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Outbreak of tuberculosis in a poor urban community
Journal of Infection (I99 I) 23, 327-329
SHORT COMMUNICATION Outbreak of tuberculosis in a poor urban community C. Teale,* D. B. CundallT a n d S. B. P e a r s o n *
* Leeds Chest Clinic, 74 New Briggate, Leeds L S I 6PH and afDepartment of Paediatrics and Child Health, St James' University Hospital, Beckett Street, Leeds LS9 7TF, U.K. Accepted for publication I7 June 1991 Summary A woman from a poor urban community presented recently with pulmonary tuberculosis. Screening of contacts revealed Io cases of tuberculosis, eight of whom were children. A further lO children had grade 2-3 positive Heaf tests and were given chemoprophylaxis. Tuberculosis remains a potential problem, particularly in young unimmunised children in deprived areas.
Introduction T h e incidence of tuberculosis in the U . K . is declining. Immigrants have been r e p o r t e d to be at increased risk of tuberculosis I b u t the risks in a poor white c o m m u n i t y m a y not be fully recognised. W e report an outbreak of tuberculosis in a deprived indigenous c o m m u n i t y where contact tracing identified 20 infected contacts most of w h o m were asymptomatic.
Description of outbreak In 1988 an outbreak of tuberculosis occurred in a p r e d o m i n a n t l y white council estate within the L e e d s U r b a n Priority Area, identified b y the council as an area o f deprivation. T h e source case was a 23-year-old w o m a n w h o presented with a c o u g h ; chest radiography s h o w e d a left apical cavity and in the s p u t u m were acid-fast bacilli which p r o v e d on culture to be Mycobacterium tuberculosis. Screening of 4oo contacts, 91 of w h o m attended the chest clinic, identified IO further cases of tuberculosis (details in T a b l e I). All b u t two patients were less than 9 years old. O n e child had a cough, one had general malaise and one adult had lost weight b u t all others were asymptomatic. O n chest radiography five patients had hilar l y m p h a d e n o p a t h y , two had areas of consolidation, two had pleural effusions and one had collapse of the right middle lobe. T e n children required chemoprophylaxis for unexplained positive H e a l tests (grade 2 or 3). T h e place of contact for Io o u t of the 2o w h o were infected was the local school or the c o m m u n i t y centre.
Discussion O u r findings demonstrate that, despite the declining incidence of tuberculosis, poor indigenous as well as immigrant communities remain at significant risk. T h e e n o r m o u s decline in the prevalence of tuberculosis since the middle of the o163-4453/91/o6o327+o 3 $03.00/0
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C. T E A L E E T
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T a b l e I Tuberculosis outbreak in an area of urban deprivation : description of cases (excluding Io children given chemoprophylaxis) Case Age/sex I 2 3 4 5 6 7 8 9 IO II
23 F 5M 5M 4F 6F 8M 2M 4F 6F 23 F 26 F
Heal
Sputum
H2 H2 H2 H2 H2 H2 H2 H4 H2 H2 H2
S+ SSSSSSSSSS-
Contact
Symptoms
Source Cough Son r } Sibs 0 Son I o S/CC Cough S/CC/* ~ o S / C C / * , Sibs o Nephew i) Sibs o Niece I Malaise S/CC o S/CC o S/CC Weight loss
Case details L apical cavity L hilar nodes L hilar nodes R mid-lobe collapse L hilar nodes L hilar nodes R hilar nodes R effusion R consolidation R consolidation L effusion
S, Sputum smear positive (+) or negative ( - ) for TB. S/CC, Contact by school or community centre. *, Mother of cases 5 and 6 is a close friend of the source case.
last century has been primarily attributed to improvements in housing and nutrition. Both factors were probably i m p o r t a n t in this outbreak. Nutritional status was not formally assessed, but poverty and social factors are likely to have led to poor nutrition, as has been described in a previous outbreak of tuberculosisfl I n addition, poor housing and the close-knit structure o f the c o m m u n i t y , with sharing of the c o m m u n i t y centre and child care facilities, probably contributed. T h e outbreak also supports the findings of an earlier study in Leeds, which showed that poverty rather t h a n race was the i m p o r t a n t risk factor for tuberculosis in the city. 3 B C G immunisation is routinely offered to children aged 12 or 13 years in Leeds and hence the majority of those infected in this outbreak were not protected. I n f a n t B C G i m m u n i s a t i o n has been shown to confer useful protection against the development of tuberculosis in childhood. 4 It has recently been suggested that B C G should be offered to all neonates in areas of deprivation. ~ Such a policy would probably have reduced the extent of this outbreak. T h i s outbreak also demonstrates the importance of contact screening in the early detection of asymptomatic tuberculosis. I n the majority of our cases contact was t h r o u g h the school or c o m m u n i t y centre; this is unusual and stresses the importance of screening n o n - f a m i l y contacts, especially in a close c o m m u n i t y . A n outbreak of tuberculosis was recently reported in an Oxfordshire school 6 in which a teacher infected nine of her 32 pupils, three o f w h o m had radiological evidence of p r i m a r y p u l m o n a r y tuberculosis. T h e r e is still a significant mortality from tuberculosis. A recent survey in E n g l a n d and Wales reported a 15 % mortality among adult patients, with the majority of deaths occurring within the first m o n t h after starting treatment. 7 N o n e of our contacts had bacteriologically proven disease. Only one had a productive cough; in y o u n g children s p u t u m collection usually involves
Tuberculosis in a poor c o m m u n i t y
329
invasive p r o c e d u r e s , and in the presence o f clear radiological evidence o f disease w o u l d n o t have altered m a n a g e m e n t , given that the source case was k n o w n to be fully sensitive. I n conclusion this r e p o r t emphasises the c o n t i n u i n g risk o f tuberculosis in p o o r indigenous as well as i m m i g r a n t c o m m u n i t i e s , and also the role o f contact tracing in limiting the severity and extent o f an o u t b r e a k o f the disease. Offering infant B C G i m m u n i s a t i o n in areas o f d e p r i v a t i o n m a y be o f value in p r e v e n t i n g such outbreaks.
References I. Joint Tuberculosis Committee. Tuberculosis among immigrants in Britain. Br Med J 1978; I : lO38-1o4o. 2. Packe, GE, Patchett PA, Innes JA. Tuberculosis outbreak among Rastafarians in Birmingham. Lancet 1985; i: 627-628. 3. Cundall DB, Pearson SB. Inner city tuberculosis and immunisation policy. Arch Dis Child 1988; 63 : 964-966. 4. Packe GE, Innes JA. Protective effect of BCG vaccination in infant Asians: a case control study. Arch Dis Child 1988; 63: 277-281. 5- Conway SP. BCG vaccination in children. Br Med ff 199o; 3o1: lO59-1o6o. 6. Frew AJ, Mayon-White RT, Benson MK. An outbreak of tuberculosis in an Oxfordshire school. Br J Dis Chest 1987; 81: 293-295. 7. Humphries MJ, Byfield SP, Darbyshire JH et al. Deaths occurring in newly notified patients with pulmonary tuberculosis in England and Wales. Br J Dis Chest 1984; 78: 149-158.
SHORT COMMUNICATION Outbreak of tuberculosis in a poor urban community C. Teale,* D. B. CundallT a n d S. B. P e a r s o n *
* Leeds Chest Clinic, 74 New Briggate, Leeds L S I 6PH and afDepartment of Paediatrics and Child Health, St James' University Hospital, Beckett Street, Leeds LS9 7TF, U.K. Accepted for publication I7 June 1991 Summary A woman from a poor urban community presented recently with pulmonary tuberculosis. Screening of contacts revealed Io cases of tuberculosis, eight of whom were children. A further lO children had grade 2-3 positive Heaf tests and were given chemoprophylaxis. Tuberculosis remains a potential problem, particularly in young unimmunised children in deprived areas.
Introduction T h e incidence of tuberculosis in the U . K . is declining. Immigrants have been r e p o r t e d to be at increased risk of tuberculosis I b u t the risks in a poor white c o m m u n i t y m a y not be fully recognised. W e report an outbreak of tuberculosis in a deprived indigenous c o m m u n i t y where contact tracing identified 20 infected contacts most of w h o m were asymptomatic.
Description of outbreak In 1988 an outbreak of tuberculosis occurred in a p r e d o m i n a n t l y white council estate within the L e e d s U r b a n Priority Area, identified b y the council as an area o f deprivation. T h e source case was a 23-year-old w o m a n w h o presented with a c o u g h ; chest radiography s h o w e d a left apical cavity and in the s p u t u m were acid-fast bacilli which p r o v e d on culture to be Mycobacterium tuberculosis. Screening of 4oo contacts, 91 of w h o m attended the chest clinic, identified IO further cases of tuberculosis (details in T a b l e I). All b u t two patients were less than 9 years old. O n e child had a cough, one had general malaise and one adult had lost weight b u t all others were asymptomatic. O n chest radiography five patients had hilar l y m p h a d e n o p a t h y , two had areas of consolidation, two had pleural effusions and one had collapse of the right middle lobe. T e n children required chemoprophylaxis for unexplained positive H e a l tests (grade 2 or 3). T h e place of contact for Io o u t of the 2o w h o were infected was the local school or the c o m m u n i t y centre.
Discussion O u r findings demonstrate that, despite the declining incidence of tuberculosis, poor indigenous as well as immigrant communities remain at significant risk. T h e e n o r m o u s decline in the prevalence of tuberculosis since the middle of the o163-4453/91/o6o327+o 3 $03.00/0
© i99i The British Society for the Study of Infection
328
C. T E A L E E T
AL.
T a b l e I Tuberculosis outbreak in an area of urban deprivation : description of cases (excluding Io children given chemoprophylaxis) Case Age/sex I 2 3 4 5 6 7 8 9 IO II
23 F 5M 5M 4F 6F 8M 2M 4F 6F 23 F 26 F
Heal
Sputum
H2 H2 H2 H2 H2 H2 H2 H4 H2 H2 H2
S+ SSSSSSSSSS-
Contact
Symptoms
Source Cough Son r } Sibs 0 Son I o S/CC Cough S/CC/* ~ o S / C C / * , Sibs o Nephew i) Sibs o Niece I Malaise S/CC o S/CC o S/CC Weight loss
Case details L apical cavity L hilar nodes L hilar nodes R mid-lobe collapse L hilar nodes L hilar nodes R hilar nodes R effusion R consolidation R consolidation L effusion
S, Sputum smear positive (+) or negative ( - ) for TB. S/CC, Contact by school or community centre. *, Mother of cases 5 and 6 is a close friend of the source case.
last century has been primarily attributed to improvements in housing and nutrition. Both factors were probably i m p o r t a n t in this outbreak. Nutritional status was not formally assessed, but poverty and social factors are likely to have led to poor nutrition, as has been described in a previous outbreak of tuberculosisfl I n addition, poor housing and the close-knit structure o f the c o m m u n i t y , with sharing of the c o m m u n i t y centre and child care facilities, probably contributed. T h e outbreak also supports the findings of an earlier study in Leeds, which showed that poverty rather t h a n race was the i m p o r t a n t risk factor for tuberculosis in the city. 3 B C G immunisation is routinely offered to children aged 12 or 13 years in Leeds and hence the majority of those infected in this outbreak were not protected. I n f a n t B C G i m m u n i s a t i o n has been shown to confer useful protection against the development of tuberculosis in childhood. 4 It has recently been suggested that B C G should be offered to all neonates in areas of deprivation. ~ Such a policy would probably have reduced the extent of this outbreak. T h i s outbreak also demonstrates the importance of contact screening in the early detection of asymptomatic tuberculosis. I n the majority of our cases contact was t h r o u g h the school or c o m m u n i t y centre; this is unusual and stresses the importance of screening n o n - f a m i l y contacts, especially in a close c o m m u n i t y . A n outbreak of tuberculosis was recently reported in an Oxfordshire school 6 in which a teacher infected nine of her 32 pupils, three o f w h o m had radiological evidence of p r i m a r y p u l m o n a r y tuberculosis. T h e r e is still a significant mortality from tuberculosis. A recent survey in E n g l a n d and Wales reported a 15 % mortality among adult patients, with the majority of deaths occurring within the first m o n t h after starting treatment. 7 N o n e of our contacts had bacteriologically proven disease. Only one had a productive cough; in y o u n g children s p u t u m collection usually involves
Tuberculosis in a poor c o m m u n i t y
329
invasive p r o c e d u r e s , and in the presence o f clear radiological evidence o f disease w o u l d n o t have altered m a n a g e m e n t , given that the source case was k n o w n to be fully sensitive. I n conclusion this r e p o r t emphasises the c o n t i n u i n g risk o f tuberculosis in p o o r indigenous as well as i m m i g r a n t c o m m u n i t i e s , and also the role o f contact tracing in limiting the severity and extent o f an o u t b r e a k o f the disease. Offering infant B C G i m m u n i s a t i o n in areas o f d e p r i v a t i o n m a y be o f value in p r e v e n t i n g such outbreaks.
References I. Joint Tuberculosis Committee. Tuberculosis among immigrants in Britain. Br Med J 1978; I : lO38-1o4o. 2. Packe, GE, Patchett PA, Innes JA. Tuberculosis outbreak among Rastafarians in Birmingham. Lancet 1985; i: 627-628. 3. Cundall DB, Pearson SB. Inner city tuberculosis and immunisation policy. Arch Dis Child 1988; 63 : 964-966. 4. Packe GE, Innes JA. Protective effect of BCG vaccination in infant Asians: a case control study. Arch Dis Child 1988; 63: 277-281. 5- Conway SP. BCG vaccination in children. Br Med ff 199o; 3o1: lO59-1o6o. 6. Frew AJ, Mayon-White RT, Benson MK. An outbreak of tuberculosis in an Oxfordshire school. Br J Dis Chest 1987; 81: 293-295. 7. Humphries MJ, Byfield SP, Darbyshire JH et al. Deaths occurring in newly notified patients with pulmonary tuberculosis in England and Wales. Br J Dis Chest 1984; 78: 149-158.