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TB outbreak contained one year after it was uncovered

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Updated: 5/17/2013 10:48 pm

By Stacey Singer/Palm Beach Post

JACKSONVILLE, Fla. -- One year after a CDC official described a North Florida tuberculosis outbreak as the worst in the nation in 20 years, the state's Department of Health has declared the outbreak contained and pulled back on a massive public health surge to find and test over 2,200 "high-priority contacts" of contagious sick people.

With its federal grant now expired, the state said it had found around 60 percent of the 2,261 people on the CDC's high-priority list, a testament to how difficult fighting contagious diseases can be when they strike people who are intermittently homeless, in jail or abusing drugs.

"It was a Herculean effort" requiring the help of health workers from around the state, added Dr. Dawn Allicock, interim director of the Duval County Health Department.

The state health officials found 32 people on the CDC's high-priority list were sick with active TB, and another 323 infected with latent TB, which isn't contagious.

Because people sick with latent TB occasionally develop the active disease, state officials were keen to treat them with preventive antibiotics, said Dr. Celeste Phillip, the interim bureau chief of the state's Bureau of Communicable Diseases.

But while all of those sick were treated, just over half of those with latent TB infection took the three-month course of weekly preventive antibiotics, she said.

Despite having discovered so many new cases of the outbreak TB strain, the state now claims the outbreak was smaller than a CDC team described a year ago, and attributes just one death to it.

The CDC's team had linked 12 deaths to the outbreak of a TB strain called FL 0046 that sickened 80 people between 2008 and 2011. Florida instead counts 60 cases during that period. Phillip said the discrepancy exists because the state was not genotyping every TB sample in the past, leaving many as "probable" or "suspected" outbreak cases. The state apparently didn't count them, while the CDC epidemiologists did. The outbreak strain is one of many TB strains circulating in the state.

Whatever the final tally, the genotyping data now show a clear decline in the percent of new TB cases that come from the outbreak strain, from 42 percent in 2011 to 12.5 percent of cases today, the state data show.

To contain its spread, the state temporarily mobilized the staff of 29 county health departments to Jacksonville. Their charge was to find, test and treat the thousands of people who might have circulated in and around people with active TB, Phillip said. For a time, they tested every person who entered a homeless shelter. The shelters and the jail adopted new protocols for screening staff and clients; beds were separated and moved head-to-toe; some shelters added UV lights and HEPA-filtered ventilation to clean their air. The CDC supplied a grant of $250,000 to support the effort.

Better antibiotics have dramatically lowered the prevalence of TB in the United States. But wherever the poor, homeless and uninsured congregate, TB has proven a stubborn foe for public health workers. That was especially true in Duval County, the epicenter of the outbreak.

Duval is a crossroads county where I-95 and I-10 converge, bringing with them a large and ever-shifting homeless population.

The FL 0046 outbreak had caught fire there in 2008 and 2009, tearing undetected through a Jacksonville assisted living home where many people with schizophrenia came and went. The state didn't aggressively try to find all the contacts of the sick, and that resulted in a second outbreak surge in 2011 and 2012, this time, linked to many more institutions. Hundreds of infected people moved to other states, although details aren't available.

The saga of the "index patient" whose illness spread so far was documented in the American Journal of Psychiatry in June 2012. Once diagnosed, he refused to take his medications and was sent to Lantana, to the A.G. Holley tuberculosis hospital, under a judge's order.

A.G. Holley was ordered closed by the Florida Legislature in early 2012, even as the CDC team converged on Duval. Most legislators knew nothing about the outbreak. The CDC team's report wasn't made public until The Palm Beach Post unearthed it in June, weeks after Florida Gov. Rick Scott had signed a bill closing the TB hospital, and downsizing and consolidating the state Health Department. The ensuing national and international attention led to the resignation and re-assignment of several high-level agency staff.

Scott's new state Surgeon General, Dr. John Armstrong, a former Army trauma surgeon, changed course and mobilized a military-style surge of specialists from health departments around the state to contain the outbreak.

TB is a sneaky disease. It spreads when droplets of moisture are coughed out by a contagious person and inhaled by someone nearby. What makes it uniquely difficult is its latent phase.

The TB bacteria can hide undetected within the lungs for years, and then burst out if stress or another illness weakens the immune system. Treating an active case takes six months or more on a combination of antibiotics, some of which have unpleasant side effects.

If there is a lesson to be learned from the experience, Phillip believes it's that an integrated state Health Department is critically important during unusual events like disease outbreaks or hurricanes.

"Because we are an integrated state system, we can work with each other, and move resources, people, supplies," she said. "This has been an unprecedented effort."

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