Cross-border outbreak finally winding down

County learns to mend its ways

Another case has turned up in the wake of the virulent, cross-border outbreak that plagued Kentucky and Tennessee between 1994 and 1996. Partially because this strain has proven to be so transmissible - with some cases becoming sick after only a few minutes of exposure in an outdoor setting - over 40 people who were briefly exposed in a hospital setting are having to be skin tested and evaluated for infection, says Marnell Kretschmer, Kentucky's public health adviser.

It's to be expected that an occasional additional case will keep turning up, says Kentucky's TB controller, Gene Simmons, MPH. "A certain percentage of people are going to break down," he says. "Some people [who were infected] will live for a long time; and by the time they turn 60, 70, or 80 years old, some of them may become active, too."

Meanwhile, Simmons and Kretschmer say, many of the people in the Kentucky county hit hardest by the outbreak have changed the way they think about TB and about directly observed therapy (DOT).

Initially, docs reluctant to prescribe DOT

Clinton County, with a population of 10,000, is served by four physicians. During the outbreak, some were reluctant to prescribe measures such as DOT, which they considered overly intrusive. It didn't help that only one TB nurse and a single outreach worker served the sprawling, 10-county district in which Clinton County is located.

The state's role during the outbreak was further complicated by a decentralized system in which public health policy is established and implemented at the county level, leaving state officials with the power only to educate and advise.

Despite the problems, Simmons says the real crisis has passed. Among cases identified since 1997, all but one was placed on DOT, says Kretschmer. (The exception was monitored by a home health aide with TB nurses going to the patient's home to check on a regular basis.)

There have been other changes, too. Funds from the Centers for Disease Control and Prevention have enabled the district to hire another TB nurse, plus another staff member to help with administrative tasks, Simmons says. The state has also provided money to hold monthly TB clinics.

A new medical director was appointed by the district who believes strongly in DOT, and Kretschmer has begun publishing a quarterly TB newsletter for local physicians. To help beef up surveillance in the area, local pharmacies have been asked to report any patient who's been issued prescriptions for more than one TB drug, Kretschmer says.

Finally, the state has sent the district medical director and a local physician to a week-long educational program held by National Jewish Hospital in Denver.

Now, DOT is the policy; DOPT's the next step

All the work is paying off, say Kretschmer and Simmons. "It's hard to convince some of the professionals, but I think we're headed in the right direction," says Simmons. Adds Kretschmer: "I don't know if we've changed people's minds completely, but I think people are much more cooperative with the health department now. They're more aware of TB. They're much more willing to do DOT, and they have a better understanding of the role the health department plays."

Currently, when someone turns up with a positive skin test, about 80% of the time he or she is referred to the health department for chest X-rays, evaluation, and regular follow-up, Kretschmer says. "It's more like co-care now," she adds.

Contact investigations are still under way for some cases, and plans call for implementing directly observed preventive therapy on newly identified converters.

Meanwhile, a contact who didn't finish preventive therapy was the most recent case. Approximately 40 patients and some hospital staff were being checked for exposure after the person showed up at a hospital and wasn't immediately isolated. Some of those who were exposed included cancer patients who were immune compromised, says Kretschmer.

Though CDC investigators found the Clinton County outbreak fascinating from a scientific perspective, Simmons says he's worn out with all the publicity. "I'm looking at this purely from the standpoint of someone who's dealing with people," he says. "My job is to make sure that folks get treated for their TB, that they take their medicine, and that they don't spread TB to their children or to anyone else."