When you hear hoofbeats, think horses, not zebras

"In summary, it is time for child health providers to embrace IGRAs rather than to cling to the antiquated TST"

Dr Deborah A. Lewinsohn
Oregon Health Sciences University

In reading over the following two studies I was reminded again over the dilemma that exists for some medical people and their contribution to the continuance of that dilemma. Two particular studies, Interferon Gamma Release Assays in the Evaluation of Children With Possible Mycobacterium tuberculosis Infection and Embracing Interferon-y Release Assays for Diagnosis of Latent Tuberculosis Infection are published in the latest edition of the Pediatric Diseases Journal and concern themselves with the finding of the study (yet to be published) by Hausein et al "The likelihood of an indeterminate test result from a whole-blood interferon-y release assay for the diagnosis of Mycobacterium tuberculosis infection in children correlates with age and immune status"

Of the study *Dr Deborah A. Lewinsohn says

This well-performed study represents the largest study of IGRA test performance in this vulnerable population to date. It provides just the sort of informative data needed to direct clinical use of IGRAs in pediatric populations. However, the main message is sobering. In this group of 237 children cared for at a tertiary care medical center, the QFT-IT assay was indeterminate in 83 children, a full 35% of the total study population. Moreover, an indeterminate result was associated with young age and immunocompromising conditions. As stated by the authors, an indeterminate result equates with an uninformative result. Hence, the test was most often uninformative in the children at high risk for developing TB after infection. Despite this finding, these results, as well as the growing body of literature regarding IGRAs in young children, support increasing use of IGRAs in children.

In his reply **Dr Dwight A. Powell says

Although I agree with many of Dr. Lewinsohn’s comments, I think there are several areas in need of additional research before a universal acceptance of the use of IGRAs for children. These are
(1) explaining the high incidence of indeterminate results in young children assessed with whole blood IGRAs;
(2) assessing the risk of progression to TB disease in children with possible latent tuberculosis infection (LTBI) based on high tuberculin skin test (TST) reactions (> 15 mm induration) but negative IGRAs; and
(3) better defining the role of IGRAs as a reliable marker of TB disease in children.

He concludes by saying

What would be my approach to diagnosing TB in children? Until more data are available, I feel comfortable using an IGRA assay to screen children older than 4 years for LTBI who have had known contact with an adult case of TB disease within the past year.

As I see it Powell expresses reluctance in using a diagnostic on children under 4 due to a lack of the same research that he is reluctant to provide. By using the diagnostic (and it has been universally proven and accepted as being more accurate) experience can be gained and as we all know, wisdom does not come before experience.

Dr Lewinson leads the way;

In summary, it is time for child health providers to embrace IGRAs rather than to cling to the antiquated TST. Expanded use of IGRAs in children, both through well-designed clinical research studies and reports of clinical practice would serve to promote better health care for children. As noted above, dual testing with IGRA’s and TST can be used in high risk young and/or immunocompromised children to increase sensitivity of diagnosed LTBI. Additionally, IGRA’s may be useful as a more specific test than TST in low risk BCG-vaccinated children. Recommendations for use of IGRAs in young children are curtailed not by negative data, but rather by lack of sufficient data in young children to support such guidelines. Cumulative clinical data can inform these guidelines. Moreover, cumulative clinical experience will clarify the deficiencies of the currently available IGRAs and proactively push manufacturers to improve the performance of their test(s) in young children. If child health providers reject IGRA use in young children, how can we expect continued improvements? There is no doubt that critical research gaps and test performance deficiencies remain, preventing the replacement of TST with IGRAs in young children at the current time. Especially, regarding QFT-IT, better test performance in young children and decreased blood volume requirements are needed. IGRAs need to be studied in a large household study of young contacts of adults with infectious TB conducted in the United States/Europe. But these issues need not immobilize us. We need to keep moving forward to prevent child health from falling behind, gain more experience with IGRAs to create rational guidelines, and continue to demand attention to one of the most vulnerable populations to TB.

*(from the Division of Infectious Diseases, Department of Pediatrics, Oregon Health Sciences University, Portland, Oregon)

**(from both the Department of Pediatrics, The Ohio State University College of Medicine and Section of Infectious Diseases, Nationwide Children’s Hospital, Columbus, OH)

Swines flew over the cuckoo nest

The ASX keeps 'em spinning

In their latest advertorial the Australian Stock Exchange gave us penniless punters the inside nod on some winning strategies. Just by picking and holding 4 stocks "Carlo" (strangely called Italian Cashflow) was able to turn $50,000 into $104,454 in 15 weeks. Ditto "Barrie" who magically transformed $50,000 into $100,860

However "Howard" bought nine times and sold six times for a profit of $49,503 whilst hyperactive "Kosmas" made 26 buys and 21 sells for a pot of $96,540.

What to make of all this priceless information?

What we can safely ascertain is that of 54,000 entries 53,996 were unremarkable.

Teens aren't twits

A 15 year old intern at Morgan Stanley produced a report that has grabbed media attention; titled How Teenagers Consume Media it has rattled media investors, particularly those in print.

On newspapers: No teenager that I know of regularly reads a newspaper, as most do not have the time and cannot be bothered to read pages and pages of text while they could watch the news summarised on the internet or on TV. The only newspapers that are read are tabloids and freesheets (Metro, London Lite…) mainly because of cost…

On radio: Most teenagers nowadays are not regular listeners to radio. They may occasionally tune in, but they do not try to listen to a program specifically… With online sites streaming music for free they do not bother, as services such as last.fm do this advert free, and users can choose the songs they want instead of listening to what the radio presenter/DJ chooses.

On (yellow pages) directories: Teenagers never use real directories (hard copy catalogues such as yellow pages). This is because real directories contain listings for builders and florists… (and) because… they can get the information for free on the internet, simply by typing it into Google

Facebook is popular as one can interact with friends on a wide scale.

On the other hand, teenagers do not use twitter. Most have signed up to the service, but then just leave it as they release that they are not going to update it (mostly because texting twitter uses up credit, and they would rather text friends with that credit). In addition, they realise that no one is viewing their profile, so their ‘tweets’ are pointless

What is hot?
• Anything with a touch screen is desirable.
• Mobile phones with large capacities for music.
• Portable devices that can connect to the internet (iPhones)
• Really big tellies

What is not?
• Anything with wires
• Phones with black and white screens
• Clunky 'brick' phones
• Devices with less than ten-hour battery life


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QFT mandatory - University of Toledo

Thats what they say;

...all international students from countries of high tuberculosis (TB) prevalence as determined by the World Health Organization (WHO), and all students born in the US who have lived abroad in one of these high TB prevalence countries, will be subject to mandatory onsite screening for tuberculosis and latent tuberculosis...

... screening for active or latent TB will be done using the QuantiFERON-TB test (QFT).

...As recommended by the CDC and ACHA, the Quantiferon TB GOLD test will be used in place of the tuberculin (PPD) skin test for screening international students for TB

..and the winner is..Stephen Conroy

The Internet Services Providers' Association UK (ISPA UK) held its annual awards and Stephen Conroy won 1st prize

Internet Villain


Stephen Conroy and the Australian Government - "For continuing to promote network-level blocking despite significant national and international opposition"

بني رشيد, الرشايدة

From the tribe of Bani Rashid (one of the largest tribes in the Arabian Peninsula) comes this snippet; QFT-G is being used to test HCWs at King Khalid University Hospital in Riyad.

Translation here.

Obama and his white glasshouse

Whilst spreading the word to the good citizens of Ghana President Obama let this slip;

No business wants to invest in a place where the government skims 20 percent off the top ...

If only he was as good as his word

Volume as a trading indicator

Business investment tends to fall into two camps, those that conduct a Fundamental Analysis (FA) of the business and those that rely on a Technical Analysis (TA) as a guide to forecasting stock movements. Generally TA ignores the nature of the company or market and use charts which illustrate market activity as functions of both price and volume.

TA is used primarily by traders and finance professionals and is the subject of ongoing debate amongst academics.

Arnuk and Saluzzi of Themis Traders say that volume and volatility has been greatly exaggerated by sophisticated computer programs or algorithmic trading. In their paper titled Toxic Equity Trading Order Flow on Wall Street (The Real Force Behind the Explosion in Volume and Volatility) they describe how these high frequency trading programs are increasing volatility;

Traders Magazine estimates high frequency traders may account for more than half the volume on all U.S. market centers.
...high frequency traders searching for hidden liquidity. Some estimates are that these traders enter anywhere from several hundred to one million orders for every 100 trades they actually execute.

Says John Mauldin;

All this "algo" (algorithmic) trading also gives a very false impression of volume. If you are a fund and see 10 million shares a day traded, you might feel comfortable that you could hold one million shares and exit your trade easily. But if 80% of the volume is false "algo" trading, that volume isn't really there. You may have a position that will be a problem if you want to exit, and not know it.

Themis Traders argue that investors should be concerned by high frequency traders (HFT) for the following reasons;

1. HFTs provide low quality liquidity.
2. HFT volume can generate false trading signals.
3. HFT computer servers are faster than other trading systems.

Q: What if a “rogue” algorithm entered the market?

A: Many HFTs are hedge funds that enter their orders into the market through a “sponsored access” arrangement with a broker. Many of these arrangements do not have any pre-trade risk controls since these clients demand the fastest speed. Due to the fully electronic nature of the equity markets today, one keypunch error could wreak havoc. Nothing would be able to stop a market destroying order once the button was pressed.

Gives new meaning to the term “mutually assured destruction?”

BCA Research - U.S. Economy: It Looks Like A Recovery

The U.S. economy is transitioning to a recovery path, though it will be bumpy and subdued compared with past cycles.

Source

The Revolution Will Not Be Televised: Democracy, the Internet, and the Overthrow of Everything

A provocative title and one well used by Joe Trippi for his book on power;

When Joe Trippi signed on to manage Howard Dean's 2004 presidential campaign, the long-shot candidate had 432 known supporters and $100,000 in the bank. Within a year, Trippi and his energetic but inexperienced team had transformed the most obscure horse in the field into a front-runner, creating a groundswell of 640,000 people and raising more money than any Democrat in history -- more than fifty million dollars -- mostly through donations of one hundred dollars or less.

Trippi was eventually replaced on the Dean team and Dean fell down. Since then a host of social networking devices have transformed the way we can experience life. Trippi reflects on the political success of Barrack Obama

the whole reason he exists, the whole reason he wins the Democratic nomination is because of the resources that millions of Americans gave to him in small numbers, under $100 contributions, over half a billion dollars raised on the internet. 13 million Americans who joined with him and join in and they're out there working and organising for common purpose.

Trippi looks forward;

To think that any country is immune, or any industry is immune from the changes that are coming because of this communications revolution, is - I mean I wish you luck, it's just not, that will not hold.

Change is going to go everywhere. You'll have industries who will adopt it faster, understand it, and there'll be those who say, 'No, no, no, it's not happening', and CEOs will hope that none of this change happens until they've retired. But it's all coming.

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A new kid in town

Google is set to take on Microsoft and its Windows operating system;

We hear a lot from our users and their message is clear — computers need to get better. People want to get to their email instantly, without wasting time waiting for their computers to boot and browsers to start up. They want their computers to always run as fast as when they first bought them. They want their data to be accessible to them wherever they are and not have to worry about losing their computer or forgetting to back up files. Even more importantly, they don't want to spend hours configuring their computers to work with every new piece of hardware, or have to worry about constant software updates. And any time our users have a better computing experience, Google benefits as well by having happier users who are more likely to spend time on the Internet.

Up the creek

The arrest of 4 RIO employees by the Chinese government has rattled some markets; rumours of heavy handed crack downs and shake outs has increased tensions within western businesses wishing to do business in China. Whilst it has been argued that the arrests were payback by the central government over a loss of face with the failed RIO/Chinalco deal the reality might be far simpler; what passes as routine intelligence gathering by commercial enterprises can be viewed as espionage if the business is an enterprise backed by a totalitarian government.

Not that China's slate is squeaky clean; they have actively practiced espionage at every level;

During the past 20 years, China has established a notable intelligence capability in the United States through its commercial presence.

China's commercial entities play a significant role in its pursuit of proprietary/trade secret U.S. technology. The vast majority of Chinese commercial entities in the United States are legitimate companies; however, some are a platform for intelligence collection activities. Although a commercial entity may not be directly involved in the acquisition of information/technology, it may provide cover for both professional and non-professional intelligence collectors. Professional collectors are usually affiliated with one of China's intelligence services, while non professionals usually collect for themselves. These collectors enter the United States to gather sensitive and/or restricted proprietary/trade secret information or to act as a liaison to consumers of intelligence back in China.

The primary targets from which China seeks to acquire sensitive and restricted proprietary/trade secret U.S. technology are the U.S. Government, private U.S. Corporations, academic institutes, laboratories, as well as persons involved in sensitive and/or restricted work. These operations are usually low-key and singular in nature, thus creating a significant counterintelligence dilemma for the FBI.

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Thermometers at 20 paces

In his piece Medicare Administrative Costs Are Higher, Not Lower, Than for Private Insurance Robert Book makes the claim

on a per-person basis Medicare's administrative costs are actually higher than those of private insurance--this despite the fact that private insurance companies do incur several categories of costs that do not apply to Medicare.

and then, by using data supplied by Medicare, sets out to explain why.

Esteemed economist Paul Krugman went straight for the soft tissue; Whenever you encounter “research” from the Heritage Foundation, you always have to bear in mind that Heritage isn’t really a think tank; it’s a propaganda shop. Everything it says is ef="http://krugman.blogs.nytimes.com/2009/07/06/a-bit-more-on-administrative-costs/#comment-195793">dismisses this as being illogical

in short, Medicare Advantage gets the healthiest Medicare Patients.

..administrative costs incurred by Medicare Advantage plans (as measured by the CBO report) include not just the cost of running the health plan, but also costs of administration by providers; that is, costs incurred by doctors and hospitals.

Brook later argues;

96% of Medicare administrative costs got to activities other than claims processing — activities like signing people up, deciding payment rates, and “general management.” None of these are a function of the number of claims, visits, or procedures, or the dollars paid out. They are all either related to the number of people, or fixed at the program level.

...Private insurance has to pay for marketing, working capital, returns to shareholders, etc…. yet they STILL spend less on administration per patient than Medicare. The fact that Medicare doesn’t have those costs yet still spends more means that Medicare is even more inefficient than the raw numbers indicate.

In testimony before the US Senate Professor Sparrow from Harvard indicated that fraud may be significantly boosting Medicare costs

in 1993 that Attorney General Reno declared Health Care Fraud to be the number two crime problem in America, second only to violent crime. That was an extraordinary position for a white collar crime to hold, and it reflected how seriously the Clinton administration viewed the problem.

...The units of measure for losses due to health care fraud and abuse in this country are hundreds of billions of dollars per year. We just don't know the first digit.

Imagine if the government was to run all healthcare.

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Riding the iron rooster

Author Paul Theroux was exasperated by travel in China and now management at RIO must be wondering if, in a past life, they had killed a Chinaman;

"It appears four employees from Rio Tinto's Shanghai office have been detained for questioning by the Chinese authorities," spokesman Nick Cobban said.

"We haven't been able to make contact with them since and we've asked the Chinese authorities for an explanation and we're haven't received anything from them."

...

On June 5, Rio announced it had dumped plans for a landmark investment from Chinalco and instead decided to seal an iron ore joint venture with rival BHP Billiton

Several days later, China's official Xinhua news agency slammed Rio Tinto's "perfidy" for scrapping the deal.

When the state is everything it pays to say SORRY - the Chinese believe that those who say "yes" when they mean "no" are bad luck.

Summer Job!

Nurse RN2B writes on her blog (a blog about my life as a former nursing student, now a Registered Nurse!)

I am working at the Children's hospital doing research in TB for a new TB test recently approved in Quebec (QFT: Quantiferon) . It's with a Public Healh PhD student and the Respiratory TB Clinic. I am amazed at how much TB there still is in North America, and I just have the kid's number let alone the adults still affected by it.
All I can say is YIKES!

Apples with oranges

Squeaky hinge Paul Krugman defends social insurance by quoting Obama;

Mr. Obama offered a crystal-clear explanation of the case for health care reform, and especially of the case for a public option competing with private insurers. “If private insurers say that the marketplace provides the best quality health care, if they tell us that they’re offering a good deal,” he asked, “then why is it that the government, which they say can’t run anything, suddenly is going to drive them out of business? That’s not logical.”

But it is logical, government enterprises have no profit motive and access to taxpayers funds so therefore can drive down private enterprise.

The Nobel prize winning economist then does some maths;

Currently, Medicare has much lower administrative costs than private insurance companies, while federal health care programs other than Medicare (which isn’t allowed to bargain over drug prices) pay much less for prescription drugs than non-federal buyers. There’s every reason to believe that a public option could achieve similar savings.

What appears to be missing from the equation is that like Fanny Mae and Freddie Mac, Medicare is backed by the government and like Freddie and Fannie Medicare is presently unfunded - and according to Federal Reserve Bank of Dallas CEO Richard Fisher the liability is not small potatoes;

If you wanted to cover the unfunded liability of all three (Medicare) programs today, you would be stuck with an $85.6 trillion bill. That is more than six times as large as the bill for Social Security. It is more than six times the annual output of the entire U.S. economy.

...add together the unfunded liabilities from Medicare and Social Security, and it comes to $99.2 trillion over the infinite horizon.

It is amazing that Paul Krugman can ignore a liability of such enormous proportions. To put it into proportion Richard Fisher also does some maths - he calculates the burden per capita of the presently unfunded liability;

With a total population of 304 million, from infants to the elderly, the per-person payment to the federal treasury would come to $330,000. This comes to $1.3 million per family of four—over 25 times the average household’s income.

These sums have appeared to have frozen the collective mind; in a publication titled Fear and a Lack of Realism pollsters found that the majority blamed rising costs on "drug and insurance company profits" rather than "aging of the population or to new and expensive drugs and treatments" and that "few concrete proposals for Medicare enjoy widespread support" - Paul Krugman's chickens are coming home to roost.


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Socialised health - between a rock and a hard place

In his provocatively titled article America's Fiscal Train Wreck Morgan Stanley bear Richard Berner warns of spiralling debt which will lower living standards and imperil economic and financial stability. And the main reason? - healthcare.

The rise in federal healthcare outlays under Medicare and Medicaid is the main long-term factor boosting deficits. These popular programs create a safety net for the elderly and disadvantaged that has been a band-aid for our flawed system of financing healthcare.

Berner sees that rising enrollments in Medicare, Medicaid and SCHIP (the State Children's Health Insurance Program) will cost 5% of GDP in 2010 increasing to 10% in 2035 and 20% in 2080. Relying on projections made by the government Berner sees that

these programs will account for virtually all of the likely growth in primary federal spending - total spending less interest on debt held by the public - in relation to GDP, and thus all the likely expansion of the deficit and debt.

In the short term Berner sees nothing but spend spend spend by the government on healthcare

in the near term, politics likely dictate that increasing access will take priority over cutting costs.

Here we have political mechanisms not market forces directing how scarce (in this case borrowed) resources are to be allocated. The cost of being socially responsible may be financial ruin.


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Not drowning just waving

Published in the May 2009 Lancet and PubMed, another ripping yarn from WHO dealing with Global Drug Resistant TB;

The countries of the former Soviet Union are facing a serious and widespread epidemic with the highest prevalence of MDR tuberculosis ever reported in 13 years of global data collection. Almost half of all tuberculosis cases in countries of the former Soviet Union are resistant to at least one drug and one in five cases are MDR.

That's a shocking result for the once glorious Motherland and their experiment to socialise medicine; almost 50% of all their TB is drug resistant. Drug resistance is man made and is a reflection of poor health care. What the Soviet health policy once provided was a universal and equal right to health and the health system provided was of universally low quality - a health system that you had to survive.

Borgdorff and Small respond to the article;

Rising trends of MDR tuberculosis in some administrative regions of the former Soviet Union suggest an epidemic of an increasingly untreatable airborne disease.

..Surveillance data have no value if they do not precipitate action; enough is now known to start urgent action to prevent and control MDR tuberculosis. Exercising basic tuberculosis control more effectively to prevent MDR disease is the highest priority..

Puts me in mind of the Russian joke;

Ivan sees his friend, Dmitri, fall into an old well. Ivan runs up to the rim of the well and calls down, “Oh my God, Dmitri, can you hear me!”
“Yes,” says Dmitri, “I can hear you.”
“And are you bleeding? Have you broken any bones?”
“No, I’m not bleeding, and I don’t think I’ve broken any bones.”
“And the bottom of the well—what’s down there?”
“I can’t actually say,” says Dmitri, ”I’m still falling.”

Think TB - think QFT

Whilst it is generally acknowledged that sputum culture is the gold test for diagnosing active TB

diagnosis made other than by culture may only be classified as "probable" or "presumed"

sputum culture is of little use in diagnosing TB that is active outside of the pulmonary system, or lungs. Writing in the American Family Physician Drs Golden & Vikram said

the diagnosis of extrapulmonary tuberculosis can be elusive, necessitating a high index of suspicion.

To that extent researchers from Holland found that when using QFT-G

a high PPV (positive predictive value) was observed for extrapulmonary TB and QFT-G might be considered in the diagnostic process in this situation

Peter Davies puts the degree of extra pulmonary tuberculosis as 15% for whites and 50% for non-whites (Bangladeshi, Pakistani or Indian ethnic origin ) whilst Mayo and Yale write that

extrapulmonary involvement can be seen in more than 50 percent of patients with concurrent AIDS and tuberculosis..risk of extrapulmonary tuberculosis and mycobacteremia increases with advancing immunosuppression

Elsewhere it was calculated that extrapulmonary TB occurred in 19.8% of an HIV+ group whilst 9.8% among the non-HIV infected group. Those findings led them to state emphatically

All cases of extra-pulmonary tuberculosis should be screened for co-existing HIV infection and vice versa, for early diagnosis of either infection and appropriate treatment.

Of equal importance to obtaining an early diagnosis is the need to diagnose for TB, to think TB. The case for thinking TB was made by Marguerite Jackson who writes;

Almost two years ago, a woman died from tuberculous meningitis after several weeks of excruciating headaches. Claudia Lacson was a physician in Atlanta, with access to the best medical care available. Several years prior to her illness, she’d had a positive tuberculin skin test and subsequently completed treatment. According to her husband, Dr. Lacson had wondered whether her headaches indicated tuberculous meningitis. Unfortunately, other, more likely, diagnoses were considered first.

More than four decades earlier, a very famous and wealthy woman died of miliary tuberculosis at a hospital in New York City. Her name was Eleanor Roosevelt. The likely source of Ms. Roosevelt’s infection was a reactivation of walled-off Mycobacterium tuberculosis that had remained dormant in her lungs for more than 40 years.

Dr. Lacson became ill when she was pregnant; in Ms. Roosevelt’s case, she was being treated with steroids for persistent anemia. Both pregnancy and steroid use are factors known to increase the risk of developing active tuberculosis from latent tuberculosis infection.

What if the women’s care providers had remembered to “Think TB”? Would these deaths have been prevented? We’ll never know. The delayed diagnosis of tuberculosis can in each case be partially attributed to the fact that nonpulmonary clinical presentations account for 15% of active cases.

In all cases, however, clinicians must do better at diagnosing it. According to the Centers for Disease Control and Prevention (CDC), each year there are almost 15,000 new cases of tuberculosis in the United States and almost 9 million new cases diagnosed worldwide. Yet even when clinicians know that latent tuberculosis infections and risk factors for reactivation are present, they often don’t recognize the signs and symptoms of the disease soon enough. Missed opportunities for early intervention lead to poorer outcomes, and others can be exposed when a person with active pulmonary or laryngeal tuberculosis isn’t managed with airborne infection isolation precautions. At the same time, providers who know they have latent tuberculosis may bear an extra responsibility to undergo treatment; in December 2005 the New York Times reported that a nurse at a New York City hospital, having developed active tuberculosis after 11 years of latency, exposed more than 1,500 patients and infected four infants.

Nothing is more important than to ‘Think TB.’

Successful detection, monitoring, and treatment of latent tuberculosis infections remain crucial to reducing the number of active tuberculosis cases. The tuberculin skin test (TST), which uses a purified protein derivative, has long been the only way to screen for latent tuberculosis infection. A new blood assay for M. tuberculosis (QuantiFERON-TB Gold) is now available and has been approved by the Food and Drug Administration for all situations in which the TST is used. The test eliminates certain interpretive and logistic challenges posed by the TST.

It’s crucial to “Think TB” when caring for patients known to have latent tuberculosis or who exhibit symptoms consistent with the active disease. This means prompt evaluation and, where necessary, the use of airborne infection isolation as a precautionary measure until a diagnosis is confirmed. We must also improve diagnostic and treatment skills among health care students. The National Tuberculosis Curriculum Consortium (http://ntcc.ucsd.edu ) is funded for this purpose by the National Heart, Lung, and Blood Institute of the National Institutes of Health, and resources are available from organizations such as the CDC and the World Health Organization to increase awareness of tuberculosis. The Bill and Melinda Gates Foundation and others provide millions of dollars each year to address tuberculosis research, diagnosis, and treatment worldwide.

Nothing is more important than for health care professionals to “Think TB.” It’s good for their patients’ health—and for their own.