Saturday, March 22, 2003

Virulent TB
spreads in isles

Hawaii doctors are worried over
the growing number of cases
of the drug-resistant strain

By Helen Altonn

State health officials are preparing an alert to physicians about a growing number of drug-resistant tuberculosis cases in Hawaii.

"I am quite concerned," said Dr. Jessie Wing, chief of the Health Department's TB control program.

She said there were 22 drug-resistant TB cases here last year, which equals 19.8 percent of cases confirmed through cultures. (There are other methods of confirming TB.)

There were 12 cases, or 9.8 percent of culture-confirmed cases, in 2001, Wing said.

Twenty of the 22 drug-resistant cases last year were among foreign-born people, Wing said. One was the worst type of multidrug-resistant TB, resistant both to isoniazid and rifampin, the two primary treatment drugs. Seven were resistant to several other drugs, and 14 were resistant to one drug.

Honolulu had 17 cases; the Big Island, three; and Maui and Kauai each had one.

"We are currently investigating this significant increase and plan to launch a new initiative to emphasize new national treatment guidelines for TB and drug-resistant TB throughout Hawaii," Wing said in a news release.

An airborne infectious disease caused by small bacteria, tuberculosis is spread from one person to another by coughing, sneezing or singing. Lungs primarily are infected, but other parts of the body also can be affected.

Five deaths were reported in Hawaii last year that were possibly due to TB or an illness related to the disease, but they are still being confirmed, Wing said.

Overall, she said Hawaii's TB rate has stabilized and dropped to 148 cases last year from 150 in 2001. "But the bad news is, cases seem to be a little sicker, with more morbidity."

TB is one of the leading causes of deaths worldwide, and the spread of HIV/AIDS and resistance to drugs are driving a worldwide epidemic of the disease, the World Health Organization has reported. It estimates 2 million deaths annually.

Hawaii led the nation the past two years with the highest TB case rate per 100,000 population, and it was second to Alaska in 2000. Last year, Hawaii's case rate was 11.9 cases per 100,000 population, a drop from 23.5 cases per 100,000 in 1992.

Hawaii's large immigrant population from poverty areas or U.S. territories where screening cannot be required for diseases is a major factor in the high TB rate, said Dr. Alan Tice, University of Hawaii infectious disease consultant.

Immigrants often come to Hawaii with TB because "they don't have the resources, methodology, epidemiology or physicians to recognize or treat the disease," he said.

Also, someone can have a controlled infection that sits dormant for many years, then is reactivated, Tice said. Most U.S. cases are of that type, he said, noting the Centers for Disease Control recommends that anyone with a positive TB case be treated with isoniazid.

Problems occur when people are treated but not enough to kill all the bacteria, and they can develop resistance, Tice said.

For example, Tice said, people can get over-the-counter cough medicines in some Asian countries that contain antitubercular drugs.

When they feel better, they stop the medicine before the bacteria is eradicated, he said. "What you have is inadequately treated TB, which is ideal for developing resistance, then you have potential for spread among people with new bacteria that are much more resistant."

Most TB is curable, but multidrug-resistant strains require "more time, effort and a longer course of drugs," Wing said. "Sometimes, second-line drugs are not as receptive and harder on the patient."

She said it is important for doctors to understand the kind of TB coming in. "They need to be sure to do cultures on sputums and do drug susceptibility tests and directly observed therapy, which we can help them with to make sure a person takes medications all the way to the end (normally six months)."

The TB Control Program is working with the American Lung Association, Hawaii Thoracic Society and bioterrorism officials to use some of their facilities to alert physicians, she said.

Hawaii Department of Health

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