By Giff Johnson
For Variety

MAJURO — The Marshall Islands has a tuberculosis rate nearly four times that of the Pacific regional average, and 47 times the rate in the United States.
But despite the high numbers, the Marshall Islands’ efforts to eradicate TB drew praise from a U.S. Centers for Disease Control official who said the high numbers were an indication that public health teams are aggressively finding and treating people with TB in this western Pacific nation of 60,000.
TB statistics released late last week by the Ministry of Health show 126 new cases for 2006, giving the country a rate of 217 per 100,000. CDC statistics show that in 2005, the most recent year for regional TB data, the Pacific islands area had an average of 55 cases per 100,000, while the U.S. rate was 4.6 per 100,000 last year.
The 126 new TB cases identified by public health nurses last year in the Marshall Islands was up slightly on the previous year, when 121 people were confirmed with TB.
“It’s alarming,” Subroto Banerji, a TB consultant to the CDC who works on TB control in the Pacific and other parts of the world, said about the high level of TB in the Marshall Islands. “But (the Ministry of Health) is going all out to identify and treat cases. In other countries, it takes 10 years to make an impact and bring the rate down.” The Marshall Islands TB eradication program was only launched three years ago, according to Dr. Kennar Briand, the director of public health for the Marshall Islands.
The geography of this watery nation is a challenge to TB control.
Although the population is relatively small, people live on islands scattered across 500,000 square miles of ocean area, and many islands are accessible only by small boats.
“In Los Angeles county, there were 2,500 TB cases 12 years ago,” Banerji said. “Now the numbers are down to 900. But there they have had millions of dollars, they don’t have (remote) outer islands to deal with, and they can use cars to reach people.” In the Marshall Islands, health staff must fly on small commuter planes to remote atolls, and then either must charter outboard engine motor boats to get to populated islands separated from islands with airports by miles of lagoon or wait for low tide to trudge across miles of reef flat in ankle deep water, all the while carrying medical equipment.
In the Marshall Islands, “they are on their way to making a dent in the TB problem,” Banerji said. With an active screening program that is backed up by functioning laboratories at hospitals in the two urban centers of Majuro and Ebeye, coupled with the direct observation therapy, the Ministry of Health has a functioning TB control system, he said.
Briand said two serious challenges to TB control in the Marshall Islands are the high rate of diabetes, which compromises people’s immune systems, making it more difficult to treat TB, and getting islanders to complete the minimum six-month regimen of daily treatment.
For diabetics with TB, Briand said he requires them to take TB medication for an additional three months to ensure a cure.
But even though in Majuro and Ebeye nurses go daily to the homes of TB patients to administer the TB medication using the director observation therapy, some patients still refuse to complete their treatments, he said.
“After a few months of taking the medicines, some patients think they are cured because their symptoms go away,” Briand said. But they’re not, he added.
This problem resulted in the discovery of two drug-resistant TB cases in the country in recent months, which Briand said is a real worry both from the standpoint that these are more difficult to treat and because of the high-cost of medicine that must be imported by the Ministry of Health to treat TB that is resistant to normally prescribed, and less expensive, medicines.
The drugs used to treat drug-resistant forms of TB are more toxic to the patient, frequently causing nausea and other reactions, and must be taken for nearly two years, Briand said.
Still, Banerji says that Marshall Islands health workers are on the right track with their DOT program for TB. Because Public Health nurses are doing a good job with the daily visits to TB patients’ homes, they are keeping the number of drug-resistant cases low, he said.