Cough! Cough! San Bernardino TB, Trends, Reporting & Treatment!
By Sarah Mack, San Bernardino County Health Department
The number of tuberculosis (TB) cases reported in San Bernardino County has declined 31% from the most recent high of 151 cases in 1993 to 105 cases in 2000 (2000 data provisional), Figure 1. There was a concomitant decline in the crude incidence rate of tuberculosis (9.7 to 6.1 cases per 100,000 population in the same period). This reduction in tuberculosis morbidity is in part attributable to increased efforts to ensure that active cases are identified and that they complete an appropriate course of therapy, thereby interrupting the chain of transmission of tuberculosis locally. The most effective means for ensuring that patients complete an appropriate course of therapy is through the administration of directly observed therapy (DOT), one of the most cost-effective preventive health programs yet explored. The Department of Public Health is not alone in the treatment of TB in the county. Approximately half of cases reported in 1998 were treated either by public health or public and private providers together. The remaining cases received their therapy from the private sector. For all of these cases, it is essential that both public and private agencies work together to provide optimal therapy for the patient. These coordinated efforts can help the county make progress toward the national goal of the elimination of tuberculosis.
TB cases reported in 2000 in San Bernardino County follow patterns established in earlier years as to their distribution over age, race and country of birth. Almost half of all cases (46.7%) are among Hispanics, followed by Asians (22.9%), Whites (18.1%), and Blacks (12.4%). Asian cases reflect a higher rate of disease in the population compared to their percentage in the overall population of San Bernardino County. Foreign born individuals represent more than half of the cases (57.l%) with US born residents accounting for 40% of cases.
Strategies leading to this decline in active TB cases include implementation of Directly Observed Therapy (DOT), an intervention initiated in 1993. Directly Observed Therapy (DOT) efforts began in 1993 with augmentation in federal and state dollars for these activities. Since 1993 when only a third of patients received DOT, the proportion of patients receiving DOT grew to 68% of all cases. Foreign born patients are still more likely than US born natives to receive DOT (1998 75% versus 61%).
Patients who are sputum smear positive for acid fast bacilli (AFB) are presumed to be infectious. It is these individuals for whom completion of an appropriate course of anti-TB therapy is crucial to prevent further transmission of tuberculosis in San Bernardino County. During the period 1993-98, 77% of sputum smear positive pulmonary cases treated jointly by both public health and a private provider completed an appropriate course of therapy, indicating that these collaborative efforts are generally effective in ensuring patients become cured. That 96% of these most infectious patients managed jointly by public and private partners received DOT is a further indication of these successful relationships. During the same period, the group of patients treated by public health alone achieved cure rates of 82% while only half of these most infectious patients who were solely treated by private providers could be documented as having completed treatment. All tuberculosis patients are considered for and offered DOT services through public health and US born patients more often receive those services.
Public Health is committed to all aspects of controlling the transmission of mycobacterium tuberculosis in the County. Any private physicians wishing to assure that DOT is available for his/her patient is invited to contact the Public Health TB Program at (909) 383-3287. To refer a TB patient to Public Health for primary treatment and case management to be undertaken by the Department, call Dr. Chris Christensen at (909) 383-3287.
Laboratory reporting is accomplished by having a subculture of the organism forwarded to the Public Health Laboratory for confirmation and further characterization. Strains are retained so that, if a patient apparently fails to respond to treatment, it may be possible to determine whether antibiotic resistant (as opposed to non-compliance, for example) is a likely explanation for the non-response. Laboratory specimen submission does not negate the need for clinical case reporting.
Hospitalized TB patients can only be discharged when appropriate plans and preparation have been approved by Public Health. This is necessary to assure that follow-up treatment is available (a prescription for anti-tuberculosis medication given at discharge is far from sufficient). Further family members and others who may be at risk need to be adequately assessed, followed up and tested/prophylaxed appropriately. To submit a TB patient discharge plan call (909) 383-3287 or fax the plan to (909) 387-2861. Discharge planning should be initiated as soon as possible when TB is diagnosed or suspected. The plan does not have to wait until just before the patient is to be discharged. If there is a need to plan a discharge at night or on weekends, the Public Health duty officer can be reached by calling the County Communication Center at (909) 356-3805. The duty officer is instructed to obtain information needed to specify the current clinical status of the patient and to ascertain how follow-up can be initiated. If all needed information is not available, the duty officer may deny authorization to release the patient and/or contact TB Program staff for further questions.
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