Download system should be closely integrated into the actual

of itself. While the pestilence raged most furiously
abroad, the Prince Prospero entertained his thousand
friends at a masked ball. there were many individuals in
the crowd who had become aware of the presence of a
masked figure And now was acknowledged the pres¬
ence of the Red Death. He had come like a thief in the
night. And Darkness and Decay and the Red Death
held illimitable dominion over all.
system should be closely integrated into the actual
practice of physicians. It should be convenient for
the doctor, not the auditor. A new system should
enhance the practice of medicine. It should improve
patient care, not detract from it. A new system
should be tested thoroughly in the field before being
implemented nationally. Lastly, alternative systems
to the medical record should be considered for
documentation of billing levels.
In case the reader thinks that I am another
disenchanted physician railing against the system, let
me respond that I am the luckiest man on the earth
to be able to practice medicine. And no one is more
committed to communicating clinical information in
the chart than me. But these new rules trivialize our
We are now in the position of techni¬
profession.
cians. Regulators in Washington will now determine
what is appropriate in our record keeping. I had
been taught that members of a profession control
their own standards of practice. It seems that our
standards are determined now by regulators.
We in the practice of medicine will not have
patients, do all the committee
enough time to see fill
work for the HMOs, out all the VNA, oxygen, and
other forms, and do proper billing. What will be left
out? The medical record will survive, but bedside
patient care will suffer. We need to spend more time
with our patients and less time filling out senseless
Having spent many years thinking about
paperwork.
record keeping, I can see clearly that the maxim, "If
it is not documented, then it was not done," will
become in reality for practicing physicians, "If it is
documented, then it was poorly done."
Robert W. Hand, MD, FCCP
Medford, Massachusetts
Chief of Medicine, Lawrence Memorial Hospital, and Associate
Clinical Professor of Medicine, Tufts School of Medicine.
Reprint requests: Robert W. Hand, MD, FCCP, 170 Governors
Ave, Medford, MA 02155
The United States and
Worldwide Tuberculosis
Control
A Second Chance for Prince
Prospero
The "Red Death" had long devastated the country. No
pestilence had ever been so fatal, or so hideous But the
retired to the deep seclusion of one of
Prince Prospero
his castellated abbeys The abbey was amply provi¬
sioned. With such precautions the courtiers might bid
defiance to contagion. The external world could take care
"The
Masque of the Red Death" Edgar Allan Poe
tuberculosis (TB) control in the United States
improves, and in the absence of comparable TB
control worldwide, we find ourselves in a position
uncomfortably close to that of Prince Prospero. In
1996, the number of newly diagnosed TB cases in
the United States fell to the lowest level since the
onset ofthe recent TB epidemic in the mid-1980s.1
This recent success is the result of increased funding,
innovative approaches to TB therapy, and the efforts
of thousands of dedicated people. Within the gener¬
ally good news are at least two sobering trends. First,
in 1996, foreign-born persons accounted for 36.6%
of all TB cases in the United States compared with
34.4% in 1995 and 22% in 1986.12 The number of
immigrants entering the United States is increasing,
as is the percentage of immigrants arriving from
countries where TB incidence rates are higher than
US rates.3 In Texas, 30% of TB cases in 1996
occurred in foreign-born persons, 67% of these cases
were in people from Mexico or Central America.4
Second, although the number of new multidrugresistant (MDRTB) cases fell slightly between 1995
and 1996, MDRTB strains have now been reported
from 42 states and Washington, DC.5 The occur¬
rence of TB in foreign-born persons and drugresistant TB rates are not unrelated. In 1996 in
Texas, for example, 86% of new MDRTB cases were
in foreign-born persons, 67% in persons from Mex¬
ico.4 The report by Harrow and colleagues in this
issue of CHEST (see page 1452) provides important
information about connected trends and suggests
that they pose the potential threat of a rebound in
TB incidence in the United States.
The epidemiology of TB in Mexico and Central
America has been difficult to define in the past
because acid-fast bacilli (AFB) cultures and in vitro
drug susceptibility studies for Mycobacterium tuber¬
culosis isolates have not been utilized routinely in
these areas. The report by Harrow and coworkers,
who studied 376 patients with TB treated at a
national thoracic medical center in Guatemala, con¬
tributes new epidemiologic data from this region. In
vitro M tuberculosis drug susceptibility results were
available for 51% of the culture-positive TB cases,
not an optimal yield, but representative of
perhaps
the population as a whole. Overall rates of drug
A
s
^*-
1434
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21767/ on 06/15/2017
Editorials
with 30% of all cases resistant to
high, 21%
for isoniazid and 5% for
drug,
Fifteen
were resistant to
two or
resistance were
at
least
rifampin.
one
percent
any
first-line agents, and 4.6% of the isolates would
be considered MDR, that is, resistant to at least
isoniazid and rifampin. Not surprisingly, a history of
previous antituberculosis medication was a significant
risk factor for resistance to two or more
independent
For
who had previously received TB
individuals
drugs. 46% had resistance
to one or more agents, 25%
drugs,
had resistance to two or more agents, and 8.5% had
MDR isolates. More surprising, however, drug resis¬
tance was also common in patients who denied having
received prior TB therapy. Among patients with no
previous TB therapy, 21% were infected with isolates
resistant to at least one drug, 10% had organisms
resistant to multiple agents, and 2.6% had MDRTB
isolates. In all patients, resistance to two or more
antituberculosis drugs was the single independent pre¬
dictor of treatment failure.
Preliminary findings from drug susceptibility stud¬
ies of TB cases from Northern Mexico near the Texas
border are yielding similar results, including very
rates of drug-resistant TB, including MDRTB,
high
and high rates of primary spread of drug-resistant TB
(Theresa Lightner, MD, Michael Kelley MD; Texas
Department of Health; personal communication;
more
1998).
An immediate concern raised by the data from
Harrow and colleagues is the impact of high rates of
primary drug resistance on initial antituberculosis
therapy for TB patients from Mexico and Central
America. Since geographic origin alone, not just
previous TB therapy, is a risk for multidrug resis¬
tance, the usual initial empiric four-drug treatment
regimen will be inadequate for some patients, and it
will place them at risk for the development of further
drug resistance. The initial treatment choices for
these patients may be between no therapy, pending
drug susceptibility results, orinfive- and six-drug initial
empiric therapy. Physicians Texas who frequently
treat TB patients, especially those along the Texas/
Mexico border, are confronted regularly by this
dilemma. The problem is certainly not confined to
Texas or other border states, since TB patients from
Mexico and Central America may present in any
geographic area ofthe United States. Unfortunately,
the threat of drug-resistant TB and MDRTB in
patients without previous therapy may not be widely
appreciated.
Physicians across the United States
must be as familiar with primary drug resistance
patterns as with previous treatment histories.
A second and more difficult issue raised by Har¬
row and coworkers is the challenge of eliminating TB
in the United States in the face of a rising percentage
of US cases in foreign-born persons and a worldwide
epidemic. Among foreign-born persons applying
for permanent US resident status screened for TB
before entry into the United States, and found to
have a chest radiograph compatible with TB but with
TB
negative sputum AFB smears, as many as 10% prove
be TB suspects after entry into the United States,
and as many as 50% are candidates for TB prophy¬
laxis.46 Aggressive follow-up of these patients is an
important and effective TB control strategy.6
The majority of foreign-born persons, however,
enter the United States without pre-entry TB
to
screening, as workers, tourists, students, consumers,
and undocumented immigrants. There are
refugees,
millions of legal US/Mexico border crossings each
day. In Laredo, Texas, a major overland transport
border crossing, approximately 3,400 trucks cross the
US/Mexico border daily. Therefore, pre-entry TB
screening and aggressive postentry follow-up of im¬
migrants seeking permanent residence status in the
United States will not discover all, or perhaps even
the majority, of TB cases in foreign-born persons
coming into the United States. With an estimated 2
billion people infected by TB worldwide, an esti¬
mated 90 million new cases of TB worldwide during
the 1990s, and the ease of international travel, there
will never be effective or complete TB control in the
United States without worldwide TB control.7
The paper by Harrow and colleagues illustrates at
least three areas where US resources could make a
significant and immediate impact on TB control in
Guatemala. The United States could provide the fol¬
lowing: (1) microbiology lab support for routine AFB
cultures and in vitro drug susceptibility testing; (2) the
full spectrum of antituberculosis medications to facili¬
tate routine administration of at least four-drug initial
and second-line agents for drug-resistant cases;
therapy
and (3) resources to promote and support routine use
of directiy observed therapy (DOT) for TB medication
administration, a process that is already expanding
across the world. These interventions would almost
certainly accomplish more effective treatment of indi¬
vidual TB cases, and thereby, reduce both acquired and
primary spread of drug-resistant TB in Guatemala. The
benefit locally in Guatemala and to the United States
seems self-evident.
That international TB control in general is in our
best interest also seems self-evident. Accomplishing
this goal, however, will require overcoming major
financial and political hurdles. As Raviglione et al7
have noted, "The major obstacle to making more
rapid progress remains the limited financial re¬
sources available for global TB control." It is not
even clear that funding levels for TB control in the
United States will remain at present levels as the
immediate threat of TB in the United States sub¬
sides. Even if adequate funding was available for TB
CHEST/113/6/JUNE, 1998
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21767/ on 06/15/2017
1435
control efforts beyond our borders, the effective
allocation of that funding would require a change in
our assumptions about responsibility for US control
of TB which is now largely the domain of state
departments of health. There is, therefore, an im¬
pression that TB control in the foreign born is also
the problem of individual states. The critical flaw in
this approach is that state departments of health are
dependent on state legislatures who base funding on
the immediate TB threat within a particular state and
not TB control policy in the United States, and
certainly not TB control in other countries. Texas, for
has already seen an effective reduction in
example,
its TB control funding after only 3 years of docu¬
mented decline in the number of new TB cases in
the state, and the growing specter of high rates of
drug-resistant TB along the Texas/Mexico border. If
the legislature in Texas has difficulty grasping this
problem, it is ineven less clear that state lawmakers
and taxpayers other parts of the United States will
see the benefit of their state tax dollars spent in
Texas; Matamoros, Mexico; or QuetzaltHarlingen,Guatemala.
enango,
Even if we muster the will to maintain funding for
US control of TB, the political barriers for international
TB control efforts remain formidable, as demonstrated
by ongoing and successful cooperative TB control
efforts along the US/Mexico border. Joint TB control
ventures in just these two neighboring countries de¬
pend on the cooperation of multiple parties, including
at
level and numerous
government agencies every
interested national and international organizations. In
this arena, diplomacy, understanding, patience, and
are at least as important as shared resources.
goodwill
Because international TB control is so much a
political and diplomatic issue, the members of influ¬
ential medical organizations, such as the American
College of Chest Physicians (ACCP), must actively
lobby for and support not only maintenance of our
present TB control effort in the United States, but
expansion of that effort beyond the US border. The
ACCP has approximately 14,500 members with
2,300 from outside the United States, representing
98 countries. This is an issue of intense and abiding
interest to the ACCP and one that should unite the
membership to form not only a base for international
cooperation, but also a leadership role for the ACCP.
It is possible that no further major strides in US
control of TB will occur without improvement in
worldwide TB control. Unfortunately, it is also pos¬
sible that our success in controlling the recent TB
epidemic in the United States will be threatened
unless TB is controlled worldwide. No amount of
xenophobic rage, no "castellated abbeys amply
and no immigration barriers will allow us
provisioned,"
to eliminate TB in die United States while it occurs
.
unabated worldwide. We are on the threshold of a
major opportunity with the United States in a position
to play a leading role in worldwide TB control if we can
maintain funding for US control of TB, and direct it on
a worldwide scale. Can we convince taxpayers and
politicians that it is truly in our self-interest to spend
effort and capital for TB control outside the US? Or
will we dismantle the formidable forces we have mar¬
shaled with the task only partially completed? The
recent TB epidemic was described as the result of a
U-shaped curve of concern by policy makers.8 It will be
a sad legacy if we allow this most recent U-shaped
curve of concern to become a "W."
David E. Griffith, MD, FCCP
Tyler, Texas
Professor of Medicine, Center for Pulmonary Infectious Disease
Control and the Department of Medicine, the University of
Texas Health Center.
requests: Dr. Griffith, UTHCT, PO Box 2003, Tyler, TX
Reprint
75710
References
1 CDC. Tuberculosis
1997; 46:695-99
2 CDC. Tuberculosis
morbidity-United States,
1996. MMWR
morbidity-United States, 1995.
MMWR
1996; 45:365-70
3 Binkin
NJ. Zuber PLF, Wells CD, et al. Overseas screening
for tuberculosis in immigrants and refugees to the United
States: current status. Clin Infect Dis 1996; 23:1226-32
4 Tuberculosis in Texas-annual statistical report 1996. Texas
Department of Health, Associateship for Disease Prevention
Bureau of Communicable Disease Control, Tuberculosis
Elimination Division. 1997; 1-138
5 Moore M, Onorato IM, McCray E, et al Trends in drugresistant tuberculosis in the United States, 1993-1996. JAMA
1997; 278:833-37
CD, Zuber PLF, Nolan CM,
6 Wells
et
al. Tuberculosis
prevention among foreign-born persons in Seattle-King
County, Washington. Am J Respir Crit Care Med 1997;
156:573-77
7
8
Raviglione MC, Snider DE, Kochi A. Global epidemiology of
and mortality of a worldwide epi¬
tuberculosis-morbidity
demic. JAMA 1995; 273:220-26
Reichman LB. The U shaped curve of concern. Am Rev
Respir Dis 1991; 148:741-42
Pulmonary Arterial
Hypertension
Dipping Into the Reserve
article by Oelberg and colleagues this
Theof CHEST
(see page 1459) brings up impor¬
detection of
in
issue
an
tant
question:
induced
useful?
is noninvasive
pulmonary
arterial
exercise-
hypertension clinically
1436
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21767/ on 06/15/2017
Editorials