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Tuberculosis is surging in Sacramento County at rates faster than the state as a whole, driven by an influx of immigrants exposed to the disease in other countries.
The county saw new tuberculosis cases rise 47 percent to 153 in 2003 from 104 new cases the previous year, according to statistics collected by the state Department of Health Services.
Ranked against other California counties, Sacramento County rose to eighth last year from 15th in 2002, with a rate of 11.9 cases for every 100,000 people, compared with a statewide rate of 8.9.
Though California's rate is the nation's highest, it has fallen by nearly half since peaking in the early 1990s.
"We have been bucking the trend," acknowledged Dr. Glennah Trochet, Sacramento County health officer. "Everyone else seems to be having a decrease in active cases."
Sacramento County was one of a handful of counties that saw new cases increase by more than 2 percent - a group that included Santa Barbara, San Joaquin and Monterey counties - though 28 counties reported increases last year.
Trochet said some of the cases in Sacramento County are among the homeless, who may sleep in crowded emergency shelters where germs spread easily. In response to an outbreak among the homeless in 2000, she said, the county began requiring homeless people to have chest X-rays to prove they are free of tuberculosis before entering a shelter.
"We are still in the process of controlling it," she said. "It takes up to 15 years to control an outbreak of this type. It's very insidious."
Most of Sacramento County's new cases are in people born in countries where the bacterial disease is still rampant, and where tuberculosis control methods are less than adequate.
"We have a large number of foreign-born residents," Trochet said. "It is not surprising we would have a higher TB rate and that it is increasing compared to other parts of California."
Statewide, 75 percent of the 3,230 new cases came from foreign-born Californians, with the highest rate - 30.4 per 100,000 people - found among Asians and Pacific Islanders.
Although immigrants may not have infectious tuberculosis when they arrive in this country, Trochet said, an earlier exposure could later cause active tuberculosis. The disease spreads when an infectious person coughs or sneezes and another person inhales airborne germs.
"About 10 to 15 percent of people with latent TB will reactivate," Trochet said. "When you have thousands of people coming into our community with latent TB, 10 to 15 percent can translate into a lot of people."
Increasing tuberculosis rates in some California counties help illustrate weaknesses in worldwide tuberculosis control efforts, said Dr. Robert Benjamin, medical director for the Alameda County TB Control Program.
Tourists, students and foreigners entering the United States on work visas, for example, are not screened for the disease, he said.
The federal government does require immigrants to be screened for the disease but cannot deny entry to someone with a latent case, determined through a positive skin test.
The screening involves a medical history, chest X-ray and a microscopic examination of a person's sputum, which can show evidence of the bacteria that causes tuberculosis.
People with infectious tuberculosis are denied entrance to the United States until they prove they are no longer infectious.
Why so many people with latent infections become ill has to do with a person's natural ability to combat the disease. A compromised immune system, in a patient with HIV, for example, can make him more susceptible to tuberculosis, Benjamin said.
Stress also plays a role in weakening the immune system.
"New immigrants are coming to a new land, they don't know anyone, don't speak the language, don't have a job, and may not have a place to live," Benjamin said.
"We find that people who come from countries where TB is highly prevalent tend within the first few years of arrival to break down and go from a latent infection to active disease."
Those illnesses are more complicated when they do not respond well to medicine, a common problem in countries where anti-TB drugs are not easy to get. Drug resistance can occur when a person who tests positive for tuberculosis fails to follow the lengthy and often complex treatment.
Starting the standard four-drug therapy for a recent immigrant with active disease without knowing a patient's drug resistance history can "further complicate the emergence of resistance," Benjamin said.
In some countries formerly part of the Soviet Union, more than 25 percent of TB cases resist current drugs, he said.
A 40 percent jump in cases of drug resistant tuberculosis between 2001 and 2002 in the United States, coinciding with state TB control budget cuts, suggests government needs to be more vigilant, American Lung Association spokes Andrew Weisser said.
"One hundred years after the American Lung Association was formed to control TB, the battle is still not won," Weisser said.
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