Fairfax County Health Department Manages Large-Scale Tuberculosis Contact Investigation
A tuberculosis outbreak at Robert E. Lee High SchoolExternal affected the community of Springfield, Virginia in the summer of 2013. It all began after three students in the same school were diagnosed with TB disease within six months of one another, prompting the Fairfax County Health Department (FCHD)External, located just outside Washington, DC, to launch a broad TB contact investigation. The purpose of the TB contact investigation was to determine who may have been exposed, find out whether transmission had occurred, and prevent future cases of active TB disease. Initial testing of the investigation included over 500 students, faculty, and staff, which indicated TB infection among the U.S. born was higher than the national average, with 5% testing positive. As a result, Dr. Gloria Addo-Ayensu, Fairfax County Director of HealthExternal expanded the investigation to the entire school of 2,277 to avoid the prolonged period of anxiety that the methodical process of a standard TB ring investigation would have created. To effectively conduct the investigation, Dr. Addo-Ayensu instituted the Incident Command System (ICS)External, a standardized, all-hazards incident management approach that organizes the planning, personnel, and resources required for a response to an event.
The Incident Command System (ICS) was essential to managing the TB investigation. Marc Barbiere, Public Health Emergency Management Coordinator, and Jesse Habourn, Senior Emergency Planner, established ICS in Fairfax at the outset of the Lee High School TB contact investigation. All FCHD employees are trained in ICS, which has become the customary method of managing large-scale communicable disease investigations. According to Barbiere, this TB contact investigation had many moving pieces such as tracking data, communication, and setting up 19 points of testing (POT) between June and October 2013. Testing sites were set up at the school, providing the Lee High School community with a convenient place to be screened and tested for the presence of latent TB infection. Although latent TB infection is not contagious, if not properly treated, the infection can progress to active TB disease, which can be fatal if untreated. A team of public health nurses, staff, and trained volunteers directed the contacts through the screening and testing sites. Habourn recalled the response as being “surprisingly calm,” which underscores the importance of ICS training and exercising.
“The best time to make a friend is before you need one.”
Partners collaborated effectively to respond. It takes an entire community of partners for a response of this magnitude to operate successfully. The community network involved health departments from four neighboring jurisdictions, community physicians, high school staff, and Medical Reserve CorpsExternal volunteers. The health departments assisted FCHD by providing nurses to administer and read tuberculin skin tests (TST). Dr. Reuben Varghese, Director of Health at the neighboring Arlington County Health Department and a former CDC Epidemic Intelligence Service (EIS) officer, emphasized the importance of building strong collaborative relationships between districts to strengthen public health preparedness and response. “The best time to make a friend is before you need one,” said Dr. Varghese. Another critical partner in the response was Fairfax County Public Schools, particularly Lee High School Principal, Abe Jeffers. Jeffers was encouraged by how FCHD incorporated school resources into its response team. The school provided classroom rosters, the primary language of each student, and assisted in contacting affected families. In addition, Medical Reserve Corps (MRC) volunteers provided surge capacity, facilitating check-in for testing and managing the flow of the crowds. Rosalia Parada, a parent of three boys who graduated from Lee High School, was among nearly 100 MRC volunteers who supported this response. Parada explained that the screening and testing processes in the Lee High School gymnasium were very well organized.
Multiple communication channels were used during the response. Dr. Addo-Ayensu made many tough decisions during the TB response. How to communicate with the parents, the public, and the media was one of them. The primary method for reaching affected people initially was by mail. One challenge included reaching over 600 students who may have been exposed to TB during the 2012-2013 school year, but who were no longer enrolled or affiliated with the school by June 2013. FCHD set up a call center that fielded calls from concerned families and proactively called contacts to encourage testing. One of the biggest communication challenges during the incident involved the media. Dr. Addo-Ayensu and her Public Information Officer, Glen Barbour, worked to ensure consistent, timely, and transparent communication. In addition to regular updates to the FCHD website, they held three news conferences to encourage those who had received letters to get tested, to explain the reasons for testing everyone in the school, and to debunk myths to ease concerns of the broader community.
The Lee High School TB contact investigation highlighted importance of the public health system to prevent the spread of disease. A total of 235 people in Lee High School tested positive for latent TB infection. These individuals were further evaluated and offered treatment to prevent TB disease. Fortunately, no new cases of active TB were found. The U.S. has a relatively low TB disease rate when compared to the other parts of the world. This investigation, however, serves as a reminder to all that TB is not yet eradicated. In fact, CDC reports that one third of the world’s population has latent TB infection. Although latent TB is not contagious, the infection can progress to active TB disease, which can be fatal if left untreated. Protecting people from infectious diseases requires planning and training, skilled public health investigators, and often requires a health department to increase its capacity through partnerships. The Lee High School TB contact investigation is an example of public health preparedness and response in action.