Fig. 10 Pulmonary abscess. Contrast-enhanced axial CT of the chest...

Tuberculosis Is Making A Comeback, Experts Warn. Why N.J. Is At A Higher Risk.

Tuberculosis, thought to be a disease of the past, is on the rise across the country and in New Jersey.

In January, public health officials in the Kansas City metro area raised alarm about an outbreak of tuberculosis leading to 67 active cases of TB disease, two reported deaths, and 79 latent TB cases, according to the Kansas Department of Health and Environment. While New Jersey's TB cases for 2024 are not yet available, the outbreak has people concerned this 20th century disease is making a comeback.

"It's always important to say it's still around, we can't turn our backs because it behaves in such a way that it sneaks up on you," said Dr. Alfred Lardizabal, executive director of the Global Tuberculosis Institute at Rutgers University and an associate professor of medicine.

Since 2020, the United States has seen an increase in reported TB cases, surpassing pre-COVID-19 pandemic levels, according to the U.S. Centers for Disease Control and Prevention.

New Jersey is experiencing a similar increase in cases and has a TB incidence rate above the national average. While TB isn't a widespread threat in the U.S., public health experts are warning it remains one of the top causes of death worldwide and public awareness is key to prevent illness.

TB, also known as tuberculosis, is a bacteria spread person-to-person through air and is often associated with coughing that lasts longer than 2 weeks, chest pain and coughing up blood, according to the CDC. While it usually attacks the lungs, it can attack other body parts such as the kidney, spine, and brain.

In 2023, the United States saw an approximately 16% increase in TB cases compared with 2022.CDC TB Surveillance Report

In November, the CDC published a report which showed TB incidence and reported cases in the United States increased for a third consecutive year in 2023. That year, the U.S. Reported 9,633 TB cases and an incidence rate of 2.9 per 100,000 persons. It's the highest incidence rate since 2016 and highest reported case count since 2013.

New Jersey has an even higher TB incidence rate than the national average, 3.7 cases per 100,000 persons, according to the New Jersey Department of Health. During 2023, the state reported 343 TB cases, a nearly 20% increase from the previous year, according to the latest TB Risk Assessment Data.

The higher rates in New Jersey are not entirely surprising. TB rates tend to be higher in big cities and coastal states, especially ones with a large foreign-born population, said Lardizabal. Within the U.S., over 88% of TB cases occur in racial and ethnic minorities, according to the CDC.

In 1900, TB was the leading cause of death in the U.S, killing 194 of every 100,000 persons, according to the CDC.

Before the advent of antibiotics, the only way to control infection was to seclude patients in sanatoriums away from friends and family. New Jersey built several of these facilities, with some of the largest being Essex Mountain Sanatorium in Essex County, Valley View in Passaic County, and the New Jersey State Tuberculosis Sanatorium in Hunterdon County, according to newspapers at the time.

Before antibiotics, TB patients had to be sent to sanatoriums like the New Jersey State Tuberculosis Sanatorium, in Glenn Gardener, Hunterdon County. The sanatorium was photographed after 1933 for the Library of Congress Historic American Buildings Survey. Library of Congress Prints and Photographs Division

After the discovery of drugs that could treat TB in the 1950s, death rates began to drop dramatically and the disease largely faded from public consciousness. However, progress toward the goal of TB elimination in the U.S. Has taken a hit in recent years.

In October, the World Health Organization published a report revealing 8.2 million people were newly diagnosed with TB in 2023, the highest number since it began global TB monitoring in 1995.

"The fact is that it's still a global epidemic. I think that's what people don't realize," said Lardizabal. "It continues to be a top five infectious disease killer in the world."

Not everyone infected with TB immediately becomes sick. In fact, data shows most people become sick after living with inactive TB for years.

"There's a lot of people who are immigrants and have been here for 30 years and then suddenly, 30 years later, it activates," said Lardizabal. "It's not like you get a flu shot and that should be it for the year. With TB, there's a constant appeal to people to recognize if you have a risk, consider preventive treatment."

According to the CDC, there are three medications used as part of treatment regimens in the U.S. For inactive TB — isoniazid, rifapentine, rifampin. The medications are used on their own or in combination for anywhere from three to nine months, depending on the treatment regimen.

Since 2010, the majority of reported TB disease cases in the U.S. Occur among non-U.S.-born persons.CDC TB Surveillance Report

The CDC estimates that up to 13 million people in the U.S. Have inactive TB, as of 2023. While not everyone with inactive TB will develop full-blown TB disease, the CDC estimates 1 in 10 people will develop TB disease over their lifetimes if left untreated.

"The other challenge is that the psyche of many American physicians is that it's a disease of the past. So when somebody presents to them, TB is oftentimes the last thing they'd consider and then there's a delay in the diagnosis, resulting in more morbidity for the person and more transmission," said Lardizabal. "All of these different facets make TB control an ongoing challenge."

The World Health Organization and CDC encourage anyone at risk for TB infection to get tested and treated.

While there is a vaccine for TB, it's not generally recommended in the U.S. Because of the low risk of severe disease in the country. The vaccine should only be considered for people who meet specific criteria, and in consultation with a TB expert, according to the CDC.

To learn more about TB and assess individual risk factors, visit the CDC website.

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Jackie Roman may be reached at jroman@njadvancemedia.Com.

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Deadly Diseases

When German biologist and doctor Robert Koch announced in 1882 that he had discovered the bacterial cause of tuberculosis, he said, "If the number of victims which a disease claims is the measure of its significance, then all diseases … must rank far behind tuberculosis." By this measure, tuberculosis today still outranks most other infectious diseases for its sheer potential to affect vulnerable populations. The World Health Organization reports that TB infects one new person every second and is the world's leading killer of women.

An ancient disease, tuberculosis has been found in the skulls and spinal cords of Egyptian mummies 3,000 years old. The Greek physician Hippocrates called "consumption" — as tuberculosis was often known in the past — the most common deadly disease of his time.

An estimated one billion people died from tuberculosis between 1700 and 1900. Even after Koch dispelled the myth that "bad air" brought about the disease by revealing its microbial cause, for decades the recommended treatment remained rest and fresh air at a sanatorium. Among those who lost their lives to TB were writers Fyodor Dostoevsky and Jane Austen, composer Frederic Chopin, and Presidents Andrew Jackson and Ulysses S. Grant.

Also known as the "white plague," tuberculosis is a contagious, airborne bacterial disease transmitted through coughing, sneezing, and talking. Even singing or laughing at close range can be dangerous. Tiny microbe-filled water droplets are expelled by one person and inhaled by another. Still, extended close contact is necessary to transmit the bacteria. A healthy adult spending eight hours a day for six months with an infected person has a 50 percent chance of becoming infected. Alarmingly, each person who has active TB may infect on average 10 to 20 others, often family members and caretakers.

Tuberculosis symptoms start with a persistent cough, fever, and night sweats. The bacteria spread rapidly, most often to the lungs, leading to tissue damage and a bloody cough. In about 15 percent of cases, the disease may spread to other parts of the body, including lymph nodes, the gastrointestinal tract, bones, and joints.

Though conventional tuberculosis is highly treatable and curable (with a 90 percent rate of success), TB kills more people worldwide in a typical year, according to the Global TB Report Card, than "all wars, earthquakes, floods, tsunamis, airline accidents, terrorist attacks, and murders" combined. Nearly two million people succumb to the disease annually, mostly in the developing world, where 98 percent of new infections arise.

Despite the overall incidence of tuberculosis dropping 20 percent since 1990, the World Health Organization still predicts 36 million TB deaths in the next 20 years. The disease has surged back in Africa, taking advantage of the vulnerability of HIV/AIDS sufferers. The frequent coexistence of the tuberculosis bacteria and the virus that causes AIDS has been dubbed the "cursed duet."

Today it's estimated that two billion people — or approximately one-third of the world's population — carry one of the three bacteria that cause TB. A healthy immune system keeps the bacteria in check in what is known as latent TB; approximately 10 percent of people with latent TB develop the active disease, and only then are they in danger of spreading it to others. But if a person's immune system becomes weakened, as in the case of HIV/AIDS patients, the TB pathogen asserts itself, and nearly 40 percent will develop active TB.

The rate of tuberculosis infection continues to decline in the United States. It fell by 3.3 percent in 2004, when there were 14,511 confirmed cases. More than half of these infections — 53.7 percent — occurred in foreign-born persons living in the country. A tuberculosis vaccine, Bacille Calmette-Guerin (BCG), exists, but its effectiveness is extremely variable, and therefore it is not recommended for use in the United States and Europe. The World Health Organization does recommend it for newborns in developing countries, because it appears to offer some protection in children. Researchers continue to seek better alternatives.

The first anti-TB drug, streptomycin, was developed in 1944, but TB has always required at least two strong antibiotics to defeat it. And treatment takes at least six months, with many patients stopping their medications as soon as they begin to feel well. Doing so allows the most resistant bacteria to remain in the person's body and spread their genes to a new generation. At the next opportunity they can attack again, with greater force. Today, to combat the growth of resistant strains, Directly Observed Treatment Short-course, or DOTS, is the conventional procedure for delivering drugs so health care workers can monitor patients fulfilling their required drug regimen. But multidrug-resistant strains of tuberculosis, called MDR-TB, are becoming extremely dangerous and require more expensive and painful drugs to cure.

A promising program in Lima, Peru, run by the Boston-based organization Partners In Health, has shown that MDR-TB in poor settings can be successfully treated with a complex regimen of drugs. But only a fraction of the estimated five million MDR-TB patients worldwide are getting the antibiotics they need. Since every TB victim is thought to infect up to 20 others, these deadly "superbugs" are spreading.

Despite the desperate need for better drugs and vaccines, it has been nearly 30 years since a new TB drug was developed. To kick-start stalled research, the Bill & Melinda Gates Foundation (The Bill & Melinda Gates Foundation is a funder of the Rx for Survival project) has donated $25 million to the Global Alliance for Tuberculosis Drug Development and $83.5 million to the Aeras Global TB Vaccine Foundation to develop new tuberculosis drugs and vaccines.

Return to Deadly Diseases

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