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Anthrax-tainted mail and other bioterrorism woes have spelled a mix of good news and bad news for TB control programs across the nation.
On the plus side, the decision to put thousands of postal workers and others on ciprofloxacin to prevent development of anthrax disease may prove an unintended bonus for Cipro-takers latently infected with TB, says John Sbarbaro, MD, professor of medicine at the University of Colorado Health Sciences Center in Denver. The reason? As a second-line anti-TB drug, ciprofloxacin attacks any active TB microbes that get in its way, Sbarbaro points out. "On the one hand, we know Cipro doesn’t kill as well in active TB as isoniazid, and it probably doesn’t kill as quickly as rifampin," he says. "Even so, it’s definitely bacteriocidal."
Plus, giving even just two months of the drug almost certainly counts as partial TB prophylaxis, Sbarbaro says. "You’re dealing with a population of sleeping bugs," he points out. "If they don’t wake up, they’re not multiplying; and if they do wake up, you’re [using the Cipro] to kill them. So you’re reducing the bacillary load, which means you’re reducing the risk for reactivation." Tack on another month of preventive therapy here and there, and you’ve finished the job, he adds. "Now that," Sbarbaro adds gleefully, "is what I call some good collateral damage against a terrorist."
On the downside, none of the avalanche of new money headed for the Centers for Disease Control and Prevention in Atlanta in fiscal year 2002 seems likely to wind up in TB controllers’ coffers, most observers have concluded. "The general feeling in the TB community is that we’re not going to see any of it," says Walter Page, executive director of the Atlanta-based National TB Controllers’ Association. "It looks as if the entire focus is going to be on bioterrorism."
By the end of last month, the Senate had approved a package of $4.4 billion for the CDC, with the House approving a package amounting to $75 million less than the Senate version. The Senate package includes $250 million for construction and $181.9 million for CDC-related "bioterrorism readiness." The Senate also was scheduled to consider supplemental funds amounting to another $1 billion.
One area where bioterrorism made itself felt was in staffing. "It seems everyone’s lost at least a few people [to combating bioterrorism]," says Page. And in public-health departments across the land, phones were ringing almost constantly with inquiries from worried citizens.
At the CDC’s Division for TB Elimination, 10 staff members had been detailed to bioterrorism, with three more poised for recruitment and another three to five on emergency standby, according to John Seggerson, associate director for external relations. The CDC staff diversions — mostly from the surveillance and epidemiology branch — have not yet hindered effective TB control, says Seggerson. "Luckily, we haven’t had any requests [from the states] for help with outbreaks," he adds.
On another front, despite rumors of TB laboratories being inundated with anthrax samples, it seemed to be business as usual in most state TB labs. An upcoming TB vaccine clinical trial did hit a bump at St. Louis University, where Sequella Foundation had been counting on the school’s vaccines and therapeutics evaluation unit to supply subjects for safety trials; instead, the school’s vaccine unit got diverted to bioterrorism research.
Instead of anthrax or smallpox, what had many state TB controllers fretting last month was state-inflicted budget cuts. In South Carolina, for example, state lawmakers finished enacting the third in a series of cutbacks to the state public health program. "Things are really, really hard right now," says Carol Pozsik, RN, MPH, head of TB control in the state. "We’re about to encounter some real trouble with our staffing." It’s not so much that TB nurses are leaving or not being replaced, Pozsik says, but that they’re having to pick up extra workloads from other programs that are short-staffed.
The war on terror may not be seriously disrupting TB control programs here in the U.S., but that’s not the case in Afghanistan, according to an article in the Oct. 27 edition of The Lancet. With already-huge refugee populations swollen further by American air strikes and overseas aid organizations struggling to keep TB programs functioning, the TB situation is expected to go from bad to worse, say experts at STOP-TB, a coalition of 120 organizations based at the World Health Organization (WHO).
Before the war began, TB caused 70,000 to 80,000 new infections each year in Afghanistan, as well as 16,000 deaths a year, according to the STOP-TB figures. Though Afghanistan has formally adopted directly observed therapy, short-course (DOTS), the WHO’s preferred TB control strategy, only 70% of Afghan patients have access to DOTS. In the country’s 30 TB treatment centers, drug supplies are often irregular, and personnel are frequently poorly trained. It would take between $11 million and $25 million to expand DOTS in the country, say STOP-TB spokesmen.