Legislature(1995 - 1996)
02/02/1995 03:07 PM House HES
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES
STANDING COMMITTEE
February 2, 1995
3:07 p.m.
MEMBERS PRESENT
Representative Cynthia Toohey, Co-Chair
Representative Con Bunde, Co-Chair
Representative Caren Robinson
Representative Tom Brice
MEMBERS ABSENT
Representative Al Vezey
Representative Gary Davis
Representative Norman Rokeberg
OTHER HOUSE MEMBERS PRESENT
Representative Bettye Davis
Representative Ivan
Representative Richard Foster
COMMITTEE CALENDAR
Overview of the Department of Health and Social Services.
Update on the TB epidemic in Alaska.
WITNESS REGISTER
KAREN PERDUE, Commissioner Designee
Department of Health and Social Services
350 Main Street, Room 229
Juneau, AK 99801
Telephone: (907) 465-3030
POSITION STATEMENT: Provided overview information on the
Department of Health and Social Services
DR. PETER NAKAMURA, Director
Division of Public Health
Department of Health and Social Services
350 Main Street, Room 403
Juneau, AK 99801
Telephone: (907) 465-3090
POSITION STATEMENT: Provided information on the TB epidemic in
Alaska
DR. JOHN MIDDAUGH, Chief, Section of Epidemiology
Division of Public Health
Department of Health and Social Services
P.O. Box 240249
Anchorage, AK 99524-0249
Telephone: (907) 561-4406
POSITION STATEMENT: Provided information on the TB epidemic in
Alaska
ACTION NARRATIVE
TAPE 95-4, SIDE A
Number 000
CO-CHAIR CYNTHIA TOOHEY called the Health, Education and Social
Services (HESS) Standing Committee meeting to order at 3:07 p.m.
Members present at the call to order were Representatives Toohey,
Bunde and Robinson.
OVERVIEW OF THE DEPARTMENT OF HEALTH AND SOCIAL SERVICES
Number 123
KAREN PERDUE, Commissioner Designee, Department of Health and
Social Services, introduced members of her staff who were present:
Deputy Commissioner, Jay Livey; Deborah Smith, Executive Director,
Mental Health Board; Janet Clarke, Director, Division of
Administrative Services; Kathy Tibble, Acting Director, Division of
Family and Youth Services; Leonard Abel, Program Administrator,
Community Mental Health Services; Russ Webb, Deputy Director,
Public Health Program; Elfrida Nord, Chief, Section of Nursing; Dr.
John Middaugh, Chief, Section of Epidemiology; Jim Dalman, Acting
Director, Division of Public Assistance; Dr. Peter Nakamura,
Director, Division of Public Health; Randy Super, Acting Director,
Division of Medical Assistance; Jim Galea, Budget Analyst, Division
of Administrative Services; and Elmer Lindstrom, Special Assistant,
Department of Health and Social Services.
Number 207
COMMISSIONER PERDUE informed the HESS Committee members that
previously she served as a Deputy Commissioner in the Department of
Health and Social Services for about six years. In 1990, she went
to Fairbanks and has spent the last several years in her own
business, working with community-based agencies in an attempt to
look at system improvements and make systems more responsive to
Alaska's needs.
Number 247
COMMISSIONER PERDUE continued that for the last year, she has been
working on a project within the Department of Health and Social
Services which strives to improve children's services. Children
and families comprise a large part of the department's customers.
Although many programs strictly serve adults, the vast majority of
efforts involve children and families. About one-half of the
department's spending is devoted to children. There are about
184,000 children in Alaska, comprising about 34 percent of the
entire population.
Number 319
COMMISSIONER PERDUE said the project was a fiscal analysis of the
money spent on children by the department. It was found that for
every six dollars spent on treatment, only one dollar is spent on
prevention and early intervention. State general funds and the
state general fund match finance mostly treatment services, and
federal funds finance most of the department's prevention efforts.
An analysis by age showed that 70 percent of the spending for
pregnant women was preventive, and in the birth to age two group
about 50 percent of efforts were preventive. But as soon as
children entered the school system at the age of six, very little
of the department's money was spent on these ages.
Number 384
COMMISSIONER PERDUE summarized that before children entered school,
the Department of Health and Social Services played a greater role
in preventive spending. As soon as children become school age, the
efforts are weak. It was concluded that the system in place is
somewhat crisis-driven. Basically the programs in place,
particularly for adolescents, require children to fail before they
qualify for services. This system probably reinforces dependency
rather than addressing the problems early and working on developing
problems. It was also concluded that the programs were fragmented.
Sixty child health programs operate on approximately 68 different
statutes, 31 sets of regulations and 49 policy and procedure
manuals.
Number 455
COMMISSIONER PERDUE explained that funding, particularly federal
funding, is very fragmented because focus is placed on the "disease
of the week," or problem-of-the-month situation. It was never
discovered how many children in total were being served, although
each program keeps its own complete data. Many people in the
department would like to rectify that problem. It is believed,
however, that 10 percent of children drive about 90 percent of
costs.
Number 517
COMMISSIONER PERDUE then told HESS Committee members the good news
concerning the Department of Health and Social Services. She does
not like to dwell on the negative to justify her budget, because in
the long run it erodes department members' confidence that programs
can work. The statistics tell Commissioner Perdue that Alaska is
a good place to raise children. Alaskan kids are, for the most
part, healthy, have good homes with loving parents (whether rich or
poor), and most grow up to be productive adults.
COMMISSIONER PERDUE continued that out of 184,000 children, about
15 children committed suicide. These children are a tragedy, but
that number is relatively small. Out of 184,000 children last
year, 84 died of injury, 1,200 children were born to teen-age
mothers, and only 400 teen-age mothers were on Aid to Families with
Dependent Children (AFDC). She stressed that each child is
valuable, but the tasks involved with care are possible to
accomplish. The focus must be on prevention. Social services
technology is available to make a difference.
Number 608
COMMISSIONER PERDUE added that all the scientific literature says
that in order to take a child and transform him or her into a
conscientious member of society, the child needs one thing:
unconditional love. Children of any socioeconomical class, genetic
makeup, or demographic statistic always do better in life if they
grow up believing there are adults in this world who care about
them, love them, and want nothing in return but love. Kids who
begin life abused or neglected and end up in foster homes and
juvenile institutions receive a very different message--life is
tough, rewards and punishments are arbitrary, the future is
unpredictable and human attachments are probably fleeting.
At 3:15 p.m. Representative Tom Brice joined the meeting.
Number 670
COMMISSIONER PERDUE stated that those facts lead her to focus on
strengthening the family, because the family is the place where the
child will find most of what he or she needs. This is critical
when the child is very young, and services are really more cost
effective and effective in general when they are designed to
strengthen the family early on, before the damage is done.
There are very good examples of these programs in Alaska. One is
the Celebration of Life program, which helps pregnant women stay
sober when they are living in a situation where alcohol is
prevalent. Other mothers provide support during this time.
The Head Start program and the Healthy Families program are based
on the Hawaii model. These programs are usable in Alaska, and they
are cost-effective programs. Every major report written in the
last decade about Alaskan children says that the focus needs to be
on prevention. Unfortunately, this is not done.
Number 737
COMMISSIONER PERDUE feels the reason prevention is not done is that
we don't have confidence that prevention will work, and there is
concern that tremendous treatment needs will be ignored.
Commissioner Perdue stresses that confidence is necessary to
gradually move toward providing prevention.
Over the next four years, Commissioner Perdue would like to make
prevention a priority for both new funding and in downsizing.
Also, a priority is the tracking of prevention dollars in order to
better coordinate prevention efforts. Another priority is to
encourage collaboration between departments. Efforts such as the
current assessment were carefully planned and barriers were
identified. The private sector has been planning like this for
years, and it works. It is important to get everyone involved in
solutions.
Number 795
COMMISSIONER PERDUE stressed that the Department of Health and
Social Services must work with the Department of Education and the
school districts if it desires to be involved with school-age
children. The department must encourage the decategorization of
funding to the fullest extent possible in order to give communities
more flexibility. Finally, the Department of Health and Social
Services needs to recognize who their customers are and increase
its accountability to them.
COMMISSIONER PERDUE said often programs ask people what they need,
but it doesn't listen when people come into an office and offer
information and help. This approach has been attempted in many
ways, and what was found is that families actually want less than
what was originally offered.
Number 843
COMMISSIONER PERDUE also stressed it was important to give front-
line people more authority to bend the rules. Families don't work
with Health and Social Services department officials, they work
with front-line workers. It is very good to let people vote
through providing them with choices, noticing what they choose, and
then working with those choices. Success should be measured by
people's happiness with the services offered. All of the
aforementioned are currently being done in the Department of Health
and Social Services. All the priorities are possible to
accomplish.
Number 762
COMMISSIONER PERDUE continued that over the next four years she
would like to expand the current programs and to make the system
more efficient and cost effective.
Number 922
CO-CHAIR TOOHEY noted for the record that the meeting was also
being attended by Representatives Bettye Davis, Ivan Ivan, and
Richard Foster.
Number 928
REPRESENTATIVE TOM BRICE asked Commissioner Perdue if the overview
would continue with a divisional breakdown.
COMMISSIONER PERDUE answered that was not in the current plans, due
to the following briefing on the tuberculosis epidemic occurring in
the state.
REPRESENTATIVE BRICE voiced concern about the status of Harborview,
a Valdez nursing facility. He also stated that during the
philosophical move away from institutional-based care to community-
based care, budgets end up being cut at institutions. He wanted to
know what is happening with inpatient psychiatric services
throughout the state.
COMMISSIONER PERDUE mentioned that she only has been at her job for
three weeks, therefore some facts may be erroneous. However, the
population of Harborview has declined significantly due to the
Intermediate Care Facility for the Mentally Retarded (ICFMR)
services. Currently, a long-term plan is in the works which will
eliminate the need for the ICFMR services in Valdez. There is a
credible plan for each and every person to place them in the
community.
COMMISSIONER PERDUE continued that the Sourdough Unit, which is a
nursing facility, still has a need for continued services for the
16 people residing there. The analysis being done currently
concerns whether that is a state mission and function. The
department does not typically operate nursing homes--it licenses
them, services them and provides Medicaid payments for them. The
question of whether the department is going to continue supporting
nursing home functions at Harborview is a large question. This is
a big policy question.
Number 1048
CO-CHAIR TOOHEY asked Representative Brice if the Sourdough Unit
contained victims of Alzheimer's disease. REPRESENTATIVE BRICE
responded yes, and also victims of severe dementia. CO-CHAIR
TOOHEY asked if there was a fairly determined life span for victims
of Alzheimer's, and whether or not it was a function of the
government to take these victims out of their homes and place them
in Harborview.
COMMISSIONER PERDUE responded that she did not know the age of
people at Sourdough. People can live a very long time with
dementia. People have to have a medical need to be in a nursing
home. She ventured that Sourdough residents therefore came from
another nursing home, and they probably require extra care.
CO-CHAIR TOOHEY said the end of Alzheimer's is quite violent.
COMMISSIONER PERDUE agreed that time was very difficult and unsafe.
REPRESENTATIVE IVAN IVAN commended Commissioner Perdue on her
positive approach. He reminisced about past problems when tribal
governments argued with the state about sovereignty issues and
control. Sometimes children were in the middle of a tug-of-war
between the community and officials from the department. He felt
the relationship has come a long way and currently there is much
coordination and cooperation. He congratulated and encouraged the
department to work with the community councils. He felt that both
the community and the Department of Health and Social Services had
something in common--the priority of taking care of children and
making sure health needs are met. He offered her assistance and
wished her luck.
Number 1180
CO-CHAIR TOOHEY noted for the record that Co-Chair Con Bunde left
the meeting to attend an audit meeting and make a quorum. He will
return shortly.
UPDATE ON THE TUBERCULOSIS EPIDEMIC IN THE STATE OF ALASKA
Number 1231
DR. PETER NAKAMURA, Director, Division of Public Health, Department
of Health & Social Services, thanked the HESS Committee members and
said he would also try to address the AIDS issue in Alaska as per
Co-Chair Toohey's request. He appreciated the opportunity to speak
on tuberculosis (TB) because the topic has gained a lot of
attention in Alaska recently. There has been significant
recurrence of problems that were considered controlled.
Number 1252
DR. NAKAMURA began with a historical perspective of TB. In 1934,
the year Dr. Nakamura was born, TB was a significant problem. The
death rate in the Alaska Native population was about 665 per
100,000. This is a very high figure. About 35.5 percent of all
deaths in America at that time was due to TB. In 1946, or, more
generally, between 1934 and 1950, the figures were even higher--
almost 50 percent of deaths recorded on death certificates.
Number 1317
DR. NAKAMURA continued that in 1952 he graduated from high school
and TB was dealt with in very different ways than from today. It
was not uncommon to find patients with glass balls in their chests
to compress their lungs in an attempt to contain the disease.
Physicians often put air into the chest to collapse a lung.
Treatment was not up to decent standards. In 1952, a drug called
INH came out which changed treatment significantly.
Number 1361
DR. NAKAMURA added that another change occurred in that year in how
the TB problem was addressed, especially in Alaska. Teams were
sent out to communities to diagnose TB. X-ray machines were taken
to communities in an attempt to diagnose problems in communities.
At that time, people were present who were the precursor to
Community Health Aides. These were people from the communities who
were assigned to make sure that patients took their medication.
This was important because the only way to control the problem was
through the consistent administration of medication. Perhaps the
unfortunate thing about that time was the practice of moving
patients to institutions, away from home, causing social problems
due to their absence from their home and community.
Number 1402
DR. NAKAMURA said the response to TB at that time was very
significant. The infection rate in 1952, not just for the Native
communities but for all of Alaska, was about 400 per 100,000. This
was a significant drop.
In 1961, when Dr. Nakamura graduated from medical school, many
invasive treatment procedures where still being used. However, the
TB rate had dropped to 100 per 100,000. This was because of the
effort to address the problem.
In 1969, Dr. Nakamura came to Alaska and worked in Anchorage at the
Native Hospital as a pediatrician. He then worked in Bethel for
two years as head of their health care program. At that time, the
rate had dropped further to 50 per 100,000. The state had a major
role in this drop. The public health nurses were overseeing the
investigation of most of the TB problems, and the state was really
responsible for much of the treatment.
Number 1469
DR. NAKAMURA said that during this time, the Indian Health Service
(IHS) invested significant amounts of money for such projects as
the creation of hospitals and for the availability of teams of
experts to tackle the problem. Because of the success, attention
to the problem began to wane and resources began to dry up to the
extent that currently the contributions by the federal government
and the IHS are minuscule.
DR. NAKAMURA stressed that the assistance did not diminish because
the federal government and the IHS was shirking the problem.
Unfortunately, other problems had to be met and resources were
shifted.
In 1991, Dr. Nakamura returned to Alaska and TB infection rates
were about 12.5 per 100,000. It was thought the problem was
controlled, and it was hoped TB would be eliminated in Alaska. At
that point, Dr. Nakamura called Dr. John Middaugh to brief the HESS
Committee members.
Number 1545
DR. JOHN MIDDAUGH, Chief, Section of Epidemiology, Department of
Health and Social Services, asked for the help of all Alaskans in
dealing with TB. Alaska has a devastating history of TB. Alaska
Native people, from about 1920 to 1950, had the highest rates and
the worst experiences with TB ever known in the world. One of the
greatest public health success stories was the almost eradication
of TB which occurred when huge efforts to deal with TB began in the
1950s.
Number 1573
DR. MIDDAUGH added that a great debt is owed to physicians and
public health nurses who controlled TB for all of us in the 1950s,
60s and 70s. He is dismayed to report that Alaskans have not been
good stewards of that debt. TB is making a huge comeback both
nationally and in Alaska. In addition to more individuals having
TB, many of those with infections have strains which cannot be
cured by modern technology and antibiotics due to the bacteria
developing resistance to antibiotics relied upon to cure infected
individuals.
In the last few years, these resistant strains have developed
nationally. Currently in Alaska there are individuals that are
resistant to all known medicines. It was a wake-up call for the
American people when 300 people on the East Coast became infected
with these multiple-drug resistant organisms. Half of those
individuals died.
Number 1635
DR. MIDDAUGH stated that TB can be controlled, but it is difficult
in terms of clinical expertise needed for diagnosis and treatment.
Each person infected must have a health evaluation. If medication
is needed, there may be side effects, medication may be difficult
to acquire, and the medicines are not effective unless taken for a
long time.
The routine treatment for TB is nine months of numerous pills which
must be taken every day. If the organism is drug resistant,
medical treatment may be required for up to 24 months. Dr.
Middaugh reminded HESS Committee members of how difficult it is to
remember to take medicine for a week.
Number 1687
DR. MIDDAUGH continued that recently unusually large, widespread
outbreaks have been identified in some rural villages. TB is a
statewide problem. There are individuals with TB in virtually all
communities, both urban and rural. No place is protected.
However, the unusual thing which has occurred is how widespread TB
has become in some villages. Constant surveillance is part of the
work of the Department of Health and Social Services. A very
complicated network of teamwork is in place between health aides
and state public health nurses, IHB physicians, health
corporations, the IHB, the military, private physicians and members
of the Division of Epidemiology. Dr. Middaugh stated that health
aides and state public health nurses are critically important for
the maintenance of the ability to respond and prevent TB. He added
that all the people in this network are trying to gain an
understanding of what is occurring.
Number 1729
DR. MIDDAUGH explained that this collective effort is critical for
the response and maintenance of outbreaks.
DR. MIDDAUGH said that it is difficult to know who has TB, or when
TB is occurring. TB is spread by respiratory droplets put into the
air by sneezing, singing, coughing, etc. TB can affect almost any
organ in the body. It is a great clinical challenge to detect TB
for expert physicians with the most modern technology in certain
cases and in certain individuals. The spread of TB occurs when the
disease settles in the lungs and the infected individual sneezes,
coughs or sings near others. For example, an opera singer was
hired to give a private performance and consequently infected
everyone in the room due to TB in her voice box.
Number 1783
DR. MIDDAUGH explained that when someone is infected, in most cases
no symptoms occur and no infection occurs. The organism enters the
body and is carried to the lymph nodes, where the body's immune
system walls it away. It can remain dormant for anywhere from
weeks to decades until an immune system breakdown occurs. The
organism then breaks out and causes disease which attacks almost
any organ. The most often organ attacked is the lungs which causes
the subsequent spread of the disease.
In some instances, when the organism first gets into the body, it
immediately causes severe illness and disease. Given that most
infected individuals have no symptoms and don't know they are
infected, how are they to be identified by health care individuals?
Number 1832
DR. MIDDAUGH explained that when the organism gets into the body,
the body produces antibodies which can be detected by a skin test.
This requires the injection of some ground-up TB bacteria (which
cannot infect anyone) into the wall of the skin--not through the
skin but into the skin--with a little tiny needle. Two days later
a person must feel that spot and feel for a bump. The bump is an
indication that the organism has entered the body. The infected
individual may not show any signs of sickness. That is why
schoolchildren are required to be tested for TB.
Number 1864
DR. MIDDAUGH stated that back in the 1940s and 1950s, 100 percent
of Alaska Natives had a positive skin test when screened for TB.
In the last few years, a Bethel area test identified five out of
2,200 children with a positive TB test. That is a tremendous
benefit of disease prevention. However, this also means that all
these children are susceptible to infection. If an adult tests
positive it is difficult to tell when he or she became infected
because once you skin test positive the test remains positive for
the rest of your life.
Number 1903
DR. MIDDAUGH continued that the only way to figure out whether the
organism is dormant or if the body is ill and therefore infectious
(can spread the disease), is through an interview with the infected
person. This interview contains questions about whether the person
has experienced symptoms of illness. These include weight loss,
coughing up blood, soaking fevers and night sweats. These symptoms
are not specific. Many illnesses can cause these symptoms.
The infected person then undergoes a chest X-ray if symptoms are
present. These show changes in the lungs which sometimes can be
very useful in diagnosing TB.
Number 1937
DR. MIDDAUGH said the final, definitive test is to obtain sputum
from coughing. It is difficult for a person to cough up sputum on
demand. Early morning sputum must be collected, and if the
infected person resides in Bethel or in a remote area, it is
difficult to get the sputum to a laboratory intact. The sputum may
be mishandled or the container's top could pop off and the sample
could become contaminated. But this sputum is important for TB
detection and to protect others who may be potentially infected.
The laboratory becomes a critical component of the ability to
control TB. The next step is the discovery of TB in the sputum in
the lab. The sputum is placed on a slide, dried and stained for 20
minutes. A person must then study the slide under a microscope for
anywhere from 15 to 30 minutes, searching for the presence of the
bacteria. The sputum is also placed into culture media which have
to grow. TB, unfortunately, grows very slowly. Therefore it takes
three weeks until the lab can look to see if the organism is
growing, they look again at six weeks, and they will check again at
eight months. All information helps determine whether an infected
individual is diseased and infectious.
DR. MIDDAUGH continued that the skin test surveillance program
consists of public health nurses testing every child every year in
rural areas. These tests indicate the otherwise undetectable
spread of TB. If the childrens' skin tests change from negative to
positive, this means they were infected by someone else who is
coughing out TB.
When the skin tests were done in Savoonga, a large number of TB
converters were found. There are children known to have a
previously negative test who suddenly tested positive. In 1990 and
1991, there was a large outbreak of TB in Savoonga. It was obvious
that business could not be done as usual.
Number 2046
DR. MIDDAUGH said teams were mobilized and sent to Savoonga. Then
it was found that converters were present in Gambell, and teams
were sent to Gambell. More skin tests found converters in villages
in Southwest Alaska. At this point, the teams were busy and the
personnel was not available to address these outbreaks. Therefore
the local public health nurses, along with the physicians at the
Yukon Kuskokwim Health Corporation and the village health aides,
began the investigation in the villages in Southwestern Alaska.
Number 2052
DR. MIDDAUGH continued that at the same time, a similar outbreak
was detected on St. Paul, and a group called "Up with People"
visited Alaska to bring young adults and entertainers. An "Up with
People" coordinator widely visited Alaska to make housing
arrangements for the entertainers and kids. This person had active
pulmonary tuberculosis and the Department of Health and Social
Services has already detected 10 people that she infected. A list
of almost 50 more people she came into contact with have yet to be
investigated.
There is a national outbreak which is being investigated by the
Department of Health and Social Services and the Centers for
Disease Control (CDC) because of the "Up with People" individual.
She was very infectious and must have infected many people.
Number 2105
DR. MIDDAUGH spoke of the logistics involved when a team is sent to
a village. Health aides, the local public health nurses, a nurse
epidemiologist from the Department of Health and Social Services,
physicians and a mobile X-ray technologist comprise a team. This
team goes out to the villages and skin tests every person who has
previously tested negative. They interview those infected with TB
for symptoms and then do chest X-rays based on that information.
The X-rays have to be flown back via one- or two-day air to
Anchorage where they are developed, processed and read by
radiologists. A radiologist calls the village to request that ill
individuals provide sputum samples. The samples are then taken to
the lab for further diagnosis.
Each ill individual must be provided with an individualized
treatment plan. Medications often have side effects which also
must be dealt with. In summary, the logistics of accomplishing
this process are formidable.
DR. MIDDAUGH showed HESS Committee members large sheets for each
person in the village of Savoonga. Each sheet lists names by
family, the ages of family members, the date of their last skin
test and the result of that test, chest X-ray data, symptoms,
sputum and sputum results. The lab is called at three and six
weeks. When a person tests positive for illness, the information
is sent back to the village in order to assist the health aide and
nurses. The nurses trace the infectious persons, and follow up to
see if a person was missed.
Number 2177
DR. MIDDAUGH said this effort is only to detect who is infected.
An infected person must be treated, and treatment for individuals
with active TB routinely consists of the administration of four
medications to start with. They must take this medication every
day for two months.
Number 2190
DR. MIDDAUGH commented that this is one of the major challenges of
TB, because if you are a busy health aide you are responsible for
many other illnesses and problems in addition to TB. If you have
one person ill with TB, the task is possible to accomplish.
However, there are situations in which 50 people are ill with TB in
a village, and 129 people in the village who are in need of
preventive treatment. It is an impossible task for a health aide
to oversee the treatment of all these individuals.
Number 2225
DR. MIDDAUGH explained that what has happened is that individuals
begin treatment, stop, and then start again and stop again. This
inconsistent medication enables the resistant organisms to develop.
We now know that it is not enough to tell people to take their
medicine. It works for some people, but not everyone. The
standard is that every single person with TB receives "direct
observed therapy," in which a health provider or an extended
provider administers medication every day for the period of
treatment.
Number 2247
DR. MIDDAUGH explained that if people are not given the medicine
that will prevent them from spreading the disease and eventually
cure them of the illness, they can not only infect others but they
will infect others with the resistant organism. These resistant
organisms are a huge problem.
DR. MIDDAUGH prepared a packet of material to build on what he had
said so far. Page 3 of the packet provided an update on the data
from seven villages from August 1994 to the present. In those
seven villages the TB treatment teams, particularly the public
health nurses, have administered 2,918 skin tests (called PPDs by
the medical profession). This involves holding children while they
are injected with the test and studying them three days later to
see if there has been a reaction.
Number 2306
CO-CHAIR BUNDE returned to the meeting at 3:51 p.m.
DR. MIDDAUGH continued that 592 persons in these villages had 656
X-rays. The X-rays were taken with a portable X-ray machine, which
had been boxed and weighs several hundreds of pounds. These boxes
are flown to the villages with hundreds of pounds of film. The
machines are set up in a clinic. X-ray film is then flown back
from the village, developed and taken over to a radiologist. The
radiologist and members of the Department of Health and Social
Services read the X-rays. Based on the results of the X-rays,
sputum is requested.
DR. MIDDAUGH said sputum was requested from 460 individuals who
provided 1,169 sputum samples. These samples have been smeared,
studied under a microscope, cultured, grown and studied. The
number of individuals finally diagnosed with active TB was 38. It
is obvious that a lot of time and money must go into the diagnosis
and prevention of this disease.
Number 2337
DR. MIDDAUGH expressed relief that there only were 38 infectious
cases in Alaska. Each one has had a medical examination and drugs
have been prescribed. These drugs have side effects, however, and
blood tests are taken to monitor liver function. Individuals are
also monitored to make sure that the medication is taken.
DR. MIDDAUGH then discussed PPD converters and reactors. A
converter is someone they know has been recently infected. A
reactor is someone who is newly recognized with a positive skin
test but may have been infected more than two years ago. All are
recommended to be put on antibiotics to protect against the
eruption of illness.
TAPE 95-4, SIDE B
Number 000
DR. MIDDAUGH stated that medication side effects can include liver
failure, therefore patients are also monitored for symptoms of
liver damage. Other things, such as infections, other drugs and
alcohol can damage a person's liver. One person was placed on a TB
drug referred to as INH a few years ago. He developed some side
effect symptoms and was told to stop taking the drug. He did not
stop taking the medicine and went into liver failure. He had to
undergo a liver transplant. The costs to that person and to the
system were huge.
Because of falling funds and staff turnover, there has been a loss
of some institutional expertise and memory. Recently an individual
known to have infectious pulmonary TB wanted to fly somewhere. As
Dr. Middaugh's colleagues were attempting to quarantine that person
and convince him not to fly, he flew to Anchorage. Presently, the
Department of Health and Social Services has the flight crew and
all passengers under surveillance to see if they were infected.
The Department of Health and Social Services is working to
reacquaint itself with how to deal with such a situation.
DR. MIDDAUGH added that some of the assumptions of quarantine laws
are that everyone will be cooperative and able to take medication
for a long period of time. Incentive programs are in place to
encourage people to take their medicine. In another case, a person
would not take their medicine so the quarantine law was implemented
only for the purposes of getting the person to take their
medication. This was not a punitive decision.
Number 179
DR. MIDDAUGH commented that this quarantine was challenged by a
public defender and there was a hearing before Christmas of 1994.
The case was heard before the Supreme Court. All this made it
clear that a new quarantine law is needed. The old law is
outdated, and the constitutionality of the old laws have changed.
A new quarantine law must be passed that protects the rights of the
individual but still enables the restraint and isolation of
individuals when needed.
DR. MIDDAUGH also said that because TB causes serious and
irreversible damage, and because of the prevalence of TB in Alaska
between 1920 and the 1950s, there are numerous individuals with
severe lung damage from TB. The flu may be fatal if contracted by
an elderly survivor of TB.
A 36-year-old woman died in the Brother Francis Shelter in December
of 1994 from unrecognized, undiagnosed TB. To Dr. Middaugh's
knowledge, that is the first death of a young person from acute TB
in about 30 years.
DR. MIDDAUGH concluded that the outbreaks have overwhelmed the
current system. The infrastructure has deteriorated and it was
wrongly assumed that the expertise was available and the system was
working. The system was actually working until the current
outbreaks highlighted the deficiencies that have occurred. In
addition, the population of Alaska has increased.
DR. MIDDAUGH said the bottom line is that TB can be controlled.
The expertise and the systems are in place. But at this time there
is not a capacity to deal properly with the extent of these
outbreaks. It will take years to rebuild the whole infrastructure.
Number 355
REPRESENTATIVE BRICE asked if measures were in place to control the
spread of TB in the homeless populations, and if Dr. Middaugh had
recommendations at this time. Representative Brice felt this was
important considering the transient nature of these populations and
the impact they may have on the urban centers.
Number 405
DR. MIDDAUGH replied that part of the current program was an effort
to both respond and contact-trace all of the detected cases, and to
provide clinical screening. Generally, this is effective. But the
problem with TB is that because it can be so difficult to diagnose,
to some degree, having adequate capacity to constantly watch these
people is the only way TB can be detected early. He said there are
instances where TB can be a master of disguise. Dr. Middaugh
doubted there would ever be a single measure which would enable the
Department of Health and Social Services to notice every case when
it occurred.
Number 468
REPRESENTATIVE BRICE asked about measures taken after the woman
passed away at the Brother Francis Shelter, and what communication
took place within the department to inform the rest of the state.
Number 496
DR. MIDDAUGH answered that the woman was very sick when she entered
the shelter. She died shortly thereafter, and TB was unexpectedly
discovered to be the cause of death at the autopsy. Immediately,
teams and the city health department tested and evaluated all
people at the shelter. A few individuals were found to have
positive skin tests, but it is difficult to tell when they
contracted TB. There were no other known active cases that she may
have caused.
DR. MIDDAUGH commented that whether the Department of Health and
Social Services finds a recent converter or a person with an active
illness, a major investigation is mounted with the local health
services. This is in order to follow up on who is infectious.
DR. MIDDAUGH said he just got a team out to Bethel villages in
January. He felt the teams should have been there six months
earlier but they were busy elsewhere. At the moment, the teams
have been scrambling in an attempt to respond to these widespread
outbreaks while all the underlying cases are occurring. These
cases are well-handled by the existing public health nurse and
community health aide/local physician structure. These people are
an important part of the TB control team, they help detect new
cases.
Number 620
CO-CHAIR TOOHEY asked why the upsurge in TB is occurring.
DR. MIDDAUGH answered that the major reason is that we are now
paying the price of 10 years of erosion in public health. This
erosion took place both in the IHS and the state of Alaska. The
Savoonga outbreak should have been far less severe. But there were
no public health nurses, the positions and money were there but
they were unable to fill those positions in Nome. The skin test
screening program which should have occurred in the fall of 1993
did not take place until the summer of 1994. It is very likely
that had the skin test program occurred on time, only one or two
individuals would have been identified with TB.
DR. MIDDAUGH said there was a huge outbreak in Savoonga in 1990 and
1991 that took two years to control. At that time, the Department
of Health and Social Services felt they had regained control.
However, they also know that they must visit villages repeatedly
because an infected person may not convert their skin test for up
to three months. That person could potentially develop illness at
any time.
Number 725
DR. MIDDAUGH continued that in the Bethel area, there are six
itinerant Public Health Nurse positions and five were vacant at the
time of the outbreaks.
CO-CHAIR TOOHEY asked about the man who refused to take his
medication and stay quarantined.
DR. MIDDAUGH said that the man was met upon arrival in Anchorage,
hospitalized and treated.
CO-CHAIR TOOHEY asked how long after the administration of the drug
INH a person becomes safe, or noninfectious.
DR. MIDDAUGH answered that a person with infectious pulmonary TB is
given three or four different medicines. Within a period of two to
three weeks those individuals become noninfectious to others.
However, that is contingent upon them taking the medicine
consistently and the organism being sensitive to the medication.
DR. MIDDAUGH stated when an organism is grown in the lab,
sensitivity tests are conducted in which the culture is exposed to
different antibiotics in order to check for resistance. If the
organism is resistent, the individual is given second-line
medications which are less effective and have more side effects.
CO-CHAIR TOOHEY asked about TB tests for food handlers.
DR. MIDDAUGH said they were no longer testing for TB in people who
handle food. TB is not spread by food, by droplets that hit a
table or chair, or by bedclothes. It is only spread by the direct
inhalation of respiratory droplets.
REPRESENTATIVE CAREN ROBINSON asked if the Department of Health and
Social Services was working on changes in quarantine laws, and if
legislation was imminent.
DR. MIDDAUGH answered that the Department of Health and Social
Services has been working closely with the Department of Law to
examine what is needed in a law, and to obtain model laws from
other states. A team from the CDC is coming to Alaska in February
in order to develop legislation and see whether it is appropriate
at this time to pursue that legislation. They want to make sure
the bill is perfect and will accomplish what is necessary in order
to protect the public health and to protect individual rights and
due process.
Number 903
CO-CHAIR BUNDE said that in other states, people with sexually
transmitted diseases have been prosecuted under a reckless
endangerment-type of statute. He stated that he understood the
department was looking at the long term, but he wondered if it was
possible to deal with the short-term with a reckless endangerment-
style statute. This would protect the public health.
Number 931
DR. MIDDAUGH gave the opinion that currently adequate protection
exists in the interpretations of the current quarantine provisions.
He didn't think that the reckless endangerment statute would be
necessary to protect short-term interests at this time. However,
it would be beneficial to update the old quarantine law in order to
streamline processes.
CO-CHAIR BUNDE asked if the decision to quarantine was made after
the ill man got onto the airplane. He recounted Dr. Middaugh's
statement that persuasion was attempted. Co-Chair Bunde asked
whether there was a "stick to go with the carrot."
Number 994
DR. MIDDAUGH clarified that the quarantine incident was not the
same as the airplane incident. In the airplane incident, the call
was placed dealing with the problem, but the airplane took off five
minutes before the team reached the airport.
Number 1009
CO-CHAIR TOOHEY asked how much help was being received by the
federal government.
DR. MIDDAUGH replied that the Department of Health and Social
Services was receiving about $300,000 in grant money from the CDC.
From that, $200,000 goes to the sectional laboratories, and the
rest goes to the center for epidemiology. Co-Chair Toohey
commented that $300,000 is not very much money.
DR. MIDDAUGH's opinion is that in the 1950s, the IHS came to Alaska
in response to a report which investigated the health status of
Alaskan Natives. Because of TB it was reported back to congress
that the health of Alaskan Natives was a national disgrace. That
was a quote from the report. IHS then attacked TB and did a good
job, but in the last 10 years, the IHS has steadily reduced its
contribution to TB control, as has the state. The resources
available today are diminished to deal with TB. We have also lost
part of the knowledge infrastructure, such as the expertise, the
knowledge of how to work together, how to work with a community
health aide and a public health nurse, how to get medication to
patients, how to get sputums into the labs and how to work with the
court system. All these factors differ in each community. The
Department of Health and Social Services needs to rebuild this
knowledge base.
Number 1110
CO-CHAIR TOOHEY mentioned that a quarantine bill would be highly
contested because of the HIV/AIDS epidemic.
DR. MIDDAUGH hoped that the quarantine effort would be limited only
to the immediate problem of TB. He would like the bill to be very
specific on that issue in order to head off contention. He finds
it hard to believe that there would be any way to develop
legislation which would provide benefits in relation to the
quarantine of HIV positive people.
Number 1156
REPRESENTATIVE ROBINSON noticed from the charts that Dr. Middaugh
supplied, it appears that TB is prevalent in the Asian populations.
She also wondered about the prevalence of outbreaks in the rural
communities. She asked if this is due to the lack of medical care
or is it just because of the location of an infectious person. She
wondered why the urban areas are not affected.
DR. MIDDAUGH responded that the lack of TB in Alaska's urban areas
is simply that year's good luck. The chart shows only data for one
year. A 10-year map would show cases in Juneau, Fairbanks and most
every community.
The rate of TB is very high in southeast Asians. The total numbers
are much lower. The total number of southeast Asians is much less
than the population of Alaska Natives in reference to the total
population. While the rate is very high and a great concern, the
southeast Asians counted for 19 cases of TB in a period of time
that Alaskan Natives contributed 66 cases.
REPRESENTATIVE ROBINSON inquired as to the fate of Dr. Frasier, a
man who warned her in the late 1980s or early 1990s about an
imminent outbreak of TB.
DR. MIDDAUGH answered that Dr. Frasier retired and is living in
Anchorage. He is owed a great debt for the contributions he made
to TB control. There are many people in public health who try to
warn individuals all the time that if the preventive practices are
eroded, a heavy price will be paid. Those systems have eroded and
the bill is coming due.
Number 1273
CO-CHAIR TOOHEY stated that people are now faced with another
epidemic and it needs to be controlled.
Number 1281
REPRESENTATIVE RICHARD FOSTER noted that six of the seven villages
listed in Dr. Middaugh's chart "Tuberculosis in Alaska, 1994-95:
Outbreak Investigation" were in his district. He estimated that
his district and the district of Representative Ivan contained
three-quarters of the cases in Alaska.
REPRESENTATIVE FOSTER stated that he was in the fourth grade in
Nome, Alaska and they all tested positive for TB in 1956. All the
way through high school, his class was 100 percent positive and
they were very thankful to the medical service that they were
monitored every year.
REPRESENTATIVE FOSTER flew Dr. Sullivan and Dr. Sanders from the
late 1960s until 1988 every year with their X-ray equipment to all
the villages. He is not aware that Dr. Sanders has been replaced
since 1989. Representative Foster wrote the Department of Health
and Social Services a letter in January of 1989 expressing concerns
that Dr. Sanders be replaced. The department responded that HIV
was of prime concern and resources were being converted to other
diseases because TB was felt to be under control.
REPRESENTATIVE FOSTER felt perhaps he was premature in his letter,
but the packet handed out by Dr. Middaugh also states that priority
was given to other diseases. The urban areas don't experience this
type of problem, and an editorial he had from the Anchorage
newspaper states that if one out of every three Anchorage residents
was infected with TB, government would respond differently.
REPRESENTATIVE FOSTER stated the Tuberculosis Control Program
status report of February 2 which was provided for the overview
states that the ability to take X-rays in the field was compromised
initially and then failed totally. Representative Foster spoke to
Drs. Nakamura and Middaugh and said that this failure was within
their own department.
REPRESENTATIVE FOSTER stated that he twice went to Vietnam as a
company captain. If a company commander or a battalion commander
messed up and didn't take responsibility, he was replaced because
the danger of his people was being compromised. Representative
Foster stressed that he has very strong feelings about this issue.
DR. NAKAMURA answered that he respected this concern. Because of
the lack of manpower to control the problem, services have been
purchased under contract. These contracts are just now being
reviewed. He agreed that if the system is not working, it should
be replaced.
Number 1422
REPRESENTATIVE IVAN remembered that everyone in his family took the
TB drug INH everyday, and they looked out for each other to make
sure the medication was taken. Neighbors also watched each other.
At that time the federal government had the resources and mobilized
to address the problem. Representative Ivan had two brothers who
became ill and were hospitalized in Anchorage. They are now
healthy, but as patients they were taught how to prevent TB. They
were the best disciples after they came out of the hospital and
would educate and admonish others on how to stop the spread of TB.
REPRESENTATIVE IVAN commented that information and education about
the disease needs to be brought back up to that level. There are
many more health services in place now to help do that, such as
health aides, the regional health corporation, the Bristol Bay
Health Corporation, etc.
Number 1520
REPRESENTATIVE IVAN asked what the plan was to get back to the
1950s level of control. He noted that bulletins are being sent out
by the Department of Health and Social Services periodically, and
messages are being put in the local papers. He said that
information should be given to regional nonprofit associations and
regional corporation because they can disseminate information well.
Number 1531
DR. MIDDAUGH responded that the moment's primary concern is to
complete the investigations in the particular villages. A team
will be returning to Savoonga and Gambell on February 6, along with
the portable X-ray equipment. Other teams will be visiting the
villages of Southwest Alaska in March, and then all of the villages
will again be visited in May and September. These visits will be
follow up visits to insure that all infected individuals have been
identified, are under treatment, and that the infrastructure is
back in place.
The next task is to widely spread the message and rebuild the
knowledge in local areas among everyone. There are great
challenges in certain communities, such as the southeast Asian
communities, some of whom are very transient and work in the
canneries. Messages to these groups are being tailored. The CDC
TB division has been asked for assistance and they may provide
additional resources.
DR. MIDDAUGH stated that education is something that entire
communities must respond to.
CO-CHAIR TOOHEY asked about cases of TB which were drug resistant.
DR. MIDDAUGH responded that the numbers since 1988 have been small,
and the resistant organisms listed in his packet of information
have been resistant to just INH, or INH and the other primary TB
drug. He knows of one southeast Asian in Alaska who has a strain
of TB that is resistant to all antibiotics. His department has
been working with the CDC and the National Jewish Hospital,
consulting with national experts about that person and her family.
At this time her sputum is negative and she is constantly being
monitored.
Number 1673
CO-CHAIR TOOHEY inquired as to the fatality rate of drug-resistant
TB.
DR. MIDDAUGH responded that the fatality rate for untreated TB is
estimated to be about 50 percent. This includes the drug resistant
strains.
Number 1690
CO-CHAIR BUNDE asked if the drug resistant strain developed here
from inconsistent treatment or if it arrived in Alaska from
somewhere else.
DR. MIDDAUGH stated the aforementioned case was imported, but the
origin of multiple-drug resistant TB is from patients who began
taking medications and then stopped, or didn't take them properly.
In many foreign countries, you can buy any antibiotic off the
shelf, therefore the emergence of some of these resistant organisms
is coming from Third-World and southeast Asian countries. They
believe this person was infected with a drug-resistant strain, and
a drug-compliance problem made it completely resistant.
Number 1740
CO-CHAIR BUNDE expressed concern that the technology is available
to control the disease, but the psychology is not available to deal
with the people who are hurting themselves and others. Co-Chair
Bunde asked if Immigration and Nationalization Services (INS) are
available in Alaska that checks immigrants for TB as they arrive.
DR. MIDDAUGH replied that the whole issue of immigration and TB is
under national review. He stated tentatively that an immigrant can
be denied admission into the United States if they have TB, and all
immigrants have to be evaluated and submit paperwork about TB and
other infectious diseases. But in the last 15 to 20 years,
numerous individuals have been permitted to arrive in America
infected with TB. There have recently been very detailed reviews
about this because in general, INS has been letting infected people
into America with resistant infectious TB and placing them on the
doorsteps of state legislators to fund their treatment and deal
with the problem--another unfunded federal mandate so to speak.
Number 1813
REPRESENTATIVE BRICE asked about global TB statistics.
DR. MIDDAUGH responded that he did not have an exact figure, but TB
is one of the leading causes of death in the world.
REPRESENTATIVE BRICE asked what international organizations, such
as the World Health Organization, were doing.
DR. MIDDAUGH answered that the World Health Organization is very
involved in the control of TB, malaria, HIV, etc. Their success
depends on the resources of each country.
Number 1856
REPRESENTATIVE ROBINSON asked what is going to be done, and if the
department would report back to the HESS Committee members with a
proposal and a plan, so that the legislature can assist in
controlling the epidemic.
Number 1880
COMMISSIONER PERDUE answered that extra funds will go to control
this year, and to strengthen prevention efforts next year. She
said the HESS Committee will be seeing plans.
Number 1889
CO-CHAIR TOOHEY agreed that the effort should be refocused on
public health and prevention.
ADJOURNMENT
CO-CHAIR TOOHEY adjourned the meeting at 4:30 p.m.
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