TB Cases Rise Dramatically in County, State : Public health: Number who get the disease increased 71% in O.C. since 1990. Officials will seek $1.5 million top open new clinics and start skin testing of all new students.

Faced with the increased danger of tuberculosis, public health officials plan to begin skin testing this fall of all first-time students to Orange County schools, from first grade through high school.

They intend to open tuberculosis clinics across the county and more closely monitor the treatment of people who are infected to make sure they take their medication so they will get well and not be contagious.

This comprehensive strategy is expensive. On Tuesday, the Orange County Health Care Agency will ask the Board of Supervisors for $1.5 million in additional money to hire 33 more health workers they can deploy in schools, clinics and jails to fight the disease, which has shown a 71% increase in new cases in Orange County since 1990.

The new resources would substantially bolster the county’s current anti-tuberculosis program, which consists of a $5-million annual budget and a 70-person staff.

Although the health agency is jumping ahead of the ordinary county budget process to ask for a mid-year increase in funding, no opposition is expected from the supervisors.

“I think it is money well spent,” said Supervisor William G. Steiner. “I think public health needs to be a high priority and preventive efforts are really cost-effective.”

Steiner said board members were alarmed by the outbreak last year of drug-resistant tuberculosis at Westminster’s La Quinta High School, where 12 students were diagnosed with active disease linked to a 16-year-old girl. One of the students, who suffered a severe relapse, now faces the prospect of surgery to remove part of her lung.

Finding such a public health threat, which often is associated with overcrowded housing and poverty, is a wake-up call for Orange County, Steiner said. “I think sometimes Orange County thinks it is immune from these kind of difficulties,” he said.

Penny Weismuller, the county’s manager of disease control, said county officials could not wait for the regular budget process, which usually does not allow new hiring by county departments to begin until October.

“We need additional staff to handle the increased demand and we need it now, not in six months,” she said.

County health officials say they want more personnel to more aggressively treat active, contagious cases of TB throughout the community. There has been a sharp increase in active TB in Orange County, up from 258 newly diagnosed cases in 1990 to 440 in 1993.

Another disturbing statistic, Weismuller said, is that only 76% of people put on treatment for active tuberculosis in the county complete their medication regimen, while the Centers for Disease Control and Prevention sets a goal of 95%. “We want to try to close that gap,” she said.

Dr. Kenneth Castro, director of the Centers for Disease Control and Prevention’s division of TB elimination, said Orange County is among many local health-care agencies nationwide that were caught off guard by the resurgence of tuberculosis, which most health experts until the mid-1980s believed was on the brink of eradication.

The recurrence of TB has been linked to increased immigration from countries such as Vietnam and Mexico where the disease is endemic and to the concurrent growth of the AIDS epidemic, whose victims are susceptible to TB.

Reversing the rise in TB will be a long-term battle, Weismuller said, that will require giving preventive treatment to the many people who have been exposed to the disease and thus have the bacteria in their system that could become active later in life.

In the area of prevention, Weismuller said, the county’s highest priority is to reach children through the school-screening program to begin next fall. She estimated that 19,000 student newcomers will need TB skin tests.

The county may get some some help in the testing from private physicians or school nurses. But she said county health-care workers are expected to bear most of the burden of follow-up care of students who are found to be infected. Weismuller estimated that 1,400 youngsters will be discovered with inactive tuberculosis.

Most of the exposed children, she said, will be referred to the county Health Care Agency for six months of medication that will greatly reduce the probability that they will develop active tuberculosis later in life. Two of the new nursing positions that health agency is requesting, she said, will be dedicated to this task. In addition, Weismuller said, the Health Care Agency wants to hire six more nurses to provide preventive treatment to an estimated 1,700 people a year who have been told they have inactive TB, but have given up on trying to get care at the county’s overcrowded clinic in Santa Ana.

“For the last three years, the clinic has operated at full capacity,” Weismuller said, and hasn’t been able to take more patients.

Besides adding nurses to the tuberculosis clinic on 1725 W. 17th Street, she said, newly hired nurses would open satellite TB clinics in other parts of the county that would be more convenient for people requiring preventive medication. Also the requested funds, she said, would enable the county to hire bilingual and bicultural community workers to work with the nurses at the new treatment sites.

Even more important than prevention, Weismuller said, is to ensure that Orange County residents with active disease are properly treated and monitored.

Of the 33 new positions the health agency is requesting, 10 would be dedicated primarily to treating people already infected with active tuberculosis, which can be spread to others through coughing.

The TB outbreak at La Quinta was sparked by the delayed diagnosis and inadequate treatment of a student who was contagious for more than two years, according to a federal investigation of the episode.

“None of us wants to live through another outbreak,” Weismuller said. To avoid that prospect, she said, the Health Care Agency is asking for another treating physician at the county TB clinic and four more public health nurses, for a total of 12, who will act as “case managers,” following patients with active TB to make certain they obtain adequate diagnosis and therapy, even if they are under the care of private physicians.

Weismuller noted that a new state law gives county health officials authority to review the TB treatment plans of private physicians and requires physicians to transfer to county care those patients who are not compliant.

One of the most worrisome problems in tuberculosis control, Weismuller said, is that patients infected with active tuberculosis tend to stop taking their medicine when they begin to feel better and they get tired of the daily treatment, which lasts a year. But when they stop taking the drugs, the disease can come back in a more virulent and drug-resistant form.

To make certain that patients stay on their medicine, the Centers for Disease Control and Prevention recommends that health authorities “observe” them. But Weismuller said because of a staffing shortage, the county provided “observed therapy” only for the most serious cases until last summer, emergency federal funds were used to hire four community workers and began witnessing the treatment of 126 patients, or 28% of its active TB caseload.

“If we get three more outreach workers, as requested, we are going to have 40% of patients on directly observed therapy,” she said.

Last, county health officials said they want to focus more attention on curbing tuberculosis in Orange County’s jails, an environment that can easily allow the spread of contagious diseases.

Dr. Hugh Stallworth, the county’s public health officer, said he wants to assign four new nursing assistants to the jail medical services “so we can screen everyone within 24 hours of coming into the jail.”

Because of a shortage of medical staff, jail inmates are screened for TB only after they have been incarcerated seven days, according to Dr. Ernest Williams, the county’s director for correctional medical services.