Reasons cited for the increasing rates of tuberculosis and drug-resistant disease include the deterioration of public health programs aimed at preventing tuberculosis and encouraging completion of therapy for the disease (IOM, 2000). Incomplete treatment is a major cause of drug resistance. Increasing rates of HIV infection, homelessness, imprisonment, and immigration also contributed to the resurgence of tuberculosis. Depending on region and age group, up to 35 percent of those with tuberculosis were also infected with HIV.
The rise in tuberculosis, particularly multidrug-resistant disease, created considerable public alarm. For example, a 1992 opinion piece in the Washington Post on the combined threat of AIDS, substance abuse, and tuberculosis (headlined as the “three-headed dog from hell”) described tuberculosis as a deadly and highly contagious disease “that you could catch from the person next to you in a movie theater or classroom” (Califano cited in OTA, 1993, p. 28). Transmission of the disease under such conditions is not very likely, but the description illustrates the level of concern being voiced by some commentators at the time.
Figure 1-1 shows both the increase in the number of tuberculosis cases beginning in the mid-1980s and the subsequent decrease in the number of cases starting in 1993. By 1999, the number of cases nationwide had dropped to 17,528 (an all-time low), and the case rate stood at 6.4 per 100,000 population (also the lowest ever). The rate of multidrug-resistant tuberculosis stood at 1.2 percent of reported cases, approximately one-third the level in 1991. In addition, the death rate had dropped to 0.4 per 100,000 population in 1998 (the latest year for which data are available), down from 0.8 per 100,000 population in 1988.
National case rates mask considerable geographic variation in the incidence of tuberculosis. In 1999, case rates varied from less than 1.0 per