HealthyCal.org

Medical officials caution women considering home delivery

By Hannah Guzik
California Health Report

A growing number of California babies are taking their first breaths not in the florescent glow of hospital rooms, but in their parents’ bedrooms.

Although the percentage of women giving birth at home is still small, home births in the state increased by 37 percent between 2004 and 2009, from 0.38 percent of all births to 0.52 percent, according to a January report released by the National Center for Health Statistics and the federal Centers for Disease Control and Prevention.

Nationwide, the percentage of births that occurred at home jumped 29 percent during the same time period, from 0.56 percent to 0.72 percent. There were 29,650 babies born at home in the U.S in 2009.

“I think part of it is the economy driving people to have home births,” said Sue Turner, a licensed midwife in Ventura. “Maybe they’ve lost their job and don’t have health insurance, and so they’re wanting the cheaper way to go. Also, I think many people want fewer medical interventions. There’s more awareness that giving birth can be a natural experience.”

Fawn Peterson is one California woman who opted to give birth at home last year, after having three previous hospital births.

“The home birth was just easier—we didn’t have to pack bags and go anywhere, and we could enjoy the comforts of our own home,” she said. “At the hospital I would have had an I.V. and wouldn’t have been able to move around as much while I was in labor.”

She gave birth to her son, August, on the bed she and her husband, Jeff Peterson, share. Under Turner’s guidance, Jeff Peterson, “caught” August as he slid down the birth canal.

Like Peterson’s, the majority of home births are planned, but an estimated 25 percent occur because women can’t make it to the hospital in time, according to a 2010 study published in the American Journal of Obstetrics and Gynecology.

The American College of Obstetricians and Gynecologists’ recommends that women not plan a home birth, because of safety concerns and a lack of rigorous scientific study. The California Department of Public Health does not have a position on home births, said spokeswoman Anita Gore.

Studies have shown that home births can be more dangerous for babies, but may result in fewer complications for mothers, said Dr. Robert Levin, health officer for Ventura County Public Health and a pediatrician.

“In terms of the mother’s health, home births appear to be as safe as hospital births, but there is some concern that with planned home birth, there’s as much as a two-fold increased risk of neonatal death,” he said. “The neonatal death rates are still quite low, but they’re something we look at every year in California and the United States.”

The 2010 study by the Committee on Obstetric Practice found that 2 in every 1,000 newborns died during planned home births, while 0.9 in every 1,000 died during planned hospital births.

Meanwhile, 1.2 percent of women who had a planned home birth received third- or fourth-degree lacerations during the delivery, compared with 2.5 percent of women who had a planned hospital birth. Rates of maternal infection were also lower among those who delivered during a planned home birth, at 0.7 percent, compared to the 2.6 percent among those who had a planned hospital birth.

The lower complication rates among those who deliver at home could be because state laws only allow midwives to care for women with low-risk pregnancies, Levin said. Those with gestational diabetes, high-blood pressure or a number of other common pregnancy conditions that can cause birth complications typically deliver in a hospital.

In addition, 25 to 37 percent of women who have never given birth before and plan to deliver at home end up being admitted to a hospital because complications arise or their labor isn’t progressing, according to the Obstetric Practice study.

If women are considering a home birth, Levin said it’s important to make sure they select an American Midwifery Board Certified midwife, have a low-risk pregnancy and haven’t had a previous cesarean section.

The percentage of U.S. births that occurred at home declined between 1990 and 2004, but has increased sharply since, the CDC study found. Home births are most common among women aged 35 and older who have had previous children.

For non-Hispanic white women, home births increased by 36 percent, and about 1 in every 90 births for this group of women is now a home birth. Home births are less common among women of other racial or ethnic groups.

The percentage of home births in 2009 varied from a low of 0.2 percent of births in Louisiana and the District of Columbia, to a high of 2 percent in Oregon and 2.6 percent in Montana.

Turner, who also operates the Ventura Birth Center, a place where women can give birth outside of the hospital, said she’s seen her business increase 15 percent each year in the past decade. She’s typically booked about four months in advance and frequently has to turn pregnant women away.

“This week I’ve gotten calls for people due in October,” she said on March 15. “We’re halfway booked now for October.”

Giving birth at home is about a third the cost of a hospital birth, Turner said. Midwives typically charge between $4,000 and $6,000 to deliver a baby at home, whereas hospital bills often run between $12,000 and $15,000. However, only about half of health insurance companies in California cover home births, Turner said.

Other women opt for home births because they’re afraid of hospitals, or associate them with negative experiences, she said.

“Perhaps they’ve had a traumatic experience giving birth previously in a hospital, or maybe they’ve had a loved one or previous child pass away in a hospital,” she said.

Some women also chose to stay home because they want more control over their environment and birth attendants, or because they want a more traditional experience, Turner said.

“It’s so interesting to me it just seems like things go full circle this way,” she said. “For so much of history, women gave birth at home.”

In 1900, almost all U.S. births occurred outside a hospital, the vast majority of which occurred at home, according to the CDC study. This proportion fell to 44 percent by 1940, and to 1 percent by 1969, where it remained through the 1980s.

Peterson said knowing that women traditionally gave birth at home helped persuade her to do so as well — but she wasn’t opposed to being transferred to a hospital if something went wrong.

“I had nothing to prove,” she said. “I think it’s silly if someone’s high risk and she still wants to grit her teeth and stay at home. The baby’s safety is what’s most important.”

By the time children in California reach kindergarten half of them already have cavities. More than a quarter of them have untreated tooth decay. Photo: emrank/Flickr

By Callie Shanafelt
California Health Report

Tooth decay, the most prevalent chronic disease of childhood in the United States, is also preventable.

Every week, children come into the Asian Health Services dental clinic in Oakland’s Chinatown with severe tooth decay. “It’s not uncommon that these children- especially immigrant children- have anywhere from 6-20 cavities in their mouth,” says Dental Director Huong Le.

In order to treat such extreme tooth decay they have to put the children under oral conscious sedation – a costly procedure. Half of their pediatric patients – about two thousand children – fit into this category.

The Centers for Disease Control and Prevention CDC that found in 2007 that as every other aspect of oral health improved, the rate of cavities in preschoolers aged 2-5 had increased since the previous study a decade before.

Experts attribute the increase to lack of knowledge among parents and lack of access to pediatric dentists.

California has the third worst children’s dental health, ranked just above Arizona and Texas in the National Survey of Children’s health conducted in 2007 – the last year most of these studies were done.

By the time children in California reach kindergarten, half of them already have cavities. More than a quarter of them have untreated tooth decay. Among poor children and children of color the numbers are even worse. Seventy-two percent of children on free and reduced lunch have cavities and a third have untreated tooth decay.

Children with serious untreated tooth decay often have nutritional problems because of difficulty chewing. They also have challenges speaking and miss school days.

Asian Health Service has two pediatric dentists on staff, but their services are in such demand that patients usually have to wait nine months before they can get an appointment for the procedure. Most of the clinic’s pediatric patients are covered by Medi-Cal, which pays for the treatment, but it doesn’t cover the oral conscious sedation medication.

In the worst cases, when the patient cannot wait nine months, AHS refers them to an outside specialist who is willing to work for the Medi-Cal reimbursement rate but charges the patient for the medication. Three years ago, Le got a grant from the Alameda County Dental Society Foundation to cover the cost of the medication.

“So that has helped out tremendously with our backlog,” Le said.

Dental departments in community clinics are usually a small part of their overall operation. The dental clinic at AHS only has the capacity to treat 8,000 of their 22,000 patients. Le recommends all pediatric patients be referred to dental by the time they are one year old.

Since they don’t have the capacity to see all those patients, they’ve trained staff in the pediatric medical clinic to apply fluoride and varnish so they don’t have to be referred to dental.

Arlene Glube, director of Southern California Operations at The Center for Oral Health, points out that extreme tooth decay is preventable. Two years ago, she started working with women in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) to educate them on how to prevent tooth decay in their kids.

“Parents think first teeth are going to fall out – so why spend the money on the first set of teeth?” Glube said.

But Glube says mothers need to start thinking about oral health from the moment they know they are pregnant. She tells the parents she works with that by the time their child is one they should go to the dentist.

“Make an appointment for yourself, have your baby sit on your lap and say ‘have a look at my baby.’ It opens the conversation,” Glube said.

Part of the problem is that some doctors and dentists don’t realize that children need to begin seeing a dentist by the age of one. Glube says there are pediatric dentists who will only see patients once they’ve turned five.

“That, to us, is malpractice,” Glube said. “We work very closely with our dentists so that they never turn a mom away with a young child.”

Both Glube and Le recommend that when a child gets their first tooth, his or her parents should start brushing with a small soft toothbrush and fluoride toothpaste after breakfast and before bed. And Glube says they should continue to help until their child is eight years old.

Glube also recommends healthy snacking and weaning from a bottle by the age of one. “And no bottles in bed,” Glube said. “Certainly no bottles in bed with anything exciting like juice or kool-aid.”

She also points out that it is better for kids to drink fluoridated water from the public water supply than bottled water.

So far the WIC program has been successful, Glube said. Most mothers are glad to learn how to take care of their children’s teeth.

“The most exciting thing is going to the WIC site and mom comes back with her next children,” she said.

There are other barriers to Californian children’s oral health. While it is much easier for children than adults to get affordable dental coverage, about a quarter don’t have any.

Parents of children in California’s thirteen rural counties may have difficulty finding a pediatric dentist willing to take new clients. They may especially have difficulty finding a dentist willing to work for the low Medi-Cal reimbursement rates.

Glube has been working in the field for more than 30 years. “I just can’t bear to retire. I love what I do and I love the people,” Glube said. “I can’t imagine waking up in the morning and not worrying about them.”

But over those 30 years, she’s seen oral health programs come and go. At one point she coordinated an eleven-person staff. “We had almost four hundred thousand children getting preventive services at school,” Glube said. “But Governor Schwarzenegger cut that program out.”

She said when that happened, it felt like she had climbed a mountain and slid all the way back down.

The Center for Oral Health got a Health Resources and Services Administration grant in 2011 to integrate dental services into the school-based health centers at Murchison Elementary, and Plasencia Elementary in the Los Angeles Unified School District.

School-based health centers provide an ideal setting for dental screening and preventative services. Dentists have easy access to their clients, and if a child misses an appointment, they can simply call the next child on the list.

“We’re just starting all over again, climbing that mountain,” Glube said.

Minority children still diagnosed less frequently because of difficulty accessing health services, lack of widespread screening

By Julissa McKinnon
California Health Report

When her toddler twin boys wouldn’t react to basic discipline, time-outs or even spankings, Stephanie Tobin assumed they were just exceptionally strong-willed.

But other things they did puzzled her. They didn’t like going into grocery stores, because they were frightened by the loud noises over the PA. When a preschool teacher led an activity, they sat with their backs to her and the other kids, each one playing quietly by himself.

It wasn’t until they were five and a half years old that a school psychologist discovered the boys had autism.

More children than ever before are being diagnosed with autism, a developmental disorder that impairs the brain’s ability to build communication and social skills, according to a report released last week by the Centers for Disease Control and Prevention. Autism has been detected in about one in 88 children, a 23 percent increase from the CDC’s last count in 2006 and almost double the number of diagnoses found ten years ago.

Experts believe better screening and growing public awareness about autism are driving the steady increase in diagnoses. Still, some say too few doctors – only 40 percent according to a 2008 survey – are screening for autism, leading to delays in diagnosis and treatment for many children.

The earlier a child is diagnosed and treated for autism, the better, according to several autism specialists.

“The brain is still developing in very young children. The earlier we can start building those appropriate connections in the brain, the better the outcome will be,” said Aubyn Stahmer, research director for the Autism Discovery Institute at Rady Children’s Hospital in San Diego.

While the latest CDC study shows an increase in children younger than three being diagnosed, the average age of diagnosis is 4 and a half. The first observable signs of autism, such as a lack eye contact or response to their own name, can start emerging in children between 12 and 24 months, said Paul Carbone, a spokesman for the American Academy of Pediatrics and a professor of pediatrics at the University of Utah.

Though there’s been an explosion of public and private autism services and institutes over the last decade, the CDC study shows there continue to be disparities in autism diagnoses between different states and ethnic groups. On the low end of the scale, Alabama showed one in every 208 children was identified as autistic, compared with one in 47 children in Utah, the highest count among the 14 states surveyed in the CDC report. Among ethnic groups, white children were more frequently diagnosed with 12 per 1,000 being described as autistic compared with 10.2 per 1,000 black children and 7.9 per 1,000 Hispanic children.

Experts believe there are fewer diagnoses among minority children because of difficulty accessing health services or a lack of widespread autism screening by pediatricians. However, the latest study shows the gaps in diagnoses between white and minority children closing. Diagnoses for Hispanic children have jumped 75 percent since 2006, the biggest increase among all the groups. The study also showed a 35 percent increase in diagnoses among children considered to have average to above average intellectual abilities because of IQ scores 85 or higher.

“Traditionally minority kids don’t have as much access to care so it’s good that we’ve been increasing identification in these populations. It doesn’t mean there are more cases but it shows that we’re getting better at picking up on the disorder and we’re also getting better at picking up milder cases of autism,” Stahmer said. “I think people are becoming more aware and I think more pediatricians are willing to make a referral.”

In 2007 the American Academy of Pediatrics began asking pediatricians to regularly screen for autism as children turned 18 months and two-years-old. One of the more popular screening tools is a questionnaire given to parents that’s available in 20 languages and takes about five minutes to fill out, Carbone said. Before the academy’s screening recommendation, a survey showed only eight percent of pediatricians were checking for the disorder. Since then about 40 percent of doctors are routinely looking for autism, according to a 2008 survey, Carbone said.

“The uptake (of autism screening tools) has been admittedly slower than we hoped for but I think we’re moving in the right direction,” Carbone said.

He said doctors’ reasons for skipping autism checks include a lack of familiarity with the screening tools and with autism specialists to refer patients to. Pediatricians also felt there wasn’t enough time to add one more thing to dozens of pediatric check-ups.

“When there’s a very busy practice with patients coming in and out it’s a very fast-paced environment. Trying to add something into that system is like trying to fix a bike while you’re riding it,” Carbone said. “It’s not a process that happens overnight.”

He said parents also play a big role in helping to identify autism since they are the ones informing doctors if their child is or isn’t meeting developmental milestones such as beginning to babble around four months or starting to play with other children around age two.

Because diagnosing autism involves observing and correctly interpreting a child’s behavior, experts say it is far from an exact science. Much about the disorder remains a mystery, including the cause. As researchers glean more insight into the disorder, it’s medical definition is continually being revised. Previously, only children with severe language delays and repetitive habits were considered autistic. Diagnoses are now given to children with various conditions ranging from severe to mild, including Asperger’s syndrome.

Now medical officials are proposing new changes to doctors’ manual for diagnosing autism that would simplify and narrow the definition of autism.

“We’ve heard a lot of concern from parents that the proposed changes in the DSM (autism criteria) would make their children no longer eligible to receive services,” said Jon Baio, an epidemiologist with the CDC and principal investigator on the Autism and Developmental Disabilities Monitoring Network.

Researchers have been trying to find more objective methods for detecting autism, such as analyzing a blood sample or checking for a genetic marker for years. This would make diagnosing autism a more straightforward process and probably lead to earlier detection among children, according to several autism experts.

But regardless of when autism is found, doctors say an array of therapies can help develop a patient’s language, motor skills, and abilities to solve problems and interact socially.

Like many autism centers, the Autism Discovery Institute at Rady Children’s Hospital specializes in both diagnosing and treating patients with autism.

One half of the building is filled with patient evaluation rooms and the other is Alexa’s Playc, a preschool with class ratios of two normally developing kids to every autistic child. Like most preschool classrooms, the walls of the “dolphin” room (three to five-year-old students are the dolphins) are papered with art: finger-paintings of blue fish, drawings of Dr. Seuss characters and a giant rainbow built from construction paper confetti.

Even the most basic activities, such as painting a picture, usually have an ulterior motive, said Sarah Denno, director of Alexa’s Playc. Teachers often set it up so that the students must share tools to complete the task at hand, pushing them to communicate and interact with their peers.

“Our kids that are on the (autism) spectrum don’t typically have challenges with academics or cognitive skills,” Denno said. “Their biggest challenge is that social piece. If we can give them skills they will need to function in a larger social environment, I think we’ve been successful.”

Christa Bailey said since her five-year-old son Nicholas started attending Alexa’s Playc he’s much more aware of his surroundings and others. As a toddler, Nicholas only wanted to play by himself and didn’t respond to his name.

“Now he looks for us to help him or to share something with us,” Bailey said of Nicholas, who was diagnosed with autism at age three. “He picks up on social cues better now. His language is becoming more appropriate with fun ‘typical kid’ statements like ‘Yay, I did it!’”

Click here to read more about the CDC’s autism report.

By Elise Craig
California Health Report

For years, obesity and autism have been on the rise. Now, a new study is providing evidence that maternal metabolic conditions like obesity and diabetes may be linked to developmental delays and autism.

Obese mothers are 1.66 times as likely to have a child with autism as normal weight mothers who do not have high blood pressure or diabetes, according to the study conducted by the UC Davis MIND Institute. They are also more than twice as likely to have a child with a second developmental disorder.

The researchers also found that mothers with diabetes were 2.33 times as likely to have children with developmental delays—some form of cognitive impairment, and sometimes delays in speech and motor skills—as mothers without the disease.

Though the findings showed that mothers with diabetes had a moderately higher chance of having a child with autism than healthy mothers, the difference did not reach statistical significance. However, the autistic children of diabetic mothers were likely to be more disabled than the autistic children of healthy mothers, with greater problems with language comprehension and adaptive communication.

Children who do not have autism who were born to mothers with metabolic disorders—hypertension, obesity and diabetes— showed slight deficits in language comprehension, socialization, problems solving and other skills.

In the U.S., 60 percent of women of childbearing age are overweight, while a third are obese and almost nine percent are diabetic. Roughly one in 110 children has Autism Spectrum Disorder.

Given these statistics, the study’s results raise concerns and “may have serious public-health implications,” said Paula Krakowiak, a biostatician affiliated with the MIND Institute. “Compared to genetic research, little investment has been made into research on environmental factors which may be contributing to autism risk (as well as risk for other developmental disorders),” she added. “We hope that this study will bring more attention to the need for research and funding to investigate environmental factors in relation to developmental disorders.”

Though this early research does not prove a causal relationship between maternal metabolic disorders and developmental delays and autism, Dr. Michael Stern, a professor of biochemistry and cell biology at Rice University believes “this is one area that in my opinion people need to take very seriously. It appears that there is a consensus emerging that our new hyperinsulinemic lifestyle is a serious health issue.”

Prior research has found a relationship between material diabetes and deficits in memory, motor and language development, but few studies have examined the relationship between development and obesity, hypertension and diabetes, all of which share an underlying mechanism—insulin resistance, Krakowiak said.

Mothers with insulin resistance have trouble regulating their blood sugar, which can result in chronic exposure fetal exposure to elevated insulin levels. Increased production of insulin necessitates more oxygen, and can mean less oxygen for a fetus.

Maternal diabetes can also lead to fetal iron deficiency. Both conditions “can profoundly affect neurodevelopment in humans,” the report said.

Though the study adds new insight into potential risk factors for autism and developmental disorders, both Stern and Krakowiak agree that it’s a jumping off point for further research.

“We need to go beyond correlation and go on to causation,” Stern said. “Does maternal high blood glucose cause an incidence of autism?”

“Another question left unanswered is whether some upstream environmental factors are increasing the risk for both maternal metabolic conditions and autism independently,” Krakowiak said.

However, there is no downside to advocating healthy diets among pregnant women, said Kelly Barnhill, nutrition coordinator for the Autism Research Institute. “Whole diets make a big difference in the long run,” she said. “For all of us. In the case of a child with developmental delays and disorders, we have research that when you change their diets, you can make a difference in their delay or disorder.”

The study, “Maternal metabolic conditions and risk for autism and other neurodevelopmental disorders,” was published today in Pediatrics, the journal of the American Academy of Pediatrics.

Researchers affiliated with the MIND Institute conducted the study using data from the ongoing, population-based control study, Childhood Autism Risks from Genetics and the Environment (CHARGE). They relied on medical records, birth files and medical questionnaires for information. Though, the report notes researchers only had medical records for just over half of participants, and self-provided data can be inaccurate, “in the 58 percent for whom medical records were available, the two sources were in good agreement.”

By Mary Flynn
California Health Report

Newborns metabolize medications very differently, even when compared to small children or infants.

Laws intended to help our understanding of how drugs affect kids have increased our knowledge, but room for improvement remains, according to a recent Institute of Medicine report.

How drugs work in newborns and the long-term effects of drugs used on children are two of the areas that need more examination, the authors said.

The report evaluated two laws: the Best Pharmaceuticals for Children Act (BPCA) and the Pediatric Research Equity Act (PREA). BPCA encourages more pediatric studies by offering economic incentives to drug companies who conduct studies requested by the Food and Drug Administration. PREA gave FDA the authority to require pediatric studies in specific circumstances. The laws, in place since 1997, are reviewed every five years.

“The laws themselves make it such that the FDA has to go back and look back at certain times, and say, ‘How well are these laws doing, are we getting labeling changes?’” said Dr. Jon Abramson, Chair of the Department of Pediatrics at Wake Forest Baptist Medical Center. “They’re doing pretty good, they’re doing a lot better than no laws when we had no laws, but they’re far from perfect.”

Many medications that doctors use in children – then and now – are not FDA-approved for use in kids.

Before the laws passed, very few of the drugs prescribed to kids had been studied in children, said Dr. Thomas Boat, University of Cincinnati College of Medicine and vice president for health affairs served as chairman of the committee.

“We were flying by the seat of our pants in a considerable way,” he recalled the early years of his practice in clinical medicine in the 1970s.

Using medications off-label has its consequences because many drugs affect children differently then they do adults. Medications that are generally safe and effective in adults can be harmful or completely ineffective – or both – for children.

“[Children] often metabolize the drug differently,” Abramson said. He explained that many drugs have a side effect in children that might not appear in an adult and vice versa.

A pediatric study conducted on Xolair, for instance, a drug used to treat moderate to severe asthma, determined that the risks of using the drug – including worsening their condition or severe allergic reaction – outweighed the benefits for children under twelve. Now the drug is recommended for use in children over twelve years old.

“If you’re going to use a drug, you want to be aware of what some of the potential side effects are in that age group,” Abramson said.

Newborns in particular metabolize medications very differently, even when compared to small children or infants. Chloramphenicol, for instance, an antibiotic that was widely used in adults and children in the 1950s, had toxic effects on newborns. Several newborns died after receiving the drug, and the case has become a classic example of the need for pediatric drug trials.

Conducting studies on newborn babies, or neonates, however, is especially difficult. The short neonatal period (28 days) is a brief window for research. Sample sizes are generally very small, and ethical issues complicate the study of sick or premature kids. Also, differences between newborns – including weight or their level of development – can significantly affect how a drug affects their body.

While recognizing these difficulties, the report still recommends more neonate studies.

We also continue to lack of information the long-term effects of drugs on kids. Treatment for young cancer patients, for instance, may create risks for later problems such as cognitive limitations, infertility, or even new cancers.

Abramson said that in some instances, it is even more necessary to do long-term studies in kids than adults, he said, because kids are still growing.

“Whether the drug is affecting their metabolic rate and the effect on them in terms growth, brain development, etc. – it takes years to figure out,” he said.

But long-term studies in children are difficult. “Let’s say you decide, ‘Alright, we’re going to study 100 kids with this drug.’ It’s easy to follow them during the time they’re getting the drug, that’s simple,” he said. “But to try to follow them for 10 years afterwards, it’s hard: these people move, and you can’t force the parents to bring the child back for the next 10 years.”

More timely planning, including the initiation and completion of the studies, would benefit children too, the report said. In the U.S. system, Boat explained, a pediatric drug studies aren’t initiated until nearly the end of clinical trials, when the drug company is applying for FDA approval.

Once approved in adults, Boat said, then the drug is also available to be used in children off-label. “So what you’re doing is protracting the period of time over which drugs will be used in kids without appropriate studies,” he said, creating an unnecessary delay that is likely disadvantageous to children.

On the other hand, it’s possible for studies to be initiated too soon. In Europe, for example, pediatric studies are happening from the beginning of the clinical trials, which Boat said might be wasteful if it is later discovered the drug does not work.

“Our feeling was that maybe the US is a little too late, maybe Europe is too early and maybe it’s somewhere in between that might be good, so we laid that out there as something for Congress to consider,” he said.

The committee also suggested the FDA might impose sanctions on studies that were unreasonably delayed or increase public access to information from pediatric studies might also further benefit children.

Dr. Rafael Laniado-Laborin and research assistant Rebeca Cazares study a chest X-ray showing the lungs of a tuberculosis patient at Tijuana's TB clinic. Laboratory equipment and TB treatment techniques in Tijuana have improved significantly in recent years due to a partnership between San Diego and Baja California called Puentes de Esperanza. Funding for the program is set to end in July. Photo: Julissa McKinnon/California Health Report

By Julissa McKinnon
California Health Report

Even though many Californians think of tuberculosis as a foreign problem, experts say the cough and sneeze-surfing bacteria remains a risk in the state.

Funding for disease control is shrinking, but tuberculosis is still spreading, and mutating new and increasingly lethal strains. The most drug-resistant variety of tuberculosis or TB known to science emerged a few months ago in India. Because it appears immune to every TB drug out there, scientists have dubbed it TDR TB, short for totally drug-resistant tuberculosis.

It’s only the latest in a string of increasingly tough-to-cure TB strains with obscure acronyms: first came MDR TB (multi-drug resistant tuberculosis) followed soon enough by XDR TB (extensively drug-resistant TB). All TB strains are easily contagious, an infected person can spread them by coughing, sneezing or simply exhaling.

When TB-stricken areas go ignored, this slowly but certainly puts more of the population at risk, especially in places like California that are magnets for migration from poorer countries with comparatively higher TB rates, said Dr. Rafael Laniado-Laborin, director of the TB clinic in Tijuana, Mexico.

“It becomes a public health issue because these drug-resistant strains are extremely difficult and expensive to cure and easily transmissible,” Laniado-Laborin said. “The only thing you have to do to acquire a TB infection is breathe.”

“In tight times the natural inclination is to cut budgets and look at other priorities,” said Dr. Kathy Moser, director of San Diego County’s TB control program. “But we’ve seen if there’s very little focus on an infectious, airborne disease like TB, it can come back.”

The Global Fund to Fight AIDS, Malaria and Tuberculosis announced that it won’t be issuing any new grants until 2014 due to a shortfall in donations, according to a November press release.

Instead of raising a target $20 billion by late 2010, the organization, which funds about two-thirds of the world’s international TB programs, gathered about $11.7 billion.

Budgets for TB control are also shrinking at the state and national level.

Between 2010 and 2012 the TB control budget for the U.S. Centers for Disease Control and Prevention dropped $4.7 million to a five-year low of $140 million in 2012, according to figures from the agency. Meanwhile the California Department of Public Health’s budget for addressing TB fell eight percent or $1.4 million between 2007-08 and 2009-10. The yearly budget has recovered about $209,000 since then, amounting to $16.2 million for TB control in 2011-12, according to department figures.

One of the first areas that disease control agencies tend to cut in a budget crunch is foreign outreach, said Richard Kiy, president of the International Community Foundation, a non-profit focusing on several humanitarian issues in Latin America including TB.

One example of an international TB effort that is about to lose U.S. funding is the Puentes de Esperanza program, a partnership between San Diego County and Baja California that has improved laboratory equipment, staffing levels and treatment techniques at clinics in Mexicali and Tijuana. Both of these Mexican border cities are struggling with rising rates of drug-resistant TB.

The Puentes program began in 2006 with $500,000 from the U.S. Agency for International Development, Rotary International and San Diego’s Lash foundation and has cured 90 percent of the MDR TB cases it’s taken on since.

Funding for Puentes is scheduled to end in July, but Laniado-Laborin says that’s too soon. He said Mexico is not yet able to sustain the new systems established by Puentes, which include lab testing to identify drug-resistant strains and staff to track patient’s medical intake and ensure precise dosing, Laniado-Laborin said.

The program is a lifeline for TB patients across Mexico with some driving two consecutive days to the Tijuana clinic from other states like Sinoloa and Sonora. Laniado-Laborin said people cross the distance because TB treatment in many parts of Mexico is severely lacking.

Health centers or private doctors that are well-intentioned but not as well-trained in treating drug-resistant TB are known for giving inadequate prescriptions that often end up making the TB bug more resilient.

Timothy Rodwell, an assistant professor with UC San Diego who studies TB control, said building sound treatment programs for drug-resistant TB not only saves individual lives but protects the population at large.

“If you’re not treating MDR properly then you have people walking around the community spreading it to others,” Rodwell said.

Even with Puentes, the numbers of TB cases along Mexico’s northern border have been steadily rising from 1,275 in Baja California in 2006 to 1,547 cases in 2010. Tijuana has the highest concentration of TB not just in the state of Baja but in all of Mexico with 53.5 cases per 100,000 people.

Laniado-Laborin said the imbalance is partly due to the fact that Tijuana is better-equipped than other parts of Mexico to test and report TB cases. Besides that, Tijuana is a draw for migrants from all over Mexico, many of whom end up living in the city in cramped quarters and unsanitary conditions, where contagious diseases can spread easily, he said.

Tijuana’s TB woes also present a problem for San Diego. The two cities share the world’s busiest border, where about 50,000 cars and 25,000 pedestrians cross from Mexico into California everyday, according to counts by the San Diego Association of Governments.

Consequently, scientists are starting to track drug-resistant TB strains in Mexico to see if these same strains turn up in California patients using DNA fingerprinting, Rodwell said. About 1.4 percent of California’s 2,324 TB cases in 2010 were drug-resistant, according to the latest counts by the California Department of Public Health.

Until recently, San Diego County’s TB caseload was gradually declining from 315 in 2006 to 222 cases in 2010. The most recent tally in 2011 counted 263 TB cases, an 18.5 percent increase from the previous year. Health officials say they are still checking whether a miscount may have occurred.

In the meantime, San Diego County isn’t planning on putting any of its limited funding toward the Puentes program. Funding for its TB control program was cut 15 percent between 2008-09 and 2009-10. Since then it’s recuperated some of those funds, receiving about $6.8 million in 2011-12 for countywide TB control and treatment, according to San Diego County figures.

“We’ve seen that even a fairly level budget is akin to a declining budget because things get more expensive from year to year,” Moser said, referring to everything from lab reagents and drugs to gasoline for department vehicles.

So far, the hope for sustaining Puentes and other foreign TB outreach appears to lie with philanthropic organizations and private donors.

It would take about $200,000 annually to sustain Puentes in both Tijuana and Mexicali, said Kiy of the International Community Foundation, which is leading a fundraising effort to keep Puentes alive.

“If we want to control TB now it has to be treated everywhere,” Laniado-Laborin said.

The last drug engineered specifically for TB came out in 1967. The product, called rifampicin, costs only $50 for a complete six-month treatment and is excellent for beating back a good old-fashioned strain of drug-responsive TB. However, the only remedies available for the newer drug-resistant strains weren’t specially designed to fight TB, so treatment can be hit-or-miss and costs can soar.

On average, treating one case of MDR TB costs $100,000 to $200,000, which yields a 60 to 90 percent chance of cure. Treating an XDR TB patient can cost upwards of $600,000 with a 30 to 50 percent chance of recovery, according to information from the California Department of Public Health.

Note: An earlier version of this story said that drug resistant TB in California had been found to originate in Mexico. Actually, scientists are still conducting DNA fingerprinting to determine the origin of the strain.