As TB Rates go Down, Drug Resistance Causes Worry

By: Juliana Barbassa AP
By: Juliana Barbassa AP

SAN FRANCISCO (AP) - Even as tuberculosis rates decline in the United States, drug-resistant strains of the disease showing up in California's large immigrant population are becoming increasingly hard to treat.

Researchers are concerned about this trend while funding for labor-intensive disease control programs is being cut in cities such as San Francisco, which has the highest TB rates in the country.

Drug resistance develops when patients start feeling better and interrupt their treatment, giving bacteria an opportunity to develop a defense against the medication.

The picture is grim, and World TB Day on Tuesday is an attempt to raise awareness of a disease that infects about 9 million people, particularly in Asia and Africa. About five percent of those patients are immune to the best drugs. About 2 million die annually.

Immigrant communities in states such as California are particularly vulnerable because many people are foreign born or travel frequently to countries where TB is a greater risk, including Mexico, India and China.

The state leads the nation with 2,696 TB recorded cases in 2008- and with 451 cases of drug-resistant TB identified between 1993 and 2007. About 83 percent of these drug-resistant cases involve immigrants born abroad.

"California, having so much exposure to the world via immigration and travel, is particularly at risk," said Gil Chavez, deputy director of the California Department of Public Health.

Patients with multidrug-resistant tuberculosis do not respond to the most commonly used antibiotics. Of even greater concern is extensively drug resistant tuberculosis, which is even more
resistant to an even greater number of drugs, making treatment extremely difficult.

A statewide analysis of drug-resistant TB cases between 1993 and 2006 found the proportion of patients that were one drug away from
becoming extensively drug resistant grew from 7 percent to 33 percent.

"It's a wake-up call," said Ritu Banerjee, a researcher with the Division of Infectious Diseases at the University of California, San Francisco, lead author on the paper published in the Clinical Infectious Diseases journal in 2008.

With extensively resistant TB, the patient can loose lung tissue and need surgery, pushing the cost of treatment up to $1 million, with no guarantee of survival, said Kenneth Castro, director of the Centers for Disease Control's Division of Tuberculosis Elimination.

"You get a couple of these patients and you can bankrupt a city program," he said.

The San Francisco metropolitan area, where about one-third of residents were born abroad, is particularly vulnerable to the disease and to the more dangerous imported strains.

About 85 percent of the 609 patients diagnosed with drug resistant TB between 1993 and 2006 were foreign-born. Of the 18 cases of extensively drug resistant TB in the same time period, 83 percent were found in foreign-born people.

"It is scary - these cases are just the tip of the iceberg," Masae Kawamura, director of the tuberculosis control section of the San Francisco Department of Public Health. "We have to expect to see more over time. We are a city of immigrants, people continue to be mobile. We have to be ever vigilant."

After a TB spike in the 1990s, the city adopted a hands-on approach to treatment.

Patients travel to the city's tuberculosis control clinic so staff can deliver their daily dose of drugs. Those who cannot visit the clinic because of work schedules, illness or other hurdles are seen by field health care workers like Virgilio Comia.

With a nod and a smile - most of his patients do not speak English, and they communicate in signs - he gives each one a handful of pills, and stays until they have swallowed them all.

Looking for his first patient of the day, he knocks on a garage door. The elderly Chinese man slumps over a narrow table, still weak though it had been two months since he was released from the hospital.

The garage was partitioned into four dark, windowless cubicles, each one home to other recent immigrants.

"You can see, it's like a refugee camp in there," Comia said.

Tuberculosis, long a disease associated with crowded conditions, is spread through coughing and sneezing.

Comia's patients include a Cambodian grandmother who shares a single-room apartment with six relatives, and a homeless man in one
of the city's shelters.

Comia's persistence ensures they complete their course of treatment. Now budget cuts are endangering this kind of proactive approach to TB.

Budget cuts have reduced the TB control staff by more than half since 1996, said Kawamura.

The city' ability to proactively test in high-risk areas and to treat latent TB cases before they become active has been hurt, said Jennifer Grinsdale, program manager and epidemiologist with the TB Control Section of the city Department of Public Health.

"Anywhere from two to 10 years from now, we'll see the impact for this," she said.

(Copyright 2009 by The Associated Press. All Rights Reserved.)

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