Health Officials Battle Sharp Rise in TB Cases

When Orange County public health worker Minh Luyen asks Vietnamese tuberculosis patients why they aren’t taking their medicine, they often complain that it makes them feel too “hot.” Their culture values a balance of cold and heat, yin and yang.

Luyen doesn’t argue with them but strongly recommends that they take their daily dose of pills and then cool off by drinking lots of water and eating fruits and vegetables.

Understanding other cultures has become essential for public health workers, who are fighting a dramatic rise in pulmonary tuberculosis cases in Orange County, mostly among Southeast Asian immigrants.

Last year, the number of new tuberculosis cases reported in the county jumped by 35% over 1991, from 305 to 411 cases--the greatest hike in 10 years. That translated into an increase in the rate of tuberculosis infection from 12.4 to 16.4 per 100,000 county residents. Southeast Asians accounted for 58% of the new cases, Latinos 19% and Anglos 18%.

County officials blame the trend largely on a change in immigration law that since June, 1991, has allowed TB-infected immigrants into the United States as long as their disease is not contagious.

Underscoring that theory, officials point to a near doubling in the number of immigrants who arrive in Orange County with test results showing they may have TB. In 1992, the number of potential TB cases increased to 1,630 from 821 the previous year, according to county health authorities.

Orange County has escaped the outbreaks of multi-drug-resistant tuberculosis strains that have killed their victims, especially HIV-infected patients, in New York and Miami. And so far, the disease has not struck with any force in Orange County’s highly susceptible HIV population or its nursing homes, hospitals, prisons, schools or shelters for the homeless--places where it could be easily spread.

However, some local health officials worry that the potential still exists here for TB to infiltrate high-risk groups and for drug-resistant strains to develop. So they are closely monitoring the groups and evaluating the county’s TB-screening programs.

“The epidemic back East has served to increase everybody’s awareness,” said Dr. Lauri Thrupp, chief of infection control at UCI Medical Center in Orange. Thrupp said he is advocating more strict adherence to TB skin testing of immigrant patients who are admitted to the university’s hospital and clinics.

In addition, the Orange County Health Care Agency plans to build isolation areas in County Jail for inmates with contagious TB and has applied for state funding to place a TB clinic in the jail to better screen and treat inmates and link them with medical care after they are released.

The agency will also ask shelters for the homeless to refer their residents to the county public health clinic in Santa Ana for free TB screening.

Health officials are confident that the risk of tuberculosis won’t become as great in Orange County as it is on the East Coast. But they acknowledge that the high number of immigrants who are infected with TB must be effectively treated.

While modern medicine has provided drugs to cure the disease, which was once a major killer, tuberculosis can still wreak havoc if it is allowed to run its course.

“You can die from untreated TB,” said Dr. Margaret Tipple, an assistant director at the Centers for Disease Control in Atlanta. In 1991, tuberculosis took the lives of eight Orange County residents. The death figure is not yet available for last year.

The ethnic groups that are most afflicted with TB, according to health officials, harbor the disease mostly within their immediate families who share the same breathing space. But they are not considered a health risk to the general public. Pulmonary TB is a lung disease transmitted from person to person by bacteria contained in phlegm that is coughed into the air.

Because of the development of effective antibiotics and widespread testing, less than a decade ago, TB seemed on the verge of extinction nationwide. But that hope was dashed by increased immigration from TB-infected countries, growing homelessness and the spread of HIV.

Orange County had problems earlier than most of the country with the arrival of throngs of Vietnamese refugees in the late 1970s, triggering a marked resurgence of TB. At that time, the county responded by establishing a refugee health screening program that controlled the ailment.

But the TB threat has rebounded.

According to the California Department of Health Services, in 1991, Orange County had the fourth-largest number of tuberculosis victims among 25 counties surveyed. Two of its cities with large ethnic minority populations, Santa Ana and Anaheim, were among the top 10 California cities for the rate of tuberculosis cases per 100,000 people.

Nationwide, Santa Ana ranked 10th in tuberculosis rates among all cities with a population of 250,000 or more.

While the highest increase in TB cases last year was among Southeast Asians, tuberculosis has always been prevalent in the county’s Latino community because of immigration from Mexico and other third-world Central and South American countries where tuberculosis is endemic.

It is especially difficult for public health officials to control TB within the county’s Latino community because many Latinos come to the United States without documentation that would require TB screening and follow-up treatment.

In 1992, 142 new tuberculosis cases were diagnosed among Latinos, compared to 139 among Southeast Asians living in Orange County.

County health officials believe that a change in U.S. immigration policy has caused the higher number of immigrant TB cases here among Southeast Asians.

Tipple said legislation that became effective in June, 1991, allows immigrants from any country to enter the United States with TB as long as the disease is not contagious. Previously, Vietnamese were treated overseas in CDC-run clinics until they were fully recovered.

This policy change, Tipple acknowledged, places more responsibility on local public health agencies to deal with TB without providing them with additional federal funds.

Refugees and other immigrants who are believed to have TB, as indicated by chest X-rays taken before their departure from their home countries, are referred by the U.S. Immigration and Naturalization Service to the county’s refugee clinic.

At the clinic, they receive skin tests to determine if they have been exposed to TB. If the skin tests are positive, they also have new chest X-rays to learn if the disease is still active. If the chest X-rays are positive, their sputum is laboratory-tested to determine whether they are contagious.

Immigrants with latent tuberculosis that causes no illness are treated with antibiotics to eliminate TB germs from their bodies so they won’t experience a flare-up later in life.

Health workers say the difficulty in curing tuberculosis is the extraordinarily lengthy treatment, requiring at least six months of daily medication and monthly checkups by a physician.

In addition, people with contagious tuberculosis must stay home--avoiding workplaces, shopping malls, churches and other places where they could infect others--until the antibiotics make them no longer contagious.

If TB patients stop taking their medication when they feel better but before the disease is eradicated, drug-resistant bacteria strains may develop that could make their disease untreatable. Also, the dangerous TB strain could spread in the community.

County health officials say that to ensure compliance they are increasing the use of outreach workers who deliver pills daily to problem patients in their homes and watch for them to be swallowed. About 60 patients are currently on such home surveillance programs.

Immigrants from countries like Mexico and Vietnam with less access to good medical care--and more reliance on home remedies--need to be educated about American-style health care, especially the concept of “preventive medicine,” outreach workers say.

“If they don’t have symptoms, they don’t believe they are sick,” said health worker Luyen, who is bilingual and works primarily within the Vietnamese community.

Those who neglect taking their TB medication, Luyen noted, are often preoccupied with what they believe are more pressing concerns, such as learning to speak English and getting a job.

In Vietnam, she said, few receive treatment for TB. “If they cough, they eat citrus, like kumquats, that thins out the phlegm,” Luyen said.

Moreover, she said, Vietnamese immigrants being treated for TB commonly complain that American medicine makes them feel “hot,” a perception that she said is magnified by the red color of one of the four or five pills they take daily. For Vietnamese, she said, feeling hot has a special cultural significance, since their philosophy values a balance of hot and cold in the body.

CDC physicians say the Vietnamese complaint is legitimate, since the medications for TB can produce uncomfortable side effects such as tiredness, hot flushes and nausea. However, simply taking pills is a vast improvement from decades ago, when TB sufferers were isolated in sanitariums.

Tuan Quoc Nguyen, 21, a newly arrived immigrant who was being tested for suspected tuberculosis last week at the Santa Ana refugee clinic, said many Vietnamese still living in Vietnam cannot afford TB medications--if they can find a pharmacy that stocks them.

Nguyen, who received a chest X-ray at a refugee camp indicating that he might have TB, was grateful to go to the clinic for a more certain diagnosis.

“It is good to have treatment when you need it,” he said.

Tuberculosis Makes a Comeback The number of tuberculosis cases in Orange County leaped to 411 last year. That was a 35% increase from 1991 and the highest in 10 years. The county’s rate per 100,000 residents also jumped, to 16.4--a 32% increase from 1991. Cases ‘92: 411 Rates per 100,000 residents ‘92: 16.4 Men, Minorities Suffer Most The disease is most prevalent among males. Latinos and Southeast Asians by far compose the bulk of tuberculosis cases; those between the ages of 25 and 64 account for more than half the cases. A look at the demographics of cases in 1992: Men: 60% Women: 39% Unknown: 1% Latinos: 35% Southeast Asians: 34% Whites: 16% Other Asians: 13% Others: 2% 14 years and younger: 11% 15-24: 14% 25-44: 35% 45-64: 24% 65 and older: 16% North County Problem About 60% of the county’s cases last year were centered in four north and central county cities--Santa Ana, Garden Grove, Anaheim and Westminster. Together they account for about 30% of the county population. Those communities also had four of the top five rates per 1,000 residents. How the cities compare, ranked according to rate: Rate per 100,000 residents Countywide rate is: 16.4 * Includes three cases from outside the cities Note: No cases were recorded in Los Alamitos, Seal Beach and Villa Park Sources: Orange County Health Care Agency; California Department of Health Services. Researched by LESLIE BERKMAN / Los Angeles Times