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N.J. District's Effort Offers a Model for Fighting TB

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CAMDEN, N.J.--Angelica Mendes, an 8th grader at Morgan Village Middle School here, stared nervously at the wall of the school nurse's office and pursed her lips in anticipation of a needle puncture in her forearm.

A recent arrival from Puerto Rico, Angelica last month became the latest in her class of 280 students to be tested for tuberculosis this year.

The test was part of the Camden school system's innovative screening and outreach effort to counter TB, a potentially deadly disease that is making a comeback nationwide.

While mass testing of students has been questioned by some experts as inefficient, Camden's comprehensive program is widely hailed as a model for fostering collaboration between school nurses and local health workers to combat the disease both among children and their families.

If Angelica's skin test was positive for exposure to TB bacteria, the 14-year-old would be ushered to the local health clinic for a chest X-ray. After that, the school nurse would summon her back to the infirmary every day for six months to insure she was taking her medicine to prevent the disease from becoming active.

If the student was found to have an active case of the disease, health workers would be dispatched to test and treat family members who might also have been exposed.

School efforts against TB come at a time when the disease is spreading faster among children than in the population as a whole. (See Education Week, Sept. 18, 1991.)

Between 1985 and 1992, the number of children under age 15 with active TB rose 35 percent, from 1,261 cases in 1985 to 1,707 last year.

The total number of Americans diagnosed with active TB last year was 26,673--a 20 percent rise from 1985.

Children's immature immune systems leave them more susceptible than adults to the tuberculosis bacteria, experts say.

Resurgence Linked to AIDS

Virtually halted by an antibiotic treatment developed in the 1950's, the spread of TB in recent years has been linked to AIDS. Weakened immune systems make AIDS patients especially vulnerable to TB, which is highly contagious.

The rising number of immigrants from Southeast Asia and Central America, where the disease is more prevalent, has also fueled the epidemic, according to the Centers for Disease Control and Prevention.

The disease has had a disproportionate impact on the urban poor. Eighty percent of those with active TB are poor or members of minority groups, and 85 percent of TB cases occur in urban areas, according to the American Lung Association.

Tuberculosis can be transmitted when bacteria in the lung are released by coughing, sneezing, or speaking. Poor ventilation and crowded living conditions often accelerate the infection rate.

Typical symptoms of TB include general fatigue, weight loss, fever, and chest pain. Though no effective vaccine exists, active cases can be successfully treated with antibiotics.

Individuals who test positive but have no symptoms are most often treated with daily medication for one year, which can prevent the disease from developing for decades.

Coping With Disease, Poverty

An impoverished community located across the Delaware River from Philadelphia, Camden developed its pioneering TB program in response to a number of factors.

The city ranks seventh in the state in the number of active TB cases, according to the Camden County health department.

Camden also ranks first in the state in AIDS cases per capita, according to Sharon O'Leary, the county's human-immunodeficiency coordinator.

Moreover, few city residents can afford the $35 cost of a TB screening from a private physician, according to Camden school officials. Forty percent of the district's students come from families on welfare, and more than 90 percent receive free or reduced-price meals under the federal school-lunch program.

Faced with the statistics of TB's toll on young people, Camden officials moved early to screen children on school grounds. When the C.D.C. issued recommendations in 1990 that high-risk children be tested for TB, Camden had already been screening students for more than two decades.

The state of New Jersey also mandates tuberculin testing for schoolchildren in high-risk areas, such as Camden.

Screening requirements may change from year to year due to changes in the infection rate. This year, the Camden schools were required to test kindergartners, 8th graders, new school workers, immigrants, and transfer students.

Despite the demands of the program, educators and health officials have embraced the guidelines for school-based TB prevention.

"Children have a long life potential, so if you treat them now you can keep them from catching the disease,'' said Ken Shilkret, the chief of TB control for the state health department.

Testing children is important, Mr. Shilkret noted, because they are "sentinels'' of transmission in the general population.

A Model Program

So far, state and local officials consider the Camden program well worth the effort.

Since the program began, school nurses have referred dozens of positive cases to the local health clinics. The nurses also help track personal contacts who may have developed the disease but have neglected to seek treatment.

As a result of these intensive efforts, Camden schools have not had an active case of TB in seven years, according to Marilynn S. Malony, the coordinator of health services for the district.

"The thrust of my mission here is preventative care,'' said Elaine Cuff, the Morgan Village school nurse, a 20-year veteran who has tested "literally thousands of students.''

Ms. Cuff said the biggest barrier to effective testing at her school has been student avoidance.

"If [students] know they are going to be tested on a certain day, they stay home,'' she said.

That is when aggressive education is called for, explained Ms. Cuff, who telephones parents, sends fliers home announcing the test, and lectures to new students at a student assembly every fall.

Ms. Cuff also trains teachers to discuss the disease with students in the classroom and provides foreign-language pamphlets for students with limited-English proficiency.

Patricia Lemke, the school nurse at Coopers Poynt Elementary School, who tested 123 kindergartners this year, said getting transportation to the clinics for the students who test positive is often her most serious challenge.

"Our principal has provided a taxi for them more than once,'' she said, adding, "We will go to any means necessary to make sure the children's needs are taken care of.''

Insuring Compliance

Because schools cannot contain the problem alone, the link between the school and local health centers is crucial to insuring that no one falls through the cracks.

Sometimes impromptu meetings are necessary when problems seem overwhelming, school officials say.

"You have to be able to pick up a phone and say, 'Can you help?''' Ms. Malony said.

For local health workers, making sure that students take their medication regularly is a significant obstacle.

"Compliance is a big issue in the inner city, and preventative health care isn't high on the list,'' said Ruth Gubernick, the head of TB surveillance for the county health department, who is primarily responsible for tracking active cases.

Because of the risk of infection in the community, health workers push hard to get affected families to cooperate.

Ms. Gubernick routinely visits the homes of patients who have neglected to come in for their monthly checkups.

"I've been in a few houses where I could almost feel the bacteria multiplying, it was so thick,'' she said. But going door to door is the most effective way to prevent other family members from becoming infected, she said.

"Personal contact is often the best way because a lot of people don't understand about TB, and compliance is higher if you spend a few minutes talking to them,'' she noted.

Other City Programs

In the past few years, several other cities have mandated that students prove they have been tested for TB before they enter school.

In addition, a handful of urban school systems have experimented with mass-testing, monitoring, and outreach approaches to students and their families. They include:

  • Los Angeles, where schools must test an average of 187,000 new students annually and coordinate outreach with local health centers. The district is planning to hire translators for immigrant students and to develop a surveillance study to track at-risk patients through pharmacy prescriptions.
  • Houston, where the health department requires that students have medical clearance before they enroll. School nurses make follow-up calls to insure treatment is being administered, and the city holds open immunizations every August on school grounds.
  • St. Paul, where the schools screened 5,000 students after a 1991 outbreak in which three students contracted active cases. School officials have monthly meetings to assess progress and are working to expand the testing program to the neighboring Minneapolis school system.

Although there is no mandate for TB testing, St. Paul school officials are pushing for state legislation to require testing high-risk areas.

Mass Testing Questioned

But the results of many testing programs have been mixed. Some school efforts have collapsed under budget pressures, while others, such as New York City's, have been hampered by the size of the city's bureaucracy.

When New York, with the highest number of TB cases in the nation, began in 1991 to require that an average of 100,000 new public and private school students each year get tested for TB, many saw it as a logistical nightmare. But supporters of the city's universal-testing program argued that the alternative--testing only at-risk students--would stigmatize poor youngsters.

Some health experts have criticized state and local governments for requiring school systems to test populations that are at minimal risk for the disease. They argue that local funds could be better used for tracking infected children and adults.

"My goal in life is to rid children of TB,'' said Dr. Jeffrey Starke, a pediatrician and the director of the TB clinic at Texas Children's Hospital in Houston.

"But if I had $1 million, and I had the chance of either screening schoolchildren or improving treatment, I have zero doubt I would put money into treatment of schoolchildren,'' Dr. Starke said.

Because mass-testing programs often have a lesser yield--when thousands of children are tested, only a handful may test positive for TB exposure--efforts should be geared first toward identifying infected individuals and monitoring them through contact investigations, he argued. Only then should schools begin screening high-risk groups.

Dr. Starke added, however, that the spending might be justified if school testing programs, such as Camden's, can help identify and treat families of infected students.

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