Fighting TB on The Last Frontier

“I knew the incidence rates going in, but the Alaskan people – that’s what captured my heart,” says Doreen Williams, Clinical Science Consultant at QIAGEN, and nurse educator for the US West Coast. “When you are feet on the ground, immersed in the culture and talking to the residents you can’t help but want to help. You just get engaged.”

The numbers she’s referring to are the incredibly high rates of TB in Alaska. In 2022, the state had the highest rate of new cases in the entire US, at 13.1 per 100,000 population – almost double the next highest figure, Hawaii’s 7 per 100,000, and nearly three times higher than California, which came third at 4.7 per 100,000 (1). In some rural areas, however, the incidence rate can be as high as 135 per 100,000, she points out. “I was in Anchorage in July 2022 and had the opportunity to meet local public health nurses and listen to their stories. When I left I thought, ‘We need to do something. We need to help.’”

It’s a problem that has roots going back hundreds of years, explains the Alaska TB program’s Bruce Chandler, MD, a highly respected physician who’s been involved in the state’s fight against TB for decades. “Until the late 1700s Alaskan Native communities were isolated, then they started to see the arrival of outsiders – explorers, hunters, fishermen, fur sealers, settlers – and some came from areas with high rates of TB,” he says. 

“They introduced tuberculosis into this population where there were very isolated villages and a very harsh environment. People tended to stay indoors in very crowded conditions – ideal for transmitting TB.” 

Indeed, until the 1940s TB was Alaska’s number one cause of death, he points out, with “astronomical rates” in Western and Northern Alaska. “There were surveys with tuberculin skin testing around 1950 where 90% of eight-year-olds in Western Alaska were infected.”

Limited services

Although things have obviously improved across the last century, years of global progress in tackling TB with new drugs, diagnostics and increased funding were thrown off track by the COVID-19 pandemic. and Alaska was no different. This was not simply the result of shifting resources to tackle COVID, however, but the unique geographical conditions of the state.

“So many of these communities have very limited healthcare services and transportation, and for COVID we asked people to hunker down as much as possible,” says Chandler. “So a lot of people spent a long time indoors. Everyone’s sharing respiratory droplets, and unfortunately there were some people who had active tuberculosis.”  

The aftermath of the pandemic has seen more people being evaluated and large clusters of TB identified. But how do you go about tackling the disease in the face of the unique physical challenges posed by such a vast – and frequently inhospitable – area? “In the Yukon–Kuskokwim region there are 49 separate villages, and almost all have no road system,” Chandler states. “And then there’s the weather.” 

Public health nurses sent to the villages can easily be snowed in for days, which means having to rely on air transportation or even snowmobiles to move medical and public health personnel, as well as patients. There’s also the challenge of limited communications, he explains. “In the past we haven’t had reliable internet in many rural areas.  We have seen considerable improvement, but then a fiber-optic line goes down and we’re in the dark again.”

Traumatic history

But it’s not just the extreme physical challenges that have hampered the fight against TB in Alaska. There’s the stigma surrounding the disease that still deters people across the world from seeking medical help, and the attitudes they can face from friends, family and colleagues once they’ve been diagnosed and started treatment. In Alaska this is further compounded by the state’s often-traumatic history of fighting the disease. 

With no effective medicines available until the 1940s and ‘50s, Alaska – like many other places – had residential facilities for people with active TB, but the sheer size of the state meant that these could be far removed from peoples’ homes. “Even children were taken away from their families and moved thousands of miles to a facility,” says Chandler. “Some of those people never came home, and their families never knew what happened to them. Some people died in the sanatorium, and there was no system to notify people of what happened. Those experiences have long-lasting effects.”

Some older members of Alaskan Native communities can still remember family members being taken away, so how does the state go about getting the message across that this is no longer the way things are done? 

“I think ongoing education is the key, especially for the residents in these communities,” he says. “To learn about the symptoms, how it’s diagnosed and treated, and to understand that – while it’s not easy treatment – for most people it’s very safe, and they can cure themselves if they take the medicine for the prescribed amount of time.”

Making sure that people complete their course of treatment can be a challenge, however, and one method the Alaskan authorities are using is directly observed therapy (DOT) – where someone in the community monitors a person taking their meds. “Now we’re moving into video DOT,” says Chandler. “It’s much more convenient using some of these technologies that don’t require someone to travel to a household or workplace every day. But for some people treating their TB is not their number one focus, so we try to help them see that if we cure their disease then they can be done with us and move on.”

Educating the public

One consequence of people not finishing their treatment, of course, is the risk of drug-resistant TB. “We fortunately don’t see a lot of multi-drug-resistant TB, but in some communities in Western Alaska we’ve seen single-drug resistance,” Chandler states. 

In his work with the Alaska TB Program, he provides recommendations for public health nurses and confers with medical providers around the state. The number one priority is finding new active TB cases in high-risk populations, he says, and treating those people to cure their disease and prevent transmission to others.

Key to this is a major new partnership with QIAGEN. “It’s going well,” he states. “We’re working hard on different programs to increase education for people residing in many of these communities.” It’s a project that’s highly collaborative, says Williams. 

“On World TB Day we went up to Anchorage and did a free screening event for residents. We provided lunch when people came in and got their QuantiFERON test – we found two cases of LTBI in that one day. Raising awareness is the key and now we’ve developed this a formal partnership agreement with the Department of Health, so we’ll be working very closely with the whole department, state-wide.”

While the department was already doing excellent work in tackling TB, there’s “only so much they can do –  it’s like salmon swimming upriver,” she says. “Our goal at QIAGEN is to support them where we can. It’s been really exciting, and things are starting to move forward.” The state has recently received a significant grant to fight TB, and QIAGEN is working closely with the public health lab in Fairbanks. 

“We’ve also heard that the Department of Corrections may be converting from skin testing to QuantiFERON, state-wide. There is a lot of potential to really make a difference.”

Key to this will be increasing the capacity to offer QuantiFERON testing across the state, not just in suburban areas. “I look back five or ten years and very few places in Alaska were able to do QuantiFERON testing, but now many of the hub communities are able to do it fine,” states Chandler. While capacity has “increased tremendously”, some very rural areas will still depend on air transportation and may still have trouble getting specimens moved in a reliable fashion, he says. “But I think for the majority of Alaskans it’s feasible to use QuantiFERON testing.”

Overcoming logistical challenges through partnerships

The use of QuantiFERON is already well established in Anchorage and some other places, but in the majority of areas it’s still skin testing, says Williams – “in part, due to logistics, but also because that’s what they’re used to doing.” The fact that there will still be logistical difficulties in managing QuantiFERON in many remote villages means “we’ll need to get creative”, she says. “There’s an understanding that we can make this feasible. Maybe we take an incubator out to the village, for example, so that buys us more time to get the samples to the lab.” 

At the provider and state level the advantages of modern IGRA tests like QuantiFERON-TB Gold Plus over skin testing are well understood. “The evidence shows that using an IGRA increases sensitivity and specificity in LTBI testing, but a lot of the focus in Alaska right now is still on active TB, because it’s highly contagious,” she says. “I think there may be a place for skin testing for awhile, but we’re definitely on the right road.” 

Crucially, QuantiFERON also offers the opportunity to be truly proactive, she stresses. “We can test for latent TB and get treatment before it progresses to active. It’s about helping to educate the providers and the community that this is such an easy disease to prevent and cure. We’re coming at it from a different angle.” 

Skin testing is not without its own challenges, she points out. “You shouldn’t just look at the cost of the tuberculin PPD, there’s additional labor, unnecessary x-rays, not to mention the compliance and inconvenience for the patient having to return to assess for a reaction to the tuberculin” – something that presents another issue with lot of rural communities. When you do go to the villages, to get them to come back twice is a little bit of a challenge.” 

Continuing to raise awareness

Continuing to raise awareness is a key priority, part of which is a new campaign to educate elementary school children. “We felt that if we can reach that age group then they’ll take the message home – I’m very excited about this,” she says. 

The awareness-raising drive also includes getting more Alaskan Native community leaders on board to help spread the message as widely as possible.

“It’s a unique culture. We are excited about our partnership with the Department of Health and look forward to extending our educational and testing services with additional agencies throughout the state” says Williams.“

I would like to see more Alaska Native providers,” adds Chandler – “who may have a more trusted relationship with their local communities.” 

The feedback from the Alaskan authorities so far has been incredibly positive, Williams says. Alaska is very open – it’s like a big hug. “The country is amazingly beautiful, and the people are just genuine. You can’t help but love being here.”