TB Outbreak in O.C. Was Preventable

A massive outbreak of tuberculosis at La Quinta High School in Westminster “could have been prevented” if private physicians who diagnosed the disease in a 16-year-old girl had informed county health authorities and her treatment had been closely monitored, said a report released Monday by the federal government.

The report concludes the Atlanta-based Centers for Disease Control’s investigation of the 1993 outbreak, in which 12 students were found with related cases of drug-resistant tuberculosis and 292 more were found infected with tuberculosis bacteria that could become active in the future.

The tuberculosis outbreak at La Quinta highlights the need for health departments nationwide to focus more resources on fighting the disease, which only a decade ago had been virtually eliminated in the United States, said federal public health officials. The disease has had a resurgence with increased immigration from Third World countries. La Quinta has a large percentage of Vietnamese in its student body.

While public health officials describe the Orange County incident as the largest school-based outbreak of drug-resistant tuberculosis in United States history, they said the public health shortcomings encountered in trying to control it are common throughout the country.

Among the problems in Orange County were failure by private physicians to report the disease, inadequate treatment of the patient believed to have spread the disease among classmates, and failure to monitor her compliance with treatment, according to the report.

Responding to those shortcomings, the county’s chief health officer Monday asked the Board of Supervisors to add $1.5 million a year to its $85-million annual public health budget to beef up tuberculosis prevention and investigation activities. The proposal will go to the board for consideration next week.

Dr. Hugh Stallworth, Orange County’s public health officer, said he would use the money to add 33 positions, including public health nurses and a public health medical officer, to the 70-member staff now assigned to tuberculosis.

Since the La Quinta outbreak, the Orange County Health Care Agency has taken several steps to improve its ability to combat the growing threat of tuberculosis, including hiring a public health nurse to serve as a liaison between the county health agency and private physicians.

State law requires hospitals, laboratories and private physicians to report immediately suspected cases of communicable diseases such as tuberculosis to county health officials so they can take necessary steps to prevent epidemics.

“We could have been more aggressive,” Stallworth admitted Monday, referring to the possibility that the county might have intervened earlier in the original patient’s care. “But this is a brand new arena, telling doctors how to practice medicine.”

The findings were also being assessed Monday by state health officials.

“One lesson learned is that we need to do a lot more,” said Dr. Richard Jackson, chief of communicable disease control for the state Department of Health Services. “La Quinta is the classic example of the event no one wants repeated.”

The findings of the Centers for Disease Control, or CDC, were published in reports received Monday by state and county officials and presented Monday at the federal agency’s Epidemic Intelligence Service Conference in Atlanta.

“The outbreak could have been prevented with earlier recognition and closer monitoring,” the report said, noting that the girl believed to have spread the disease might have been contagious for 30 months before she was removed from school at the end of her junior year to prevent any further spread.

She had a persistent cough symptomatic of active tuberculosis in January, 1991, the report noted, but her physician did not diagnose tuberculosis until 13 months later, and then failed to report the diagnosis to the county health department. County officials said the physician might have delayed notification pending confirmation by lab results.

County health officials learned of the diagnosis four months later, the report said, when results of a sputum culture were reported to them by the testing laboratory, as required by law.

But even after that, the county was unable despite repeated attempts to obtain information from the two attending physicians (including a pulmonary specialist) to determine if the student’s treatment was adequate, the report said.

A review of medical records by the CDC showed that the student’s two physicians did not document whether she followed the prescribed daily treatment regimen. Also, a review of pharmacy records showed she infrequently filled her prescriptions.

Dr. Penny Weismuller, the county’s manager for disease control, said the student was born in Southeast Asia and most likely contracted a drug-resistant strain of tuberculosis before moving to the United States. Her disease was probably activated by puberty, when sudden growth undermines the body’s immune system, Weismuller said.

The student was not placed on an adequate combination of drugs by her physicians and did not take the medication properly, she said. As a result, she said, the student’s infectious period was prolonged.

Dr. Kenneth Castro, director of the CDC’s division of tuberculosis elimination, said that problems in stopping the spread of TB at La Quinta are similar to the those the CDC has found in other TB outbreaks in the nation.

Castro said public health departments nationwide have been caught unprepared for the resurgence of TB, caused in part by increased immigration from Third World countries and the concurrent spread of the HIV epidemic, whose victims are particularly susceptible to drug-resistant forms of TB.

Dr. Renee Ridzon, who wrote the CDC’s report on TB at La Quinta, said the outbreak “underscores the need for prompt recognition, treatment and bacteriologic monitoring of all cases of tuberculosis.”

Among the report’s recommendations were that the county should develop education materials on TB for all Orange County physicians, review the propriety of treatment by private physicians, monitor patients to catch any relapses, and keep a lookout for tuberculosis that has a drug-resistant pattern.

“Most of these recommendations have been implemented or are in the process of being implemented,” Stallworth said.

In asking the board for additional funding, Stallworth said he wants an enlarged staff to implement his plans to skin-test all students who are new to Orange County and similarly to screen for TB all new prisoners to Orange County jails within 24 hours of their admission.

The county needs more staffing to make certain that TB patients complete their treatment, which can take up to a year, Stallworth said.

“We will assess early on the likelihood of someone following therapy and, if there is any question, we will make arrangements to have the person observed taking medication. If they can’t come to us, we will go to them,” he said.

The purpose of such vigilance, he said, is to reduce the chance that TB patients may infect others or develop drug-resistant TB, which can be deadly.

Tuberculosis Outbreak

Tuberculosis has been diagnosed in 12 students at La Quinta High School in Westminster. Some characteristics of these students: SEX Male: 2 Female: 10 AGE AT DIAGNOSIS 15: 1 16: 4 17: 4 18: 2 19: 1 BIRTHPLACE United States: 4 Vietnam: 8 ETHNICITY White: 3 Asian: 9 SITE OF INFECTION Lung lining (not infectious): 3 Lung tissue (infectious): 8 Neck lymph node (infectious): 1 Source: U.S. Centers for Disease Control