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Tuberculosis Then and Now: A Personal Perspective on the Last 50 Years

Gordon L. Snider, MD
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From the Boston Veterans Affairs Medical Center and Boston University School of Medicine, Boston, Massachusetts. For the current author address, see end of text. Acknowledgments: The author thanks Clark Sawin for his many helpful suggestions and for valuable assistance with the bibliography on randomized clinical trials and Susan Rappaport, Manager, Epidemiology and Statistics, Medical Affairs Division, American Lung Association, for help with the statistics on tuberculosis. Requests for Reprints: Gordon L. Snider, MD, Medical Service (III), Veterans Administration Medical Center, 150 South Huntington Avenue, Boston, MA 02130.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1997;126(3):237-243. doi:10.7326/0003-4819-126-3-199702010-00011
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Rates of death from tuberculosis in the United States decreased from 194 per 100 000 persons in 1900 to 40 per 100 000 persons in 1945, in part because the epidemic of tuberculosis in the western world was running its course and in part because of public health initiatives and improved socioeconomic conditions. In 1945, 63 000 persons died of tuberculosis and 115 000 new cases of the disease emerged. Streptomycin and para-aminosalicylic acid had just been discovered; the discovery of isoniazid followed, in 1952. Sanitarium care, nonsurgical and surgical collapse therapy, and resectional surgery were in widespread use. By the middle of the 1950s, it was evident that bedrest did not add to the benefit produced by effective chemotherapy, and sanitariums began to close, a process that was completed by the 1970s. As mortality and morbidity due to tuberculosis rapidly decreased, the U.S. government decreased funding for tuberculosis and many states and cities downgraded their tuberculosis control programs.

After 1984, the rate of new cases of tuberculosis, which had decreased to 9.4 per 100 000, began to increase and focal outbreaks of multidrug-resistant tuberculosis were reported. Noncompliance with drug therapy, homelessness, immigration to the United States from developing countries, and human immunodeficiency virus (HIV) infection were invoked as explanations. With the reinstitution of federal funding, improved case-finding and surveillance, and the practice of having patients receive therapy while under direct observation, the rate of new cases of tuberculosis decreased to 8.7 per 100 000 in 1995, the lowest rate since national surveillance was begun in 1953. However, at the end of the 20th century, the worldwide burden of tuberculosis, which is engrafted onto the pandemic of HIV infection, is enormous: an estimated 7.6 million new cases in developing countries and 400 000 new cases in industrial nations.




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Figure 1.
Tuberculosis mortality rates per 100 000 persons in the United States. Top.[4]Bottom.[4, 5]

1930 to 1949. The arrow marks 1944, the year in which streptomycin was discovered. Mortality decreased steadily, from 70 per 100 000 persons in 1930 to 40 per 100 000 persons in 1945; this was a result of the natural course of the tuberculosis epidemic in the western world, improved socioeconomic conditions, the public health measures of case-finding and isolation, and sanitarium treatment. The rate of decline accelerated after 1944 . 1945 to 1992. The arrow marks 1954, the year in which isoniazid was introduced. The rate of decline in mortality that had been maintained between 1945 and 1954 slowed after 1954 but reached the low single digits by 1965 .

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Figure 2.
Annual newly reported cases of tuberculosis per 100 000 persons in the United States, 1930 to 1992.[3-5]

The arrows mark 1944 and 1954, the years in which streptomycin and isoniazid, respectively, were introduced. Rates of new cases decreased steadily after 1930. The increased rates between 1941 and 1954 probably represent an increased burden of cases in armed forces personnel and immigrants as a result of World War II. Note the increase in the rate of new cases beginning in 1984 .

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Figure 3.
Tuberculosis hospitals and beds in the United States, 1946 to 1992.[4, 7]

The increase in the number of hospitals from 1953 to 1956 probably represents building that was planned during World War II but was delayed until after the war. The rapid decline in the numbers of hospitals and beds that began in 1956 coincided with the recognition of the superiority of chemotherapy to bedrest for the treatment of tuberculosis and the rapid sputum conversion that occurred with isoniazid-containing regimens. Few tuberculosis hospitals remained after the late 1970s .

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Figure 4.
Newly reported cases of tuberculosis per 100 000 persons by year in the United States, 1980 to 1995[2, 3, 5, 29][30]

. The rate of decline of about 0.85 new cases per 100 000 persons per year seen between 1975 and 1984 is continued to 1995. After 1984, however, the previously downward-trending curve of new cases against time leveled off and then began to increase from 9.3 per 100 000 persons in 1985 to 10.3 per 100 000 persons in 1990, when it again leveled off. The downward trend resumed in 1993 and decreased to 8.7 per 100 000 persons in 1995; this was the lowest rate of new cases of tuberculosis to be seen since surveillance began in 1953. The shaded area represents the excess of new cases above the number expected between 1985 and 1995. (Figure adapted from .).

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