Case in chaotic ‘family’ fuels big school outbreak
Case in chaotic family’ fuels big school outbreak
Town panics as 22 cases found in junior high
In Forrest City, AR, a 14-year-old boy with infectious TB apparently went undetected by any adult for so long that at least 21 more cases of TB have developed as a result. He appears to have infected only about twice as many people, say TB experts, but in a contact investigation that ultimately expanded to encompass almost 5,000 people, at least 158 people have turned up with a positive skin test.
State and local TB experts are still baffled by some details of the case. In hindsight, they say two things clearly could have made a difference.
"Originally, we focused on the household contact investigation," says Rosalind Abernathy, MD, associate professor of pediatrics at the University of Arkansas School for Medical Sciences in Little Rock. "If we’d gotten to the school sooner, we might have gotten to some of the kids there before they became cases. But this whole thing just caught us unaware," she adds. "What we thought was a two-day illness in fact had probably been going on for two months."
The source case first sought treatment this past spring, when he arrived at an emergency room suffering from pleural effusion, says Abernathy. He was found to be smear-positive for TB, with a lower-lobe infiltrate. He denied having had a cough, and his family, such as it was, affirmed what he said, she notes.
The teenager had been living with a 21-year-old female cousin, two younger children, a toddler, and a teenager who came and went, say TB controllers. He was known in his school as a "sickly child," administrators say. "When I asked specifically about a cough, [the family] denied that," Abernathy recalls. "Later, they did say there had been some weight loss."
Because the boy’s history suggested he’d been sick only briefly, and because the first round of skin testing at his household turned up a mix of positives and negatives, Abernathy says she thought the source case might be somewhere outside the family and still undiscovered.
By the time the contact investigation expanded to the junior high school, an epidemic was under way.
As cases at the school rose from five to 10 to 22, TB controllers from the state and local level began holding meetings with an increasingly panicky parent body. Parents began issuing calls to have the school shut down completely. In the end, TB controllers found the only way to allay parent fears was to agree to do skin tests on virtually everyone in town who wanted one.
"The community got tremendously worked up," says Frank Wright, assistant director of state TB control. "As we kept finding more cases and more reactors, people perceived that the cases were occurring at that time. So it looked to them as if things were getting worse. We really couldn’t overcome that perception."
Go to town leaders first, parents second
In retrospect, Wright adds, he wishes he’d met with town leaders and members of the media first and saved the parent meetings until later. "That way, we could have brought [the leaders] the truth about all these scary-sounding things that began capturing everyone’s imaginations," he says. Instead, TB experts found themselves trying to stay on top of events as they unfolded, with TV cameras rolling, and the nightly news filled with fearful tidings the townspeople only vaguely comprehended.
Luckily, none of the additional suspect cases is contagious, says Wright, and DNA testing shows all but one are linked to the source case. (That one, the 22nd, was probably an instance of reactivation of an old infection and was found in an adult.)
With summer vacation under way, Abernathy says TB experts are appealing to peoples’ sense of civic responsibility and offering monetary incentives to encourage compliance with regimens. "These people are easily distracted from [tending to] their medical needs," she adds. "They don’t keep appointments well; they have so many other things on their minds."
The town, which lies in the flat delta country, is an hour’s drive from Memphis and is known as "the rice capital of the world," according to Elisia White, RN, communicable-disease nurse specialist with area 9 of the state Department of Public Health. White and six other nurses are providing directly observed therapy to the 22 suspect cases.
There still may be more chapters to come, says Abernathy. The index case, remarkably, already had completed a course of directly observed preventive therapy for latent TB infection several years before, after his mother was diagnosed with TB. Now, his lymphocyte count is inexplicably low, Abernathy says. Tests for HIV have consistently turned up negative, she adds.
"Of course, I wish we’d paid more attention to the fact that this boy was smear positive," she adds. But the fact that several people in the household progressed rapidly from negative skin tests to active disease — coupled with the infectiousness of the source case — suggests to her that the strain of TB itself may show remarkable traits. "We may eventually have evidence to show this [strain] is more virulent than average," she concludes.
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