Waging war on a resurgence of TB Baltimore's simple visiting program has become a model for the nation

January 31, 1993|By Jonathan Bor | Jonathan Bor,Staff Writer

With tuberculosis staging a national resurgence after thre decades of decline, Baltimore has guarded itself with a low-tech program that some federal officials cite as a model for urban America.

From New York to Miami, health officials are voicing concerns that tuberculosis could soon claim more victims than AIDS. But in Baltimore, the tuberculosis rate has held steady.

Nurse Walter Jones may be a reason why.

Making house calls last Tuesday, Mr. Jones visited Hattie McKoy, a 51-year-old woman who has a gracious smile and nagging TB.

Maybe she caught it as a child and it has lain dormant until lately. Maybe not. The point is to cure it now.

Inside her rowhouse on North Eden Street, she sat on a wobbly chair and cupped her hand. Mr. Jones opened an envelope and poured out big white pills and red capsules -- a cascade of 23 pills. She must take them all -- in one sitting -- twice a week, and Mr. Jones was there to watch her do it.

"I got used to him, so I don't mind him too much," Mrs. McKoy said of her visitor, a public health nurse with the Baltimore City Health Department. "I feel normal with him. Some people, I don't really feel comfortable talking about my feelings, opening up, telling him exactly where it hurts."

His bedside manner -- affable, respectful, as non-intrusive as a government agent can be -- is important. It gets him inside the door, and makes it possible to do the crucial business of tuberculosis control: making sure patients take all of their pills on a precise schedule.

Late last year, the federal Centers for Disease Control declared that home visits like this may be the best way to control the resurgence of tuberculosis and curb the growth of deadly strains that are resistant to front-line medications.

The strategy is called "directly observed therapy," and it means watching people take their pills. In Baltimore, three nurses covering all corners of the city are monitoring about 40 patients a week. On an average day, a nurse can see eight patients, spending five minutes or a half hour with each.

The time varies because the nurses not only deliver pills. They talk and listen.

For many patients homebound by disease or poverty, the nurses may provide their only regular contact with health care.

With new patients beginning therapy and others finishing all the time, the caseload adds up to 80 or 90 patients a year -- about 70 percent of the city's yearly TB tally.

Baltimore isn't the only city to adopt this approach. Russ Hanson, a tuberculosis consultant with the CDC in Atlanta, says San Francisco, Denver, and El Paso and Fort Worth, Texas are waging good programs too. So, he says, are the states of Alabama and Mississippi.

"But we really look to Baltimore as the prototype of a big-city TB program that has been very effective in turning the corner," he said. Baltimore has been doing it for 12 years -- longer and more extensively than any other city.

The strategy is based on years of observation that patients cannot be trusted to take the complicated regimen of pills required to kill TB. This isn't like taking aspirin for a headache. Most patients must take four antibiotics -- several of each -- and a vitamin for six months.

Because doses are tailored to body weight, the total pill count can be enormous. While Mrs. McKoy, small and wiry, takes 23 pills, heavyweight patients are sometimes expected to take 30 in one sitting.

This goes on five times a week initially, and twice weekly later on. The danger is that patients, if left unsupervised, will stop taking their medicine once they start feeling better. This can happen just a few weeks into therapy, much too early to cure the disease.

"This program works because we go to them," Mr. Jones said, reciting the words like a mantra.

Resistant forms

Tuberculosis is a bacterial infection spread through the air by coughing or sneezing. While its hallmark is a persistent, hacking cough -- the consequence of lung infection -- it can also infect other parts of the body, including the brain, kidneys and spine.

Nationally, tuberculosis has spread among AIDS patients and drug addicts who lack immunity; through prisons, homeless shelters and nursing homes where one person's cough can infect many; and by immigrants who carry the infection from countries in Asia, Latin America and Africa where TB has always been a threat.

Kill it quickly, and tuberculosis doesn't have time to evolve into a resistant strain. Otherwise, the constantly mutating bacterium can change into forms that are harder and more expensive to treat. It can change from a disease that is almost always curable to one that has fatality rates as high as 50 percent.

"Most multi-drug-resistant TB has not come from being spread," said Dr. John Lewis, who heads preventive medicine at the city health department.

"Most is manufactured by poor treatment and poor compliance. That's the part we have prevented."

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