For 10 busy weeks, action — but little TB

Fort Dix is screening base for Kosovar refugees

Screening 4,045 Kosovar refugees in 10 weeks for TB, syphilis, and HIV, while providing acute care, was as tough as it sounds, say experts from the Centers for Disease Control and Prevention (CDC) in Atlanta.

But with hindsight supplied by the experience, future repetitions of such an experience — if there are repetitions — may be easier, predicts Susan T. Cookson, MD, acting chief of medical screening and health assessment at the Division of Quarantine (DQ) at the CDC.

The marathon ordeal began last March, when NATO intensified its bombing campaign, leading the Yugoslav army, Serb police, and paramilitary forces to gear up terrorist activities euphemistically known as "ethnic cleansing." Soon, neighboring Montenegro, Albania, and the borders of Macedonia were mobbed by more than 600,000 refugees fleeing the violence. By the end of May, more than 1.4 million people had been displaced from their homes. Macedonia refused entry to the refugees, calling instead on other nations to help; with thousands of refugees camped in a cold and muddy no-man’s land along the Macedonian border, the United States and 39 other countries began to consider taking in refugees.

On April 21, President Clinton announced the decision to take in 20,000 people. By April 28, Fort Dix, NJ, had been designated as the chief processing facility.

That meant there was work to be done, says Cookson. Long before the first refugee set foot there, she explains, the fort had been decommissioned and its hospital mothballed, a consequence of Defense Department spending cuts. Inside the empty fort sits McGuire Air Force Base. The plan called for refugees to be flown into McGuire and then bussed to Fort Dix, there to be "in-processed."

Climbing aboard the glory train’

To recruit medical and nursing personnel, electronic notices went out over the Internet to all Public Health Service employees seeking volunteers, says Cookson. Response was immediate. "This was the glory train, and everybody wanted to get on," she says. In all, 90 physicians and 160 nurses did a tour of duty of between 10 and 20 days. Tours were staggered so that crews arrived every three days.

The first order of business was to construct facilities. With little more than the bare shell of an army base to work with, local contractors were hired to bang up walls in an old base dining hall, using a diagram someone had drawn the day before. Supplies and equipment were moved in, and a portable X-ray unit was rented and parked outside the dining-hall clinic.

Just five days after Clinton gave the go-ahead to an airlift, the first planeload of refugees touched down. Their new "home" consisted of a 10-acre fenced compound surrounded by security guards. There were dormitories, a grassy recreation area, a dining hall, a prayer room, and, because no one could leave the base, a convenience store.

The first plane load of 400 people arrived May 5 on a Tower Airlines flight, a Canadian line under contract to the U.S. State Department that specializes in refugee transport. Staff began screening the first arrivals for TB and other "inadmissible conditions" (which include syphilis and HIV); at the start, even though the refugees had a long list of medical conditions that also needed tending to, things went smoothly enough.

Everyone age 15 years and over was X-rayed and assessed for TB; those with medical problems that had gone untreated during the refugees’ months in outdoor camps were treated for their diabetes, pregnancy, chronic heart conditions, and the like.

As more planes arrived every other day, the population of the fort began to climb rapidly. So did the demand for acute care, the general workload, and the level of chaos.

"These people had been two months in the field," says Cookson. "They’d been under a lot of stress." There were pulmonary embolisms, pregnancies, head lice, and mental health problems to be tended to. An emergency medical service furnished transportation to a local hospital when necessary, and medical care was provided on site as well.

In the 10-week period, 7,500 prescriptions were written. On a typical day, 200 chest X-rays were performed and read; in all, 2,600 were done. If a chest X-ray looked suspicious, three sequential sputums were collected, and smears performed. In some cases, skin tests were applied.

Under physical and emotional stress

Only six people were hospitalized for mental health problems. "Probably a lot more needed help," adds Cookson. "They’d been without regular medical care for two months, and everyone had endured an incredible amount of stress, both emotionally and physically."

The laboratory, busy to the point of overload some days, found no cases of HIV infection and two cases of infectious TB; the lab performed smears on 76 sputums, of which six were positive for acid-fast bacillus. Chest X-rays showed evidence of inactive TB in 65 people. All told, 10 people were placed on TB treatment.

Keeping medical records straight was challenging, Cookson notes. At first, records were kept by hand; eventually, the system was computerized. Adding to the confusion was the fact that refugees sometimes shared the same name and birth dates; nor were names in the slightest bit familiar to American ears, making the job of keeping charts matched to lab results especially difficult.

Most refugees were re-settled in California, New York, Texas, Washington state, Illinois, and Florida. Follow-up was pursued aggressively for everyone placed on TB treatment or for those with significant findings on chest X-rays, says Cookson. TB controllers in receiving jurisdictions were notified by a telephone call that they were about to get a refugee with a TB-related condition.

By now, 1,800 refugees have returned home, says Cookson; the TB patients have been advised to remain in the United States until they finish treatment.