Tracking a Killer's Comeback

By MARGARET TALEV

May 15, 2000 12 AM PT

TIMES STAFF WRITER

Rudy said he couldn’t figure out how he might have caught tuberculosis.

On a recent morning, several weeks after he was first diagnosed, the withered 66-year-old waited for his checkup at the Ventura County Public Health Department. He searched his memory to explain his condition.

“I don’t hang out with a lot of people,” said the retired shoe repairman, who, like other TB patients interviewed for this story, asked that his last name be withheld. “I cannot think of where I got it.”

But when Rudy talks about his childhood, the origin of his case seems clearer: He grew up in Ventura with eight siblings in a family of Latino crop pickers. One sister died of TB at 23. Two brothers caught the disease in their youth but have survived. Rudy’s exposure could date to the 1940s, a health worker explains.

While tuberculosis cases nationwide have declined in the last decade, the disease has been on the upswing in Ventura County. Although the higher rates locally do not indicate anything close to an epidemic, the increase concerns local health care officials.

As they track the numbers, county officials have found that a disproportionate share of senior citizens have the disease--many of them longtime county residents who have spent years working and living among immigrants or who are foreign-born.

In 1998, the countywide TB rate was 21 per 100,000 in residents ages 70 to 79, and 26 per 100,000 in those 80 and older, compared with a rate of seven in 100,000 for all ages surveyed.

Marilyn Billimek, the county’s director of communicable diseases, said the trend may indicate a much delayed aftershock of an epidemic already passed. This could be a generation of people who were infected decades ago--who harbored the infection in a dormant, noncontagious state--and are only now developing the disease, as age diminishes their resistance to a mycobacterium inside them most of their lives.

“It’s people whose past histories caught up to them,” said Dr. Robert Levin, director of the county’s Public Health Department. “If you live long enough and that bug’s been living inside you, it’ll probably reawaken.”

That revelation is guiding health officials as they work through this fall to establish a two-person tuberculosis outreach team. Although the team eventually could visit migrant camps or manufacturing plants with large numbers of immigrant workers, its task will start with senior citizen centers and veterans groups.

“We feel we don’t have all the cases,” Billimek said. “If we can step up and do something now, maybe our cases will go down.”

Billimek said teaching older residents to recognize the warning signs--such as weight loss and excessive coughing--is crucial.

“Tuberculosis is curable. It is not a death sentence,” she said. “And everybody who has the disease has the right to be treated. We don’t refuse anybody.”

Cost of the tests range from $21 for those who can pay to free for those who can’t.

Once the leading cause of death in the U.S., tuberculosis--caused by an airborne bacterium--was contained by the 1950s with the advent of potent drugs. In 1953, 12.4 of every 100,000 Americans died of the disease. By 1997, that rate had dipped to 0.4 of every 100,000 Americans, according to the Centers for Disease Control.

Tuberculosis can now be treated and in most cases cured with a combination of drugs, Billimek said.

Tuberculosis infection, the precursor to the actual disease, can often be fended off with a months-long regimen of one of four drugs. That preventive treatment is not recommended for some older patients but is a good idea for younger people who register positive on TB skin tests but show no signs of the disease.

Still, it is helpful for senior citizens to know whether they have been exposed to the bacteria so they can be diagnosed quickly if they develop the disease. People with active tuberculosis infect an average of 10 to 15 people a year, the Centers for Disease Control reported.

To put the disease in context locally, only 79 cases were identified in 1997, the county’s peak year since the upswing began.

The county does not keep track of how many residents have the dormant TB infection, although officials concede that such information could help in preventing recurrences.

Nationally, officials estimate as many as 15 million Americans are infected with TB. About 10% of those people will develop the disease during their lives if the infection goes untreated, according to the CDC.

Local health officials say there are more pressing concerns than tuberculosis--particularly AIDS, hepatitis C and chlamydia. Even with a tuberculosis upswing in the 1990s, the countywide rate at its peak in 1997 was shy of the statewide average of 12 cases per 100,000 residents that year--but higher than the national rate.

Still, the annual rate of TB cases nearly tripled locally between 1988 and 1997, from four per 100,000 residents to 11 per 100,000. It dipped to seven per 100,000 in 1998 but was on the rise again last year, Billimek said.

Local health officials’ concerns about the disease extend beyond seniors.

Countywide, seven children age 9 and under were diagnosed with active cases of tuberculosis in 1998, as were 11 residents between ages 10 and 40.

Tuberculosis is still a serious problem in many countries, and immigrants can carry the infection into the county. The Centers for Disease Control says 2 billion people worldwide have the TB infection, and 1.5 million die of the disease each year.

Nationally, health groups are calling for increased TB screening and preventive treatment for those moving to the U.S. Locally, health officials see particularly high rates of the infection among Mexican and Filipino immigrants, Billimek said.

In 1998, Santa Paula and Oxnard, cities with large Hispanic and immigrant populations, showed disproportionately high rates of the disease at 17 and 15 respectively per 100,000 residents--that translated to five cases in Santa Paula and 23 in Oxnard.

Drug users, diabetics and people with HIV also are at high risk of contracting the disease because their immune systems are compromised. Rudy, the retired shoe repairman, is a former drug user and a diabetic.

In addition to a focus on the elderly and those with weak immune systems, health officials say they are also particularly watchful of a trend seen nationally in which improperly treated strains of the disease mutate into forms resistant to conventional treatment.

Although drug-resistant TB strains haven’t been a big problem in Ventura County, local health officials are so concerned about the possibility that they have assigned a caseworker to go to some patients’ homes each day to ensure that they take their pills.

Nellie Godina, a short, grandmotherly woman with a gentle temperament, begins her weekday rounds about 8 a.m. She currently has eight patients of Hispanic, white and Filipino descent. Some are seniors, others are young adults. Two are homeless and have been put up in area motels by the county so they can be monitored daily during their treatment.

Once they start to feel better, patients often stop taking their pills, Godina said. They don’t like taking four to 16 pills a day. Treatment can last six months to a year. Skipping days or quitting early invites a mutated form of the disease to develop.

If her patients are contagious when her visits begin, Godina said she is careful to administer the pills without entering their rooms. Clients wear masks while they are contagious, and Godina stays out of sneezing range.

Within weeks, though, patients say they start to feel better. When they are no longer contagious, she’ll go inside their dwellings. She gets to know their spouses and children, who also must be tested for exposure to TB.

One patient, a 62-year-old groundskeeper several months into his treatment, said he likes the discipline Godina provides.

This patient hasn’t been able to pinpoint the source of his infection. He was born and raised in Mexico but has lived in California since the mid-1970s, and for years came up negative on TB skin tests administered during regular medical checkups, he said. He was diagnosed last fall after painful coughing and a 30-pound weight loss.

His wife and other family members have since had positive skin tests but have not developed the disease. He doesn’t know whether he gave them the infection or if they all caught it simultaneously--perhaps on a trip to Tijuana--but only he got sick.

Another patient on Godina’s daily rounds, a 53-year-old farm worker, said none of his family members has tested positive for exposure. He said he likes Godina’s daily visits because they force him to take the pills even though the medicine turns his urine a reddish tint.

Until he recovers, he can’t go back to the fields. But staying home forever isn’t an option, he said. “I need to work.”

The laborer, who asked not to be identified, also doesn’t know how or when he contracted the disease. As far as he knows, none of his co-workers had TB, although it’s possible one did and kept it secret, just as he has.

Back in the clinic examination room, Rudy has been checked by his doctor and is ready to go. He is still severely underweight, at 113 pounds on his slender frame.

Though he is experiencing a rash as a result of his medication, he said he is hopeful that doctors caught the disease in time.

“I’m lucky to be alive,” he said. “Things are going to be OK.”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Ventura County TB Rates

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City Rate per No. 100,000 of cases Camarillo 1 1 Fillmore 5 1 Moorpark 9 3 Ojai 0 0 Oxnard 15 23 Port Hueneme 0 0 Santa Paula 17 5 Simi Valley 4 5 Thousand Oaks 4 5 Ventura 4 4 Countywide 7 47

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Ventura County TB Trends (1988-1998)

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Year Rate per No. 100,000 of cases 1988 4 25 1989 4 29 1990 8 56 1991 8 54 1992 8 55 1993 8 55 1994 9 63 1995 10 73 1996 10 70 1997 11 79 1998 7 47

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County TB Rates by Age Group

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Age group Rate per No. 100,000 of cases Birth-9 6 7 10-19 1 1 20-29 6 6 30-39 4 4 40-49 7 8 50-59 6 5 60-69 10 5 70-79 21 7 80-89 26 4 All ages 7 47

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County TB Rates by Ethnicity

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Ethnicity Rate per No. 100,000 of cases Asian/Other 34 15 Black 0 0 Hispanic 11 24 White 2 8