Chicago: TB Threat is growing in suburbs -- Some immigrants pose new challenges*

Even as overall tuberculosis rates decline, worried health officials are marshaling resources to treat a group that has defied the trend: emigrants from the developing world who unwittingly bring the TB bacteria into this country. And with more such people heading straight for suburbia, where they may be spread out and far from public health centers, those officials expect it to be even harder to stem the growth of the disease. The immigrant population is "the future pool of the disease," said Dr. Kenneth Castro, director of tuberculosis elimination at the Centers for Disease Control and Prevention in Atlanta. He called immigrants "the crucial factor to be addressed if we're ever going to eliminate TB in the United States." "If we don't keep our efforts, we run the risk of the disease making a comeback. It would be a big mistake to allow that history to repeat itself," he said. Foreign-born residents now account for 43 percent of active TB cases nationwide. According to the CDC, another 7 million immigrants could be at risk of developing tuberculosis in the U.S., most of them having been infected abroad. The immediate danger is relatively small. Of Cook County's 603 active cases in 1999, 183 were attributed to foreign-born residents. But those numbers only hint at the threat, officials say. In suburban Cook alone, another 2,000 residents have tested positive for the tuberculosis bacterium. Based on samplings, as many as 75,000 foreign-born residents may be infected but undiagnosed, according to Dr. James B. Gallai, vice chairman of the Metropolitan Chicago TB Coalition. TB is a respiratory ailment marked by coughing and fever and is spread through airborne bacteria. Prolonged exposure is necessary for transmission, so TB is far less contagious than such diseases as measles and chickenpox. Less than a tenth of infected patients develop into active TB cases, the only kinds that are contagious. Workers in high-contact jobs such as health care and education are screened for the disease. So are immigrants, who must show they don't have active TB when applying for legal entry. Because the disease can remain dormant for years, health officials say immigrants should be screened in America too. Suburban health officials cite several challenges specific to treating immigrants: limited transportation; a distrust of government health agencies; a shortage of bilingual outreach services; and cramped living conditions that can help foster the disease.

The Illinois Department of Public Health is asking the CDC for money under a new grant program to fight TB among immigrants. The grant--which would help pay for multilingual literature and partnerships with foreign doctors, among other initiatives--would be limited to efforts in suburban Cook. "The suburbs are where the numbers are," said Vicki Biddle, the department's acting section chief for tuberculosis control. In the 1940s, TB was the leading killer in the U.S. and a major focus of public health authorities. But after the discovery of powerfully effective drugs, health officials gutted TB budgets and dismantled sanitariums. A second wave of TB, linked to the emergence of AIDS and a rise in emigrants from the developing world, appeared in America's inner cities in the mid-1980s. Many health agencies were shorthanded in fighting the disease. Poor populations, especially some African-Americans and some immigrant groups, found themselves battling new drug-resistant strains of TB. But a series of intense campaigns in troubled urban neighborhoods, sometimes even sending workers door-to-door, helped quell that outbreak. TB cases nationwide plunged 32 percent in the 1990s, which should have given health officials cause to celebrate. Instead, they are nervously tracking a 21 percent increase in cases involving foreign-born residents during that same period. Suburban Cook County plans a five-year push to reach immigrants, which could include the hiring of an outside consultant, greater coordination with immunization programs and more on-site screenings. Of those who tested positive last year in suburban Cook, more than half are immigrants--the highest rate ever.

Kane County attributes 65 percent of active TB cases to foreign-born residents; in DuPage County, the rate is about 81 percent. In both counties, TB cases only number a few dozen. "It's a daunting situation, and we struggle with it sometimes. This group is going to be a tough nut to crack," said Gallai, executive vice president of the Suburban Cook County Tuberculosis Sanitarium District. Cases involving foreign-born residents have been less of a concern for the City of Chicago, which has made great strides in this regard among African-Americans, its largest high-risk group. Doctors and health officials say the suburbs present specific challenges in fighting TB among immigrants. Many immigrants work part-time jobs in the service industry with few benefits--a recent study found that more than 1 in 4 immigrants in Chicago's suburbs lacked health insurance. Also, suburban health departments are sprawled across the landscape, making it hard to coordinate efforts. Many village departments have only skeleton staffs, relying instead on county officials farther removed from local populations. "They may be down to one public-health nurse that may do vaccines, [sexually transmitted diseases], TB, a little bit of everything," Castro said. "Because of competing needs, the TB program may be a low priority." Health officials say they are especially frustrated because TB is relatively easy to treat. But it still carries a stigma. Outreach workers recall a screening program at a Palatine apartment complex in which residents peeked out their windows to see which neighbors attended. Screening programs do not cover tens of thousands of illegal immigrants who enter the country each year. In response, authorities are launching initiatives on the Mexican border, including mobile screening labs to test migrant workers. For the TB skin test, a patient receives a serum injection in the arm. A lump formed after three days indicates a positive result. Outreach workers have screened immigrants at every conceivable site: a Palatine condominium, a Cicero school, a Schaumburg pizza parlor. But getting to the screenings can be tough for immigrants--or anyone--without a car. And if finding transportation once isn't challenging enough, patients must return three days after the test so health workers can read results. In one instance, 82 immigrants were tested in a Cicero church. Only 32 returned for the results. Gallai said many immigrants also forgo therapy until TB becomes active, even though a steady battery of pills can greatly reduce the risk that patients will become contagious. Because they come from nations where positive TB tests are common--and few actually get sick--they are skeptical that preventive therapy is needed. Health officials and social-service workers say foreign-born residents are generally reluctant to fill out government paperwork. Outreach workers say it isn't rare to place follow-up calls and find that patients gave false names or numbers on their applications. "I have seen scenarios where a patient believes that if they go in for treatment, they will be turned in to the [Immigration and Naturalization Service]," Castro said. "So they don't go." Another disturbing trend, according to a CDC study released in January, is that Mexican-born patients in four border states were twice as likely to be resistant to drug therapy than U.S.-born patients. Health officials say many immigrants don't complete therapy, leaving them resistant to follow-up treatment. In both groups, multidrug resistant cases remain rare. Statistics identify emigrants from Mexico, India, Pakistan, Vietnam and the Philippines as the leading carriers of foreign-born tuberculosis locally and nationally. U.S.-born residents also would be at risk after extended stays in those nations.

The international nature of the disease will be the prime topic when hundreds of TB specialists from around the world are to meet in Chicago on Thursday. Health officials worry about causing a backlash or public-health panic against immigrants. After a Hispanic employee of a Wheeling factory recently tested positive for TB, his Hispanic co-workers raised money to pay his medical bills, but other co-workers asked to be transferred, said Margaret Rohter, outreach program supervisor in suburban Cook County. As Steve Wolf, communicable disease program manager for Kane County, said: "You don't want to sound like raving lunatics saying, `Don't let these foreigners in.' You just try to present the facts. And the facts show that this is a problem we all have to take seriously.

* Thanks to Prevention News Update for providing this news story.

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