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Why Is TB Still Such a Big Threat in the United States?

Tuberculosis is a disease whereby treatment is prevention. The pathogen is spread via inhalation of droplet nuclei that are aerosolized by coughing, sneezing, or talking and the air remaining infectious after an infected person leaves the room. Prolonged exposure is usually required for infection to occur while brief contact carries little risk. Utilizing strict infection-control measures, such as respiratory isolation, with potential cases is of utmost importance. Furthermore, screening high-risk populations with the purified protein derivative test or interferon-gamma release assays is necessary to identify those with latent or active disease. Treating those with latent disease will prevent future active disease from occurring, and treating those with active disease will minimize the morbidity and mortality associated with the infection. Ultimately, in both scenarios, the goal is to prevent the spread of M. tuberculosis.
The populations most at risk for TB include immigrants, the urban poor, alcoholics, intravenous drug abusers, the homeless, migrant farm workers, prison inmates, and those infected with HIV. Furthermore, there are five to ten times higher rates of infection in African Americans, Hispanic Americans, Asian Pacific Islanders, and Native Americans.4 It remains to be seen how the rates of TB (and HIV) will be affected by the current US opioid epidemic. Identifying and isolating cases is the first hurdle that needs to be addressed on an ongoing basis.
Once a patient with active disease is discovered, the next obstacle in treating tuberculosis is that a minimum of 2 drugs, generally 4, must be used in combination. Adherence is extremely important for eradicating the disease. Directly observed therapy is recommended when possible, especially for difficult cases such as those with multidrug resistant (MDR) or extensively drug resistant (XDR) M. tuberculosis. It may be demanding for patients to complete the complex regimens required for treatment based on the number of tablets needed, the prolonged duration (6-9 months or more), drug-drug interactions with other medications they are taking for comorbidities, and adverse drug reactions, such as gastrointestinal upset, fever, skin rash, or hepatitis.
Specialists with experience treating TB are needed to monitor and assist with adjusting regimens based on interactions and side effects, and determining if patients need to start the clock over again, in terms of duration, when treatment regimens are altered or paused for a certain period of time. More extensive information regarding treatment regimens and monitoring plans for patients with drug-susceptible TB are described in the updated clinical practice guidelines by the American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America, published earlier this year.8

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