Nov 032009

Winnipeg Free Press – PRINT EDITION

The number of TB cases in Manitoba is on the rise, and the doctor who used to be responsible for keeping the disease in check says the system has developed cracks and people are falling through

By: Jen Skerritt

It’s just six years since Hershfield retired as the longtime director of Manitoba’s tuberculosis-control program, but he’s already watched the system he worked for 37 years to build break down and lose track of patients.

He recently saw a woman in his downtown cityplace medical clinic who’d been prescribed enough TB medication to kill her.

Another woman who came for a checkup had been exposed to infectious TB, but no one did a skin test, chest X-ray or referred her for followup.

He was infuriated when a man with infectious TB recently came to see him — the man hadn’t filled his prescription for TB drugs and was walking around, spreading the disease.

Hershfield has phoned, written and met with some of Manitoba’s most senior medical officials to tell them the province needs what he calls a TB czar, someone to take charge and ensure no cases go undetected.  The 74-year-old offered to re-organize the TB program himself.

So far, he hasn’t received a response.

“You can’t convince them. People who control the money are more interested in West Nile virus that’s going to affect 10 people and kill one out of 3,000,” Hershfield said. “Without a co-ordinated system, without people going out and getting the entire population, you can’t win. “I see that things are falling apart.”

The number of TB cases reported across the province and in Winnipeg is on the rise, yet cases are being missed, health officials admit. The latest provincial disease statistics show the number of TB cases between January and August 2009 increased nearly 25 per cent over the same period last year. Manitoba used to record about 100 cases of TB a year, but the province hit 113 in August and the numbers are still climbing.

Most TB cases are reported in the north and Winnipeg.  Northern health officials in Thompson blame the increase on poor living conditions on many northern reserves. Winnipeg health officials say the numbers are up because they’re doing a better job of finding people with the disease.

Hershfield suspects the reason is cut and dried: The system doesn’t work anymore. TB is out of control. Things have changed since he was at the helm, and privacy laws now ban some of Hershfield’s past unorthodox ways of ensuring his patients took their medication — including training Main Street bartenders to dispense drugs to regulars.

The system to track and treat TB was handed over to regional health authorities, and Hershfield thinks that shift left no one in charge of making sure things work properly.

“Now, there are too many cases,” Hershfield said. “The public health system broke down. It’s now fragmented. Patients are less visible. There isn’t what I call a czar.”

Hershfield’s no-nonsense approach to TB was simple — find cases of TB, put the patients on drugs, watch them take those drugs, track down everyone else they exposed to the airborne bacteria and put them on drugs, too.

He and nurse Joann MacMorran co-ordinated the Manitoba Lung Association’s TB program out of a small office at Health Sciences Centre for more than three decades. Their program kept the number of TB cases relatively stable. Doctors and nurses across the province and on reserves knew
Hershfield was the TB point man and would send him patients with symptoms. New immigrants under surveillance for TB were referred to  Hershfield for followup after they entered the country.

Contacts across Manitoba alerted him when patients didn’t show up to take their pills, and Hershfield had a way to keep track and ensure people took their medication — what is called “directly observed therapy.” Nurses on reserves and in the city met with patients and watched them ingest their pills. The nurses went looking for missing patients when they didn’t show up. Infectious patients who refused to take their medication were
arrested and put in isolation in hospital.

The number of cases a year hovered around 100 from the late 1980s right up until Hershfield’s departure in 2003. His system worked so well that the Canadian Society for International Health asked Hershfield to set up the same program in Guyana.

Hershfield took a tough and sometimes unorthodox approach to finding his patients and getting the job done. He often trained people in the community — including staff in Main Street hotels — to dispense TB drugs to patients. If patients didn’t show up to take their pills, staff would phone Hershfield and MacMorran would scour watering holes in search of the missing patient. Sometimes Hershfield would even troll the  downtown bars himself to hunt for patients.

“We trained the bartender to do it, so the bartender would give him his medication,” he said. “We were concerned about getting the medication into the patient. I didn’t care whether you’re drunk or not, take your medication.”

Things didn’t always go Hershfield’s way.

The outspoken physician wanted better housing for his patients and more money to bolster TB prevention. As far back as 1987, Hershfield warned that treaty natives had a high rate of TB because of poor living conditions. He hit bureaucratic roadblocks and became increasingly frustrated.

“The problem with these kinds of situations is health is a department. Housing is a department. Everybody has their own budget. If I was to say I need more housing on this reserve because of tuberculosis they’d say, ‘meh, we don’t need it there,’ ” Hershfield said.

“Those are the realities. I see patients today who are still in overcrowded houses that 10 years ago I wrote letters about.”

The TB-control program changed when Hershfield retired in 2003.

The program was shuffled to an interim director who resigned a year later. No one was in charge for months until the province took over TB care in April 2006. Several months after that, the province handed the responsibility of finding, diagnosing and treating TB patients to regional health authorities.

Because most TB cases in Manitoba are reported in Thompson and Winnipeg, the Winnipeg Regional Health Authority and Burntwood Regional Health Authority took lead roles in some of the most difficult and time-consuming aspects of TB care — the medical sleuthing in the community to
find patients, getting them to take drugs and rounding up people they’d exposed to TB and putting them on drugs, too.

Dr. Sande Harlos, a WRHA medical officer, remembers the days when the front-desk clerk at Main Street hotels would help administer TB medication, but said the revamped system is more efficient and ensures no one falls through the cracks.

And yet, the TB numbers reported in Winnipeg nearly tripled between 2007 and 2008.

Harlos said there are more public health nurses, and the system no longer relies on proxies — such as bartenders — to keep an eye on TB patients.

Public health nurses now make a point of meeting TB  patients when they are still quarantined on HSC’s sixth-floor isolation unit.  Patients with infectious TB are usually required to stay in the isolation unit for two weeks until drug therapy has kicked in to be sure they can’t spread the
disease to others through coughing or sneezing.

Harlos said the nurse starts building a relationship with the patient early, to make it easier to get the patient to follow through with the entire nine-month drug treatment. Nurses make arrangements and find out the best place for patients to receive their drugs, whether that’s in their homes or a spot in Central Park. The WRHA offers incentives for patients to show up, including sandwiches, bus fare, sometimes even cash.

Even on the isolation ward, infectious patients are given incentives to stay — their TV and phone is paid for and they’re often offered favourite meals. While other jurisdictions have offered cigarettes to TB patients in isolation, medical officer Dr. William Libich said they’ve decided against offering tobacco or alcohol. The idea, he said, is to encourage patients to take a stake in their own health and recovery, although some patients are allowed to go outside to smoke.

“If they’ve rejected offers of nicotine replacement therapy, and they insist on going out (for a smoke) we have to be careful about that,” Libich said. “We don’t want folks leaving isolation and not coming back.”

Some patients slip through the cracks.  Months before double-amputee Brian Sinclair was found dead in a Health Sciences Centre waiting room, the WRHA investigated another critical incident — this time a homeless man with a history of substance abuse who told emergency room staff he believed he “had TB.”  A July 2008 summary of the incident reveals the man initially came to the ER with an unrelated complaint, and a chest X-ray
indicated fluid in the lining of his lung — something that could indicate TB or lung cancer. A follow-up CT scan was done, then the patient was discharged and told he needed a followup appointment. He didn’t go to any of the scheduled appointments.

Three months later, the man showed up at the ER drunk, complaining of shortness of breath, a cough and weight loss. Again, he told ER staff he believed he “had TB.”   ER staff did not heed his concerns, and six months later the patient was admitted with advanced TB and told that his prognosis was “poor.” The report doesn’t say what happened to him.

“I don’t think we’re doing well enough,” said Dr. Joel Kettner, Manitoba’s chief medical officer.

Kettner said he believes doctors initially miss some TB cases because the symptoms — including coughing and night sweats — are similar to other respiratory diseases. Although Manitoba has one of the highest TB rates in the country, Kettner said it is not a mainstream disease and many
doctors would see only a few cases throughout their careers.

“For a well-trained doctor, an experienced doctor, this is a challenge to pick out amongst all those reasons that people come and see a doctor,” Kettner said. “There’s a lot of diseases that have those symptoms. The key (with TB) is those symptoms usually don’t get better.”

Wayne Harper knows what can happen when TB is missed.  He buried his 28-year-old brother, Herman Joseph, two years ago. Wayne, a band
councillor at Garden Hill First Nation, said his brother was living in Winnipeg with his girlfriend when he started getting sick. Wayne said his brother went to HSC’s ER many times, but staff there said he had a bad cold and sent him home repeatedly.

Months later, Herman was so sick his lungs were failing, and there was little doctors could do. Harper said TB “got him” when Herman succumbed to the disease after four days of drug treatment in hospital.

“He lay there, and they just took the (life-support) machine out. Shut it off. Just gone,” Harper said.  “Probably he had that TB maybe for months, and they didn’t treat him. They couldn’t do anything because it was too late.”

jen.skerritt  AT

Free Press reporter Jen Skerritt received a $20,000 Journalism Award from the Canadian Institutes of Health Research to investigate tuberculosis in Manitoba. The stories, photos, videos and interactive website are the result of months of research and collaboration with the Free Press TB

Republished from the Winnipeg Free Press print edition November 3, 2009 A10

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