WAGING THE WAR AGAINST TB: HEALTH WORKERS KEEP ON FIGHTING DEADLY MALADY.

Byline: Carol Bidwell Daily News Staff Writer

For nearly as long as man has been on this Earth, mycobacterium tuberculosis - the bacteria that causes tuberculosis - has been his deadly partner.

Despite the discovery that antibiotics can cure most cases of TB, the disease - which continues to infect an estimated one-third of the world's population - is growing more drug-resistant.

That has doctors worried.

``Tuberculosis is the Slobodan Milosevic of infectious organisms,'' said Tarzana internist Dr. Michael Hirt, who diagnoses and treats a half-dozen TB patients annually. ``It requires prolonged bombardment in order to make it surrender. And sometimes even that doesn't work. It's survived this long because it's built strength.''

The World Health Organization estimates that about 8 million people worldwide are newly infected by TB each year, and that in 1999, 3.1 million people worldwide will die from the ailment. Only 16 percent of sufferers get treatment, according to WHO.

The picture is rosier in the United States. In 1998, the fifth straight year of diminishing cases, 18,371 cases of TB were reported, down 7.5 percent from 19,851 cases in 1997, according to the Centers for Disease Control and Prevention.

But doctors who gathered in Florida on March 24 - on World Tuberculosis Day, the 117th anniversary of the day the TB bacteria was first identified under the microscope - were reluctant to cheer the apparent success.

``We spend more in the U.S. on (thinning) hair-care treatments than tuberculosis treatment,'' complained Ray Collins, superintendent of the A.G. Holley State Hospital in Florida, the nation's last TB treatment center.

But there are doctors trying to find a cure for the worldwide scourge.

St. Vincent's Hospital and Medical Center in New York has launched a national study to see whether ultraviolet germicidal irradiation and better ventilation will kill TB germs. This summer, the Los Angeles Mission will be one of the study's test sites.

And the National Institutes of Health, the CDC and the WHO are working together on plans to develop a vaccine to prevent TB. But medical experts say the cure - if it is ever found - is probably many years away.

``It's like trying to find a vaccine for HIV,'' said Dr. Paul Davidson, director of the Tuberculosis Control Program for the Los Angeles County Department of Health Services. ``It's a very complicated thing. I think it'll be a minimum of 20 years before a vaccine is developed and tested. And we're talking about probably 50 years before it's available to the world as a whole.''

In those decades, many more people will contract the disease. Even in the U.S., which has the highest treatment and cure rate, medical experts fear the disease has the potential to mushroom as the population of people with compromised immune systems (the aging and people with HIV/AIDS, for example) increases. WHO estimates that every person with TB infects 15 to 20 others in just one year.

It's a frightening prospect, especially because the potentially fatal disease can be spread to a susceptible person by a cough or a sneeze, a laugh or a song, or even a conversation, said Paula Rutan, a Los Angeles County Department of Health Services public health nurse.

Once a person is exposed to the disease, it can lie dormant in the body until the bacteria finds a way past a person's immune system, when it can flare up and spread, Rutan said.

Los Angeles' high immigration rate and crowded urban setting makes it a breeding ground for TB, said Davidson. Los Angeles County's TB rate of 14.9 cases per 100,000 people in 1998 was double the U.S. rate of 7.4, and higher than the state's 12.6 rate.

A person's chances of being exposed to the disease are just as close as the person in the next seat on an airplane, in the library, or at a restaurant.

``It's a disease that truly knows no boundaries,'' Hirt said. ``Wrong time, wrong place, and you can be exposed to somebody with TB very briefly and be infected.''

Mindful of how easily the disease is spread, before children can start school in Los Angeles County, they must show that they tested negative for TB within the past 12 months. Although children do contract the disease, they are not generally considered contagious because they usually can't cough deep enough to spread the bacteria to others, Rutan said.

The county Department of Health Services, which treats TB patients who do not have insurance or cannot pay for their own treatment, spends more than $10 million a year on drugs to fight the spread of the disease.

Most patients willingly comply with the order that they be quarantined for two to four weeks, until treatment makes them no longer contagious. But some TB sufferers balk at taking the medication, quit taking it before the infection is gone, or refuse to isolate themselves while they are contagious. So the Health Department seeks court orders a dozen times a year to force compliance - in the isolation of a hospital or jail - until all danger of contagion is past.

Health workers take a quarantine seriously. In Stockton, a grandfather diagnosed with incurable TB is in jail, and his son, daughter and daughter-in-law face child endangerment charges for allowing their children to visit their quarantined grandfather. The man's 1-year-old grandson and 2-year-old granddaughter, whom the Health Department had ordered to stay away, are infected with the same drug-resistant strain of TB that their grandfather has.

``That's a rare situation,'' Davidson said, ``but people in public health care are prepared to do whatever we have to do to keep TB from spreading.''

The prevention, detection and cure of tuberculosis

The Egyptians documented the disease in tomb paintings dating back to 3000 B.C.

A century ago, most people died from what was then called ``consumption.''

And the bacterial infection, now known as tuberculosis, afflicted all classes, including famous folks such as gunslinger ``Doc'' Holliday, pianist Frederic Chopin, former first lady Eleanor Roosevelt and novelist Robert Lewis Stevenson.

What are the symptoms?

Coughing, fever, night sweats, chest pain, fatigue and weight loss.

How is TB diagnosed?

There are three stages of testing: a skin test, in which a testing medium called tuberculin is injected under the skin; a chest X-ray; and a sputum test. If the skin test is negative, the person has not been exposed to the TB bacteria; if the test is positive (the bump at the injection site grows in size and becomes red), a chest X-ray will be taken; if that shows a shadow on the lung, a sputum test is ordered to confirm the diagnosis.

How is TB treated?

Generally two, or as many as five or six, antibiotics are given, generally twice a week for six to nine months. But some TB sufferers have such serious infections that antibiotics will not cure them; eventually, they die.

Where do the bacteria come from?

Once rampant worldwide, TB was controlled in the United States in the mid-1940s with the discovery of streptomycin. Now, the infection is often brought into the United States by immigrants from countries with high TB rates. It often spreads in areas where many people are crowded together. Lack of light and poor ventilation help the bacteria multiply.

How is TB spread?

When an infected person coughs, sneezes, laughs or talks, small droplets are emitted into the air; the bacteria exists in those droplets. Anyone who breathes those droplets may come down with the disease.

How soon does a TB infection show up?

It may show up within weeks, or may lie dormant in the body for years. Some exposed people may never develop the disease, while it may flare up in others as their immune systems become compromised.

Who is most susceptible?

The very young and the very old, people who are 10 percent or more below their ideal weight, people whose immune systems are compromised, diabetics, substance abusers, people who are recovering from throat or mouth surgery, and people suffering from end-stage kidney disease.

How can you avoid being exposed to TB?

The only sure way is to never go outside your house and never let anybody else in or, if you venture out, to wear a surgical mask, both impractical solutions. But to minimize your risk, ask people to cover their nose and mouth when they cough or sneeze (and do the same yourself), keep your distance from coughers or sneezers, keep your surroundings clean and wash your hands often.

Source: Los Angeles County Department of Health Services

CAPTION(S):

2 Photos, Box, Map

PHOTO (1--Color--Cover) On the cover: Dr. Paul T. Davidson checks the X-rays of tuberculosis patients for the county health department.

(2) A patient is tested for tuberculosis in the 1930s. The TB bacteria was first identified under the microscope 117 years ago, and most infections can be treated with antibiotics.

BOX: The prevention, detection and cure of tuberculosis (See text)

MAP: WORLD TUBERCULOSIS RATES