Bay Area vulnerable to TB epidemic

In a beautiful home filled with mementos of world travel, a 44- year-old Silicon Valley executive reluctantly picks up the telephone to tell several business contacts that he might have infected them with tuberculosis.

In a one-bedroom apartment in Oakland, a new mother feels her life slipping away. She is losing her hearing, her feet are going numb and her face carries a rash from the toxic drugs being used to fight the drug-resistant bacteria in her lungs. Her body has dwindled to 87 pounds and she wonders: Would my husband and infant son be better off if I were dead?

In Helena, Mont., the state's tuberculosis official takes an urgent call from the laboratory and feels her stomach knot. She has a patient with a potentially infectious, dangerous TB strain -- a case her state lacks the money and the medical resources to treat.

Those three small snapshots are all part of a global tuberculosis epidemic that threatens the Bay Area -- with its web of international connections -- like few places in the nation. Call it one price of globalism.

Last year, tuberculosis increased in four of the Bay Area's five largest counties, and the San Jose area in 2006 had the highest TB rate of any large American metro area, according to data from the U.S. Centers for Disease Control and Prevention and the California Department of Public Health. San Francisco, after an outbreak of TB among Latino dayworkers in the Mission district, has the highest TB rate of any county in California -- quadruple the U.S. rate.

From the bodies of Peruvian mummies to 21st-century tech workers, tuberculosis has been mankind's dark partner for centuries -- a highly infectious disease that never followed the path to eradication of smallpox and polio. One in three people worldwide are infected, and 1.7 million died last year, mostly in poor countries where people lack the access to detection and treatment available in the United States.

No case of TB is easy. The waxy-sheathed, rod-shaped, slow- growing bacteria, if untreated, colonizes the lungs, creating such dense cavities of disease that pieces must sometimes be excised. TB spreads through the air; untreated, one person infects 10 to 15 people a year, according to the World Health Organization.

But among public health officials, nothing is more worrisome than the relative handful of drug-resistant TB cases. WHO and U.S. experts are warily watching the record level of such cases -- found from former Soviet prisons to remote provinces in China -- as hints of something even scarier on the horizon.

"It worries me that we're going to have increased cases of multi- drug resistance because we have no control over the rest of the world," said Dr. Marty Fenstersheib, the public health officer for Santa Clara County, which has had a 21 percent jump in TB cases since 2005. San Mateo County saw an 11.2 percent increase from 2006, and is the only county in the state whose numbers have increased for five consecutive years.

"The person on the street, when you go up to them and say, 'Do you know what one of our major problems is?' and they guess everything else and you go, 'Tuberculosis,' and they go, 'No. We still have TB? We have that?"'

Treating one drug-resistant case can easily cost several hundred thousand dollars or more -- the bill often ends up with the county health department if a patient lacks insurance. And in a growing number of extremely resistant cases -- including a few in the Bay Area -- there are no drugs that can cure the disease, raising the specter of an infectious, incurable, potentially fatal infection.

With California in a budget crisis -- and the state's total number of TB cases declining -- a disaster which hasn't happened yet is not a high priority for politicians. But that is precisely what worries Bay Area TB officials. They say emerging drug resistance, global travel connections, and Gov. Arnold Schwarzenegger's plans to cut TB spending will all handicap California's ability to protect residents from dangerous drug-resistant TB.

"It drops our pants around our ankles," Alameda County TB control officer Dr. Robert Benjamin said of the budget cuts. "And we can't run like that."

Demographics

If affluent, modern Silicon Valley seems an unlikely hunting ground for a disease often presumed a medieval scourge, nothing could be more wrong. This region has intimate ties to countries with the world's highest TB burdens, countries where the lack of access to antibiotics and basic health care has allowed the disease to flourish in the 21st century.

Ninety percent of Santa Clara County's 241 TB cases in 2007 were in students, immigrants, temporary workers, tourists and others born in other countries. At the same time, the number of multi-drug- resistant cases in the county -- bacteria resistant to isoniazid and rifampin, the first-line TB antibiotics -- jumped from two to seven.

"Our TB reflects the countries of origin that our patients come from, and it's the Philippines and Vietnam and India where there is a lot of drug resistance," said Dr. Sundari Mase, Santa Clara County's former TB control officer, now with the CDC.