Suburban health departments take aim at an old disease
You could get it on a 16-hour flight from New Delhi to Chicago, or catch it sitting eight hours a day next to a co-worker with a nagging cough.
In either case, tuberculosis is probably the last thing you'd think of. But this ancient disease is still a threat, not just in developing countries but throughout the world.
Though the number of active TB cases is down nationwide, millions of people carrying a dormant germ could develop the disease. Health workers are racing to make sure this doesn't happen, but worry the progress to eradicate TB in the United States is slowing.
At the same time, they've got to combat widespread myths and misconceptions about the disease.
Tuberculosis is a contagious, potentially life-threatening disease transmitted from person-to-person by tiny airborne bacteria particles. It is usually curable, and not all types of TB are infectious.
Studies estimate one in three people worldwide have inactive TB.
Dr. Susan Marantz, medical director of the TB program for suburban Cook County Department of Public Health, says between 9 million and 11 million Americans are infected with the latent TB germ. Those cases could potentially become active, especially since many of the carriers don't realize they have it.
"That doesn't mean anything to you, if you are sitting in suburban Chicago," Marantz said. But "the disease is here."
Active in suburbs
Like most people who contract TB, Indira Vemuri of Buffalo Grove doesn't have a clue where or how she got it.
The 36-year-old stay-at-home mom twice had an enlarged lymph node removed that was diagnosed as a non-communicable form of TB.
"I only used to think that TB is confined to lungs," she said. "I never knew you could contract TB anywhere in the body, even hair and nails."
Vemuri came to the United States more than nine years ago from India, where TB is prevalent, and likely carried the latent TB germ in her body.
She developed the disease for the first time in March 2004 and is again undergoing treatment for it through the Lake County Health Department's TB clinic.
Vemuri was shocked to get the disease again after undergoing a full course of treatment the first time, following all the rules. She was told that perhaps she had developed a resistance to one of the medications.
That most often happens if a patient does not take the full course of prescribed medication. The remaining bacteria develop resistance to the treatment, and the drugs don't work as well -- or at all -- the second time around.
While it's up to individual to take the drugs, health departments monitor sick patients to ensure they aren't neglecting their medications and there is no danger of the disease spreading.
If necessary, a sick TB patient can be forced into isolation.
"We can do it if the person is going to be noncompliant to staying away from the public," said Dhiya Bakr, coordinator for the Lake County Health Department's TB program. "There's a fine line between public being at risk and a person's civil rights being violated. Even if one person has TB, at least 10 people will be exposed to it."
The same compliance cannot be forced on a person with latent TB, who must take a course of preventive medication for six to 12 months. Many people discontinue he pills or disappear during treatment.
The slim but real threat of TB transmission on a commercial flight made headlines last year when Andrew Speaker, an Atlanta lawyer, flew to Paris with drug-resistant TB, potentially infecting others on two trans-Atlantic flights.
In April, the CDC had to contact and test 44 passengers from 16 states who sat near a Sunnyvale, Calif., woman on a 16-hour American Airlines flight from New Delhi to Chicago's O'Hare International Airport in December.
The woman had contracted a dangerous case of drug-resistant TB in India, which she failed to disclose until she went to the emergency room at Stanford Hospital. Officials feared she may have infected another passenger on the flight.
National health agencies are trying to improve the system of notifying local health departments when high-risk immigrants arrive, and are improving coordination of TB control with Mexico and other international partners, said Scott Bryan, CDC spokesman.
What makes it difficult is ease of foreign travel, a transient worker population and a growing number of immigrants or visitors from countries where TB is prevalent, such as China, India, Mexico and other Asian and Latin American countries. Nationally, health agencies are stepping up testing for people arriving from those countries.
Bryan said among the challenges is an increasing population of Latinos in need of targeted testing and treatment services. Poverty and poor access to medical care also may place African-Americans at a higher risk for TB disease.
"Half of our cases sometimes, they are not people who live in Lake County," Bakr said. "They are people who live in other states but come here for work. We still have to find all the people who have been exposed to them."
Suburban health departments are using limited resources to do targeted testing and pushing education about TB screening through health fairs and community outreach efforts.
Counties and local districts have the power to levy taxes to pay for TB services. Many local TB programs charge fees for screening to cover all or part of their costs, but most TB programs provide or arrange for free diagnostic testing for active TB cases and testing of those who come into contact with active TB cases, to patients without insurance or other sources of payment.
Some counties have not levied their TB tax in recent years and are now unable to do so due to local tax caps, said Melaney Arnold, spokeswoman for the Illinois Department of Public Health.
Suburban health officials say the need for TB screening and testing is increasing and so is the demand for more funding. That may eventually result in counties increasing their TB tax levies, raising fees for TB services or trying to obtain state grants.
Arnold said no local jurisdiction has approached the state legislature for additional funds thus far.
The state provides grants using CDC funds to local TB programs for directly observed therapy for patients, and developing and maintaining partnerships with other agencies working toward TB elimination. CDC funds cannot be used for testing or medications.
Suburban health departments are predominantly targeting high-risk populations, including foreign-born people from countries where TB is common, senior citizens, those who come into close contact with an active TB case, people infected with or at risk for HIV and those with medical conditions that increase the risk of TB once they have been infected.
People with weakened immune systems infected with the TB germ are more susceptible to developing the disease later on.
The big picture
National surveillance data show the rate of active TB disease in the U.S. fell to an all-time low in 2007 -- 4.4 cases per 100,000 people, or 13,293 cases.
Yet, the decline in the national TB rate from 2006 to 2007 was only 4.2 percent. The average annual decline has decreased from 7.3 percent per year between 1993 and 2000 to 3.8 percent between 2000 and 2006.
"This overall slowing in progress, combined with the continued disproportionate impact on racial/ethnic minorities and foreign-born individuals, as well as the threat of drug resistance are all reasons for concern," Bryan said.
In 2007, there was a record low number of new TB cases in Illinois -- 521 cases of active TB, a decrease from 569 cases reported in 2006.
Arnold said a lot of the new TB cases are seen in foreign-born individuals, a large concentration of whom live in the Chicago area.
Public health agencies are far from eradicating TB in the U.S. by 2010, a goal set by the CDC and World Health Organization.
"Everybody believes now there's no way that's going to happen," Marantz said. "People who think they are infected need to be screened and the public needs to support continued funding of TB education and control."
Health officials' biggest obstacle -- after funding concerns -- might be changing people's misperceptions about the disease.
They say most people don't realize the difference between the latent and active phases of TB and assume all TB is contagious.
"You don't pick up TB at the grocery store," Marantz said. "It is extremely rare that you are sitting (in a train) and the person sitting beside you is going to infect you."
Still, said the main thing is to educate the public that TB could affect anyone, he said.
"People who were born in this country think that it's not me, it's somebody else's problem," Marantz said. "We don't want (that) complacency, but we also don't want mass hysteria."
TB myths & misconceptions
Myth: I'd know it if I had TB.
Truth: Many people don't realize there are two phases of TB, latent and active. People with a latent TB infection have the TB germ in their bodies but are not sick because the germs are inactive. In this phase, they cannot spread TB to others. They may develop the disease in future and often are given preventive treatment. People with active TB disease are sick from the germs that are active in their bodies. They show symptoms of the disease, and if they have TB of the lungs or throat, they can spread it to others. Active TB is usually curable through drugs.
Myth: TB only occurs in poor people.
Truth: Anyone can get TB, though the disease disproportionately affects racial and ethnic minority groups. In the United States, more than 80 percent of childhood cases of TB occur in minority groups. Those at higher risk are people who come into close contact with an active TB case; those infected with or at risk for HIV; foreign-born people from countries where TB is common; people with medical conditions, such as diabetes, silicosis, end-stage renal disease and some forms of cancer that increase the risk of TB once infection has occurred; people 65 years or older; residents of long-term care facilities such as nursing homes; people who abuse alcohol or use intravenous drugs; those who work with groups at high risk for TB; medically under-served populations, and prisoners.
Myth: You can catch TB by contact with objects, like a phone or a door handle.
Truth: TB is spread from person to person through the air. When people with TB of the lungs or throat cough or sneeze, they can release TB germs into the air. Others who breathe in the air containing these germs can become infected. People with TB disease are most likely to spread it to people with whom they spend time with every day, such as family members or co-workers. A person must have active TB disease to spread it; infected people who do not have the disease cannot spread TB to others. Not all manifestations of TB are contagious.
TB facts
Symptoms: TB can mimic flu symptoms such as feeling sick or weak, weight loss, fever and night sweats. TB of the lungs also causes coughing, sometimes producing blood and chest pain. Symptoms may vary depending on the part of the body that is affected.
Treatment: TB can be cured by taking several drugs for six to nine months, but they must be taken as prescribed. A drug known as isoniazid can be taken to prevent TB infection from developing into TB disease. It must be taken for six to 12 months and may cause liver problems in some people, especially older adults and those with liver disease.
Illinois Department of Public Health, county health departments, Daily Herald research