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http://www.nytimes.com/2002/05/20/nyregion/20TUBE.html

The New Front in the Battle Against TB

By SARAH KERSHAW

decade after a tuberculosis epidemic gripped New York City, raging through Harlem at a rate not seen since the early 1900's, the disease has taken another turn in the circle of its history. While overall numbers have declined, tuberculosis is now most prevalent in the immigrant neighborhoods of Queens, where it poses a growing public health threat.

In Corona, immigrants from the countries most ravaged by the disease — including China, Ecuador, Haiti, India, Mexico, Bangladesh and Pakistan — have settled in droves over the last decade. The city's Department of Health runs one of the busiest tuberculosis clinics in the country there, one that treated 37,000 patients last year.

The rate of tuberculosis in Corona was the highest in the city in 2001 — 36.1 cases per 100,000 people, more than double the citywide average of 15.7 cases and at least seven times the national average. For the first time, the incidence of tuberculosis in Corona surpassed the rate in Central Harlem, for decades the epicenter of tuberculosis in the city.

Tuberculosis, an airborne lung infection that kills 2 million people a year worldwide, was largely brought under control in New York City after the epidemic peaked in 1992, when it was fueled by AIDS and homelessness. City health officials have reported a steady decline since then in new tuberculosis cases among New Yorkers born in the United States.

The disease's shift to immigrants reflects a kind of turning back of the clock to the turn of the 20th century, when tuberculosis rippled through the city's immigrant population, spreading rapidly through tenements and windowless factories.

"It's a dramatic change in the disease," said Sonal Munsiff, assistant commissioner for the Tuberculosis Control Program at the New York City Department of Health. She added, "We are no longer in crisis mode, but in certain places, case rates are many, many times more than they should be."

While the change has occurred in cities around the country, it is most striking in New York, which has the highest rate of tuberculosis in the nation. In 1992, only 18 percent of the new tuberculosis cases were among foreign-born New Yorkers, according to the Department of Health. In 2001, 64 percent of the 1,261 new tuberculosis cases were among immigrants.

And so, Queens is now the front line of the city's aggressive battle, which commands an annual budget of $37.5 million. Most worrisome to health officials is that people with an active infection, which typically festers in the lungs, shutting them down with wrenching pain if untreated, can be highly contagious.

The disease is most likely to spread through the air in enclosed or crowded spaces. On average, a person with an active infection will spread the disease — through coughing or sneezing — to 15 to 20 other people in a year's time, according to the World Health Organization.

A team of health workers based in Corona fan out through the borough to find and treat patients. The workers often comb remote places like a junkyard in the shadow of Shea Stadium, and not long ago they stumbled on an apartment crammed with Ecuadorean immigrants. In all, more than 60 people who had lived there were infected.

"This is a tough bug to kill," said Errol Robinson, director of the Queens Network for the city's tuberculosis program, who oversees the Corona Chest Center.

Mr. Robinson, who began working in the program 14 years ago, used to spend much of his time working in homeless shelters, at encampments under bridges or in the streets of Harlem and the South Bronx. Now his staff works with immigrants, knocking on their doors before they head to work, and he relies on translators or bilingual workers to communicate with patients.

While the incidence of the disease in Corona is still far below the case rate in Central Harlem at the epidemic's zenith in 1992 — 240 cases per 100,000 people — it has nevertheless sounded an alarm.

For one thing, the Corona tuberculosis rate reflects only those patients who have been tested at the city's newly renovated clinic on Junction Boulevard or by other area doctors. Health officials say that countless more are likely to be infected but untouched by the city's campaign to track them down and treat them with a course of medication that takes six to nine months to complete.

Lloyd Walker, one of the public health workers, sees an average of 13 patients a day. He zooms through the streets of Queens in his blue Ford Taurus with a medication log and a bottle of hand cleanser for patients who need to wash up before taking their pills. His job is part of a treatment for tuberculosis known as Directly Observed Therapy, which was credited with bringing the epidemic under control and drastically reducing the number of cases in Harlem and other hot zones. Under the treatment, patients are observed taking their daily medication, usually five days a week.

At the beginning of treatment, a patient must take as many as four different drugs every day. And it is often a challenge to get patients who work up to 14 hours a day, drift from home to home or leave and re-enter the country, to stick to the regimen.

If they do not complete the treatment, which cures the disease but does not prevent contracting it again, patients can build up immunity to the drugs and then face years of treatment. And drug resistant strains have been on the rise.

Each day about noon, Santos Rodriguez, who lives in the junkyard near Shea, meets Mr. Walker in the back of an auto body shop. The men who work in the nearby auto parts shops know Mr. Walker, and they usually help him find Mr. Rodriguez, a 42-year-old Salvadoran immigrant.

Mr. Rodriguez said he became ill with tuberculosis last year, experiencing night sweats, fatigue, loss of appetite, a severe cough — all symptoms of the disease — and was hospitalized for more than two months.

"Santos!" the men called the other day, when they saw Mr. Walker's car pull up to the shop on Willets Point Boulevard. A few minutes later, Mr. Rodriguez walked to a cabinet where he keeps his bottles of medication, in a drawer full of wrenches and bolts. In the back of the shop, Mr. Walker put down two pieces of paper towel on a plank of plywood. Mr. Rodriguez, who does odd jobs in the shops, washed the grease off his hands with the cleanser Mr. Walker gave him and took six pills.

Mr. Rodriguez has missed his medication several times and once lost his three bottles, he said, but he has been observed five days a week for the past month. For that, he has reaped regular rewards from the health workers, including coupons for Kentucky Fried Chicken and juice. "I know I have to do this," he said in Spanish.

Many immigrants are arriving with the dormant form of tuberculosis, which can either develop into an active infection if the immune system is weakened or never lead to illness, according to experts and several medical studies. Screening for tuberculosis is common among immigrants arriving legally, but many others make their way to New York City without ever being tested.

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