"Rural, economically depressed Asian areas still have a lot of TB, but that's really no different than the situation in the United States as little as 60 years ago," said Dr. Steve Berman, an infectious disease specialist in Honolulu.

Hawai'i's TB rate has long been among the highest in the country, and last year it was the second-highest in the nation at 9.2 cases per 100,000 people, according to data from the U.S. Centers for Disease Control. There were 116 active TB cases in the state in 2004.

The disease has been declining in Hawai'i and across the United States but worldwide it remains a huge problem.

"The World Health Organization says that one-third of the people in the world are infected with TB. This disease is going to outlast all of us until we have a vaccine," said Dr. Jessie Wing, a Centers for Disease Control and Prevention medical officer who runs the Hawai'i State TB Control Program.

She expressed frustration that there is not a greater global response to developing a vaccine for the disease. "TB is one of those orphan diseases without enough funding," Wing said. "A third of the people infected and no vaccine? We need a vaccine for this."

She called TB a "smart" disease because it adapts readily. Sixty years ago, just six months after the development of antibiotics, there were already antibiotic-resistant strains. Today, active cases are treated with multiple antibiotics over a six-month period. The regimen is carefully monitored by the Department of Health to ensure patients faithfully take their medication.

Tuberculosis is an air-borne bacterial disease that infects the respiratory system, although it also can affect bones, brains and other organs. Untreated infections can lead to fever, chills, weight loss and coughing up blood, although the symptoms can be different depending on where in the body the infection is centered.

Before the development of antibiotics, people with active tuberculosis were isolated — sometimes for life — in special facilities such as the Kula Sanitarium on Maui and Le'ahi Hospital on O'ahu.

"It was essentially quarantine. It was a terrible time. Families were torn apart," Wing said.

Most people now can be treated on an outpatient basis. They can use personal physicians, but if they are treated through the state Department of Health, the treatment is free. Berman, who is not involved with the state TB program, said he is impressed with how well it is run.

"The Department of Health TB branch is and has been a success. They have done a fabulous job. They are on the cutting edge of new developments," he said.

Many people acquire the disease, but it becomes dormant in their bodies. Some may go their entire lives symptom-free. But the tuberculosis can activate, often when a body's immune system is challenged by HIV, cancer, steroid use or chronic kidney disease. Many of Hawai'i's cases involve elderly people whose TB, acquired in their home countries, was latent but became active as they aged and their immune system weakened.

Wing said that 50,000 health-care workers, students, food-service workers and others are tested for TB in the Islands each year. About 20 percent of those tested at state facilities test positive, although with the existing skin test, there are many false positive results.

Those with positive tests are sent for X-rays to check for active lung involvement. Berman said the X-ray is the least expensive screen to determine whether someone has evidence of active TB. Even without a confirmation of active disease, those who test positive are offered a nine-month antibiotic treatment program for latent TB. About 2,000 Hawai'i residents every year take the program.

Wing said that a new blood test for latent tuberculosis, QuantiFERON, appears to be much more accurate than the skin test, and should cut out most of the false positives. It was approved by the Food and Drug Administration in December, she said.

Representatives of the manufacturer, Cellestis, will be in Hawai'i next week to brief officials on use of the test, according to Wing. Berman said he expects the new test to entirely replace skin testing within five years.