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Otherwise, skin testing is just a waste of time
Sometimes, less is better. Take Miami for example, where David Ashkin, MD, medical adviser to the state’s TB control program, thinks it might be best to resist the urge to pile on more infrastructure and more mandates for screening. In fact, Ashkin says he may try to persuade county TB controllers to put existing screening programs on a diet, at least until their usefulness has been determined.
That means resisting the city’s current appetite for more — more TB skin testing in the schools, more on the job site, and more among patients of clinicians who serve the private sector where, for example, one concerned pediatrician recently called for city kids to be skin-tested at least every three years.
The call for action comes in the wake of two widely publicized cases of TB: one at a city-run youth center, the other at a Miami Beach elementary school. Contact investigations, though they turned up no evidence that anyone had been infected recently, revealed that roughly one in seven children and teachers at the elementary school were tuberculin reactors, a proportion county health authorities pronounced to be perfectly normal for that population.
"What we really need to be talking about right now is not screening more people," says Ashkin. "The issue is how to get more people who’ve been screened to start preventive therapy and then finish it. Otherwise, it’s all just a waste of money."
A high incidence of HIV infection, a big foreign-born population, and crowded living conditions have helped push the city’s morbidity rates to about twice the national average (15.5 cases per 100,000 in 1997). Between high incidence and an overflowing pool of latently infected people, the city poses "a dilemma that’s almost unique in this country," says Ashkin.
A look at Dade County school system demographics is illuminating. Students hail from more than 100 countries, often places where TB is endemic; about half are Hispanic, with African-Americans kids making up the second-highest representation. Although no one keeps tabs on how often, school officials say children and their families frequently travel back home to see friends or family.
Despite, or maybe because of, the exceptionally high background rate of tuberculin reactivity among students, resource limits make a notion like school-based prophylaxis almost laughable. No regularly scheduled health care service is provided in 174 of Dade County’s 292 schools; in the remainder, a nurse is available one day a week, says Nancy Humbert, director of the county’s school health program.
There’s a possibility, though apparently not a strong one, that the state’s new secretary of health might provide schools with a few more pairs of hands, health department officials say. "That is our dream — to have a nurse in every school," sighs Eleni Sfakianaki, MD, medical executive director of the county health department.
Other TB control measures now on the table at the health department include mandating more TB skin testing for school children; now, kids must be tested once only, upon entry to the school system. Plus, since the case at the elementary school involved a staff member, not a student, others have mulled over the proposition that the county school should act like any other employer and foot the bill for testing its own employees on a regular basis.
Ashkin, if he gets his way, says he plans an all-out educational assault aimed at convincing physicians and communities of the merit of preventive therapy. For physicians, in particular, that will mean explaining the American take on the efficacy of the BCG vaccine and the vaccine’s effect on tuberculin skin testing.
Meanwhile, the Dr. Ashkin skin-test diet works like this: "If you can’t [provide and] finish preventive therapy, we’re almost to the point of saying don’t screen at all."