Singing group spreads TB along with goodwill
Singing group spreads TB along with goodwill
With lots of INH, world tour ends on happy note
When a troupe of youthful performers from a popular United States-based singing group set out to tour the world several years ago, it was looking forward to having a truly international experience but it’s doubtful that getting exposed to tuberculosis was what they had in mind.
Nonetheless, that was the fate of one ill-starred cast of performers and their hosts several years ago, after a group member from a Western European nation fell ill with TB. The disease wasn’t diagnosed until she’d infected scores of people and transmitted the disease to several more.
For the TB control officers who investigated it, the outbreak posed a unique set of headaches.
For one thing, says Randall Reves, MD, MSc, medical director of the TB control program in the Denver Metropolitan TB Clinic, there was the question of jurisdiction. Who takes responsibility for coordinating an outbreak that spans a dozen cities in two countries and involves youngsters from 31 different nations? Who oversees the gigantic contact investigation? And who tackles the task of convincing fretful parents of (in this case) 75 youngsters, all far from home, that their kids must submit to a six-month course of preventive therapy?
As it turned out, much of the burden fell to Reves’ department because the singing group is based in a small town outside Denver. There, high school and college graduates audition for parts in one of five traveling companies, each of which, following two months’ rehearsal, tours the world for ten months.
Time with host families, community service
According to a representative for the organization, the kids divide their time between putting on Broadway-style productions, doing volunteer service (such as building Habitat for Humanity houses, reading to kids in daycare centers, and visiting the elderly in nursing homes), and getting to know the host families with whom they stay overnight in towns and cities where the troupe performs.
The trouble apparently began in one of the five touring troupes in the late winter or early spring of 1994. A young woman from Belgium, a member of a 125-member cast that was working its way through Alaska and British Columbia, began to feel sick.
Investigators say they still haven’t gotten to the bottom of the question of whether the child had the tuberculin skin test that the organization routinely requires of participants; and, if she had the test, who read it. Her records indicate that she was tuberculin skin-tested and that her skin test was negative; yet she later told doctors that a family member had been ill with TB when she was a young child.
Either way, she dismissed her symptoms, at least at first. "She attributed it to being on the move, to the irregular hours and so on," says James Sparling, MD, FRCP, director of the Capital Regional Tuberculosis Service in Victoria, BC.
By May, playing to enthusiastic crowds in high-school auditoriums and churches, the cast was booked into seven or eight Alaskan towns and villages, says Michael Beller, MD, MPH, medical epidemiologist with the Alaska Division of Public Health in Anchorage.
In Alaska, the girl saw three different physicians and received a variety of diagnoses. Meanwhile, she grew sicker, coughing dreadfully everywhere she went.
The cast packed up for Canada. In Victoria, BC, the girl felt so sick she allowed herself to be taken to a hospital. There, physicians quickly diagnosed TB; X-rays showed she had extensive disease, says Sparling.
In one host family, five kids infected
In Victoria, before she’d agreed to be hospitalized, the girl had been billeted "with a very nice middle-class family," Sparling recalls. "The father was a university professor, the mother a psychologist, and there were five children, age six through 20." The young woman boarded with the family for three nights, which proved plenty of time for all five children, plus their mother, to convert their skin tests to positive, Sparling says.
Further contact investigation, he says, showed the girl was "evidently wildly infectious." In Canada, all told, about three dozen people eventually converted their skin tests and were put on isoniazid prophylaxis. (Luckily, the mycobacterial organism was found to be pan-sensitive.)
Sparling was left to wrestle with the problem of how long to keep the young woman in Canada before letting her board an airplane for the long flight home. In the end, he erred on the side of caution and kept the girl a month two weeks longer than most clinicians would have, he guesses before releasing her.
Meanwhile, back in Alaska, Beller began to follow up with the 35 people in the eight households with whom the child had stayed during the Alaska leg of the tour. "It was pretty discouraging," he says. Investigators found one case of active TB, one convertor, and one reactor. Remarkably, the degree of infectiousness appeared to vary in wholly unexpected ways, Beller adds. Though the girl was coughing the entire time, transmission and infection occurred in the first three towns but not the remaining five or six.
A month later, an unpleasant surprise
A month into the contact investigation, the Alaska branch of the investigation got an especially unpleasant surprise. The young woman had also served on the cast’s advance team, and had routinely flown ahead of the troupe to make arrangements for housing for the rest of the cast. That produced another 70 people she had met with, which was narrowed to 16 critical close contacts. Several of them eventually converted or reacted; and again, there was an instance of active disease.
Back on tour, another youngster in the cast had fallen sick with TB.
The rest of the group posed a different set of challenges, Reves says. For one thing, many of the cast members from abroad were skin-test positive already; for another, they were extremely nervous about what the American doctors planned to do to them.
Linda Williams, MD, the troop’s medical director, was constantly on the phone, calling parents and physicians in Russia, Norway, and Malaysia, patiently explaining why their kids needed a course of preventive therapy.
That left just one more problem: how to administer INH to dozens of kids hopscotching their way across Europe, without a qualified health care provider available to monitor for side effects, answer questions, place and read follow-up skin tests, and calm anxieties and fears.
As luck would have it, Reves found the ideal person for the job BJ Catlin, RN. She had been Denver’s chief public health nurse and is a motherly but redoubtable woman who calls herself "The Enforcer." And she had just retired after 26 years of duty. Catlin accepted the challenge and caught up with the tour in Frankfurt, armed with a huge supply of INH. She found that the young woman from Belgium had rejoined the tour, by now smear-negative, but utterly despondent and needing lots of reassurance. "She was feeling dejected, because in Belgium, TB is considered a disease of people who are unclean," says Catlin. "I knew how to handle it; I’d dealt with a lot of foreign people over the last 26 years."
The grandmother’ of the tour
By the time Catlin left the tour, she’d ministered to broken arms, treated head lice, and instated herself as the kids’ unofficial grandmother. Even after she returned to Denver, as kids continued to convert their skin tests, they called Catlin from Switzerland or Germany or England, asking her advice.
To date, all the convertors evaluated for INH have successfully completed their therapy, say the clinicians and investigators involved. The source case has been cured, as have the other cases.
And, Sparling says, the young lady from Belgium plans to re-visit her Victoria host family the professor, the psychologist, and their five kids sometime soon.
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