Tuberculosis cases are on the rise again in California, and health officials are urging those at higher risk, as well as doctors, to be alert to the disease, which can lurk in people's bodies for years before it potentially emerges becomes fatal.
The number of tuberculosis cases in 2023 rose by 15% in California compared to the previous year, according to the Department of Health. That is the highest annual increase since 1989, when it concerned people who were co-infected with HIV.
Last year there were 2,113 cases across California; that's about the same amount as in 2019, before the COVID-19 pandemic. Seniors age 65 and older had the highest percentage increase in cases from 2022 to 2023.
Tuberculosis rates are also rising nationally, up 16% in 2023 compared to the previous year, the U.S. Centers for Disease Control and Prevention reported. said Thursday. The 9,615 cases provisionally reported last year were the highest since 2013 and were 8% higher than the number of 8,895 cases reported in 2019.
Those at high risk for tuberculosis include people who have lived outside the US, where tuberculosis rates are high, including most countries in Asia, the Middle East, Africa, Eastern Europe and Latin America.
Nationwide, tuberculosis cases increased among all age groups and among those born inside or outside the U.S. in 2023, the CDC said.
Caused by bacteria Mycobacterium tuberculosis, the tuberculosis disease is spread through the air. Unlike COVID-19 — where infection can occur within minutes — a person typically must be exposed for hours to inhale enough TB bacteria to become infected, said Dr. Julie Higashi, director of LA County's tuberculosis control program.
Most active cases in California are in people with latent tuberculosis who picked up the bacteria decades ago but were not contagious or showed symptoms. “Then something happens. Either they get older… and their immune systems actually get weaker… and then they progress' to acute tuberculosis, Higashi said.
On the other hand, an estimated 18% of tuberculosis cases in LA County stem from recent transmission.
California officials said 13% of people with tuberculosis died in 2020. That's up from 8% in 2010. Overall, more than 200 Californians die from tuberculosis each year, state officials say.
TB has plagued humanity since the beginning of history, and at some point in the 17th and 18th centuries a quarter of all deaths in Europe.
It was not until March 24, 1882 – 142 years ago on Sunday – that a scientist announced the discovery of the bacterium that causes tuberculosis. (Decades earlier, tuberculosis was thought to be hereditary, and in New England this was inspired by 'vampire panicsBecause people thought the first family member to die of tuberculosis would come back as a vampire to infect the rest of them, according to the CDC.)
Tuberculosis existed at the beginning of the 20th century one of the leading causes of death in the United States.
Governments began making serious progress in preventing infectious diseases early in the last century. According to the CDCHome improvements reduced overcrowding – a risk factor for the spread of tuberculosis – and programs were launched to control tuberculosis. In 1940, the death rate from tuberculosis was one-fourth of what it had been at the turn of the century. Further progress was made with the discovery of TB treatments in the mid-20th century.
Tuberculosis cases have generally declined in California since the early 1990s but continue to take a significant toll, a tragedy given that the disease is detectable and treatable.
“Not only can you treat the active disease, you can also treat the latent disease, which is much easier to treat – fewer drugs, much shorter time – and then prevent progression to the active form of the disease,” Higashi said.
The CDC estimates 13 million people in the US have latent tuberculosis infection, meaning they have no symptoms and cannot spread the bacteria. Without treatment, 5% to 10% will develop active disease that can become contagious and possibly fatal later in life.
Outbreaks can occur locally. In Contra Costa County, 11 confirmed cases last year were linked to staff and customers at the California Grand Casino in Pacheco. At least ten cases were genetically linked.
According to the most recent data, California counties with the highest tuberculosis rates per capita tend to be along densely populated coastal areas. In Southern California, Los Angeles, San Diego, Orange and Imperial counties had the highest rates. In Northern California, these were Santa Clara, Alameda, Sacramento, Contra Costa, San Francisco, San Mateo, San Joaquin, Solano, Monterey and Napa counties.
Officials noted a significant drop in tuberculosis cases in 2020, due to stay-at-home orders and reduced travel during the early phase of the pandemic. Since then, cases have risen 4% to 5% each year before rising 15% in 2023.
The increase in the number of tuberculosis cases Orange Country, California's third most populous area, was particularly pronounced, with a 20% increase between 2022 and 2023; in LA CountyCases rose by about 4% over the same period, according to local data.
According to data isThe per capita rate of tuberculosis in Orange County is 10% higher than that in LA County.
“We have a lot of people who travel, and we also have relatives who come from other countries where the number of tuberculosis cases is higher,” says Dr. Regina Chinsio-Kwong, Orange County Health Officer.
Cities in Orange County with a higher number of tuberculosis cases than the county's overall rate include Laguna Hills, Westminster, Garden Grove, Buena Park, Santa Ana, Fountain Valley, Anaheim, Costa Mesa and Lake Forest, according to county data.
Those most at risk in Orange County are people born outside the U.S., Asian Americans, men and seniors 65 and older. Having diabetes, HIV or smoking cigarettes increases the risk of latent tuberculosis developing into full-blown tuberculosis, Chinsio-Kwong said.
With “latent tuberculosis, if someone's immune system is nice and strong, you don't have any symptoms, it doesn't affect your organs,” Chinsio-Kwong said. “But it can develop into active tuberculosis if you are immunosuppressed. So that's where diabetes, smoking or any infectious disease like HIV can really put you at greater risk of developing active tuberculosis.”
Routine testing for people at higher risk, such as health care workers, can be helpful. Chinsio-Kwong said she was diagnosed with a case of latent tuberculosis earlier in her career, prompting her to undergo nine months of treatment.
“If we can properly treat all latent tuberculosis cases, we can really reduce the number of active tuberculosis cases,” she said. “The hope is that you detect latent tuberculosis before you develop symptoms – because by the time you develop symptoms, you are an active tuberculosis patient, spreading your germs and possibly even spreading the infection to others.”
In Los Angeles County91% of tuberculosis cases were among Latino or Asian American residents. The top seven countries of birth for people with tuberculosis were Mexico, the Philippines, Guatemala, China, Vietnam, El Salvador and South Korea.
Areas with the highest rates of tuberculosis cases in regions monitored by the LA County Department of Public Health were in downtown LA, which the agency defines as downtown, Echo Park, Silver Lake and the Hollywood Hills; South LA; and an area in the western San Gabriel Valley that includes Alhambra, Monterey Park and San Gabriel.
Other areas with TB rates above the LA County average include the Hollywood neighborhoods, Northeast LA, El Monte, East LA, Inglewood, Torrance and Bellflower.
Of the regions with the highest tuberculosis cases in LA County, the regions with the highest death rates were in the Alhambra-Monterey Park-San Gabriel area, where 15.4% of tuberculosis cases resulted in death; and Central LA, where 20.5% of cases resulted in death.
A major problem with tuberculosis is that doctors can miss a diagnosis because tuberculosis is relatively rare. The California Department of Public Health last month urged health care providers to consider tuberculosis as a possible cause of respiratory illness in people at higher risk.
There are situations in which doctors may misdiagnose people with tuberculosis. Although the disease usually grows in the lungs – leading to symptoms such as chronic cough, chest pain and coughing up blood – the bacteria can also grow in other parts of the body, including the gastrointestinal tract or nervous system, and can doctors overlook a report. TB diagnosis in that atypical presentation.
Examples of misdiagnosed TB cases previously documented by The Times include a San Fernando Valley businessman who grew up in Chile and suffered for 11 years until a TB diagnosis was made; and a Shanghai-born UC Berkeley Mandarin teacher who was misdiagnosed with Crohn's disease and given a steroid to suppress her immune system, allowing her tuberculosis to spread. It was only when she was seriously ill in a hospital that a doctor seriously considered tuberculosis.
One prominent misdiagnosis occurred in 2004, when Dr. Claudia Lacson – pregnant with her first child – fell into a coma in Georgia after complaining of severe headaches and persistent fever. Doctors initially suspected bacterial meningitis, but by the time doctors began treating tuberculosis it was too late and she died at age 38, weeks after giving birth to a daughter, who also did not survive.
“What we want healthcare providers to know is that when someone comes to them with respiratory symptoms, they need to start thinking about the next question: Could this possibly be a person at risk of developing tuberculosis?” said Chinsio-Kwong. 'Even if you weren't born [in] from another country, if you are around those who come from the United States, there is a risk.”
