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.