The following story appeared in the Toronto Star. I fail to see why potential immigrants with active TB should be admitted to Canada. Public safety demands that they should not be admitted. In my view, it is a "no-brainer".
TB’s deadly comeback
Toronto, with its growing immigrant population, will likely see an increase of deadly, contagious tuberculosis, experts say. The current system simply couldn't handle an outbreak, but the province has yet to make the changes required to protect citizens
February 24, 2008 Megan Ogilvie Health Reporter
At first, Lynda thought it was a cough like any other: a dry hack that rattled her chest from time to time. Nothing to be bothered about.
But soon the tickle was accompanied by a high fever, unrelenting fatigue and a deep, aching pain in her right lung.
Worried, the 41-year-old mother went to see her family doctor in Newmarket. She told him about the persistent cough, that she had inexplicably lost 20 pounds in the spring, and how she felt dark shadows of depression slowly creeping over her.
He advised her to work fewer hours and stop smoking, and he sent her home with stronger asthma medication. But months passed, and Lynda, who continued to see her doctor, kept getting weaker and weaker, until one day she was unable to climb a flight of stairs.
"That was a scary feeling because I knew something was not right," recalls Lynda. "In my head I heard a voice. It said, I think I'm dying."
She was.
Hordes of tuberculosis bacteria were living in her lungs, thriving and multiplying, steadily destroying the delicate tissues.
But since many Canadians consider tuberculosis a thing of the past, Lynda's family doctor misdiagnosed the deadly disease for months. Since she got her diagnosis two years ago, she has told few people, for fear of being ostracized – which is why she asked the Star not to use her last name.
Experts say few family doctors know the singular signs of tuberculosis any more. And few patients nowadays consider that they might be suffering from a disease that once killed thousands of Canadians every year, and then seemed to vanish.
Yet tuberculosis hasn't disappeared from our neighbourhoods. In Toronto, more than any other city in Canada, there is still an undercurrent of disease. About one-quarter of the country's TB cases are here – there are currently about 1,600 active cases in Canada and 400 in Toronto – and experts expect the incidence to rise as immigration swells from countries where TB is epidemic.
Despite those concerns, Ontario is the only TB-afflicted province without a centralized system of tuberculosis clinics. Right now, many Ontario TB patients are seen by doctors who have little experience with the disease, rather than specialists.
That means patients are being diagnosed too late and given less-than-aggressive treatment – and so are more likely to develop resistance to the antibiotics, to have permanent lung damage, to relapse later on in life, and even to die. They are also more likely to pass on the disease to the people around them.
Experts also say the current system is only just keeping up with demand and would be woefully inadequate if a TB outbreak hit the city.
"Many developing countries are doing a better job of managing TB than we do," says Dr. Michael Gardam, chief of infection control at the University Health Network and head of the tuberculosis clinic at Toronto Western Hospital.
Tuberculosis is a highly infectious disease that is passed from person to person when an infected person coughs or sneezes and spreads bacteria into the air. More than one-third of the world's population is infected with the TB bacillus – of them, about 10 per cent will go on to develop full-blown TB, which then becomes infectious (according to Dr. Kamran Kahn, a tuberculosis expert at St. Michael's Hospital, close to a million Canadians have latent tuberculosis). Close to 2 million people will die from it this year.
In recent years, some strains have become resistant to our best antibiotic treatments, making what is often a curable disease much more difficult – and sometimes impossible – to treat. The World Health Organization says extremely drug-resistant tuberculosis, or XDR-TB, is one of its top concerns and calls it a grave public health threat.
The threat of drug resistance first emerged in Tugela Ferry, a rural town in KwaZulu-Natal province in South Africa, when an outbreak of XDR-TB killed 52 of 53 infected patients. XDR-TB has been reported in 41 countries, including Canada.
Concern about drug-resistant tuberculosis proliferating in North America came into focus last May and June when infected Atlanta lawyer Andrew Speaker ignored public health warnings and endangered fellow passengers when he took commercial flights to his wedding in Greece and then returned to North America via Montreal.
Meanwhile, it's the rampage of tuberculosis outside our borders that has Toronto TB experts so worried. The WHO warns, "TB anywhere is TB everywhere." And especially with the surge in global travel and the role of the GTA as a hub for new immigrants, this city may be particularly vulnerable.
"Toronto reflects the world, and the world is having an epidemic of TB," says Gardam. "If the world has a problem, then we have a problem."
Up until the early 1980s, Ontario did have a centralized system of tuberculosis clinics managed by each region's public health unit and run by the province. But as infection rates fell, officials assumed the disease would eventually be eliminated, and the system was dismantled.
"It seemed like infectious diseases would disappear from the planet," says Dr. Elizabeth Rea, an associate medical officer of health for Toronto Public Health's TB prevention and control program. "They haven't. Particularly for Toronto. Our rates are driven by what is happening outside the city ... TB is not going to disappear from Toronto as long as we are an immigration centre. We need to plan for cases to continue to arrive here and to be able to deal with them at the highest level of care."
Toronto's TB rate has slowly been slowly going down for the past 10 years but, cautions Rea, "Every single jurisdiction that has cut back on TB control has had a resurgence."
New York City offers the most striking object lesson. In the early 1990s, after the city had repeatedly cut spending on TB control, an outbreak swept through the most vulnerable communities – the homeless, working poor crammed into tight living quarters, people with immune systems beaten back by HIV. By 1992, there were 3,811 new cases of TB, up from 1,307 cases in 1978, the first year the city kept statistics.
"It was a massive, heartbreaking outbreak," says Rea. "It took years and millions and millions of dollars to get it under control."
According to The New York Times, the city spent $40 million on tuberculosis control in 1993, in the midst of the epidemic, compared to $4 million in 1988.
Toronto has seen it's own mini-outbreaks of TB in the shelter system. In 2001, Joseph Teigesser died of tuberculosis while living in a city shelter during a 17-month-long outbreak that also infected 15 other homeless people.
A 2004 inquest into Teigesser's death made 13 recommendations, primarily to the provincial government, for reducing TB transmission among the homeless. One of them was for the Ministry of Health to establish a centralized clinic system for TB management, funded 100-per-cent by Queen's Park.
Since 2000, at least seven reports, including one by the Ontario Medical Association, have recommended a centralized model of TB care. In 2005, the ministry convened a task force of tuberculosis experts to outline how such a system could be implemented. Eighteen months ago the task force submitted its 25-page report – endorsed by the Lung Association, the Homeless and Underhoused Community Advisory Panel and the Tuberculosis Prevention and Control Program of the Public Health Agency of Canada – but still hasn't received a response from the province.
According to ministry spokesperson Andrew Morrison, the ministry supports the proposed model for developing a centralized clinic system in Toronto and is currently reviewing the task force's proposal.
According to the provincial task force, the current fragmented system means TB patients are not being managed properly as set out by Canadian Tuberculosis Standards, a book on prevention and treatment published by the Public Health Agency of Canada and the Lung Association. The task force also says they are at higher risk of dying or developing drug resistance and are staying sick longer, which increases their likelihood of spreading the disease.
Right now, there are four tuberculosis clinics in Toronto – at Toronto Western, St. Michael's and Sick Kids hospitals and at West Park Healthcare Centre, the only hospital in the province to offer long-term in-patient care for TB patients. All these facilities get funding from their respective hospital foundations. There are no such clinics in 905 areas.
Kamran Kahn of St. Michael's Hospital says it's becoming more and more challenging for the four clinics to keep up with demand, because patients are arriving with complex health and social issues. And he points out that three of the clinics are downtown and hardly accessible to the many immigrant patients who live east, west and north of the city.
The 2006 task force, which Kahn was a part of, highlighted the immediate need for two additional TB clinics, one in Etobicoke and one in Scarborough, a neighbourhood that sees, on average, one-third of the city's active patients.
What all of this means, says Kahn, is that family physicians in the GTA have to pick up the slack. In 2002, he points out, there were 178 physicians managing TB cases in southern Ontario, and few doing it well since almost two-thirds had managed less than one TB case per year.
These front-line health-care workers, used to diagnosing diabetes, heart disease and the other chronic diseases confronting modern-day North America, can miss the cluster of symptoms that spell tuberculosis – a constant cough, unexplained weight loss, night sweats, a general feeling of malaise. Especially when the patients do not come from prisons, homeless shelters and the other overcrowded settings where TB usually emerges.
In a 2006 study published in the Canadian Medical Association Journal, Kahn and Gardam found patients who were treated by TB-experienced physicians were less likely to die than those treated by inexperienced physicians.
Just as cancer patients are referred to cancer clinics, experts say tuberculosis patients need to be managed by specialists. Kahn says this is particularly true for complicated TB cases, including patients who are new to the country and who may not speak English and those who have other health problems, such as HIV or mental illness. More than 90 per cent of TB patients in Toronto are foreign-born.
Most days, Lynda can hardly believe she has tuberculosis. It's been two years since she was diagnosed with the disease, and she's not sure if she'll ever get her old life back.
At 43, the vivacious mother in York Region wants to be out playing with her two young daughters, not confined to a couch because her lungs have been ravaged by TB. Even now, a cough could turn into a phlegm-filled fight for breath.
"It's changed my life so much," she says. "I'll have a couple of good days, then some bad days. Every morning I cough, every morning I gag, every morning I retch. It hurts to laugh. I can't run. I was always a hard-working person, I can try to go-go-go, but ... "
Lynda is waiting to hear whether her right lung, which has been almost completely destroyed by the disease, will have to be removed.
"I guess if it was caught sooner, maybe it wouldn't have been so bad," she says.
Gardam, who now treats Lynda at his clinic at Toronto Western, confirms that she would be well now if she had got proper care from the start. Not only was Lynda misdiagnosed by her family doctor, but when she finally got a proper diagnosis six months later, the community hospital gave her the wrong regime of antibiotics.
"There is no doubt, the earlier you catch it, the better you do," he says. "In general, (Lynda's) case is a very common story for us."
Lynda never wanted to be an example of what is wrong with Ontario's current tuberculosis care system. But that is exactly what she has come to be. She still doesn't know where she got infected, though there's some evidence she got it at the factory where she worked for three years.
Lynda pauses to cough, making a gurgling sound, and then goes on.
"It's not just a Third World problem, I don't think," she says. "It's coming back here ... People need to be educated about tuberculosis ... It's not a dead disease."
No comments:
Post a Comment