use them.
Dr. Paul Sax is the clinical director of the Division of Infectious Diseases at Brigham and Women's Hospital, Professor of Medicine at Harvard Medical School, and blogs on infectious disease here.
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