Agency Faults Itself for Major TB Outbreak : Health: County officials say they failed to properly monitor tubercular student who developed contagious strain that probably infected 12 classmates.

County health officials acknowledged Friday that they failed to adequately follow the treatment of an Orange County high school student with active tuberculosis who probably infected 12 classmates.

They also said that from what they have learned from the recent TB outbreak at La Quinta High School, the Orange County Health Care Agency has initiated reforms to assure closer collaboration between the county public health office and private physicians and laboratories in the care of tubercular patients.

“We have instituted more aggressive systems to assure this will never happen again,” said Penny Weismuller, the county’s manager for disease control.

The changes come in response to recent critiques of the agency’s handling of the La Quinta outbreak by the federal Centers for Disease Control in Atlanta and the state Department of Health Services.

After the County Health Care Agency learned in June, 1992, that a student at Quinta High School in Westminster had tuberculosis, a county worker made 25 unsuccessful attempts during a seven-month period to obtain information from the girl’s physicians about the progress of her treatment, Weismuller said.

Later, it was determined that the student’s erratic practice of taking prescribedantibiotics led to her to develop a contagious, mutant form of the tuberculosis bacterium that was drug-resistant, she said.

“We were assuming, maybe it was a false assumption, that the patient was being treated adequately,” said Dr. Hugh Stallworth, Orange County’s public health officer. He noted that the student was being seen by both a primary care physician and pulmonary specialist who had assured county officials that she was not contagious.

Federal and state investigators, whom the county invited to critique their handling of the tuberculosis outbreak, concluded that the county should have been “more aggressive” in its monitoring of the initial infected student, Stallworth said.

The county ultimately took over the girl’s treatment in June when her doctors were puzzled why she had a “positive” sputum culture, a sign of active tuberculosis, after a year of treatment, Weismuller said.

Then, in September the student was hospitalized because she was violating quarantine requirements that she stay out of public places, Weismuller said.

Because of growing concern that the infected student might be spreading her disease, Weismuller said, county health workers last spring tested 225 of her La Quinta classmates, followed in the fall by a screening of the entire student body.

In all, 16 cases of active TB were discovered at La Quinta, 12 of which were linked to the girl. An additional 178 students were found to be infected with the bacteria that causes TB.

Stallworth believes that the outbreak was the largest one in an American high school this century.

Weismuller said the La Quinta case illustrates shortcomings of the private medical community and the county in monitoring tubercular patients.

She said a review of medical records shows that the student believed responsible for the TB outbreak at La Quinta was infectious since January, 1991, when she went to a private doctor complaining of a cough.

The private physician, Weismuller said, misdiagnosed her ailment as bronchitis.

The student, who wasn’t getting well, went to another physician who, as early as January, 1991, suspected that she had tuberculosis but did not report that to the county until June when he received laboratory reports that confirmed his diagnosis.

“He should have reported even a suspicion of tuberculosis to us,” Weismuller said.

Stallworth and Weismuller said they have taken steps to make certain the mistakes at La Quinta will not be repeated.

“We probably could have policed the private physicians more,” Stallworth said. Because tuberculosis had almost disappeared in the United States, and has been increasing only since the mid-1980s, he said, many physicians need help in diagnosing and treating it.

“What public health is being asked to do is monitor what private physicians are doing,” Stallworth said.

In the wake of the problems associated with the outbreak, he said, the county has hired a public health nurse to work with doctors who report TB cases to the county.

Stallworth said the physicians will be asked to show the county the kind of treatment they are prescribing and will be advised if any change should be made.

Because the treatment for tuberculosis can take as long as 12 months, Weismuller said, it it especially important to keep tabs on patient compliance.

“It is very difficult for any patient to comply with a long-term course of therapy,” she said, “and the resources available in a private physician’s office to keep track, for instance, of broken appointments with doctors, is limited. So we have to work together.”

In addition, Stallworth said, he has added a new position of tuberculosis program manager and an epidemiologist to oversee the search for people who have had contact with confirmed TB patients and must be tested.

County officials said they also plan to hand-deliver letters to all local laboratories, asking them to report initial positive TB tests, without waiting for final results. Weismuller said the county will be assisted by changes in a state law, which became effective in January, that requires the county health agency’s approval of the treatment plan for every TB patient.

“I think it came out of increased concern for the rising number of TB cases nationwide,” she said.