Dallas County's unyielding approach on tuberculosis has cases of the disease falling

12:00 AM CDT on Thursday, April 15, 2010
By SHERRY JACOBSON
sjacobson@dallasnews.com

In Dallas County, there's a disease so dreaded that people diagnosed with it must agree to take medication for six months and allow a government worker to watch them swallow the pills every day.



MONA REEDER/DMN
Tesfa Kidane (left) of Dallas County Health and Human Services took tuberculosis medication to Wayne Hawn on Wednesday morning. The number of TB cases in the county fell below 200 for the first time last year.It is so serious that the medication is hand-delivered wherever an infected person can be found, even if it's in a cardboard box under a downtown bridge.

"We can meet them at a McDonald's or a 7-Eleven or a gas station," said Tesfa Kidane of Dallas County Health and Human Services.

He oversees the 10 outreach workers who religiously keep track of and treat Dallas County's nearly 200 tuberculosis patients – an approach so successful that TB cases dropped 11 percent in 2009 from the previous year.

Why such a hard-nosed approach for a disease that has nearly been stamped out in the U.S. and is highly treatable?

"This disease, if left untreated and unchecked, could decimate a community," said Dr. Garry Woo, medical director of tuberculosis control for Dallas County.

And if patients refuse to take their meds or miss too many of these rendezvous, county health officials will have them quarantined.

That rarely happens.

"Usually, a strong attachment grows between the patients and the outreach workers," Kidane said. "We also give them incentives to stay involved, such as meal vouchers and bus coupons."

Last year, 195 county residents were diagnosed with active tuberculosis, compared with 219 the previous year. The decline marked the first time TB dropped below 200 cases a year.

"I thought it was time to open some champagne," said an ecstatic Woo, who has led the county's TB fight for nearly a decade.


$1.9 million budget

Dallas County devotes 60 full-time employees and a $1.9 million annual budget to the prevention effort.

"We're fortunate in Dallas County to have a real robust surveillance program and a public clinic working hand in hand," said Zachary Thompson, executive director of Health and Human Services.

The county clinic sees 40 to 60 people a day, including health care professionals undergoing TB tests for work or educational requirements.

Despite such vigilance, the rate of TB cases in Dallas County, and Texas overall, was much higher than the national average, which was 4.2 cases per 100,000 people in 2008.

That same year, TB cases throughout Texas totaled about 1,500, putting the statewide rate at 6.3 per 100,000. Dallas County's rate that year was 9.2 cases, although it dropped to 8.1 last year.

Experts say there's a reason for the higher incidence: Dallas County and Texas have a large immigrant and refugee population, coming from countries where the disease is endemic.

Nationally, there were 644 deaths from TB in 2006, the most recent year for such data. That's a 46 percent decrease from a decade earlier, according to the Centers for Disease Control and Prevention.

"It takes a very strong public health approach to keep track of the active cases," said Dr. Brian Smith, director of Region 11 for the Texas Department of State Health Services. The 19 southern Texas counties in Region 11, mostly along the border, reported 11 cases of TB per 100,000 people last year.

A key to controlling the disease is to start treatment as quickly as potential cases are identified.

"It is an airborne disease that can spread as easily as the flu," Woo said. "When we suspect a TB case, we immediately begin to test people wherever they shared air with the patient – at work, leisure and home."

People with TB can spread the disease by coughing, sneezing, speaking or singing, all of which send droplets of bacteria flying toward others.


High-risk groups

Most often, TB cases are discovered by screening certain high-risk groups in urban and border counties, including state and county prisoners and people arriving from other countries.

Users of homeless shelters, methadone drug treatment centers and HIV treatment centers also must be screened regularly.

Among those diagnosed in Dallas last year was a 33-year-old homeless man who was HIV positive and tested positive for TB in the county jail.

"You've got to fight for your life," he said early Wednesday when he ran into Kidane dispensing TB medication on a downtown street corner.

"I've been on the streets for eight years, but people are trying to help me get a place now," said the man, who declined to be identified.

TB cases also turn up in emergency rooms when its sufferers develop pneumonia or other symptoms. The disease usually attacks the lungs but can also affect the brain, kidneys and spine.

The most common symptoms are weight loss, fever, night sweats, persistent coughing, chest pain and coughing up blood.

"Some people can ignore their symptoms for a long, long time," Woo said.

Normally, each TB patient is referred to the county clinic and assigned a field nurse to coordinate treatment. All patients are warned that failure to comply will result in being quarantined. The threat of state custody for the duration of treatment – up to a year – persuades most patients to follow the rules.

In February, however, Dallas County got permission from a state district judge to send a noncompliant TB patient to the Texas Center for Infectious Diseases in San Antonio for the duration of treatment.

"Taking the medication is the best opportunity for people to be cured of this disease," Woo said. "No one has to die of tuberculosis in Dallas."

The disease was a leading cause of death in the U.S. until the 1940s, when scientists discovered the first of several medicines to treat it.

Until then, doctors tried a variety of treatments, including placing patients in sanatoriums for months where they could sit in the sun, breathe fresh air and, ideally, get better. It was not unusual for five Dallas residents to die from TB in a single week.

In 1942, for example, 72 Dallas residents per 100,000 were dying from tuberculosis each year, compared with a national average of 52 per 100,000, according to media reports at the time.

The hodgepodge fashion of dispensing TB drugs throughout the world was blamed for their lagging effectiveness. And in recent years, the lack of follow-through gave rise to patients developing a resistance to the drugs.

In 2003, Dallas County set higher performance standards that required staffers to watch at least 95 percent of TB patients taking their pills every day. Other health departments adopted the same "observed therapy" goal.

"As a result, we have a low incidence of drug-resistant cases in Dallas County," Woo said. "It's less than 10 cases per year. We've been fortunate."


Challenging work

The standard TB treatment requires four medications – from nine to 16 pills total – to be taken daily. If symptoms subside after two months and the patient has been compliant, the dosage can be adjusted for the remaining four months.

But the county monitoring stops only when the patient is cured.

Standing before a wall-size map of Dallas County, Woo pointed to the colored pins that mark where each active TB patient lives. Most pinpointed southern Dallas locations, but some also were in the suburbs, including eight in Grand Prairie, four in Carrollton and five in Mesquite.

"We're trying really hard to serve all these patients," Woo said. "It's a very challenging and exciting time."


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