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Outbreak: Tuberculosis in a School

A Speech by Charles Smedly, Preparedness Manager, Denver Public Health, to a Colorado Legislators Forum Tuberculosis is still a threat. Prevention and early treatment are critical and cost effective. Thank you for the opportunity to speak at this forum.  I’d like to start by harkening back to some common names; people who no doubt wandered in the Capital - Baron Manfred von Richthofen, Former Denver Mayor Robert Speer, and architect and philanthropist Temple Hoyne Buell were all prominent in their day. They also shared one other thing; each one suffered from tuberculosis. Tuberculosis, or TB, is a contagious disease caused by a bacteria. It is typically spread by breathing in respiratory droplets contaminated from a cough or sneeze of an infected person. In the United States, about 3% of the population has TB infection using the TB skin test[1], [2] and over 11,000 develop active or infectious tuberculosis each year.  When health departments evaluate household members of a person with infectious TB, more than 1% have active TB and 30% will have a positive TB skin test and a normal chest X-ray.  These latter people are infected, have no symptoms and have a form of disease called latent TB infection. The longer and more you are exposed to a person with active, infectious TB, the more likely you will get an infection. About 5% of newly infected individuals will progress to active TB within 2 years of infection, increasing to 10% over their lifetime. These individuals are a high priority for diagnosis and treatment to prevent future TB cases. In December of 2011, a student was discovered to have active tuberculosis while attending a high school in Longmont Colorado.  Denver Metro TB Control and Boulder County Public Health staff tested students and staff who were at highest risk – those who shared more than one class with the student.  Over 50% of those students were found to have evidence of exposure to the TB organism. The next cohort of students tested shared one classroom and had a 40% infection rate. Eventually, it was determined that the entire school, students and staff, needed to be tested. This situation posed a public health problem in several contexts. One, those with indoor exposure needed evaluation to be sure there were no other active or latent TB cases.  Second, anyone with either form of TB needs to be treated for extended periods of time.  Diagnosis was initially done by obtaining chest X-rays for those with symptoms and use of a newer and more costly blood test (QuantiFERON).  The advantage of the blood test is a higher level of accuracy and it requires just a single clinical encounter. The operational problem was how to test more than 1,200 individuals either by drawing their blood or injecting a small amount of material into the skin of their forearm. Drawing blood has more factors to consider in transport and processing the specimen. The skin test is time tested and a public health standard, but requires a second visit (increasing the time and effort of staffing clinics). When the decision was made to test the entire school, the public health community had to determine the most efficient method for testing over 1,200 individuals, perhaps the largest TB investigation ever in Colorado. We could expect approximately 10% of those individuals to have latent TB and require treatment with one anti-tuberculosis drug for either 4 or 9 months depending upon the drug used. The standard treatment for active TB is six months in duration and uses four anti-tuberculosis drugs. How did public health in Colorado manage this investigation? Our ability to respond efficiently was due to three points: Experience in Planning for Mass Events:  In 2001, public health agencies had no efficient or coordinated process to work with each other or communicate with partners or the public. Over the past decade, the capability to rapidly distribute and dispense medical countermeasures to large numbers of people became a national priority. The bioterrorist attack of 2001, Hurricane Katrina and the H1N1 pandemic posed significant public health challenges and exposed gaps in multi-sector coordination and response.  Federal funding has allowed public health to improve our response and management of a spectrum of  public health emergencies. Denver Public Health also has received some funding from the City and County of Denver. Those funds help us to develop plans, test and then apply continuous quality improvement methods to refine our response. As a result, we now use:

  • An Integrated command and control structure, called Incident Command System. Incident Command system is a standardized, flexible approach that enables a coordinated response across  jurisdictions, agencies, and sectors including both public and private entities.
  • Time studies to estimate how long it would take to process 1200 or more patients to receive an injection or, in the case of TB, a skin test or blood draw. These time study skills were developed during the 2009 H1N1 pandemic clinic operations.

The second point is public health surge capacity: To test over 1,200 individuals, we have needed to recruit from nurses and staff across the North Central Region.  The region includes the Denver-Boulder metro area public health departments. These agencies have worked closely together to develop relationships, plans and interoperable response structures. We also a signed Mutual Aid Agreements with all the local public health departments in Colorado. So far, eight local health departments, the Colorado Department of Public Health and other organizations, such as the Medical Reserve Corp, have provided staffing support to this Longmont TB outbreak. We worked with the school district and administrators to get their support. Our estimated total cost of this public health intervention, including much in-kind support, may reach $240,000. Denver Public Health’s direct costs for this investigation, including the blood test, skin testing and x-rays is approaching $100,000. Through this established relationship, public health agencies and professionals want to support doing the right thing. They help each other and help our communities through collective surge; a single health department would have insufficient surge capacity for prolonged periods, as this Longmont TB case required. Lastly, we were lucky:  We are identifying victims of TB infection and providing treatment before they can spread TB. We currently estimate 150-200 people will require treatment for TB infection.  Preventive treatment can take 6-9 months, but costs far less than the treating an active TB infection. The cost for outpatient treatment of TB is approximately $6,000. We were lucky it was not a drug resistant strain of TB.  Decades ago TB became relatively rare due to the use of antibiotics in the 1950s. Today, a dangerous form of multi-drug resistant TB for commonly used drug treatments has created a worldwide public health crisis.  Treatment of this resistant strain takes much longer, is more expensive, and has more side effects than standard TB treatment [3].  Some resistant cases cost close to $1 million. After the Civil War, Colorado gained a reputation as a health resort due to its sunshine, clean air and hot mineral springs. Thousands of people came to the state seeking a cure for consumption, as tuberculosis was commonly known then, and many hospitals and sanatoriums sprang up to serve them. At one point, someone estimated that one-third of the state's population came to Colorado for health reasons People still come to Colorado for the scenery, the quality of life and the healthy life style offered by our great state. However, TB is still here. Travelers bringing it back to classrooms, restaurants, and nursing schools. PH needs capability to respond to these threats. Tuberculosis is still a threat. Prevention and early treatment are critical and cost effective. [1] CDC TB Basic Facts http://www.cdc.gov/tb/topic/basics/default.htm. Accessed 2/24/10. [2] World Health Organization. Tuberculosis Infection and Transmission http://www.who.int/mediacentre/factsheets/fs104/en/index.html. [3] WHO. Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 Global Report on Surveillance and Response; March 2010. Source: Outbreak: Tuberculosis in a School

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