TB Still On Rise In N. Va.
Drug Resistance, Immigration Cited In Disease's Spread

By Leef Smith
Washington Post Staff Writer

http://www.washingtonpost.com/wp-dyn/articles/A42393-2002Mar17.html

TB Still on Rise in N.Va.
Monday, March 18, 2002; Page A01
Drug resistance, immigration are cited in spread of the contagious disease.

Bucking the national trend, tuberculosis continues to rise in Northern Virginia, where state health officials say immigration is fueling the spread and new, drug-resistant strains of the contagious disease are gaining a foothold.
Figures being released today by the Virginia Department of Health show that the number of new TB cases increased nearly 5 percent statewide from 2000 to 2001, with 57 percent of the total -- 174 of 306 cases -- occurring in Northern Virginia. [See end of article.]
That represents a one-year jump of 17 percent for the region, on top of a 5 percent rise the year before. The latest tally was boosted by reports from Prince William County, which recorded an increase of 188 percent with 26 new cases in 2001, and continuing high numbers from Fairfax. 
Although state health officials stopped short of declaring the new data a crisis, they concede that Virginia now stands in contrast to much of the nation. Officials with the Centers for Disease Control and Prevention, headquartered in Atlanta, said provisional 2001 reports indicate that the national TB rate declined slightly last year, for the ninth year in a row. Actual numbers will not be released until later this week.
Consistent with the national trend, Maryland health officials reported 262 cases for 2001, a 7 percent decline from the previous year. The District's numbers, and a more comprehensive breakdown for Maryland, will be released this week as well.
Health officials say the rise of TB, a bacterial disease spread through the air, is largely a consequence of the migration of people from parts of the world where the disease is common. It is thought that two-thirds of the cases of TB brought into the United States originated in just three countries: Mexico, the Philippines and Vietnam. The World Health Organization declared TB, which kills 2 million people annually, an international emergency in 1993.
"This is a major global health problem and one that is having a direct impact on Virginia, because it is very much one of the gateway states," said Ram Koppaka, director of the state Department of Health's division of tuberculosis control. "I would not want people to get the impression that this is a crisis [in Virginia.  At the same time, it's something people need to be aware of. TB is not gone."
Although U.S. doctors have the drugs and knowledge to treat TB, health experts say it could spread in this country if it is not brought under control in the rest of the world.
The problem is exacerbated in the United States because underinsured patients often balk at the cost of treatment -- prescription co-payments can run as high as $100 a month for the six to nine months' duration -- and take themselves off the drugs prematurely, increasing their susceptibility to multi-drug-resistant strains of TB. As a result, the more dangerous permutations also are on the rise, according to health statisticians. 
"From a public health perspective, poorly supervised or incomplete treatment of TB is worse than no treatment," because patients can pass on a drug-resistant strain to others and will require years of treatment at 100 times the original cost, WHO said.
Virginia is one of two states (Washington is the other) that does not automatically provide free medication to anyone with TB, though officials in Richmond say that, in practice, no one is denied treatment. Drug costs are fully covered for the indigent, they say, and in cases where private insurance doesn't cover the tab, the state uses a sliding scale based on income to determine how much of a drug bill a patient must pay.
In 2001, there were 10 new reports of multi-drug-resistant TB in Virginia, up from seven cases in 2000 and four in 1999. Six of 10 new cases were in Fairfax County.
Multi-drug-resistant strains are particularly alarming to health officials because treatment can stretch over several years and cost tens of thousands of dollars for hospital stays, intravenous drugs, chemotherapy and sometimes even surgery to repair damaged lungs.
Lee Reichman is executive director of the New Jersey Medical School National Tuberculosis Center and the author of the 2002book "Time bomb: The Global Epidemic of Multi-Drug Resistant Tuberculosis."
Virginia, he noted, pays the full cost of treating sexually transmitted diseases and recently footed the bill for anthrax medication. Not doing the same for TB is not only shortsighted but "disgraceful and appalling," he said.
"The first, second, third, four and fifth rules of public health say if you have a condition that affects the greater society more than the individual person and you don't make it worth his while to take his medicine, then what's he going to do?" Reichman said. "He's going to stop taking the medicine, which is against society's interest."
In a statement last week, Virginia's acting health commissioner, Robert Stroube, defended the state's policy as a way to "prioritize limited resources so that the neediest Virginians can be served at no cost to them" while taxpayers are spared funding full treatment for everyone.
James Lamberti, a Northern Virginia pulmonologist who heads the TB advisory committee of the Virginia chapter of the American Lung Association, said the state needs to do more to make sure that people with tuberculosis obtain, and complete, their drug regimen. 
"The Department of Health tells you no one goes without medication, but the truth is, it's a lot of paperwork and sometimes patients slip through the cracks," Lamberti said. "We need to be doing everything we can."
The cost to the state of providing drugs for everyone would be negligible compared with paying to combat drug-resistant strains, he said.
Testing for TB among people entering the country is currently limited to those who apply for immigrant or refugee visas. If active TB is found, the patient must undergo drug treatment.
With the amount of traveling people do nowadays, health experts agree with Reichman when he says, "To control TB anywhere, you have to control it everywhere."
Ken Castro, director of TB elimination at the CDC, said health officials are working on new strategies for combating the spread of TB, which strikes somewhere in the world every second -- about 31 million people are exposed each year, and about 8 million become sick, according to WHO figures.
Testing everyone before any travel is not the answer, Castro said. "Imagine if you needed a chest X-ray to go to London or France" on vacation, he said. "The more important way to solve the problem is to reduce the rate in countries that are highly impacted," he said.