TB in Schools: Prompt, Large-Scale Response Needed

Troy Brown, RN

October 03, 2013

Managing and investigating Mycobacterium tuberculosis (TB) in a school can be beyond the capabilities of local agencies, requiring leadership at the state and county levels, according to a report published in the October 4 issue of the Morbidity and Mortality Weekly Report. A plan needs to be in place for informing and educating the public, the report adds.

According to Carolyn Bargman, MA, from the Boulder County Public Health/Denver Metro TB Clinic in Colorado, and colleagues, a student at a Longmont, Colorado, high school with 1381 students and staff was diagnosed with TB after being admitted to a hospital in late December 2011 with a 2-month history of cough, fever, and night sweats.

After testing of close contacts suggested transmission had occurred at the school, testing was extended to all students and staff present during the fall 2011 semester. Quickly testing more than 1000 contacts with an interferon gamma release assay (IGRA) blood test was beyond the local laboratory's capabilities, so officials developed a combined strategy using IGRA and the tuberculin skin test (TST). Those who had resided outside the United States, who had received bacille Calmette–Guérin vaccination, or who had a positive TST result were tested with IGRA; all others were tested with TST.

Public health preparedness programs for Colorado and for Denver and Bolder counties were activated, and an incident command structure led by the TB control authorities in those counties was established.

A total of 12 screening clinics were held at the school from mid-February to mid-March 2012. In all, 1249 (90.4%) of 1381 school contacts were evaluated: 4 who had previously been treated for latent TB infection had a chest radiograph only, 435 received IGRA testing, and 810 were tested with TST.

Those with latent TB infection were given a choice between self-supervised daily isoniazid for 9 months or rifampin for 4 months until rifapentine became available in late February 2012. After that, a 12-week regimen of once-weekly isoniazid and rifapentine administered at the school was recommended.

Five registered nurses from 4 health departments, with the support of a single clerk, provided patient counseling, gave the first directly observed doses of isoniazid-rifapentine, and provided the isoniazid or rifampin used for daily self-supervised treatment. The Centers for Disease Control and Prevention reassigned 2 persons from elsewhere in the state health department for supervision of the weekly isoniazid-rifapentine regimen at the school for 1 month each, followed by 2 Denver Metro TB Clinic outreach workers who supervised treatment first at the school and then in homes during summer vacation.

A total of 162 (13%) of the index patient's school contacts had latent TB infection, including a contact whose diagnosis was changed to latent TB infection after completing 2 months of treatment; 159 of the contacts (99%) began treatment and 153 (96%) completed treatment.

Local news media began covering the investigation in mid-January 2012, and Internet social media reported that students were dying from TB, that the TB came from illegal immigrants, and that the school would close. Public health and school officials held public meetings with school staff, students, their families, and the media throughout the investigation to address these concerns. Follow-up meetings were held to report the investigation's progress; as of July 2013, no further TB cases had been reported in school contacts and no additional M tuberculosis isolates with this genotype had been seen in the state.

Officials reinforced the need to prevent future TB disease by completing latent TB infection treatment.

"Drug-susceptible TB disease is curable, but its historical reputation as a lethal contagious disease generates stigma, and misinformation can amplify fears. When communicating to the public about a crisis, the information should be simple, credible, accurate, consistent, and on time," an editorial note states. "One of the best ways to counter the public's fears is to provide useful information about the event and let them know what they can do."

Morb Mortal Wkly Rep. 2013;62:805-809. Full text

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