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TB Notes 1, 2000
Earthquakes, Population Growth, and TB in Los Angeles
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 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
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
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.