• E-mail
• Print
• Comment
• Font Size
• Digg
• del.icio.us
• Discuss article

Drug-Resistant TB Poses Threat to California Control Efforts

Posted on: Saturday, 6 August 2005, 03:01 CDT

Issues at the state and community levels

Breaking cultural barriers key to progress

ALTHOUGH California health workers have been successful in curbing the state's tuberculosis rate, drug-resistant strains of the disease pose a substantial threat to control efforts.

According to a study released in the June 8 edition of the Journal of the American Medical Association, the level of multidrug- resistant TB cases remained steady in California between 1994 and 2003, despite a 33 percent reduction in TB cases overall. Although relatively rare in the United States and other developed nations, 16,377 domestic cases of TB were documented in 2000, according to the Centers for Disease Control and Prevention.

TB and its drug-resistant variations are curable, however drug- resistant strains are often more life-threatening and require more complex treatment, which can last 18 months to 24 months and cost between $28,000 and $1.3 million per patient. Non-drug-resistant TB is curable using an inexpensive four-drug regimen over six months to nine months.

Reuben Granich, MD, MPH, the lead author of the journal study and a medical epidemiologist with CDC's National Center for HIV, Sexually Transmitted Disease and TB Prevention, told reporters at a June news conference in Washington, D.C., that the drug-resistant strains, in which conventional drugs become ineffective, can develop if a patient's original strain is not treated properly or if an individual is infected by someone carrying a non-drug-resistant strain.

Of the California TB cases tested by Granich and his colleagues, 1.4 percent were multidrug-resistant, spreading throughout 62 percent of the state's health jurisdictions. Granich said this finding surprised researchers, who expected the cases to be more concentrated around urban areas. Even small outbreaks in rural areas can be taxing on health practitioners due to limited resources and less experience treating the disease, Granich told The Nation's Health.

"Five TB cases is a big deal in some areas and one multi-drug resistant case is a really big deal and causes a lot more problems," he said.

"There's an issue of maintaining experience (among health care providers)."

The study also reported that 72 percent of patients with non- drug-resistant TB and 83 percent of patients with drug-resistant strains were born outside the United States.

Although California had the most TB cases in the United States in 2003, it remains a microcosm of the nation as a whole, as health care providers throughout the country must decide how to best use shrinking resources, Granich said.

However, the study's findings could help public health workers learn to deal with TB more successfully. For example, physicians in rural areas should be trained in treating the disease, and more focus should be placed on tracking patients and ensuring they complete treatment, said Jovita Fernandez, MPH, TM, RN, a public health training specialist for the San Francisco-based Francis J. Curry National Tuberculosis Center.

Fernandez said that TB patients are at high risk for developing drug-resistant TB if they stop taking their medications mid- treatment because they feel better.

"This is the major problem at this time- that we make sure everyone completes their course," she said.

Compounding the problem, Granich's study found that individuals with drug-resistant strains were significantly less likely to complete treatment than conventional TB patients.

In turn, tuberculosis control programs should be vigilant with treatment because each new case could infect many more people, Granich said.

"It is the program's responsibility to make sure the patient is cured," he said. "Each case is very important to us; it's too important not to follow through."

Following through can involve home visits, patient education and directly observed therapy, in which a health care worker meets with the patient several times a week to witness them taking their medication, answer questions and observe progress.

"You take it on an individual basis to try to get a better understanding of what motivates them to take the medication," Granich said.

According to Catherine DeAngelis MD, MPH, the editor-in-chief of the Journal of the American Medical Association, one-third of the global population is infected with TB and 2 million die annually from the disease.

However, only 10 percent of those infected will contract the active form of the disease, Fernandez said, adding that most immigrants who contract TB were infected in their home country, but that the disease did not become active until later. Of those with latent tuberculosis who eventually develop active cases, half become active during the first few years after infection, a time frame that Fernandez called "critical."

"This is why we try to target people that are high-risk to treat for latent TB," she said.

For public health workers in California and the rest of the nation, the study's findings mean that prevention and treatment methods must be patientfriendly.

Opening barriers to health care access caused by language and cultural differences is important to quell TB and multidrug- resistant TB, Fernandez said. Some people are afraid to come forward for treatment because they falsely believe that they will have to pay for treatment or that they will be deported if they are illegally in the country, she said.

However, word of mouth among high-risk populations is a good way to quash fears that keep individuals with tuberculosis out of the doctor's office.

"Someone who already had TB could be a spokesperson for a community," Fernandez said.

"It's a way to get integrated with the community, and the people have a trusted figure. It's what we do with TB in other parts of the world."

Fernandez and Granich said they hope that funding for tuberculosis remains a priority, because if health officials and the public believe the disease is going away and become complacent with control efforts, the problem will only grow, as it did in the late 1980s. During that time, the nation underwent a resurgence of TB as well as TB strains resistant to multiple drugs that seriously encroached on disease control efforts. In turn, CDC conducted drug resistant surveys in the early 1990s and included drug susceptibility results in national surveillance information, according to Granich's study. Nonetheless, health workers can't afford to let their guard down, Fernandez noted.

"Now, TB (control) is going well, but we are risking that it could happen again, that it could be forgotten," she said.

For more information, the study is available on the Journal of the American Medical Association's Web site at . For more on TB, visit CDC's Division of Tuberculosis Elimination at .

- Patti Truant

Copyright American Public Health Association Aug 2005

Source: Nation's Health, The

More News in this Category