Tuberculosis Outbreak at Archbishop Riordan High School
Something unexpected occurred at Archbishop Riordan High School last fall.
In September, a student from the Bay Area attended a health care appointment due to a persistent cough. However, it took two months to receive a diagnosis: tuberculosis. The San Francisco Department of Public Health started an investigation, which showed a notably high incidence of latent tuberculosis in the school, indicating that many were infected with the Mycobacterium tuberculosis bacteria without showing active symptoms.
As per the latest update on February 24, there were confirmed cases of four individuals with active tuberculosis, while the public health department suspected three more cases.
San Francisco, especially a private school, might not seem like a typical setting for a tuberculosis outbreak. Tuberculosis is often linked to poverty and is primarily prevalent in the developing world, with about 87 percent of new cases emerging from just 30 low- to middle-income countries.
Yet, if we look back, tuberculosis used to be a widespread global issue. On March 24, 1882, German physician Robert Koch announced he discovered the cause of the disease that claimed one in every seven lives in the US and Europe. Fast forward to now, on this very day which honors World Tuberculosis Day, we recognize that after a brief period of overshadowing by Covid-19, tuberculosis has re-emerged, becoming the leading cause of death due to infectious diseases in 2023.
Tuberculosis, sometimes called consumption or “the robber of youth”, isn’t eradicated — far from it. While Covid-19 took the spotlight, tuberculosis has claimed around 10 million infections and 1.5 million deaths each year despite being preventable and treatable. Shockingly, a quarter of the global population may be infected with the bacteria.
“The global is local and the local is global,” says Priya Shete, a tuberculosis researcher at the University of California San Francisco. She emphasizes that neglecting the worldwide burden of tuberculosis leads to its emergence in unexpected areas.
In the US, we have the necessary infrastructure for tuberculosis testing and treatment, and thankfully, it’s not currently an endemic issue. But it hasn’t always been this way; tuberculosis may have claimed up to a quarter of the American population in the past. Improvements in living conditions, nutrition, sanitation, and particularly the introduction of antibiotics drastically changed the landscape. Yet, being “not endemic” isn’t equivalent to being “erased completely.”
After three decades of decline, tuberculosis rates are on the rise in the US. This February brought cases to high schools beyond the Bay Area, including locations like Long Island, New York, and Seattle. Notably, a large epidemic was recorded just two years back in Kansas, with 68 active cases and 91 latent infections.
Factors such as decreased investment in public health, medication shortages, the impact of Covid on delay in diagnoses, and hurdles in managing latent cases illustrate why tuberculosis remains a pressing concern in the US.
This year, World Tuberculosis Day carries the theme “Yes! We Can End TB!” But that assertion feels rather ambitious considering ongoing challenges, even within the wealthiest nations. The fight against this ancient pathogen, which has likely been around for 3 million years, is ongoing. Fortunately, advocates are pushing for sustained investment in tuberculosis research and are resisting funding cuts. Meanwhile, scientists are striving for new treatments for this longtime foe.
Tuberculosis spreads easily through the air, with even normal breathing capable of transmitting it. “No nation on Earth has completely eradicated TB,” states Lucica Ditiu, executive director of the Stop TB Partnership. “As long as we breathe, we are all at risk.”
An estimated 13 million individuals in the US carry latent tuberculosis, and left untreated, 5 to 15 percent of these cases could progress to active disease. Tuberculosis preventative treatment can effectively eliminate the infection in about three months with the right antibiotics, yet many face challenges accessing these medications.
Left untreated, an individual with active tuberculosis can potentially infect up to 15 people yearly. In the US, more than 80 percent of tuberculosis cases come from latent cases converting to active forms. The clear division between latent (non-infectious) and active (contagious) tuberculosis can often be blurry, with symptomatic patients sometimes remaining undiagnosed. Some research suggests that asymptomatic cases may account for a significant portion of global tuberculosis transmission.
“It’s quite plausible that some of the latent TB within the Archbishop Riordan High School community could have been spread by asymptomatic individuals,” Sadoff notes. “Understanding more about how subclinical transmission works might allow us to respond to outbreaks in a timely manner.”
Compared to highly contagious illnesses such as measles, tuberculosis is stealthy. Its primary symptom is often a chronic cough, which may mislead people regarding its seriousness.
Diagnosing tuberculosis can be tricky since chronic symptoms may resemble other ailments. Many might dismiss night sweats, a common symptom, as something less serious rather than recognizing it as a potential indicator of tuberculosis. Thus, vigilance is crucial.
Delays in tuberculosis diagnosis worsened due to the Covid pandemic, and many patients are now diagnosed at sicker stages compared to pre-pandemic times, allowing more opportunities for the disease to circulate unrestrained. This creates a greater possibility for antibiotic resistance and increased human suffering. Additionally, effective treatment requires following a rigorous multiple-antibiotic regimen for several months to prevent bacterial resistance.
However, cost represents another significant roadblock in fighting tuberculosis in the US. Treating latent tuberculosis could reach around $857 for a three-month regimen, while active tuberculosis treatment can exceed fifty times that amount. If TB and multidrug-resistant TB incidences in the US matched global averages, it could potentially cost over $11 billion annually.
In the US, the disease frequently spreads in areas with inadequate healthcare access, overcrowded living conditions, or increased malnutrition, such as prisons and homeless shelters. The most vulnerable populations bear the brunt of this, making treatment more complex.
“A failing health system in a high-income nation can lead to a tuberculosis outbreak,” Sadoff says. “Whenever we see TB outbreaks in the US, it points to underlying issues that need addressing.”
Preventing the Spread of TB in the US — and Beyond
At Archbishop Riordan High School, 207 community members have been identified with latent tuberculosis. To resume in-person classes, students needed to disclose their test results and medication status, though they weren’t required to have negative results. An anonymous grandparent of an infected student expressed concern over the school’s handling of treatment and prevention, noting that the approach hasn’t effectively mitigated the spread.
As of February 24, around 80 percent of students with latent tuberculosis were undergoing treatment. The school isn’t legally permitted to mandate treatment for these students, despite its potential to prevent progression to active disease. However, the grandparent criticized the absence of continued remote learning opportunities for untreated students.
Efforts to gather responses from Archbishop Riordan High School about their treatment policies went unanswered. According to the latest updates from the public health department, all identified individuals with active tuberculosis are undergoing treatment and are no longer deemed contagious.
The San Francisco Department of Public Health reiterated the position that individuals with latent tuberculosis infections can be present on campus since they are not contagious. They also stress the importance of beginning and completing treatment to avert future outbreaks. Once a person tests positive for tuberculosis, that result persists indefinitely, creating challenges for ongoing health assessments and monitoring, as it is still possible to become reinfected.
This situation at Archbishop Riordan High School underscores how challenging it is to contain outbreaks and reassure communities about safety. Ultimately, prevention remains the key strategy in tackling tuberculosis.
Public health officials emphasize that the community’s overall risk remains low, and there isn’t extensive transmission occurring at this time. However, continued cuts to public health and research funding pose risks to maintaining low disease incidence.
