Worst TB outbreak in 20 years kept secret ---- In Florida

[NowVoyager]

TB is not to be taken lightly, either by those with it or by those trying to care for those with it. Worst is when it becomes 'politicized'.......

http://www.palmbeachpost.com/news/ne...-secret/nPpLs/

(full story at link)

Palm Beach Post Staff Writer

JACKSONVILLE —

The CDC officer had a serious warning for Florida health officials in April: A tuberculosis outbreak in Jacksonville was one of the worst his group had investigated in 20 years. Linked to 13 deaths and 99 illnesses, including six children, it would require concerted action to stop.

That report had been penned on April 5, exactly nine days after Florida Gov. Rick Scott signed the bill that shrank the Department of Health and required the closure of the A.G. Holley State Hospital in Lantana, where tough tuberculosis cases have been treated for more than 60 years.

As health officials in Tallahassee turned their focus to restructuring, Dr. Robert Luo’s 25-page report describing Jacksonville’s outbreak — and the measures needed to contain it – went unseen by key decision makers around the state. At the health agency, an order went out that the TB hospital must be closed six months ahead of schedule.

Had they seen the letter, decision makers would have learned that 3,000 people in the past two years may have had close contact with contagious people at Jacksonville’s homeless shelters, an outpatient mental health clinic and area jails. Yet only 253 people had been found and evaluated for TB infection, meaning Florida’s outbreak was, and is, far from contained.

The public was not to learn anything until early June, even though the same strain was appearing in other parts of the state, including Miami.

Tuberculosis is a lung disease more associated with the 18th century than the 21st, referred to as “consumption” in Dickensian times because its victims would grow gaunt and wan as their lungs disintigrated and they slowly died. The CDC investigator described a similar fate for 10 of the 13 people who died in Jacksonville.

They wasted away before ever getting treatment, or were too far gone by the time it began. Most of the sick were poor black men.

“The high number of deaths in this outbreak emphasizes the need for vigilant active case finding, improved education about TB, and ongoing screening at all sites with outbreak cases,” Luo’s report states.

Today, three months after it was sent to Tallahassee, the CDC report still has not been widely circulated.

Backer of closing hospital didn’t know

Meanwhile the champion of the health agency consolidation, Rep. Matt Hudson, R-Naples, said he had not been informed of the Jacksonville outbreak and the CDC’s role as of Friday.

Told the details, the chairman of the House Health Care Appropriations Committee vowed that there would be money for TB treatment.

“There is every bit of understanding that we cannot not take care of people who have a difficult case of TB,” Hudson said.

The governor’s office asked a reporter to foward a copy of the CDC letter on Saturday, but did not comment by press time.

Treatment for TB can be an ordeal. A person with an uncomplicated, active case of TB must take a cocktail of three to four antibiotics — dozens of pills a day — for six months or more. The drugs can cause serious side effects — stomach and liver problems chief among them. But failure to stay on the drugs for the entire treatment period can and often does cause drug resistance.

At that point, a disease that can cost $500 to overcome grows exponentially more costly. The average cost to treat a drug-resistant strain is more than $275,000, requiring up to two years on medications. For this reason, the state pays for public health nurses to go to the home of a person with TB every day to observe them taking their medications.

However, the itinerant homeless, drug-addicted, mentally ill people at the core of the Jacksonville TB cluster are almost impossible to keep on their medications. Last year, Duval County sent 11 patients to A.G. Holley under court order. Last week, with A.G. Holley now closed, one was sent to Jackson Memorial Hospital in Miami. The ones who will stay put in Jacksonville are being put up in motels, to make it easier for public health nurses to find them, Duval County health officials said.

They spoke about CDC’s report Friday, only after weeks of records requests from The Palm Beach Post. The report was released late last week only after a reporter traveled to Tallahassee to demand records in person. The records should be open to inspection to anyone upon request under Florida Statute 119, known as the Government in the Sunshine law.

TB strain spreads beyond homeless

In his report, the CDC’s Luo makes it clear that other health officials throughout the state and nation have reason to be concerned: Of the fraction of the sick people’s contacts reached, one-third tested positive for TB exposure in areas like the homeless shelter.

Furthermore, only two-thirds of the active cases could be traced to people and places in Jacksonville where the homeless and mentally ill had congregated. That suggested the TB strain had spread beyond the city’s underclass and into the general population. The Palm Beach Post requested a database showing where every related case has appeared. That database has not been released.

It was early February when Duval County Health Department officials felt so overwhelmed by the sudden spike in tuberculosis that they asked the U.S. Centers for Disease Control and Prevention to become involved. Believing the outbreak affected only their underclass, the health officials made a conscious decision not to not tell the public, repeating a decision they had made in 2008, when the same strain had appeared in an assisted living home for people with schizophrenia.

“What you don’t want is for anyone to have another reason why people should turn their backs on the homeless,” said Charles Griggs, the public information officer for the Duval County Health Department.

Even the CDC was not forthcoming about the outbreak. An agency spokesperson declined requests from The Post when asked to make an expert available to discuss a CDC-authored scholarly paper on the possible origins of the Jacksonville outbreak, offering only general fact sheets on TB.

[Kassy]

This is going to be some problem. I don't think there's an easy way to screen for TB, they mention having trouble finding the contacts as it is & meanwhile they put patients in motels...great.

[NowVoyager]

Originally Posted by Kassy

This is going to be some problem. I don't think there's an easy way to screen for TB, they mention having trouble finding the contacts as it is & meanwhile they put patients in motels...great.

I agree, Kassy.

Years and years ago when I was a kid my mom was diagnosed with TB. Even though I tested negative, I still had to take a full course of the antibiotics for a year. Mom was banned from any work with public contact; yeah right, she work in food service, so back then, the county pulled her health card .... I was out of school most of that year as well. Other than the irritating side effects from the heavy duty antibiotics and our trying to scrape by taking in laundry and such; what I most recall was having to answer the same questions over and over again:

Had either of us handled food others consumned that week?

Had either of us donated or sold blood?

Had we washed our laundry in a 'communal washer'?

And this was back in the late 60's when the TB wasn't a resistant strain and we were both other wise healthy people, not inclined to NOT take the medications or cooperate with the county health people.

But the population most at risk to carry and be exposed, is a highly population made of homeless who, even if they are deal with an addiction, may not always have the ability to or desire to, follow the rather nasty course of treatment.

And those who work with the homeless, while they might have healthier lives overall, are still at risk for exposure.

[proteus]

Sorry for what may be a silly question but do you not innoculate/ vaccinate against TB in the US? In Britain we all got jabbed age 14............ regards N.

[Kassy]

A part of the problem is that people forget about the potential of these diseases because they don't remember examples from experience or family tales.

A now a tale from my family which is only a slight variation of yours.

Had either of us handled food others consumned that week?

Do US motels have salad bars?

Would homeless people suddenly put in a motel because they have TB think about that?

Why would Florida politicians close their TB hospital...because there's no more TB but as recent history has shown that's not true.

In this case somebody who was involved in shutting down the hospitals must have known about this outbreak but decided to ignore that.

I think they also made a mistake in their judgement.

assisted living home for people with schizophrenia.

They probably don't get around too much but the homeless do and more importantly it's not contained to that group any more.

BTW: If i were working with the homeless i'd appreciate a heads-up if it was detected in the community at all. Here they didn't communicate a major outbreak for all the wrong reasons.

[Mama Alanna]

Originally Posted by proteus

Sorry for what may be a silly question but do you not innoculate/ vaccinate against TB in the US? In Britain we all got jabbed age 14............ regards N.

If you can believe Wikipedia, there is only a vaccine for one strain of TB, and there are multiple strains. The CDC says

BCG, or bacille Calmette-Guérin, is a vaccine for TB disease. This vaccine is not widely used in the United States, but it is often given to infants and small children in other countries where TB is common. BCG vaccine does not always protect people from getting TB. The BCG vaccine should be considered only for very select persons who meet specific criteria and in consultation with a TB expert.

So I would expect that "specific criteria" probably involves living with, or frequent contact with, someone who carries that particular strain of the bacterium.

[Oric]

Originally Posted by proteus

Sorry for what may be a silly question but do you not innoculate/ vaccinate against TB in the US? In Britain we all got jabbed age 14............ regards N.

We were all screened with a BCG swap, i think it was not a innoculation

Edit : well wikipedia sez it is a vaccine

[Sysiphus]

A part of the problem is that people forget about the potential of these diseases because they don't remember examples from experience or family tales.

True, plus there is an unusually large number of bat-shit crazy people on the streets in Jacksonville. A BFF is a Jacksonville fireman, and you should hear the tales he has to tell.

[NowVoyager]

Originally Posted by Kassy

A part of the problem is that people forget about the potential of these diseases because they don't remember examples from experience or family tales.

A now a tale from my family which is only a slight variation of yours.



Do US motels have salad bars?

Would homeless people suddenly put in a motel because they have TB think about that?

Why would Florida politicians close their TB hospital...because there's no more TB but as recent history has shown that's not true.

In this case somebody who was involved in shutting down the hospitals must have known about this outbreak but decided to ignore that.

I think they also made a mistake in their judgement.


They probably don't get around too much but the homeless do and more importantly it's not contained to that group any more.

BTW: If i were working with the homeless i'd appreciate a heads-up if it was detected in the community at all. Here they didn't communicate a major outbreak for all the wrong reasons.

Here's the problem as I see it:

The 'homeless' aren't just one homogensous group of people. ANd with the current economic problems you're not only seeing 'homeless' people in need of food and services showing up at homeless providers, but those who are new to the system and don't know the 'ins and outs' as it were. So between the chronic addicts, criminal element (both of who IMO prey upon the fragile homeless who are elderly or have non violent mental health issues) and those who are homeless often with children because they have some income but there's more month than money..... If you know what I mean. It's a difficult group to work with. And except for the poverty pimps who make money from the whole process; they aren't a group that as a whole a community wants to deal with of acknowledge.

But like you, if I were volunteering at a homeless out reach, I'd want to know if there was a TB or Hep C spiking in the area. Not to mention, that IMO, spike in things such as TB or Hep C are often tied to either a transient, immigrant or drug using group; whether that is PC or not. SO the media will either ignore the issue or spin it in such a way so as to deflect rightful concern about how some social services are run.

[dharma]

Like HIV, malaria, and many other scourges, there is no effective vaccine for TB.

[CanadaSue]

It's disappointing to read of this serious an issue being hushed up and/or not correctly prioritized.

Look we live in a world if increasing mobility & in many cases, decreasing prosperity. More may be moving to seek jobs & those who can't face increasing deprivation leading to both a poor basic state of health & higher exposure to risks.

As dharma pointed out, there's no effective vaccine. Add to that increasing resistance. Mark my words, we'll soon be seeing the reopening of sanitoriums.

Here's a ProMed post on increasing drug resistance in the Midlands in the UK:


***The number of drug resistant cases of tuberculosis (TB) in the West Midlands continued to rise last year [2011]. One in every 14 cases of tuberculosis diagnosed in the region last year was resistant to at least one routine drug. More worryingly, a handful of cases were resistant to several drugs.

Coventry has some of the highest rates of TB in the country. Professor Ibrahim Abubakar, head of TB surveillance at the Health Protection Agency, said: "The increase in drug resistant cases remains a concern and a challenge to our efforts to control TB in the UK."

There are 4 main antibiotics used to treat TB, but a growing number of cases are resistant to one or more of those drugs. Patients usually contract a drug resistant strain of the disease from another person or as a result of inappropriate or incomplete treatment. The number of patients who complete their course of treatment has risen during the last 10 years but one in every 6 patients still does not finish their medication. Professor Abubakar said: "Failing to complete treatment is one of the key causes of drug resistance.

"TB disproportionately affects those in hard to reach and vulnerable groups, particularly migrants."

He said it was vital that NHS [National Health Service] managers in cities like Birmingham and Coventry that have the highest rates of TB prioritised the disease to reduce the number of cases in future. The West Midlands saw cases of TB fall to 872 in 2010. However, that figure rose to 1011 last year [2011] -- similar to the number of cases diagnosed in 2008 and 2009. Of those 38 cases were resistant to at least one drug. Professor Abubakar said: "Although we are disappointed that there has been an increase in new TB diagnoses in the past year, we are pleased that TB cases overall have been stabilising since 2005."

TB is often considered a historic disease but rates remain high in many deprived urban areas. People who are born in areas where TB is common are at a greater risk, as they are more likely to have been exposed to the disease. A regional project has been launched to tackle TB in hotspots such as Coventry. Target TB West Midlands is being coordinated by the Health Protection Agency and backed by councils, the NHS and the charity TB Alert. West Midlands director Dr Huda Mohamed said: "We must be aware that health services sometimes fail to reach some groups in the community and that increases the risk of delayed diagnosis and treatment. By working with these communities we hope to make a real difference."

[Byline: Warren Manger]

--
Communicated by:
ProMED-mail from HealthMap alerts
<promed@promedmail.org>

[Seven to 8 percent of those with no previous history of tuberculosis reported to the US National Tuberculosis Surveillance System in recent years had _Mycobacterium tuberculosis_ isolates with resistance to at least isoniazid (INH), a 1st-line drug used to treat TB; but the frequency of isoniazid-monoresistant TB cases has remained at slightly above 4 percent from 1993 to 2005 (http://archinte.jamanetwork.com/arti...ticleid=773435 and http://www.lung.org/lung-disease/tub...resistant.html).

Multidrug-resistant tuberculosis (MDR TB) is a form of tuberculosis that is resistant to at least isoniazid plus rifampin, 2 1st-line drugs used for the treatment of tuberculosis. The CDC reported that 1.0 percent of those with no previous history of TB (primary tuberculosis) in the US were resistant to both isoniazid and rifampin (http://www.lung.org/lung-disease/tub...resistant.html). The proportion of primary MDR TB cases disproportionately affects foreign-born persons in the United States. This group accounted for over 80 percent of such cases in 2010 (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6111a2.htm). Most of these cases are due to activation of latent TB infection. For persons with a previous history of TB, the percentage with MDR TB in 2010 was approximately 4 times greater than among persons not previously treated for TB. 4 cases of extensively drug-resistant TB or XDR-TB (all occurring in foreign-born persons) have been reported in the U.S. for 2011 (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6111a2.htm). XDR-TB is a form of the MDR-TB that is resistant to a fluoroquinolone and at least one of the injectable 2nd-line anti-TB drugs (kanamycin, capreomycin, or amikacin), in addition to being resistant to rifampin and isoniazid. Drug-resistant TB requires more extensive chemotherapy, involves drug therapy over more extended period of time, is more often unsuccessful, and is more expensive than treatment for drug-susceptible TB.***


http://www.promedmail.org/?p=2400:1000

[rb.]

Sue, am I "misremembering", or is it possible I had TB tests in elementary school in through the 70s, along with my classmates?

TB scares the crap outta' me. My grandfather spent about a year in sanatoriums after returning from WWII...England only.

[CanadaSue]

I remember those. I was exempted because at some point in my early childhood in Quebec - I got BCG.

[Mama Alanna]

As part of his regular military health checkups, DH had to take the TB stick test. It always reacted as positive, but more sensitive and accurate tests would show no sign of it. Could he have had this vaccine, I wonder? He doesn't know, and even if his mother were still alive, she couldn't tell him.

I wonder if that kind of test is what proteus is remembering as a vaccine. When you're a kid, a shot is a shot. You don't care, even if you know, whether it's a vaccination, an antibiotic, or a vitamin shot. They all hurt.

[Feather]

As part of his regular military health checkups, DH had to take the TB stick test. It always reacted as positive, but more sensitive and accurate tests would show no sign of it.

A friend always has a positive stick test and then they do an X-ray and it shows nothing in her lungs.

[rb.]

My mother always tested positive, due to having lived with her father when he had it. I think once you're exposed to it for a while, you are always positive on the stick tests.

[NowVoyager]

Originally Posted by rb.

My mother always tested positive, due to having lived with her father when he had it. I think once you're exposed to it for a while, you are always positive on the stick tests.

I think that may be possible.

But I don't believe it provides immunity, just ascertains that the bug is in your system, though inactive?

Regardless, with the growing number of strains that are drug resistant and a mobile population, etc; this is something which bears watching.

I do know that to volunteer in some situations, you have to get a TB test, and when my hubby was in an ALF, he was tested upon being admitted.

And I still think that it's a good idea for all food service workers to be tested. Back in CA when I was a kid, you had to be tested annually for TB and were issued a health card which could be revoked if you tested positive. Of course back then they also did regular inspections of food service businesses and said place had to display the grade they received, where the public could see it.

I understand where that is something that wouldn't make it today, due to PC attitudes and budget realities.

[oldasrocks]

This may be one of Mother Natures way of controlling the population. Sad but true. First the disease then low IQ, inept, PC thinking that camps like the old leper colonies are not feasable.

Whenever there is an overpopulation of rabbits a disease goes through the herd and kills off a high percentage of them. Unfortunely this same natural way of controlling overpopulation seems to be taking hold. We can avoid starvation, to a point, and othe minor problems that arise. These diseases will be unstoppable.

[spinnerholic]

I've tested positive with the stick test since I was a little kid. X-rays show no sign of the disease. Have been told it means that I was once exposed but my body was strong enough to fight it off.

It spreads fastest, as I understand it, when a lot of people live close together. Or ride crowded buses to and from work - things like that. Seldom, if ever, hear of out breaks in rural populations.

Just one more good reason not to live in a big city!