A New War on TB : Myths and Poor Medical Care Have Allowed Tuberculosis to Make a Comeback, but O.C. Health Officials Are Ready to Get Tougher in Their Battle Against This Potential Killer

Arrested by police and brought to UCI Medical Center last month, the man was confined to a hospital bed and closely watched. Yet one night the hospital staff found the bed empty.

Police, quickly alerted by health workers, began a search, for there was no telling how many people the man could harm if allowed on the outside.

This was no Hannibal Lecter. This was a man in his 20s with no record of violence but who nonetheless was carrying something deadly: tuberculosis.

It’s the disease that’s so hard to catch and so easy to cure, the disease we thought was wiped out. Yet tuberculosis still kills more people in the world than any other infectious disease.

It’s on the rise even in suburbanized Orange County. Never really absent, TB has been on a five-year increase here, and now local health officials are stepping up their attack. For not only are there more cases, there are more people unconcerned with saving themselves and others.

“I think you just have to look at some of the changes in society,” says Rick Greenwood, deputy director of public health for Orange County. “There’s more homelessness, more drug use, and that gets mixed into the tuberculosis problem. You have to take your medication for a long time--it requires a routine--and these people have other problems. They are irresponsible, and we are asking them to act responsibly.”

These people wind up in jails and other institutions, where they can infect others, Greenwood says. Five cases turned up in Orange County Jail last year, prompting tests of other inmates but uncovering no unusual outbreak.

But the disease is found in more respectable settings as well. Discovering TB cases among students at La Quinta High School in Westminster last spring prompted testing both there and at Golden West College in Huntington Beach, where one of the students attended a class. Again, no unusual outbreak was detected.

County health officials say they will be more aggressive in 1994, demanding quicker notification from health-care providers and institutions so they can act fast. They will order tests of students entering school for the first time, which has been optional in recent years. And they will be quicker to force compliance when cooperation is not forthcoming.

A new state law proposed by state and county health officers took effect Jan. 1, clarifying how health officers may enforce TB quarantine and treatment. In Orange County, health officials have conferred with the district attorney, preparing for what they fear may be more cases of uncooperative people.

“It’s rare,” Greenwood says. “Almost always when you get a chance to explain things, people cooperate. And it usually only takes three or four weeks of treatment until a person is no longer contagious.

“But we had two people in the last six weeks” who refused to follow treatment programs and for whom arrest warrants were issued, Greenwood says. One was arrested and sent to a hospital ward; the other has moved away from the county, officers believe.

Greenwood, who has a budget of $4.5 million and 70 health workers to fight TB in the county, says he thinks the increase in cases has reached a plateau. The struggle now may be to resume the steady decline that had continued through most of the ‘80s.

The irony of TB is that while it is the oldest scourge of human beings that we know of--the World Health Organization calls it “humanity’s greatest killer” even today--it is usually difficult to contract and easy to cure.

The bacteria is transmitted in tiny droplets exhaled in the breath. A person must be in close, prolonged contact with a contagious person--perhaps six to eight hours a day for six months--before the TB bacteria settles in the lungs. Even then, a healthy person’s immune system can suppress the infection.

But often some bacteria survive and wait for the immune system to lose its punch through age or illness. (AIDS victims are particularly vulnerable.) Then bacteria contracted perhaps 50 years earlier can revive and spread, eating away at the lungs and other organs.

Plentiful and cheap antibiotics taken regularly for six to 12 months purge the body of lingering TB bacteria.

But for active cases, four antibiotics are taken simultaneously for nine months to a year. The reason is that the first attack on the bacteria must succeed. Each failure, usually in patients who stop taking their medication too soon, makes the bacteria more difficult to cure.

About one in 10 billion TB bacteria will change its characteristics when it reproduces, and these new, mutated bacteria often are resistant to one or another type of antibiotics. If all the bacteria are not killed in the first attack, they have time to develop super-resistant strains.

“That’s what they have back East,” Greenwood says. “They have bacteria that are resistant to three or four different kinds of antibiotics.” Health officials have called for increased drug research because they are running out of alternative antibiotics, Greenwood says.

Resistant strains have been found in Orange County, but none that are immune to all four antibiotics used in treatment.

In Orange County, 81% of the reported TB cases came from either the Latino or Asian communities. Immigration is obviously one source of the disease, Greenwood says, but attitudes toward the disease and its treatment are a big contributor.

Arthur Rubel, a UCI professor of both family medicine and anthropology, is a specialist on the cultural aspects of illness and its treatment. He has studied Latino communities extensively, and one of his researchers, Tiny Luu, is studying the local Vietnamese community.

The researcher, so far, has found that “a large proportion (of Vietnamese) assume you can’t get TB in this country, that it can be caught in places like Vietnam but not here,” Rubel says.

“It’s in part because of their perception of relative dirtiness. It’s more dusty and dirty there--that’s the causal relationship they have. They also see it as a disease of the poor, and they don’t think of people here as being poor. So when symptoms appear, they tend not to self-diagnose them as related to tuberculosis. They seek treatment for something else,” often using over-the-counter medications.

But in the case of those not long from Mexico, the major factor is shame, Rubel says.

“There’s a lot of stigma. I was surprised to find the extent of it,” Rubel says. “And the fear that should it become known, it will affect their close family and extended family relationships. You could be disowned, yes, particularly wives. They’re more fearful of being stigmatized than of the ravages of the disease itself.”

Thus, seeking treatment when symptoms appear raises the fear of being diagnosed as tubercular, Rubel says. The fear is an inducement to leave treatment early and lessen the risk that your ailment will become known.

“You can say this about both communities,” Rubel says. “The disease is associated with the underclass, and the underclass is associated with dirtiness. TB is (mistakenly) seen in some way due to a lack of personal hygiene.”

And among Latinos especially, the fear of being isolated or quarantined is significant, he says.

Ironically, that is what health officials want most to avoid, Greenwood says. Locking an uncooperative person in jail or a hospital ward is very expensive and is resorted to only in extreme cases of non-cooperation, he says.

The county provides TB treatment at no cost to the patient, although it will bill the patient’s insurance company or Medi-Cal for whatever benefits they offer. Treating a TB case normally costs the county about $8,000. Treating a difficult case in a hospital setting can cost $100,000.

Instead, using state and federal funds, Greenwood has case workers assigned for what health officials call “directly observed therapy.” It is much simpler in practice than in name. A health worker goes to the patient every day and watches him or her take the prescribed medication. “It is much less expensive than putting them in a hospital,” Greenwood says.

That is only one aspect of a stepped-up program the county Health Care Agency is planning for 1994. Health officials will also require all private health care providers to report their TB cases within 24 hours. Jails will not be permitted to release prisoners who have TB without first notifying health officials. The agency has one full-time health worker devoted to TB diagnosis and treatment in Orange County Jail.

In the past, TB testing of schoolchildren has been optional, but beginning in September, it will be required at all schools in the county, Greenwood says. “We’re going to recommend testing for all new entrants,” Greenwood says.

And health officials will meet with officials of the Vietnamese and Latino medical associations to urge an all-out effort to educate their patients about TB.

Dr. Thuy Thanh Nguyen, president of the Vietnamese Physicians Assn. in Orange County, says his personal efforts at educating patients shows the approach will succeed.

“The patients I see here, most of them came here since ’75 and are starting to understand the problem,” he says. “Not only TB, but all infectious diseases that are preventable. I spend a lot of time educating them, and they are getting much better. Before, they didn’t take the treatment because they did not know. I come from a part of the world where they don’t have preventive medicine.”

“I think the war on TB will continue obviously past the year 2000,” Greenwood says. “We will see some real improvements probably within the next couple of years, but with the way people migrate and move, even if we get control here, we’ll still continue to have cases.”

The Facts About Tuberculosis

INFECTION--By prolonged inhaling of droplets exhaled by contagious person. Close contact required over period of months.

INCUBATION--Usually unnoticed. Bacteria alive but inactive in 95% of cases. Most hazardous period six to 12 months after infection.

SUSCEPTIBILITY--Risk of developing disease highest in children under 3, lowest in later childhood, high again in adolescents, young adults and the very old. Those with HIV extremely vulnerable.

SYMPTOMS--Some or all: fatigue, weakness, anorexia, weight loss, night sweats, low-grade fever, cough, chest pains.

DIAGNOSIS--By tuberculin skin test, chest X-ray, analysis of exhaled lung fluids. Tests available at Health Care Agency clinic, 1725 W. 17th St., Santa Ana. Recorded information: (714) 834-8796.

TREATMENT--In inactive cases, daily dose of an antibiotic for six to 12 months. In active cases, daily doses of four antibiotics for nine to 12 months.

Snapshot of Tuberculosis

* Tuberculosis cases are rising in Orange County.

1992: 411

* Racial and ethnic breakdown of O.C. tuberculosis cases in 1992:

Southeast Asian: 34%

Other Asian: 13%

Latino: 35%

White: 16%

Other: 2%

* 1992 Vital Stats

Age: Most cases are people in their prime--35% are 25 to 44 years old. Thirty patients (7%) were young than 5 years old.

Gender: Sixty percent of patients are male. Source: Orange County Department of Health

Tuberculosis, City by City

Number of Orange County tuberculosis cases in 1992 and rate per 100,000 people:

City Cases Rate Anaheim 51 18.2 Brea 2 6.0 Buena Park 7 9.9 Costa Mesa 12 12.2 Cypress 1 2.3 Dana Point 2 6.0 Fountain Valley 14 26.0 Fullerton 16 13.6 Garden Grove 53 35.8 Huntington Beach 17 9.2 Irvine 8 7.0 Laguna Beach 4 16.7 Laguna Hills 7 14.4 Laguna Niguel 1 2.0 La Habra 5 9.6 Lake Forest (El Toro) 7 11.8 La Palma 2 12.8 Los Alamitos 0 0.0 Midway City 1 14.8 Mission Viejo 6 8.0 Newport Beach 4 5.9 Orange 18 15.7 Placentia 3 7.2 San Clemente 3 6.9 San Juan Capistrano 3 10.9 Santa Ana 111 36.4 Seal Beach 0 0.0 Stanton 5 15.9 Tustin 8 14.6 Villa Park 0 0.0 Westminster 36 45.0 Yorba Linda 2 3.6 Unincorporated 1 --

Source: Orange County Department of Health