County wary of increase in TB cases

Sunday, Dec. 6, 1998 | 8:09 a.m.

Richard and Michelle Smith learned first-hand about the stigma attached to tuberculosis when they contracted the disease nearly eight years ago.

It was bad enough that their son Christian, then 10 months old, was hospitalized for seizures attributed to the disease. But Richard Smith also was fired from his construction job, and several friends and even some relatives disowned them. They were mystified because they had no idea how they became infected.

"We had family members who said 'you're unfit people,'" Michelle Smith said. " 'We're going to take your kid from you.'"

For Richard Smith the ordeal was a test of friendships.

"You just get the cold shoulder," he said. "These days we don't have that many friends. If they're not going to be around for your ordeals, you don't need them anyway."

Today the Smiths are a healthy family who live peacefully in a middle-class Henderson neighborhood. Richard Smith has a good job as an executive chef at a casino, and Michelle Smith toils as a housewife with three sons in tow.

They are proof that patients with tuberculosis, or TB, can be cured of the potentially fatal disease and go on to lead productive lives. Most other patients who have been monitored by the Clark County Health District's Tuberculosis Treatment and Control Clinic at 625 Shadow Lane also have been cured.

But the number of new cases reported in the county has steadily increased after hitting a seven-year low of 18 in 1987. With 95 new cases reported through November this year the county is on pace to break 100 for only the second time ever.

Nationally, TB cases steadily declined from the 1950s until the mid-1980s, rose again through 1993, then began declining again.

Clinic coordinator Diane Lewis and fellow health care professionals say much of the case increase locally can be attributed to foreign-born immigrants, particularly from the Philippines and Mexico. Of the 91 new cases in Clark County last year, slightly more than half involved foreign-born individuals.

Many immigrants come to the county because of the abundant entry-level jobs, such as those in the hotel, construction, landscaping and restaurant industries, where they can survive without having to speak much English.

But Lewis and two Las Vegas doctors, Charles McPherson and Ruben Diaz, agree that tighter immigration controls are needed to reduce the possibility of a tuberculosis-carrying individual entering this country.

Lewis said one difference between immigrants who come to this country for jobs and refugees who move here to escape political or religious persecution is that the latter usually go through camps with top-notch medical screening.

"Immigrants may have had testing done so long ago that it may not be effective at this time," Lewis said. "It is my belief that the physicals should be done no more than 60 days before a person emigrates. There should be no waivers given for people with TB, and they should be cleared before they come into the United States."

McPherson, medical director of the Lung Center of Nevada, said little is being done to prevent TB-infected individuals from entering this country.

"They could come over in an airplane with 100 people that they could have exposed," McPherson said. "One of the problems is the local control in the foreign country. They're doing the screening but still letting these people come through.

"They currently let them travel even if they are suspected of tuberculosis. I don't know if it's because those (foreign) doctors don't know enough or they're receiving payments. The process could definitely be tightened up."

Diaz, a pediatric pulmonary specialist, added that he's had cases in which "I question why some of these individuals were allowed to come in with TB." He acknowledged that local health care officials have an obligation to treat such immigrants, but he would like to know more about the quality of TB screening in foreign countries.

"I'd like to know what the screening is, how thorough patients are screened, and what we need to do to bolster that process," Diaz said. "Some of the physicians may not be current on how to handle patients in their own populations."

The two biggest problems could be with illegal aliens and foreigners who come to the United States on temporary visas, said Russell Ahr, special assistant to the director of the U.S. Immigration & Naturalization Service office in Phoenix, which covers Nevada and Arizona.

Ahr said foreigners are not allowed to immigrate here unless they are screened in their own country by a physician certified by the U.S. State Department. Individuals who test positive for active TB will not be allowed into this country, he said.

Foreigners who are already in this country who wish to apply for permanent residency may be approved only after they have been medically screened. If they test positive for active TB, their applications can be rejected. But Ahr said even TB-positive applicants can obtain waivers if they are married to or the sibling of a U.S. citizen.

With a waiver, however, the individual still must seek treatment for TB within 30 days. This includes written acknowledgement from a physician and the health district that the person will be treated, Ahr said.

"But can we compel them to show up for the doctor and take their medicine?" he said. "The answer is 'no.' "

Illegal immigrants, naturally, are hard to track.

"We have no way of knowing how many people get in contact with local health authorities who are undocumented," Ahr said.

Lewis agreed, adding that local health officials usually don't ask foreign-born patients if they're illegal immigrants.

"We've got to work with them, not lose them," Lewis said. "They're just as contagious illegal as legal."

Foreigners who come to this country on temporary visas include students, workers in such fields as data processing and agriculture, and State Department-sponsored professionals such as scientists and academicians. None of these individuals are required to undergo medical screening before they arrive in this country unless they have visible medical problems when they apply for their visas, Ahr said.

"Speaking personally I think it would be marvelous if all nonimmigrants also got medical screenings," he said.

In a meeting last month in Thailand, the World Health Organization urged governments and international organizations to join in a new worldwide initiative to stop the spread of TB. The organization said those efforts will fail, however, if the disease is not controlled in Asia.

But Diaz noted that international organizations were already overloaded with responsibilities.

"It seems to me UNICEF is up to its eyeballs just keeping people fed," Diaz said. "There's such an overwhelming problem of insufficient medical care and insufficient nutritional care."

About 2 billion people globally carry the TB germ, of which an estimated 200 million are expected to develop active disease, according to the health district. Worldwide, TB kills about 3 million people annually, including 100,000 children. Someone dies of the disease every 10 seconds globally.

So far in 1998, six of the 95 new cases monitored by the county resulted in the patient's death, for which TB was considered a contributing factor.

TB is spread by tiny airborne germs. An infected person who coughs, shouts or sneezes can pass the disease to others who breathe the germs into their lungs.

Casual exposure usually doesn't lead to infection. But people may be at high risk if they are in constant contact with an infected individual in a small room or other close quarters. That's why health care professionals always urge people to cover their mouths when they cough.

"We don't know how we got it," Richard Smith said. "It might have been one of my friends who came over. You could be around anybody who coughs a lot, but those things don't really run through your mind."

TB patients often feel weak, lose their appetite and weight, have fevers and sweat a lot at night. When in the lungs, the disease can cause sufferers to cough up blood or mucus or have chest pains when they cough.

"The symptoms are a lot like a common cold," Michelle Smith said.

The most common way to determine whether someone has TB is through a skin test. Chest X-rays also may be used to determine whether there is lung damage from the disease.

There are no immunizations for TB. But the disease can be cured if the patient takes the prescribed medications on a regular basis. The most common medications, Isoniazid, Rifampin, Ethambutol and Pyrazinamide, are available in pill form. Patients are advised to take more than one type of medication to combat the disease.

When a patient takes the prescribed medication, which is available for free at the health district clinic, the symptoms usually disappear within a few weeks. But the medications still must be taken, often for six months to two years, and the disease may remain dormant in the body even though the active germs have been eliminated. The health district monitors all TB patients at least monthly and often for a year.

"If you get the symptoms, get help as soon as you can," Richard Smith said. "For three months we were told we couldn't leave town."

Health care professionals have always been at risk of contracting TB from patients. McPherson was infected with the disease as a medical resident in Nashville, Tenn, a decade ago. But federal regulations in recent years have been strengthened on behalf of medical personnel. One such improvement is the use of surgical masks with extra padding designed to protect doctors and nurses from breathing TB germs.

The most severe TB patients are typically hospitalized in isolation rooms where uncontaminated air flows in. The outflow air is released outdoors, where it becomes harmless.

Despite the high success rate of curing patients with the disease, one of the biggest problems is treating individuals who have TB that is resistant to multiple drugs. McPherson said this problem began in the 1980s. During that time public funding to combat TB was declining, forcing medical professionals to play catch-up with increasing case loads.

"There was a lack of proper treatment and follow-up," McPherson said. "Some people would take medications for a time and then stop taking them. This on again, off again treatment increases the chance of resistant organisms increasing.

"The key to treating TB is to take enough medication for a long enough period of time to eliminate the organisms."

McPherson said the local patients who die from TB or related causes are usually the ones who don't seek treatment until it's too late. Children under age 5 are particularly susceptible to the disease as are the elderly. The Smiths said that Christian, now 8 years old, is slower to learn than other children at school, a condition they attribute to his TB as an infant.

"Developmentally, when he got sick the doctors figured he would be six to eight months behind schedule," Michelle Smith said.

Some patients make the mistake of discontinuing their medication once they feel better, Lewis said. She said the health district is in the process of devising a plan to obtain court orders when individuals with TB refuse treatment.

"When you get somebody who refuses to do something and would endanger others you have to act," Lewis said.

The county usually finds out about TB patients through doctors and hospitals. Applicants for county health cards, such as food preparers, are also screened by the clinic.

On Lewis' wish list is access to more Asian-language interpreters. She'd also like a vehicle that would help transport patients to and from the clinic who might otherwise be discouraged from showing up because of their distaste for long bus rides.

"Transportation is always an issue," she said. "We have individuals who live in Henderson where you're looking at two and a half hours on a bus coming in and two and a half hours back."

The Smith also want people to know that tuberculosis patients shouldn't be abandoned by their friends and relatives.

"People with tuberculosis are still normal people," Michelle Smith said.

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