Lung Cancer and Coughing Up Blood: When to See a Doctor

After 30 Years Of Decline, Tuberculosis Is Rising In The U.S. Again. How Did We Get Here?

Since the pandemic's explosion in 2020, resource diversion to COVID tracking and treatment may have allowed TB to spread unchecked.

A colorized X-ray of a patient's chest shows lesions (tubercles, pink) caused by tuberculosis (TB) consisting of infected dead tissue. Treatment for the highly contagious disease requires consistent taking antibiotics for several months.

ByLeah Worthington

May 28, 2024

After declining for three decades, tuberculosis (TB) rates in the U.S. Have been increasing steadily since 2020, according to a new report from the Centers for Disease Control and Prevention. It's a disturbing trend given that 1.5 million die from TB every year, making it the world's most infectious killer.

"Even the people who don't die of the disease, they're hospitalized [and] have a lot of long-term problems from having TB," says Priya Shete, associate medical professor and co-director of the University of California, San Francisco Center for Tuberculosis. "If we allow continued increases in tuberculosis globally…over time that's going to affect us as well."

Nationwide, 2023 saw the highest number of cases reported in the last decade. Most of these recent cases are not instances of novel transmission, but sudden activation of latent infections that were undetected or improperly treated.

While TB impacts thousands nationally and millions around the world, "most people in the U.S. Are not at risk of developing TB," says Philip LoBue, director of the CDC's Division of Tuberculosis Elimination. 

Compared with high TB incidence countries like India, China, and the Philippines, the chance of infection in the U.S. Is still one of the lowest in the world. But the recent trend reversal has raised questions—and some alarm bells—among infectious disease and public health experts. Here they offer insight into the causes and implications of the sudden upswing in cases.

What is tuberculosis, and why is it so serious?

Tuberculosis is one of the oldest and deadliest diseases in human history. For millennia, the infection has afflicted people around the globe, earning ominous nicknames like "the white plague," "consumption," and even "the robber of youth." A century and a half ago, TB was essentially a death sentence—roughly 80 percent of active infections were fatal. Since then, rates have been on the decline in the U.S. And abroad, thanks to new vaccines, diagnostics, and antibiotic treatments.

The disease is caused by a highly contagious bacterial infection that primarily affects the lungs but can also damage the kidneys, heart, bones, joints, and blood vessels. If it spreads, it can cause meningitis, swelling of the brain and spinal cord, or hepatitis, inflammation of the liver.

TB transmits through prolonged exposure to infectious airborne particles, such as from coughing or sneezing. A person infected with TB often does not display symptoms or know they're sick for weeks or even years—called a "latent" infection. But the infection may become active, and contagious, at any time. 

Even if the bacteria is detected and an effective antibiotic is prescribed, the treatment regimen is long—several months—which makes patient compliance difficult. 

"We need constant surveillance and suppression to keep TB in a latent form," says Jeffrey Cox, professor of immunology and pathogenesis at University of California, Berkeley. "If you remove that pressure, the bacteria can then start growing again."

While both preventable and curable, TB remains a leading infectious killer worldwide, claiming over a million lives every year. The disease affects millions in every country and age group, but hits particularly hard in low- and middle-income populations.

Why are TB rates rising in the U.S.?

From a public health perspective, it's no surprise that tuberculosis counts have been on the rise since 2020. When the pandemic hit, reporting of other communicable diseases like TB initially plummeted as the majority of resources went towards COVID. 

"Most countries actually had a dip [in cases] from 2019 to 2020," Cox says. "But that doesn't mean that TB went down."

In fact, the pandemic-era emphasis on coronavirus tracing and treatment may have allowed TB infections to multiply unchecked. 

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"A lot of those lower priority activities of health care—maintenance and prevention—were deferred," says Shete. "We weren't doing a great job prioritizing TB prevention."

Cox describes a sort of snowball effect: If people don't get tested or report infections, they don't get the treatment they need and can transmit the infection to others. Waning mask-wearing and increased travel can also exacerbate the spread.

Compared with previous caseloads, new TB patients are "often more sick at the time that they're diagnosed," Shete says. During the pandemic, some physicians may have misidentified or failed to take their symptoms seriously. "It can be kind of the slow burn of a disease where people start to lose weight, they start to feel crummy, they have a chronic cough, and maybe not seek care as quickly."

LoBue agrees, citing "the similarity of pulmonary TB disease and COVID-19 symptoms" and disrupted health care access during the pandemic as key factors in the initial drop, then rise, in cases. 

As before the pandemic, most recent cases—a whopping 80 percent—occur when untreated, latent infections become active. This most often happens to people whose immune systems are weakened, particularly from diseases like HIV or certain immune-suppressing medications, according to LoBue. In contrast, a healthy immune system could keep the infection at bay indefinitely.

Who's most affected by tuberculosis? 

Within the U.S., those most susceptible to TB continue to be people born in, or frequent visitors to, countries where TB is common, working or living in riskier settings like schools and high-density housing, or those with weaker immune systems, according to Shete.

"Tuberculosis, just generally speaking, is often called a 'disease of poverty,'" she says. People experiencing food insecurity, poor access to basic health services, and inadequate or crowded living conditions are at higher risk of infection and often lack the resources for testing or treatment.

Of people born in the U.S., TB rates are highest among those "who have historically been minoritized or marginalized, socioeconomically or racially or ethnically," Shete says, including Black and Latinx populations. According to the latest CDC report, Black Americans represented the largest number—33 percent—of U.S.-born TB cases, followed by Hispanic and white Americans. 

Still, Cox emphasizes that national numbers "pale in comparison" with the rest of the world. And whether the increased cases are just a "blip" or continue to trend upwards remains to be seen. "Until we have more years of data, we can't say for sure," agrees the CDC's LoBue.

What are the larger implications of these rising rates?

Experts urge people to stay informed about TB, without raising unnecessary alarm. Shete says it's important to remember it's fully preventable, diagnosable, and treatable.

Those outside of high-risk groups generally don't have to worry unless they notice symptoms or are exposed to someone with an active infection. That said, Shete adds, "I hesitate to make it less important to most people only because it just takes one person in your community to have TB."

The greater burden falls on healthcare professionals and the public health system. Particularly among high-risk populations, Shete says that physicians should regularly screen for TB. These preventative measures should be included in Medicare coverage, which is not always the case. Just last year, the U.S. Preventive Services Task Force issued a recommendation for screening asymptomatic adults at increased risk of latent tuberculosis infection for the first time since 2016.

Long-term management of TB cases will require ongoing investment in clinical research and the development of more effective diagnostics and antibiotics, Cox says.

"It does take that kind of infrastructure and constant surveillance and funds from the government to keep those programs going," Cox says. 

Ultimately, the risk of TB for U.S. Residents is mercifully low. But effective mitigation of the infection at home relies on attacking it on a global scale. The U.S. Has made this a priority, through international programs like USAID's Global TB Strategy and the CDC's Division of Global HIV & TB, which is working to combat the two epidemics simultaneously. 

As Shete says, "Whatever is happening in the world is going to affect us too in the U.S."

Tuberculosis Fast Facts

CNN Editorial Research

(CNN) — Here's a look at Tuberculosis (also known as TB), an infection, caused by a bacterium called Mycobacterium tuberculosis, that usually affects the lungs. It can also infect other parts of the body including the kidneys, spine and brain.

About TB

Two types of TB exist – Latent TB infection (non-infectious) and TB disease (infectious).

Latent TB infection:– A person infected with latent TB shows no symptoms and may not feel sick.– A skin or blood test will indicate if a person has been infected with the bacteria.– It is not possible to spread TB bacteria from the infected person to others.– Individuals with a latent TB infection may never develop the disease, as bacteria remains dormant. In other cases, especially involving people with a weak immune system, the bacteria may become active and cause TB disease.– Treatment is required to ensure the infected person does not develop active TB disease but in some cases preventative treatment may not be an option.– Without treatment, about 5-10% of individuals infected with latent TB will develop the disease.

TB disease:– Symptoms of TB of the lungs include coughing up blood and chest pain.– Other symptoms include weight loss, night sweats, fever, chills and fatigue.– It is possible to spread TB bacteria from the infected person to others.– A skin or blood test will indicate if a person has been infected with the bacteria.– Treatment typically involves a combination of drugs taken for six months.– Persons with a weak immune system, such as those with HIV or diabetes, are more prone to catching TB disease.

Facts

TB spreads through the air when a person with an active TB infection coughs, sneezes, speaks or sings. Germs can stay in the air for hours.

In 2022, about 10.6 million people worldwide became ill with TB, and 1.3 million died (including 167,000 with HIV).

In 2022, a total of 8,331 new TB cases were reported in the United States.

Up to 13 million people in the United States are living with latent TB.

Timeline

1546 – Italian scientist Girolamo Fracastoro hypothesizes that TB is contagious.

1679 – Dutch scientist Francis Sylvius details the impact of TB on patients.

1865 – French military doctor Jean-Antoine Villemin proves the illness can transmit from human to animal or from animal to animal.

1882 – German doctor Robert Koch identifies the bacterial strain as Mycobacterium tuberculosis.

1800s – Tuberculosis causes as much as one-quarter of all deaths in Europe during the 19th century. Famous people who die from tuberculosis include John Keats, Frédéric Chopin, Charlotte, Emily and Anne Bronte, Anton Chekhov and Franz Kafka.

1921 – After years of trials involving animal testing, French bacteriologists Albert Calmette and Camille Guérin successfully administer a vaccine called Bacille Calmette-Guerin (BCG) in an infant whose mother died of TB.

1930 – In Germany, more than 70 infants who received the BCG vaccine die of TB. It is later concluded that the vaccine was contaminated in the lab.

1944 – Microbiologist Selman A. Waksman and his associates at Rutgers University report the discovery of a new antibiotic called streptomycin.

1944 – Physicians H. Corwin Hinshaw, Karl H. Pfuetze and William H. Feldman successfully use streptomycin to treat a patient with TB.

1952 – A scientific journal publishes studies heralding the success of a breakthrough treatment called isoniazid.

1985-1992 – Tuberculosis makes a resurgence. Scientists attribute this to several factors, including the spread of HIV.

1994 – The World Health Organization declares tuberculosis a global emergency.

1995 – The WHO launches Directly Observed Therapy Short-Course (DOTS). It is a treatment plan containing five components, including standardized recording and reporting.

2008 – The WHO reports the highest rates of MDR-TB worldwide.

December 8, 2010 – The WHO endorses a new test that diagnoses tuberculosis within hours instead of months.

2018 – A promising new vaccine called M72/AS01E is shown to be effective in many people already infected with TB.

2021 – A study concludes that a four-month multidrug regimen to treat TB is as effective as a six-month regimen.

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Tuberculosis: Out Of 6,031 Diagnosed Cases In Delta, 3,476 Are Children

Joseph Onojame, Delta State Commissioner for Health, on Thursday, said that in 2023, the state was estimated to have 13,641 cases of tuberculosis (TB) based on an incidence of 219 people per 100,000 population.

Out of the estimated number, only 6,031 cases were diagnosed with 3,476 being children, he revealed.

According to him, tuberculosis remained a major health challenge globally as 361,000 cases were reported in Nigeria in the year under review of which nine percent of that figure were children.

He made the revelations during the flag-off ceremony of the 2nd Nigeria National Childhood Tuberculosis Testing Week in Asaba.

The flag-off was in line with the National TB Testing Week for Children with the theme 'Every Child's Life Matters,' slated for  May 27 to June 2, 2024, across the country.

Onojaeme listed some objectives to be achieved including increased awareness, community engagement, strengthening the health systems, collaboration with partners and data collection and analysis.

He said the state government was committed to improving the detection mechanism, as well as ensuring the treatment of recorded cases to save lives and build a healthier future for Deltans.

Tobore Oborevwori, wife of the state governor, and founder of 'You Matter Charity Foundation', also reiterated the state government's commitment to ensuring that every child receives timely screening, diagnosis and treatment to safeguard the health and wellbeing of children.

"TB remains a formidable challenge, 70% of children continue to remain undiagnosed despite our best efforts, unfortunately in Africa every 3 minutes a child dies of TB. It is our duty therefore to ensure that every child receives timely screening, diagnosis and treatment.

She used the medium to call on all, especially mothers, to be advocates of this cause and make efforts to spread the message far and wide and also make their children available for testing.

She assured Deltans that her husband,  would through the M.O.R.E. Agenda, bring about affordable health care to their doorsteps and solicited their support to bring it to a reality in the state.

Goodwill messages from Partners such as representatives of the World Health Organization and KNCV Nigeria pledged more support to the State in the fight against the spread of TB.

The Highlight of the event was the demonstration of sample collection by the wife of the Governor and the demonstration of the use of the mobile digital X-ray machine coordinated by the State TB Programme Manager, Dr Francis Bakpa.

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