- Email: [email protected]
TUBERCULOSIS OUTBREAK AMONG RASTAFARIANS IN BIRMINGHAM
627
these variables operate independently of one another in distinguishing suicide victims from their matched controls. This supports the validity of the statistical differences between the suicide group and each of the matched controls.
Discussion
findings of this study provide evidence that perinatal experience influences the risk of suicide in adolescence. Many babies survive adverse perinatal conditions, and therefore we do not suggest a direct relationship between perinatal adversity and eventual suicide. It would seem plausible, however, that whatever environmental conditions, such as family stresses, economic pressures, or adolescent turmoil, might precipitate suicide, those individuals whose early life experience included adverse perinatal conditions are more vulnerable to suicide during adolescence. The
In recent years, neonatal intensive care has saved many infants who formerly would have died from respiratory distress. That a substantial proportion of adolescent suicide victims were survivors of neonatal respiratory distress suggests that resuscitation may contribute, in ways not yet understood, to early death by suicide. Though the mechanisms are not yet understood, the identification of previously unknown suicide risk factors
Public Health TUBERCULOSIS OUTBREAK AMONG RASTAFARIANS IN BIRMINGHAM P. A. PATCHETT
G. E. PACKE
J. A.
We thank the Harris Foundation, the W. T. Grant Foundation, and the Hoffman-La Roche Corporation for research suport. Correspondence should be addressed to L. S., 941 Park Avenue, New York, NY 10028, USA.
REFERENCES 1. US Bureau of the Census. Statistical abstract of the United
States, 104th edition. Washington DC, 1983. 2. Eisenberg L. The epidemiology of suicide in adolescents. Padiatr Ann 1984; 13: 47-54. 3. Solomon MI, Hellon CP. Suicide and age in Alberta, Canada, 1951 to 1977. Arch Gen Psychiatr 1980; 37: 511-13. 4. Murphy GE, Wetzel RD. Suicide risk by birth cohort in the United States, 1949 to 1974. Arch Gen Psychiatr 1980; 37: 519-23. 5. Littman B, Parmelee AH Jr. Manual for obstetrical complications, unpublished, 1974; modified from Littman B. The relationship of medical events to infant development. In: Field TM, ed. Infants born at risk: Behaviour and development. New York and London: Spectrum Publications, 1979: 60-61. 6. Prechtl HFR. Neurological findings in newborn infants after pre- and perinatal complications. In: Jonix JHP, Visser HKA, Troelstra JA, eds. Aspects of prematurity and dysmaturity. Leiden: Stenfert Kroese, 1968: 303-21. 7. Prenatal care in the United States, 1969-1975. Vital and Health Statistics, ser 21, no 33, 4. DHEW publication no (PHS) 78-1911. US Department of Health, Education and Welfare, Public Health Service, National Center for Health Statistics, September, 1978.
green, gold, and red of the Ethiopian flag; and communicate with one another in a Jamaican patois. In this way they have created an exclusive status and distanced themselves from white society.’ The outbreak spread by casual contact among young Rastafarians living in an inner suburb of Birmingham.
INNES
Birmingham Chest Clinic, 151 Great Charles Street, Queensway, Birmingham B3 3HX IN1’ROVUCllON
OVER the past two decades, attention has focused on the incidence of tuberculosis in Asian immigrants to the UK. By contrast, the incidence among West Indians, the other major immigrant group, has been much lower, though above that for the indigenous population.’-3 This trend has been mirrored in Birmingham.4,s Since 1981 there has been a marked rise in the annual notifications for tuberculosis in West Indians caused by an outbreak among young West Indians belonging to the Rastafarian cult (figure). This religious movement began in Jamaica in the 1930s although its origins can be traced back to the African slave trade. It was initiated by Marcus Garvey, a black activist, who prophesied the coronation ofa black king in Africa. When, in 1930, Prince (Ras) Tafari was crowned Emperor Haile Selassie of Ethiopia, followers of Garvey took this to be a fulfilment of his prophesy and they became known as Rastafarians.6 The cult was popularised in the 1970s by the reggae singer Bob Marley, and was adopted by many young West Indians living in the UK who felt rejected by white society and who wanted to shape a new identity for themselves.The cult has no formal religious structure. Members meet together in "reasoning sessions" where cannabis ("holy herb") is smoked to promote exchange of ideas. The bible is taken as the central text but is radically reinterpreted. Rastafarians believe in the divinity of Haile Selassie and in Africa as their spiritual homeland. They style their hair long ("dreadlocks"); wear items of clothing in the
high
offers opportunities for prevention. Further studies of infant and maternal factors which combine with subsequent life events to compound the risks of adolescent suicide seem warranted.
THE OUTBREAK
patient presented in August, 1981, with tuberculosis. Up to the end of 1983, 44 Rastafarians (including their children) were diagnosed-most during a 12 month period in 1981-82. There were 36 males and 8 females. The median age was 18 years (range 4 months to 41 years). 8 were immigrants, the remainder were born in the UK. 2 other West Indians contracted tuberculosis from Rastafarians. 7 children were given chemoprophylaxis, 5 of whom were included with notifications for tuberculosis. 53 individuals received treatment. The first
pulmonary
Annual tuberculosis notifications in Birmingham for patients of West Indian descent.
628
Most patients lived in the Handsworth district of Birmingham. All except 5 of the adults were unemployed. 2 of the men were living in derelict property. The outbreak centred on three families in each of which the male head of the household had been born in the UK and had cavitating pulmonary tuberculosis. 25 patients presented to their general practitioners, and 6 to hospital casualty departments. 1 patient was diagnosed after attending a radiography centre. Screening of domestic contacts yielded 19 cases out of 318 subjects examined. Attempts to extend contact tracing to the casual contacts of those with open pulmonary disease were unsuccessful-Rastafarians were reluctant to disclose the names of close acquaintances. Later it became evident that many of the adults were known to each other although a source case could not be identified. 2 patients were diagnosed after routine screening-1 while in a detention centre and 1 while in prison-both had been in recent contact with Rastafarians with tuberculosis. 42 had pulmonary disease. 10 had radiographic shadowing occupying an area greater than one hemithorax, 8 with cavitation. 20 patients were positive on sputum culture of whom 16 were positive on direct smear. 17 patients with primary tuberculosis had a primary complex on the chest radiograph and a positive tuberculin test. 3 patients with respiratory tuberculosis had disease at other sites; 1 had ileocaecal and testicular involvement,1 had testicular disease, and 1 had tuberculous peritonitis. Military disease was present in 2 other cases. In Birmingham, children aged 13 years are offered BCG vaccination. Local authority records confirmed that 15 Rastafarians had been vaccinated. Among these were 5 patients with cavitating lung disease and a patient who died from tuberculous meningitis. Treatment was supervised by chest physicians at three hospitals. 1 patient was treated by a specialist in infectious diseases. All except 9 patients were treated initially as inpatients. Most were given ethambutol, isoniazid, and rifampicin for two months, followed by isoniazid and rifampicin for not less than seven months. Rifampicin had to be stopped in one case because of thrombocytopenia. Those given chemoprophylaxis received isoniazid for six months, either alone or combined with ethambutol or rifampicin. Many of the Rastafarians complied poorly with treatment and- often did not attend clinics. Drug therapy was, nevertheless effective in most. 14 patients had their treatment supervised for an initial two-month period in hospital, while in 8 others the recommended nine-month period of treatment8 was extended by up to eight months. In an effort to encourage patients to take their therapy a team of health visitors took regular tablet counts in the patients’ homes and checked that patients were collecting their prescriptions. All except 5 patients made an uncomplicated recovery. 1 patient died of tuberculous meningitis, 1 was left with a spastic paraparesis, and 1 had extensive cavitating disease destroying a lung. 1 had an orchidectomy, and another underwent spinal fusion because of spinal collapse. DISCUSSION
This outbreak of tuberculosis was unusual in that it occurred exclusively among young West Indians. The preponderance of males is noteworthy. The Rastafarian movement emphasises the role of the male, the matriarchal family structure of traditional West Indian society being seen as a legacy of colonial domination. Gatherings of Rastafarians are likely to have been attended mainly by males.
What factors could have favoured the spread of disease in this outbreak? Many had advanced disease at presentation, and 16 had positive sputum smears. This could have been due either to increased susceptibility to disease or to delay in seeking medical attention. Two recent outbreaks in the UK have illustrated how patients with open tuberculosis can transmit disease to contacts by only slight exposure.9,IO There was therefore a core of highly infectious subjects who could have easily spread infection during meetings of young
Rastafarians. The Rastafarian diet, known as I-tal, is vegetarian and associated nutritional deficiencies have been reported. Vitamin B12 deficiency has been described in young adult Rastafarians in Jamaica, 11 and rickets in the children of Rastafarians in the UK.12 Many of those in the present outbreak were vegetarian. Under conditions of socioeconomic disadvantage, a deficient diet could have resulted in impaired host resistance and increased risk of infection. Failure of BCG vaccination to confer protection in 15 cases was unexpected. BCG vaccination is thought to act by limiting multiplication of bacilli rather than by preventing the establishment of disease.13The patients with open
pulmonary diseases are likely to have been disseminating large numbers of bacilli, and active disease is more likely to develop in subjects inspiring a large infective dose of tubercle bacilli. 14 In some cases the protective effect of BCG may have been overwhelmed by a large innoculum of tubercle bacilli. In the most recent national survey of tuberculosis in the rate for children born in the UK of immigrant parents was between that of children born abroad and that of white children born in the UK.3 The future pattern among these children as they grow older is unknown, but the disease may, as the present outbreak illustrates, pose a
UK, the notification
serious threat
to
health.
We thank Mrs M. Connolly for supervising contact tracing, Dr V. H. Springett for comments on the paper, and physicians in Birmingham for allowing us to study patients under their care.
Correspondence should be addressed to G. E. P., Department of Thoracic Medicine, East Birmingham Hospital, Bordesley Green East, Birmingham B9 5ST.
REFERENCES 1. British Tuberculosis Association. Tuberculosis among
immigrants to England and Wales: a national survey in 1965. A report from the Research Committee of the British Tuberculosis Association. Tubercle 1966; 47: 145-56. 2. British Thoracic and Tuberculosis Association. A tuberculosis survey in England and Wales 1971; the influence of immigration and country of birth upon notifications. A report from the Research Committee of the British Thoracic and Tuberculosis Association. Tubercle 1973; 54: 249-60. 3. Medical Research Council. National survey of tuberculosis notifications in England and Wales 1978-9. Br Med J 1980; 281: 895-98. 4. Springett VH. Tuberculosis in immigrants. An analysis of notification-rates in Birmingham, 1960-62. Lancet 1964; i: 1091-95. 5. Springett VH. Tuberculosis in immigrants in Birmingham 1970-72. Br J Prev Soc Med 1973; 27: 242-46. 6. Barrett LE. The rastafarians. The dreadlocks of Jamaica. London: Heinemann Educational Books, 1977. 7. Cashmore E. Rastaman. The rastafarian movement in England. London: Unwin Paperbacks, 1983. 8. British Thoracic and Tuberculosis Association. Short-course chemotherapy in pulmonary tuberculosis. Lancet 1976; ii: 1102-04. 9. Rao VR, Joanes RF, Kilbane P, Galbraith NS. Outbreak of tuberculosis after minimal exposure to infection. Br Med J 1980; 281: 187-89. 10. Roderick Smith WH, Davies D, Mason KD, Onions JP. Intraoral and pulmonary tuberculosis following dental treatment. Lancet 1982; i: 842-43. 11. Campbell M, Lofters WS, Gibbs WN. Rastafarianism and the vegans syndrome. Br Med J 1982; 285: 1617-18. PS, Drakeford JP, Milton J, James JA. Nutritional rickets in rastafarian children. Br Med J 1982; 285: 1242-43. 13. Sutherland I, Lingren I. The protective effect of BCG vaccination as indicated by autopsy studies. Tubercle 1979; 60: 225-31. 14. Rouillon A, Perdrizet S, Parrot R. Transmission of tubercle bacilli: the effects of chemotherapy. Tubercle 1976; 57: 275-99.
12. Ward
these variables operate independently of one another in distinguishing suicide victims from their matched controls. This supports the validity of the statistical differences between the suicide group and each of the matched controls.
Discussion
findings of this study provide evidence that perinatal experience influences the risk of suicide in adolescence. Many babies survive adverse perinatal conditions, and therefore we do not suggest a direct relationship between perinatal adversity and eventual suicide. It would seem plausible, however, that whatever environmental conditions, such as family stresses, economic pressures, or adolescent turmoil, might precipitate suicide, those individuals whose early life experience included adverse perinatal conditions are more vulnerable to suicide during adolescence. The
In recent years, neonatal intensive care has saved many infants who formerly would have died from respiratory distress. That a substantial proportion of adolescent suicide victims were survivors of neonatal respiratory distress suggests that resuscitation may contribute, in ways not yet understood, to early death by suicide. Though the mechanisms are not yet understood, the identification of previously unknown suicide risk factors
Public Health TUBERCULOSIS OUTBREAK AMONG RASTAFARIANS IN BIRMINGHAM P. A. PATCHETT
G. E. PACKE
J. A.
We thank the Harris Foundation, the W. T. Grant Foundation, and the Hoffman-La Roche Corporation for research suport. Correspondence should be addressed to L. S., 941 Park Avenue, New York, NY 10028, USA.
REFERENCES 1. US Bureau of the Census. Statistical abstract of the United
States, 104th edition. Washington DC, 1983. 2. Eisenberg L. The epidemiology of suicide in adolescents. Padiatr Ann 1984; 13: 47-54. 3. Solomon MI, Hellon CP. Suicide and age in Alberta, Canada, 1951 to 1977. Arch Gen Psychiatr 1980; 37: 511-13. 4. Murphy GE, Wetzel RD. Suicide risk by birth cohort in the United States, 1949 to 1974. Arch Gen Psychiatr 1980; 37: 519-23. 5. Littman B, Parmelee AH Jr. Manual for obstetrical complications, unpublished, 1974; modified from Littman B. The relationship of medical events to infant development. In: Field TM, ed. Infants born at risk: Behaviour and development. New York and London: Spectrum Publications, 1979: 60-61. 6. Prechtl HFR. Neurological findings in newborn infants after pre- and perinatal complications. In: Jonix JHP, Visser HKA, Troelstra JA, eds. Aspects of prematurity and dysmaturity. Leiden: Stenfert Kroese, 1968: 303-21. 7. Prenatal care in the United States, 1969-1975. Vital and Health Statistics, ser 21, no 33, 4. DHEW publication no (PHS) 78-1911. US Department of Health, Education and Welfare, Public Health Service, National Center for Health Statistics, September, 1978.
green, gold, and red of the Ethiopian flag; and communicate with one another in a Jamaican patois. In this way they have created an exclusive status and distanced themselves from white society.’ The outbreak spread by casual contact among young Rastafarians living in an inner suburb of Birmingham.
INNES
Birmingham Chest Clinic, 151 Great Charles Street, Queensway, Birmingham B3 3HX IN1’ROVUCllON
OVER the past two decades, attention has focused on the incidence of tuberculosis in Asian immigrants to the UK. By contrast, the incidence among West Indians, the other major immigrant group, has been much lower, though above that for the indigenous population.’-3 This trend has been mirrored in Birmingham.4,s Since 1981 there has been a marked rise in the annual notifications for tuberculosis in West Indians caused by an outbreak among young West Indians belonging to the Rastafarian cult (figure). This religious movement began in Jamaica in the 1930s although its origins can be traced back to the African slave trade. It was initiated by Marcus Garvey, a black activist, who prophesied the coronation ofa black king in Africa. When, in 1930, Prince (Ras) Tafari was crowned Emperor Haile Selassie of Ethiopia, followers of Garvey took this to be a fulfilment of his prophesy and they became known as Rastafarians.6 The cult was popularised in the 1970s by the reggae singer Bob Marley, and was adopted by many young West Indians living in the UK who felt rejected by white society and who wanted to shape a new identity for themselves.The cult has no formal religious structure. Members meet together in "reasoning sessions" where cannabis ("holy herb") is smoked to promote exchange of ideas. The bible is taken as the central text but is radically reinterpreted. Rastafarians believe in the divinity of Haile Selassie and in Africa as their spiritual homeland. They style their hair long ("dreadlocks"); wear items of clothing in the
high
offers opportunities for prevention. Further studies of infant and maternal factors which combine with subsequent life events to compound the risks of adolescent suicide seem warranted.
THE OUTBREAK
patient presented in August, 1981, with tuberculosis. Up to the end of 1983, 44 Rastafarians (including their children) were diagnosed-most during a 12 month period in 1981-82. There were 36 males and 8 females. The median age was 18 years (range 4 months to 41 years). 8 were immigrants, the remainder were born in the UK. 2 other West Indians contracted tuberculosis from Rastafarians. 7 children were given chemoprophylaxis, 5 of whom were included with notifications for tuberculosis. 53 individuals received treatment. The first
pulmonary
Annual tuberculosis notifications in Birmingham for patients of West Indian descent.
628
Most patients lived in the Handsworth district of Birmingham. All except 5 of the adults were unemployed. 2 of the men were living in derelict property. The outbreak centred on three families in each of which the male head of the household had been born in the UK and had cavitating pulmonary tuberculosis. 25 patients presented to their general practitioners, and 6 to hospital casualty departments. 1 patient was diagnosed after attending a radiography centre. Screening of domestic contacts yielded 19 cases out of 318 subjects examined. Attempts to extend contact tracing to the casual contacts of those with open pulmonary disease were unsuccessful-Rastafarians were reluctant to disclose the names of close acquaintances. Later it became evident that many of the adults were known to each other although a source case could not be identified. 2 patients were diagnosed after routine screening-1 while in a detention centre and 1 while in prison-both had been in recent contact with Rastafarians with tuberculosis. 42 had pulmonary disease. 10 had radiographic shadowing occupying an area greater than one hemithorax, 8 with cavitation. 20 patients were positive on sputum culture of whom 16 were positive on direct smear. 17 patients with primary tuberculosis had a primary complex on the chest radiograph and a positive tuberculin test. 3 patients with respiratory tuberculosis had disease at other sites; 1 had ileocaecal and testicular involvement,1 had testicular disease, and 1 had tuberculous peritonitis. Military disease was present in 2 other cases. In Birmingham, children aged 13 years are offered BCG vaccination. Local authority records confirmed that 15 Rastafarians had been vaccinated. Among these were 5 patients with cavitating lung disease and a patient who died from tuberculous meningitis. Treatment was supervised by chest physicians at three hospitals. 1 patient was treated by a specialist in infectious diseases. All except 9 patients were treated initially as inpatients. Most were given ethambutol, isoniazid, and rifampicin for two months, followed by isoniazid and rifampicin for not less than seven months. Rifampicin had to be stopped in one case because of thrombocytopenia. Those given chemoprophylaxis received isoniazid for six months, either alone or combined with ethambutol or rifampicin. Many of the Rastafarians complied poorly with treatment and- often did not attend clinics. Drug therapy was, nevertheless effective in most. 14 patients had their treatment supervised for an initial two-month period in hospital, while in 8 others the recommended nine-month period of treatment8 was extended by up to eight months. In an effort to encourage patients to take their therapy a team of health visitors took regular tablet counts in the patients’ homes and checked that patients were collecting their prescriptions. All except 5 patients made an uncomplicated recovery. 1 patient died of tuberculous meningitis, 1 was left with a spastic paraparesis, and 1 had extensive cavitating disease destroying a lung. 1 had an orchidectomy, and another underwent spinal fusion because of spinal collapse. DISCUSSION
This outbreak of tuberculosis was unusual in that it occurred exclusively among young West Indians. The preponderance of males is noteworthy. The Rastafarian movement emphasises the role of the male, the matriarchal family structure of traditional West Indian society being seen as a legacy of colonial domination. Gatherings of Rastafarians are likely to have been attended mainly by males.
What factors could have favoured the spread of disease in this outbreak? Many had advanced disease at presentation, and 16 had positive sputum smears. This could have been due either to increased susceptibility to disease or to delay in seeking medical attention. Two recent outbreaks in the UK have illustrated how patients with open tuberculosis can transmit disease to contacts by only slight exposure.9,IO There was therefore a core of highly infectious subjects who could have easily spread infection during meetings of young
Rastafarians. The Rastafarian diet, known as I-tal, is vegetarian and associated nutritional deficiencies have been reported. Vitamin B12 deficiency has been described in young adult Rastafarians in Jamaica, 11 and rickets in the children of Rastafarians in the UK.12 Many of those in the present outbreak were vegetarian. Under conditions of socioeconomic disadvantage, a deficient diet could have resulted in impaired host resistance and increased risk of infection. Failure of BCG vaccination to confer protection in 15 cases was unexpected. BCG vaccination is thought to act by limiting multiplication of bacilli rather than by preventing the establishment of disease.13The patients with open
pulmonary diseases are likely to have been disseminating large numbers of bacilli, and active disease is more likely to develop in subjects inspiring a large infective dose of tubercle bacilli. 14 In some cases the protective effect of BCG may have been overwhelmed by a large innoculum of tubercle bacilli. In the most recent national survey of tuberculosis in the rate for children born in the UK of immigrant parents was between that of children born abroad and that of white children born in the UK.3 The future pattern among these children as they grow older is unknown, but the disease may, as the present outbreak illustrates, pose a
UK, the notification
serious threat
to
health.
We thank Mrs M. Connolly for supervising contact tracing, Dr V. H. Springett for comments on the paper, and physicians in Birmingham for allowing us to study patients under their care.
Correspondence should be addressed to G. E. P., Department of Thoracic Medicine, East Birmingham Hospital, Bordesley Green East, Birmingham B9 5ST.
REFERENCES 1. British Tuberculosis Association. Tuberculosis among
immigrants to England and Wales: a national survey in 1965. A report from the Research Committee of the British Tuberculosis Association. Tubercle 1966; 47: 145-56. 2. British Thoracic and Tuberculosis Association. A tuberculosis survey in England and Wales 1971; the influence of immigration and country of birth upon notifications. A report from the Research Committee of the British Thoracic and Tuberculosis Association. Tubercle 1973; 54: 249-60. 3. Medical Research Council. National survey of tuberculosis notifications in England and Wales 1978-9. Br Med J 1980; 281: 895-98. 4. Springett VH. Tuberculosis in immigrants. An analysis of notification-rates in Birmingham, 1960-62. Lancet 1964; i: 1091-95. 5. Springett VH. Tuberculosis in immigrants in Birmingham 1970-72. Br J Prev Soc Med 1973; 27: 242-46. 6. Barrett LE. The rastafarians. The dreadlocks of Jamaica. London: Heinemann Educational Books, 1977. 7. Cashmore E. Rastaman. The rastafarian movement in England. London: Unwin Paperbacks, 1983. 8. British Thoracic and Tuberculosis Association. Short-course chemotherapy in pulmonary tuberculosis. Lancet 1976; ii: 1102-04. 9. Rao VR, Joanes RF, Kilbane P, Galbraith NS. Outbreak of tuberculosis after minimal exposure to infection. Br Med J 1980; 281: 187-89. 10. Roderick Smith WH, Davies D, Mason KD, Onions JP. Intraoral and pulmonary tuberculosis following dental treatment. Lancet 1982; i: 842-43. 11. Campbell M, Lofters WS, Gibbs WN. Rastafarianism and the vegans syndrome. Br Med J 1982; 285: 1617-18. PS, Drakeford JP, Milton J, James JA. Nutritional rickets in rastafarian children. Br Med J 1982; 285: 1242-43. 13. Sutherland I, Lingren I. The protective effect of BCG vaccination as indicated by autopsy studies. Tubercle 1979; 60: 225-31. 14. Rouillon A, Perdrizet S, Parrot R. Transmission of tubercle bacilli: the effects of chemotherapy. Tubercle 1976; 57: 275-99.
12. Ward