Drug-Resistant TB Hits New Group

Cases Among Immigrants Rise in U.S., Report Says;
California Is Most Affected

MARILYN CHASE / Wall Street Journal 8jun2005

The face of tuberculosis that is resistant to drugs is changing in the U.S., researchers say.

Increasingly, immigrants are the ones with the difficult-to-treat illness, reflecting "a raging pandemic overseas," said the author of a report in the Journal of the American Medical Association today. HIV patients, prisoners and homeless people, the U.S. groups at high risk in the past, still are at risk of multidrug-resistant TB. But increasingly, cases of the potentially deadly, airborne disease are imported.

Separately, the World Health Organization's coordinator for TB, HIV and drug resistance, Paul Nunn, urged world leaders to boost funds for TB at the Group of Eight leading nations summit next month in Scotland. "TB doesn't need a passport to get across borders," he said.

California has the largest concentration of U.S. drug-resistant TB cases, according to the JAMA report by Reuben Granich of the U.S. Centers for Disease Control and Prevention. California's 37 cases of multidrug-resistant TB in 2004 reflect an increasing portion of the nation's total drug-resistant cases, from about one-fifth in 2001 to an estimated one-third today.

The bulk of California's multidrug-resistant TB cases involves people born outside the U.S., the JAMA study said. Dr. Granich said it is crucial to care for immigrants and enhance TB care overseas rather than close borders.

The nation's multidrug-resistant TB burden has declined 76% since outbreaks in 1993. But in California, Sarah Royce, chief of the Tuberculosis Control Branch of the California Department of Health Services, said, "Our progress has stagnated and MDR-TB has persisted." Imported multidrug-resistant TB is a major concern because immigrants are often poor, frightened and prone to move frequently.

The 37 California cases of multidrug-resistant TB, and 120 people who developed latent infections from them, cost $8.72 million in direct medical costs and contact tracing, not including administrative expenses, Dr. Royce said.

Among the 3,400 Hmong refugees who have come to California since June 2004, 27 had TB, and four had the multidrug-resistant variety. About 10,000 Hmong refugees entered the U.S. under a State Department resettlement program. The Hmong are mountain people who fled Laos for refugee camps in Thailand.

In April, local health officers in California, citing the cost of dealing with drug-resistant TB, asked Sen. Diane Feinstein (D., Calif.) for $4 million in federal funds a year for three years. The request is pending, according to Dr. Royce.

Drug-resistant tuberculosis arises when doctors prescribe ineffective drugs, or patients stop short of a complete treatment, allowing mutant strains of the TB bacteria to multiply. Once a drug-resistant strain arises, it can pass from person to person.

Regular TB cases can be treated in six months with about $2,000 of standard antibiotics. Multidrug-resistant TB requires 18 to 36 months of expensive -- and often toxic -- second-line drugs costing $28,000 to $1.2 million per patient.

In the past, doctors saw simpler multidrug-resistant TB with resistance to two or three drugs. But now, "Instead of resistance to two drugs, we're seeing resistance to six drugs or 11 drugs," said San Francisco's director of TB control, L. Masae Kawamura, in an interview.

At a clinic in San Francisco General Hospital, Dr. Kawamura has been treating a 33-year-old Asian woman, diagnosed with multidrug-resistant TB while giving birth in July 2003. Dr. Kawamura believes the patient, who has lived in the U.S. for nine years, was exposed overseas, because her particular strain had never been seen in California.

Quarantined in her apartment, the patient was separated from her five-day-old son, who was placed in the care of his grandmother a block away. For eight months, she was only allowed to visit him outdoors in the open air and while wearing a mask. The drugs cleared germs from her sputum, but surgery was required to remove a persistent TB spot on her lung. The surgery and just under two weeks of hospital isolation cost the county $76,859. Drugs and outpatient care brought her costs to $102,289, "And we're not done yet," Dr. Kawamura says.

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