Res ipsa loquitur.
The United States does not have an adequate forecast, situational awareness, and timely notification system for its public. Make special note of the text highlighted in red. To practicing physicians in Jacksonville, Florida, the question should be asked: where you notified in February of the Health Department being "overwhelmed" with TB cases?
Worst TB outbreak in 20 years kept secret
Palm Beach Post Staff Writer
JACKSONVILLE —
The CDC officer had a serious warning for Florida health officials in April: A tuberculosis outbreak in Jacksonville was one of the worst his group had investigated in 20 years. Linked to 13 deaths and 99 illnesses, including six children, it would require concerted action to stop.
That report had been penned on April 5, exactly nine days after Florida Gov. Rick Scott signed the bill that shrank the Department of Health and required the closure of the A.G. Holley State Hospital in Lantana, where tough tuberculosis cases have been treated for more than 60 years.
As health officials in Tallahassee turned their focus to restructuring, Dr. Robert Luo’s 25-page report describing Jacksonville’s outbreak — and the measures needed to contain it – went unseen by key decision makers around the state. At the health agency, an order went out that the TB hospital must be closed six months ahead of schedule.
Had they seen the letter, decision makers would have learned that 3,000 people in the past two years may have had close contact with contagious people at Jacksonville’s homeless shelters, an outpatient mental health clinic and area jails. Yet only 253 people had been found and evaluated for TB infection, meaning Florida’s outbreak was, and is, far from contained.
The public was not to learn anything until early June, even though the same strain was appearing in other parts of the state, including Miami.
Tuberculosis is a lung disease more associated with the 18th century than the 21st, referred to as “consumption” in Dickensian times because its victims would grow gaunt and wan as their lungs disintigrated and they slowly died. The CDC investigator described a similar fate for 10 of the 13 people who died in Jacksonville.
They wasted away before ever getting treatment, or were too far gone by the time it began. Most of the sick were poor black men.
“The high number of deaths in this outbreak emphasizes the need for vigilant active case finding, improved education about TB, and ongoing screening at all sites with outbreak cases,” Luo’s report states.
Today, three months after it was sent to Tallahassee, the CDC report still has not been widely circulated.
Backer of closing hospital didn’t know
Meanwhile the champion of the health agency consolidation, Rep. Matt Hudson, R-Naples, said he had not been informed of the Jacksonville outbreak and the CDC’s role as of Friday.
Told the details, the chairman of the House Health Care Appropriations Committee vowed that there would be money for TB treatment.
“There is every bit of understanding that we cannot not take care of people who have a difficult case of TB,” Hudson said.
The governor’s office asked a reporter to foward a copy of the CDC letter on Saturday, but did not comment by press time.
Treatment for TB can be an ordeal. A person with an uncomplicated, active case of TB must take a cocktail of three to four antibiotics — dozens of pills a day — for six months or more. The drugs can cause serious side effects — stomach and liver problems chief among them. But failure to stay on the drugs for the entire treatment period can and often does cause drug resistance.
At that point, a disease that can cost $500 to overcome grows exponentially more costly. The average cost to treat a drug-resistant strain is more than $275,000, requiring up to two years on medications. For this reason, the state pays for public health nurses to go to the home of a person with TB every day to observe them taking their medications.
However, the itinerant homeless, drug-addicted, mentally ill people at the core of the Jacksonville TB cluster are almost impossible to keep on their medications. Last year, Duval County sent 11 patients to A.G. Holley under court order. Last week, with A.G. Holley now closed, one was sent to Jackson Memorial Hospital in Miami. The ones who will stay put in Jacksonville are being put up in motels, to make it easier for public health nurses to find them, Duval County health officials said.
They spoke about CDC’s report Friday, only after weeks of records requests from The Palm Beach Post. The report was released late last week only after a reporter traveled to Tallahassee to demand records in person. The records should be open to inspection to anyone upon request under Florida Statute 119, known as the Government in the Sunshine law.
TB strain spreads beyond homeless
In his report, the CDC’s Luo makes it clear that other health officials throughout the state and nation have reason to be concerned: Of the fraction of the sick people’s contacts reached, one-third tested positive for TB exposure in areas like the homeless shelter.
Furthermore, only two-thirds of the active cases could be traced to people and places in Jacksonville where the homeless and mentally ill had congregated. That suggested the TB strain had spread beyond the city’s underclass and into the general population. The Palm Beach Post requested a database showing where every related case has appeared. That database has not been released.
It was early February when Duval County Health Department officials felt so overwhelmed by the sudden spike in tuberculosis that they asked the U.S. Centers for Disease Control and Prevention to become involved. Believing the outbreak affected only their underclass, the health officials made a conscious decision not to not tell the public, repeating a decision they had made in 2008, when the same strain had appeared in an assisted living home for people with schizophrenia.
“What you don’t want is for anyone to have another reason why people should turn their backs on the homeless,” said Charles Griggs, the public information officer for the Duval County Health Department.
Even the CDC was not forthcoming about the outbreak. An agency spokesperson declined requests from The Post when asked to make an expert available to discuss a CDC-authored scholarly paper on the possible origins of the Jacksonville outbreak, offering only general fact sheets on TB.
“After checking in with the Division of TB Elimination about your specific questions, they have suggested that you reach out to your health department,” wrote Salina Cranor of the CDC’s TB prevention office. . “They are really the best source for your questions.”
“With TB it’s a judgment call,” said Duval County Health Director Dr. Bob Harmon in a telephone interview Friday, after the state’s new surgeon general referred questions back to him.
“There have been TB outbreaks where we do alert the public, such as a school or a college,” Harmon added.
For weeks, there had been a dissonant message coming from the Department of Health press office in Tallahassee. It released overall numbers of Florida tuberculosis cases showing a marked decline statewide, supporting the argument that A.G. Holley had become irrelevant. Asked whether she had been aware of the severity of Jacksonville’s outbreak while delivering that message, she did not answer.
“Florida experienced a 10 percent decrease in cases for 2011 compared to 2010. For the period 2007—2011, there was a 24 percent decrease in cases,” wrote agency spokeswoman Jessica Hammonds in an emailed response to written questions on May 18. She declined, at the time, to make agency experts available for interview.
In an article published in June’s American Journal of Psychiatry, CDC experts Dr. Joseph Cavanaugh, Dr. Kiren Mitruka and colleagues described the apparent origins of the current outbreak, when a TB strain called FL 046 came to claim two lives and sicken at least 15 mentally ill residents of one assisted living facility in 2008.
A single schizophrenic patient had circulated from hospital to jail to homeless shelter to assisted living facility, living in dorm housing in many locations. Over and over, the patient’s cough was documented in his chart, but not treated. It continued for eight months, until he finally was sent under court order to A.G. Holley. That year, 2008-2009, a total of 18 people in that community developed active tuberculosis from the strain called FL 046 and two died. The CDC sent a $275,000 grant to help pay for the staff needed to contain it.
After the money ran out, Harmon said, staff were redeployed to other needs. But in 2011, suddenly, the number of active cases of FL 046 spiked, rising 16 percent to 30 cases of a specific genotype, the one seen in 2008.
“We thought after 2008 that we had it contained,” Harmon said. “It was not contained. In retrospect, it would have been better to inform the general population then.”
Harmon said the Duval County Health Department will need more resources if it is to contain the current TB outbreak. In 2008, when the TB outbreak hit, his department employed 946 staff with revenues of $61 million. “Now we’re down to 700 staff and revenue is down to $46 million,” Harmon said. “It has affected most areas of the organization.”
If he can raise at least $300,000, he will use the money to hire teams of experts — epidemiologists, nurses, outreach workers, to look under bridges, in fields — in all the places where Jacksonville’s estimated 4,000 homeless congregate, to track down the people who may still be infected unknowingly. Fortunately, only a few of the cases have developed drug resistance so far. The vast majority respond to the first-line antibiotics.
In downtown Jacksonville, in the homeless shelters and soup kitchens, the TB strain called FL 046 continues to spread.
On a recent June morning, 60-year-old Lilla Charline Burkhalter joined about 100 other poor and homeless guests being served a free hot meal of scrambled eggs, grapes, potatoes and butterless bread by a local church youth group.
The youth group was volunteering at the Clara White Mission, where a man with active tuberculosis had been identified just three weeks earlier.
Looking weary but friendly, Burkhalter described her life of late, sleeping in grassy fields and in shelter dormitories. She lived on a small Social Security disability check, she said. It had enabled her to pay for a room in an apartment, for a while. But her roommate had kicked her out for making his girlfriend jealous, she said, and she hadn’t been able to find any other accommodations. It had been a rough few months, she acknowledged. But she had been through tough times before.
As she spoke, she coughed often. It was her emphysema acting up, she explained.
Asked if she was fearful about the TB in the community, she shrugged.
“The health department tests me for TB once a year, so I know I don’t have it,” she said. “I’m not worried.”
The Clara White Mission is now playing a key role in helping Jacksonville fight TB. Its housing case manager, Ken Covington, had spent most of his career helping bank branches assimilate after mergers. Two months ago, he joined Clara White, charged with placing homeless veterans and recently released jail inmates into homes. But the job has became much larger.
Today, Covington is the new chairman of the Duval County TB Coalition. In his hands he holds a massive binder with the intimidating title, “Core Curriculum in Tuberculosis: What the Clinician Should Know.” It was given to him by Vernard Green, the CDC’s visiting TB liaison.
Covington said he was a banker, not a clinician. But he had learned what to watch for with TB – coughing up blood, night sweats, sudden weight loss. The coalition members were looking at buying air filtration equipment, drafting intake protocols, getting to know the TB experts in the community, and educating shelter staff on what to watch for and what to do if a client appeared ill.
“We’re trying to do what we can to rein it in, and stay in front of it, and not let it get any worse,” Covington said. “I take it as a very important role for the community.”
WHAT THE POST UNCOVERED
In 2008, a schizophrenic patient contracted TB but went untreated for eight months, wandering among many places where the homeless congregate, infecting at least 17 others.
In 2012, the CDC was invited to help with a sudden spike in cases of the same rare strain the schizophrenic patient had. What they found is the worst outbreak they have investigated in 20 years, and it is not contained.
ON THE TRAIL OF TB
Hard to track: Homeless and mentally ill people and those they have come in contact with are especially hard to treat.
Long, tough treatment: Several pills a day of several virulent antibiotics for a minimum of six months, often up to two years.
What’s at stake: If treatment regimen isn’t strictly followed, antibiotic resistent strains emerge.
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