Ellington

About six months ago, Candace Houston's world went wonky. That's when she learned that her cousin's persistent cough wasn't bronchitis. Instead, the diagnosis was tuberculosis, a highly contagious and potentially lethal lung disease.

The finding meant that the Mississippi State Department of Health had to test Houston, her family and everyone who had come into contact with the cousin or with people he had infected, as required by law.

The disease had spread. Houston's mother and another cousin had active, communicable forms of TB. Houston, her baby boy and the baby's father all tested positive for latent infections, as did numerous other members of the family and their friends.

"It had to be a hundred if not more," Houston said of the numbers of people in the Jackson area who the MDH eventually diagnosed.

Finding out that she and so many others tested positive scared her, Houston said, but she didn't cry until she found out her baby was infected. "He had it bad," she said, and he's still under medical care.

"For a minute, I thought it had infected the whole Jackson, Mississippi, area," said Morlyn Russell, a nurse practitioner with the state Health Department and the Hinds County TB clinic. 
 Every infected person had to undergo at least a three-month course of treatment, with check-ins twice a week. Small children, such as Houston's baby, and those whose disease was active are undergoing longer treatments, up to nine months.

The state's homeless population is especially vulnerable due to extreme poverty, poor nutrition and lack of regular medical care, Russell said. In Hinds County from 2004 to 2009, the rates of TB among homeless people ranged from three times to nearly eight times the national rate, which hovered around 6 percent. The overall rate in Jackson is still higher than the national average.

Russell's clinic is part of Mississippi's aggressive program for dealing with TB. She and other clinic staff visit shelters weekly to test homeless men and women for TB and evaluate them for symptoms of disease--persistent coughing, night sweats, sudden unexplained weight loss and weakness.

In addition, public health-care workers in hospitals and nursing homes receive regular tests, as do patients who may be at risk. Treatment for people with compromised immune systems is more complex and takes more time, a year or longer.

People with active TB cases--Russell said she's seen about 10 in the nine months she's worked in the Hinds clinic--must be quarantined to prevent spreading tuberculosis, which means someone needs to deliver medicines to them, and the state may have to pick up the tab to keep someone in isolation if they're homeless.

"We go above and beyond," Russell said. "If they don't come to us, we go to them."

Overall, Mississippi has seen a decline in TB cases, said Dr. Thomas Dobbs, a state epidemiologist and Public Health District 8 health officer in Hattiesburg. Last year, the state saw 81 active cases.

"More and more of our cases are coming from people born in other countries," he said, adding that travel is one of the things that made TB a global problem. About a quarter of Mississippi's cases are people over 65. "Even people exposed in their 20s and 30s can still break down with tuberculosis," he said.

Infected individuals can transmit TB through breathing or coughing. Tuberculosis can lie dormant for decades, and then--much like the chickenpox virus can produce a painful case of shingles years after infection--the disease can become active and deadly--and dangerously contagious.

TB is responsible for untold millions of deaths worldwide. Back in the 1980s, epidemiologists thought tuberculosis was on the verge of eradication. "A lot of people thought TB had been done away with," Russell said.

Starting in the mid-1940s, antibiotics began a 40-year period of cures for even the most stubborn strains of the disease. Then, in the mid-1980s, drug-resistant strains of tuberculosis began appearing. The bacteria, mycobacterium tuberculosis, adapted and mutated, especially among people who didn't complete their course of treatment when they began to feel better, leaving the toughest bacteria to thrive. Monitoring of the disease, its treatment and funding had all slacked off.

"We got complacent," Dobbs said.

Though Mississippi hasn't seen a lot of drug-resistant TB, Dobbs said we have seen a few imported cases. They are costly to treat and may take years to cure. "A single case could actually eat up our entire federally allocated budget for tuberculosis," Dobbs said. "It's very, very expensive--up to a quarter million dollars for a single person. That's just medications. Hospitalization could even be more."

The worldwide HIV/AIDS epidemic produced a corresponding rise of tuberculosis; TB is the leading killer of people with AIDS. The problems of the two diseases is tangled with religion and morality. In poor countries, native "healers" declare people well without any treatment, while fundamentalists thump Bibles, condemn homosexuality and oppose condom use.

Thokozile Phiri Nkhoma of the Malawi Interfaith AIDS Association in southeast Africa lost her father to AIDS and TB in 1997. After he died, Nkhoma's mother, sister, 6, and brother, 3, all tested positive. The children were born infected with HIV. Nkhoma was 11.

Back then, she said, Malawi had no drugs to fight the diseases, though the country had declared HIV/AIDS a national emergency in 1985. AIDS was a death sentence. In 2002, the Global Fund began providing money for antiretroviral drugs in Malawi, where today, an estimated 51,000 people die of AIDS and related illnesses, such as TB, every year.

Nkhoma's little brother died in 2008 of tuberculosis; her mother died in 2011. Nkhoma and her organization work to educate and raise awareness of the diseases in Malawi and to bring faith leaders around as allies to help stem the tide. She was in Jackson a few weeks ago with two representatives of RESULTS, a Washington, D.C.-based grass-roots anti-poverty organization.

"We can't stop," she said, adding, "TB anywhere is TB everywhere."

"It's a forest fire, almost." Dobbs said of the risk of TB becoming epidemic in the U.S. "There are areas and populations that are vulnerable ... and it could spread through those populations very, very quickly."

"There is a constant risk," he added. "... If we ignore it, it will come back."