County opts for new strategy to fight TB

Plan is set to counter unexpected jump in cases

Tuberculosis rates are on the decline throughout the U.S., but in Santa Clara County the numbers remain high. With more cases of tuberculosis per year than most states, county officials are looking to shift the approach to fighting the spread of the disease, starting with a revamp in the way patients are tested for the disease.

Pulmonary tuberculosis, or TB, is a bacterial infection that most often affects the lungs. The disease is highly contagious, and spreads when an infected person talks, coughs, or sneezes tuberculosis bacteria into the air. Tuberculosis deaths are rare in the United States, but ranks second for leading cause of death from infection worldwide.

Dr. Daniel Shin
On Monday, March 24, Santa Clara County health officials announced that tuberculosis cases have increased in the county for the first time in six years, up to 181 from 176. It was also announced that the county planned to eliminate universal screening of children entering school in favor of a risk-assessment system.

Dr. Teeb Al-Samarrai, the TB Controller for Santa Clara County, said use of universal testing began in 1989 in response to rising tuberculosis rates in the late 80s and 90s. The mandate was to identify children who had been exposed to active tuberculosis and had been infected by latent, or silent, tuberculosis. As the tuberculosis rates started to decline, the Center for Disease Control and Prevention and the American Academy of Pediatrics recommended that testing shift away from the universal mandate and focus more on children at greatest risk of getting the disease.

The problem with continuing mandatory, universal screening is that it's both an inefficient and problematic way to test for tuberculosis, according to Al-Samarrai. The mandate tested a high number of students who were at very low-risk of contracting tuberculosis, and resulted in a lot of false positives. This meant more unnecessary testing and chest X-rays for healthy children who had not contracted the disease. Santa Clara County is the only county in the state that still uses mandatory tuberculosis testing for entry into the school system.

In the coming months, Santa Clara County will be phasing out universal testing for tuberculosis. Effective June 1 of this year the county will instead do a universal test for risk factors, and screen for tuberculosis if the child is at high risk. Health care providers will fill out a risk assessment in the form of a check list for children, and both the list and any subsequent tests will be required to enter the school system.

Dr. Daniel Shin, infectious disease specialist at El Camino Hospital, said he agrees with the county's decision to move away from universal screening of children entering school. "The new approach is more accurate," Shin said. "It's better to get a risk assessment and test students at high risk instead of testing every student."

High-risk factors for tuberculosis include whether a person was born in a country where tuberculosis is widespread Those countries include India, China and Southeast Asian countries like the Philippines and Vietnam. An overwhelming 91 percent of tuberculosis cases in Santa Clara County have been in people who were born in a different country.

Shin said other risk factors include whether the person has a chronic illness, such as diabetes, HIV or is on kidney dialysis. People are also at higher risk if they have been exposed to someone with active tuberculosis, have an abnormal chest X-ray or live in a densely populated living space, like a nursing home.

The emphasis on testing children is not because they are more likely to have active tuberculosis. Al-Samarrai said only five of the 181 tuberculosis cases last year were in children, and a majority of tuberculosis deaths occur between ages 25 and 64. But children are more likely to go from a latent form of tuberculosis into active tuberculosis in their lifetime, and screening children at high risk before they enter school can catch any early cases of the disease.

Al-Samarrai said one reason why it's important to diagnose the disease during its latent phase is that the first line of drugs used to treat active tuberculosis haven't changed in 50 years. Treating active tuberculosis involves taking four antibiotics with harsh side effects for several months.

Shin said that El Camino Hospital has treated anywhere from 11 to 18 people annually between 2011 and 2013. The hospital takes a number of precautions for every case. If anyone suspects a patient has tuberculosis, that patient is isolated in a negative pressure room, and anyone who sees that patient must wear a mask.

Part of the change is to also spread awareness about the risk factors for tuberculosis and recognizing who is at risk. Al-Samarrai said risk assessments should be done at the doctor's office, and physicians and pediatricians are being told to ask about a patient's exposure to high risk factors. Al-Samarrai said the county and health care providers need to let parents know about the risk factors, and take initiative to get their children screened.

With risk assessment, early detection and treatment, Al-Samarrai said the rates of active tuberculosis will hopefully decline in Santa Clara County. With today's modern medicine and technology, Al-Samarrai said tuberculosis shouldn't be a problem. "It's curable. It's treatable. Nobody should be dying from tuberculosis," she said.


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