Officials Scramble to Deal With Resurgence of Tuberculosis : More than 26,000 new active cases were reported nationwide last year. Rewriting quarantine laws, reopening sanitariums are options being considered.

Alarmed by the resurgence of tuberculosis as a major health problem, authorities nationwide are considering rewriting quarantine laws and reopening long-closed sanitariums.

Before 1985, TB was considered to be under control in the United States. Many tuberculosis sanitariums had been shut or reduced in size years earlier, and in many cities, programs to identify and treat infected people had been relaxed.

But during the last three years, the number of cases has risen steadily and experts estimate more than 39,000 “excess” cases have occurred since 1985.

Between 1985 and 1991 the increase in active cases was 79% in New York, 51% in California, 34% in Texas and 19% in Florida, according to the federal Centers for Disease Control.

In the nation as a whole, 26,283 new active cases were reported last year, a 2.3% increase over 1990.

“The resurgence of TB caught most public health departments off guard,” said Don Kopanoff, an expert on the disease at the Centers for Disease Control. “Over the years the norm has been to decrease budgets with no thought of whether proper facilities are there in case TB resurges.”

Many of the new cases are among high-risk groups--people who are likely to resist treatment or fail to complete it.

While the decline of tuberculosis control programs is partly to blame, the sudden surge of cases is attributed largely to the growing number of intravenous drug users (many of whom test positive for the AIDS virus), to the expansion of the homeless population and to an influx of infected foreign nationals.

Although the poor are the most vulnerable, more affluent neighborhoods are not immune. CDC Director William L. Roper recently told Congress that people living in the richer half of the nation’s ZIP codes accounted for 29% of TB cases.

Normally, TB is a relatively simple disease to diagnose and treat. The vast majority of patients can be made non-infectious within a few weeks by taking medication at home. But some individuals in the high-risk groups avoid detection and treatment, or they begin treatment but do not complete it.

Failure to complete an initial treatment is one way to make the disease resistant to medication, and health authorities are especially concerned about the growing number of patients infected with strains of TB that are resistant to the standard drugs.

The states with the highest percentage of drug resistance are New York, New Jersey, Hawaii, Florida, Alabama, Illinois, Arizona, Texas, Virginia, Washington, Georgia and California. The percentage of cases that are resistant range from 42.5% of all TB cases in New York to 1.5% in California.

Drug-resistant cases pose a major problem because their treatment takes months, rather than weeks, sometimes requires hospitals with isolation wards and poses a significant risk to health care workers. Most cities have isolation wards, but they are usually small units in acute care hospitals, which are not set up for long-term care. In some cities the available beds in such wards are being overwhelmed by the number of cases.

Harlem has the highest TB rate in New York City because of the high rate of intravenous drug users and homelessness, said Dr. Charles P. Felton, chief of pulmonary medicine at Harlem Hospital. Studies at the hospital show that 89% of the patients treated there for TB are lost to follow-up after discharge.

Felton says it is essential to make patients complete treatment. If the patient refuses, the system “must think of using compulsion,” he said, because those who escape treatment can spread the disease elsewhere in the city.

The Advisory Council for the Elimination of TB, appointed originally to administer the demise of tuberculosis, is now focused on the new problems.

Dr. John Bass, a University of South Alabama expert and council chairman, said two options are a broader use of quarantine laws and the reopening of sanitariums. Because state quarantine laws are often ineffective or unconstitutional, he said, one task force is working on a model law that states could adopt.

Another option under discussion is the creation of “national centers of excellence”--three or four regional hospitals to which states would send patients they cannot handle. One place under consideration for such a center is the National Jewish Center for Immunology and Respiratory Medicine in Denver.

Kopanoff said many health departments jail recalcitrant patients in order to be able to treat them, a means not recommended by TB experts. The CDC and the American Lung Assn. say the permanent solution is for health departments to be able to hire enough outreach workers to keep track of infected people and personally see that they get their medication. Dr. Lee B. Reichman, American Lung Assn. president, believes that reopening old sanitariums is “totally the wrong way to go. It would be less expensive to hire nurses and field workers to go to patients’ homes or to take them to a clinic, he said, than to pay $600 to $1,000 a day to put them in a TB hospital. He would apply quarantine law to patients who refused to cooperate.

“I am concerned that putting patients in sanitariums . . . avoids doing the things needed to correct the social problems which are at the root,” he explained.

In Los Angeles, Dr. Paul Davidson, the county’s TB control officer, credits a patient incentive program with reducing to a minimum the number of people who must be forced involuntarily into treatment. Each year, six to 12 patients must be legally forced to undergo treatment, he said. The incentive program works by having community health workers keep an eye on areas where the homeless gather and offer them vouchers good for lodging and meals if they go to a clinic for diagnosis and treatment. This made it possible to increase the percentage of people who complete treatment to 90%. Before the program it had been 50%.

Davidson said about 10% of the 2,126 new cases reported in 1991 were drug-resistant. The county now operates 25 tuberculosis beds at Rancho Los Amigos Hospital, a county facility, and has no need now to open extra isolation beds for patients who do not comply with health authorities, Davidson said.

“But we are worried about the hard-core patient with no stable environment who is unable to cooperate with care,” Davidson said. “We can’t put them in jail or keep them at Rancho forever.”

At a state level, Davidson said, health officials are discussing the possibility of creating a single treatment facility to which communities could transfer patients who could not be handled locally. “They may have to stay there until they are cured or die,” he said.

A sharp increase in cases in Atlanta, which the CDC lists as third in the nation for its TB rate, has caused officials to consider doubling the number of beds at a former 2,000-bed sanitarium, which was converted to a mental hospital in the 1970s. Officials are now considering expanding its 40 beds for TB cases to 80.

“It’s a huge problem,” said Dr. Gary Voccio, statewide tuberculosis control officer. “Unless TB officials and politicians become pro-active, not reactive, we are just stamping out fires and we will never get rid of this.”

A Deadly Disease Makes a Comeback

Tuberculosis, TB, is an infectious disease that eats away at the lungs or other vital organs. The disease was a leading cause of death in the United States before the advent of antibiotics.

How it spreads: Someone with active TB can pass it by coughing or sneezing. Infection occurs when the germs are inhaled, usually after close and prolonged contact with the diseased person. Close and prolonged contact is considered to be six to eight hours a day for six months.

How it attacks: The bacteria first infects an organ, typically a lung. Normally, a healthy immune system is able to trap the TB germs before they attack. However, when a body’s immune system is weak, the disease can become active. The bacteria then multiply, causing cavities, lesions and inflammation to the organ tissue. The germs breed and can spread through the lymphatic system to other organs.

Treatment: There are two types of treatment for TB. The first, to prevent active TB, requires taking an antibiotic for six to 12 months to rid the body of the bacteria. The second treatment is for combatting active TB and involves taking multiple antibiotics for six to nine months to stop the germs from multiplying and to eliminate the TB bacteria.

Reported cases in California 1991: 5,273 Sources: American Lung Assn., Centers for Disease Control