Doctors Battle High TB Rate In Alaska

Alaska has the highest rate of tuberculosis in the country – more than double the national average. And many of the cases pop up in rural areas of the state where treating the disease is especially difficult. But health officials hope new tools for identifying and treating TB will help slowly bring down Alaska’s high infection rate.

Three years ago, Dr. Michael Cooper was a family practice doctor, working in the remote northwest section of the state. Occasionally he would see patients complaining of a persistent cough. They may also have been experiencing night sweats or weight loss. Classic signs of tuberculosis, but, “TB was rarely on my list of diagnoses, when I would see a patient. I hate to admit that.”

Last July, Dr. Cooper took a job managing Alaska’s infectious disease program. And now, working to lower the state’s high rate of tuberculosis consumes at least half of his time on the job.

“And as I look back now I go through these patients some nights and think, that patient could have had TB and why didn’t I at least do this? Why wasn’t I even aware of it?,” Cooper said.

So Dr. Cooper is focusing part of his efforts on educating other doctors and nurses in Alaska about tuberculosis. That education includes understanding why the TB rate is so high in the state. Dr. Cooper says to get the answer, you have to look back to the early 1900s.

“We experienced probably the highest rates of TB back in the early 20th century found anywhere in the world at the time,” he said.

That’s partly because Alaska Natives had no natural resistance to the newly introduced disease.

“So if you just imagine a nice cold winter and a packed house full of people. And one person having picked up this brand new disease that they have no immunity against. And then spreading it. It just can spread like wildfire,” Cooper said.

Some areas of Alaska had rates of TB up to 100 times higher than today. And the legacy of that history- is that a large number of Alaskans are now latent carriers of the disease. That means they have no symptoms, they aren’t contagious, but full blown TB can flare up at anytime. Each new case that does pop up triggers a rapid response from the state. Karen Martinek – a state nurse epidemiologist – occasionally flies to villages to limit the spread of the disease.

“If we see a small, isolated village. Usually they are accessible only by air or snowmachine in the winter. And we have a case or two of active tuberculosis identified in that village. We can be quite confident that there’s transmission going on,” Martinek said.

Worldwide, TB is the second deadliest disease, after HIV/AIDS. In the U.S., it doesn’t usually kill people, because it can be cured with pills. But the treatment is arduous. Patients have to take several pills a day for six to nine months and endure difficult side effects. Because the disease is so contagious, each dose needs to be witnessed by a provider. Treating latent TB involves taking one pill a day for nine months. But Martinek says patients don’t always follow through.

“I think that’s one of the strategies we’ve struggled with particularly in Alaska, to get people to start and complete treatment for latent TB infection,” she said.

But a much shorter and easier treatment course became available last year. Now patients can take two pills a week for three months. Patients are much more likely to complete the shorter treatment. And Martinek thinks the new drugs can have an impact on Alaska’s TB rate.

“If we can successfully complete treatment in more folks with latent TB infection, we would hope we would ultimately see a reduction in TB case rates down the road,” Martinek said.

Dr. Cooper says other new tools may also make a difference. New rapid TB tests can identify the disease in 24 hours. In the past, it could take six weeks. And every new TB case is now genotyped at a Centers for Disease Control lab. That means the DNA strain of each infection is identified and treatment can be targeted to each case. All of those things combined give Dr. Cooper some hope Alaska can eventually bring down the TB rate. But until then, the disease will continue to take up a huge amount of his time.

“The impact today is not nearly the scale as it was 50, 60 or 70 years ago in Alaska. But it’s still being felt and the threat is always there that this little cluster and this little villages which we rush out and contain and get people on drugs and we do the investigation, if that doesn’t happen quickly enough, if that doesn’t happen thoroughly enough. If people aren’t tolerating the drugs and decide not to take them, or refuse to take them. It still has the potential to turn into a big infection very quickly,” Cooper said.

The state hasn’t had a big TB outbreak since 2006. And Dr. Cooper hopes he can help the state hold down the infection rate. With a sheepish smile he says that will involve making sure more doctors in Alaska think about the possibility of TB when each new patient walks through their clinic door.

This story is part of a reporting partnership that includes APRN, NPR and Kaiser Health News.

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