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TB Notes 1, 2000
Introduction
Where We've Been and Where We're Going: Perspectives from CDC's Partners in TB Control
Changes I've Seen
TB Control in New York City: A Recent History
Not by DOT Alone
Baltimore at the New Millennium
From Crickets to Condoms and Beyond
The Denver TB Program: Opportunity, Creativity, Persistence, and Luck
National Jewish: The 100-Year War Against TB
Earthquakes, Population Growth, and TB in Los Angeles County
TB in Alaska
CDC and the American Lung Association/ American Thoracic Society: an Enduring Public/Private Partnership
The Unusual Suspects
The Model TB Prevention and Control Centers: History and Purpose
My Perspective on TB Control over the Past Two to Three Decades
History of the IUATLD
Thoughts about the Future of TB Control in the United States
Where We've Been and Where We're Going: Perspectives from CDC
Early History of the CDC TB Division, 1944-1985
CDC Funding for TB Prevention and Control
Managed Care and TB Control - A New Era
Early Research Activities of the TB Control Division
The First TB Drug Clinical Trials
Current TB Drug Trials: The Tuberculosis Trials Consortium (TBTC)
TB Communications and Education
TB Control in the Information Age
Field Services Activities
TB's Public Health Heroes
Infection Control Issues
A Decade of Notable TB Outbreaks: A Selected Review
International Activities
The Role of CDC's Division of Quarantine in the Fight Against TB in the U.S.
The STOP TB Initiative, A Global Partnership
Seize the Moment - Personal Reflections
 
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This is an archived document. The links are no longer being updated.

TB Notes 1, 2000

Earthquakes, Population Growth, and TB in Los Angeles County

by Paul T. Davidson, MD
Los Angeles TB Controller

In the late 1960s, Los Angeles County built a state-of-the-art TB hospital. Most of the 1,300 or more persons being diagnosed with new cases of this disease each year were spending many months in the hospital before receiving treatment as outpatients. The Sylmar earthquake of 1971 essentially destroyed the hospital and propelled the County into considering other approaches to managing this disease. Some patients were transferred to Rancho Los Amigos Hospital, a long-term rehabilitation facility. The majority were referred to the over 40 Public Health Centers then in existence throughout the county. This began what has since become a largely outpatient system for the follow-up and care of TB patients. Six county hospitals have continued to diagnose and treat many TB patients. Liaison nurses assigned by the TB Control Program facilitate the transfer of these patients to the Public Health Clinics. Approximately 25% of TB patients are diagnosed and followed by the private health sector.

During the past 30 years there have been numerous changes in Los Angeles County that have impacted upon the TB problem. A dramatic increase in the population has occurred. Many of the new residents are immigrants from countries where TB is prevalent and in many cases increasing in incidence. By the end of the 20th century nearly 75% of all the new cases in Los Angeles occurred in the foreign born. Poverty and homelessness have been a persistent social and cultural factor supporting continued spread of TB. By the late 1980s, the emergence of HIV infection and disease contributed to the number of TB cases, reaching a peak of 15% of all the cases being HIV positive in 1991.

In the 1980s efforts were increased to fight the TB problem among the homeless. A satellite clinic in the Skid Row area of downtown Los Angeles was established. This clinic depended on outreach workers to find and transport patients to the clinic for directly observed medication and medical management. Because many of the homeless still defaulted on treatment and spent repeated episodes in the hospitals, a pilot project funded by the State of California was instituted. It provided housing and food incentives to the homeless in Skid Row in exchange for taking medication and completing TB treatment. The results were dramatic, with better than 95% of the participants completing therapy and the number of hospital days being much reduced. The program was eventually funded by the County and extended to other areas where homelessness is also a problem. This program continues, and the number of TB cases among the homeless is declining more rapidly than the overall number of cases.

In the late 1980s an HIV/TB program was established to provide liaison with HIV providers. Screening guidelines for TB were established regarding admission of HIV patients to hospitals, hospices, and other congregate living facilities. The liaison nurse essentially case-managed all known HIV/TB cases and helped to facilitate their care throughout the healthcare system. To date, there have been no known outbreaks of TB in any of the health care facilities within the County. Today the HIV/TB liaison program continues to work closely with the many early intervention clinics where TB testing is a standard of care for all patients.

Image 1: Picture of a patient receiving directly observed therapy (DOT). In Los Angeles County, DOT is now the standard of care for TB patients.

The 1990s have been a time of rapid influx of both federal and state funding for the elimination of TB. This allowed the implementation of a number of new programs. Directly observed therapy (DOT) is now the standard of care and in 1998 more than 75% of public health clinic patients were on DOT. The TB Control Program has contracted with a number of community-based organizations (CBOs) to screen high-risk persons for TB and provide preventive therapy. This has resulted in thousands of persons being screened and given preventive therapy who otherwise would not have been reached by the health department. A project to screen homeless persons for TB by using a mobile radiology unit detected dozens of cases of TB that were treated earlier than otherwise, preventing further transmission of infection to this vulnerable population. This helped to accelerate the decline of TB disease in the homeless. An MDR unit was established to monitor and consult on every MDR patient in the county whether under private or public care. The percentage of such cases has been kept below 2% of the total cases for many years. Most of the cases that do occur come into the county from other locations already with MDR. Most of them are successfully treated while remaining in Los Angeles County. The Public Health Laboratory for the county was given personnel resources and the latest technical equipment to better serve the needs of the TB control programs.

The State of California has been very active in addressing many of the problems that have hindered TB control. For example, a law is now in place that requires health care facilities to obtain permission from the local health officer or TB controller before any person suspected or diagnosed with TB is discharged. The health officer can refuse discharge if the follow-up plan is inadequate or the patient continues to be a threat to the public health of the community. Another law establishes a process for the legal detention of patients with TB who represent a threat to the public health. The State has also appropriated money to pay for the detention of TB patients and also to pay for housing of the homeless. Los Angeles County has taken full benefit of these actions. The Surveillance Unit at the TB Control Program and the Liaison nurses at the county hospitals have been given the responsibility for approving hospital discharges under the Director's supervision. The County, with the help of State funding, has recently opened a Southern California regional center for the detention of TB patients at one of our county facilities. This facility can also provide long-term skilled nursing care for any TB patient needing it and the services of a drug and alcohol treatment center.

An earthquake of another nature occurred in 1995. The Los Angeles County Department of Health Services faced the possibility of bankruptcy. A huge, complicated reorganization of the department resulted. TB services as well as all public health services were condensed into 11 locations throughout the county where previously there had been more than 30. This created trying times, but fortunately TB cases were not lost. On the other hand there was a significant drop-off in the number of patients being screened and placed on preventive therapy. In addition, the Public Health Programs and Services Division of the Department of Health Services has continued to undergo extensive reorganization, redirection of priorities, and change of leadership.

The 20th century has clearly ended with a period of constant change. One can only predict that the new century will continue in the same mode, possibly as the norm. In the meantime, the number of TB cases continues to decline, to an all-time low by the turn of the century. Hope, tempered by the reality of a huge problem with TB in the world as a whole, suggests that the goal of elimination of TB can be reached in Los Angeles County during the early decades of the 2000s.

 


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination - http://www.cdc.gov/tb

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