State to fight high
tuberculosis rate

TB rates nationwide are down
but some health officials want
widespread screening in cities
where most immigrants gather

By Susan Kreifels
Star-Bulletin

With some of the highest tuberculosis rates in the nation, the state TB program hopes to increase local and federal funding this year for new screening equipment and more education and outreach programs among target populations.

But experts here say Hawaii, where TB rates reflect the high number of immigrants, maintains an aggressive testing and treatment program.

Tuberculosis is rampant in much of the developing world and immigration from those countries into the United States is at a record high. So public health officials on the mainland are calling for large-scale TB screening programs in cities with large immigrant communities, and along the nation's borders, according to a New York Times report.

In 1998, immigrants accounted for nearly 42 percent of the 18,361 TB cases reported nationwide, yet they represented just more than 10 percent of the total population. In 1986 they totaled about 22 percent of all cases.

Preliminary 1999 figures in Hawaii show 81.1 percent of a total 185 TB cases were found in foreign-born residents, according to the Department of Health. In 1998, they represented 79 percent of a total 181 cases.

Numbers are down, however, from the peak year of 1992, when cases reached a total 273, with 83.2 percent among immigrants.

Dr. Jessie S. Wing, new chief of the state tuberculosis program, said that while nationwide TB numbers are down, "there are pockets and areas where rates remain somewhat high."

Hawaii's high numbers "are not unusual for a gateway city. It's the nature of our geography."

Wing said the TB program and the prison system both hope to acquire digital X-ray scanning machines and coordinate test results. She also wants to increase education and outreach programs.

For years Hawaii has seen higher TB rates than the national average -- roughly double since at least 1992. One concern is the lack of screening among Micronesians. The relationships between the United States and the Federated States of Micronesia, the Republic of the Marshall Islands, the Commonwealth of the Northern Mariana Islands and the Republic of Palau allow free movement into the United States without the TB screening required of immigrants from other countries. Recent counts show more than 6,000 immigrants from the islands, and some officials estimate there could be at least twice as many.

Of the 181 reported TB cases in Hawaii in 1998, 38 were found in native-born Americans, 96 were found in immigrants from the Philippines, 11 from Micronesia, 10 from mainland China, seven from South Korea, and six from Vietnam. Filipinos far outnumber other immigrants to the state, totaling more than 60 percent of all foreigners to move here in 1996, according to state census figures.

"If there is one message we can send, it's better communication and cooperation with the countries of origin," said Wing, who has worked with the World Health Organization and is currently on field assignment from the Centers for Disease Control and Prevention.

Hidden danger

Doctors say, however, that U.S. citizens traveling to countries with high TB rates can become affected as well, and it can happen as quickly as during a flight. The airborne bacteria that spread tuberculosis can lie dormant in a person's lungs for years. Most people who have been exposed never develop the active form of the disease. But about 5 percent do; for various reasons, including an underlying medical problem, stress or malnutrition, the bacteria may become active and highly contagious years later.

While TB numbers in Hawaii have remained high compared with the national average, the state also has developed aggressive testing and treatment programs, Wing said. It works closely with federal quarantine officials, requires TB tests for students entering schools here, tests food handlers, screens target populations such as immigrants who have arrived within the past five years, and follows up on recent immigrants.

Each year, the state, which provides free testing and treatment, gives 25,000 to 30,000 skin tests and 16,000 to 18,000 X-rays, and it saw a total 40,505 patients in 1998, Wing said.

Doctor allays fears

Dr. Richard I. Frankel, who headed the state TB program from 1985-91 and now heads Queen Emma Clinics at the Queen's Medical Center, said people should not be alarmed by tuberculosis numbers. "Just be aware that it can be a serious disease and fatal," Frankel said. "But almost everyone can be treated successfully.

"Most important is for people not to take things out of proportion and use it as a scare to not have as many immigrants," Frankel said, noting that TB was the most common cause of death in Hawaii and the United States in the first 30 years of the past century.

Hawaii saw four TB deaths in 1998, Department of Health numbers show.

"We've made tremendous strides," Frankel said.

The Centers for Disease Control and Prevention and the American Medical Association said recently that the key to eliminating TB in the United States is eliminating it in the country's foreign-born population, the New York Times report said.

In southeast Texas, where thousands of illegal immigrants are placed in crowded detention centers after trying to cross the border, doctors have installed X-ray machines to help isolate quickly anyone who might be infected with tuberculosis.

In New York City and other metropolitan areas, doctors have set up outreach programs and TB testing at places where immigrants congregate, like English-language schools and churches. The goal, officials said, is to reach and treat those most at risk because they come from countries with high rates of TB.