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If a Kenyan student attending college in Mobile, AL, had either possessed health insurance or undergone a tuberculin skin test before arriving at school, chances are he’d still be alive. Lacking both, the 28-year-old died in late December, in what the local TB controller calls the most severe case of TB he’s ever witnessed.
It’s hard to imagine a lonelier death. The dormitory where the 28-year-old died had been empty for several weeks, its other occupants gone on Christmas vacation. Despite advice to the contrary from local TB controllers, shaken college officials say they plan to mandate tuberculin skin-testing for all entering students in the wake of the incident.
At Spring Hill College, a Jesuit school of about 1,500 students about an hour from the Gulf Coast, the longstanding policy has been to require only entering freshmen to show proof of a skin test, says Greg Walker, director of communications at the college. As it happened, the young man from Nairobi was the only foreign-born student among 475 graduate students. More to the point, perhaps, the school traditionally exempts all its older students from the skin-test requirement, Walker explains.
"They’re adults, and most of them are holding down jobs," he says. "We didn’t think it was right to treat them like children." The student visa the Kenyan obtained after a year-long struggle also required no skin test, Walker notes.
Other students report that the young man was sick with a racking cough by late October or early December. He could have gone to the school’s Wellness Center, as some students urged him to do, but he had little money and no health insurance — a requirement the school has always waived for its adult students, Walker says. Apparently, he mistakenly decided he was suffering from malaria, Walker adds. "We think he made contact with some friends at another college in town and tried to get some malaria medication from them," he says.
As Christmas holidays drew near, the young man sought permission to stay in the dormitory, because he couldn’t afford the plane fare back home to Nairobi. Permission was granted, though reluctantly, since the dorm would be virtually empty for several weeks, says Walker.
The autopsy showed wasting, cavitation, and extensive caseation, says Joseph Jablecki, MPH, the TB controller for Alabama’s Public Health Area 11. "It was pretty rough," Jablecki says. "It was certainly the worst I’ve seen." College professors and local businesses in Mobile helped raise the nearly $5,000 needed to fly the body and casket back home to the family, Walker adds.
After the cause of death was discovered, contact testing began. Using a cutpoint of 5 mm for close contacts and 10 mm for more casual acquaintances, Jablecki and other health-department staffers set up a testing station at a central portion of the campus. The school, for its part, braced itself to cope with an onslaught of reporters, worried parents, and frightened students.
"First, we had to get educated ourselves; then, we began to educate others," says Walker. That meant sending out campus-wide e-mails every time any new information turned up and holding a long town-hall-style meeting. Walker also spent three weeks doing daily TV and radio broadcasts, "pounding home what we were doing and where we were in the investigation," he says.
"Four or five" students became almost hysterical with fear; their fear infected other students and made the going rough, Walker recalls. "We were definitely dealing with a fear factor," he notes. At the same time, some students refused to show up for testing, or, once tested, wouldn’t come back for a re-test until the school threatened them with penalties.
For the town hall meeting, the school brought in John Bass, MD, chair of the Department of Internal Medicine at the University of South Alabama in Mobile. Bass and Jablecki sat for hours patiently answering "the same questions over and over," recalls Walker.
Meanwhile, Jablecki and his team of "epi screeners" had identified a group of 144 close contacts, consisting of friends, students from the young man’s dorm, and students who’d shared a phone room or a library computer station with the index case. Of these, about one-fifth tested positive the first time, with another five students converting from negative to positive at the second round of testing, Jablecki says. Among 695 more casual contacts — kids who may have sat beside the case at lunch in the cafeteria, for instance — only five converted. About half of all reactors and converters chose to begin preventive treatment, Jablecki says.
Jablecki has advised the school to require skin-testing only for foreign-born students, in concordance with federal TB guidelines not to test low-incidence groups. But Walker — who readily admits that he doesn’t entirely grasp all the subtleties associated with skin-testing in a low-prevalence setting — says the plan for now is to make all undergrad and graduate students provide skin-test results. "We just want to make sure the school is safe," he adds.
The new policy may be expanded next fall to include older adults returning to school, he adds. The school may also revisit its policy of not requiring grad students to carry health insurance, Walker adds.