Biological Health Hazard – Tuberculosis Outbreak: Mukono District, Uganda
TUBERCULOSIS – UGANDA: (MUKONO) BOARDING SCHOOL
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Administrative Map of Uganda, Map based on a UN map. Source: UN Cartographic Section. Image: Nations Online Project.
Tuberculosis (TB) is a contagious and often severe airborne disease caused by infection with Mycobacterium tuberculosis (Mtb) bacteria. TB typically affects the lungs, but it also can affect any other organ of the body. It is usually treated with a regimen of drugs taken for six months to two years depending on whether the infecting organisms are drug resistant. (Mtb) bacteria is listed as a Category C pathogen/Bioterrorism Agent.
Published Date: 2017-11-09 17:26:47
Subject: PRO/EDR> Tuberculosis – Uganda: (MV) boarding school
Archive Number: 20171109.5434514
Date: Tue 7 Nov 2017
From: Alex Riolexus Ario <riolexus@musph.ac.ug> [edited]
On 5 Oct 2017, a rumor about a TB [tuberculosis] outbreak in a boarding secondary school in Mukono District was received by the Ministry of Health via the National TB and Leprosy Program’s social media WhatsApp platform.
The Ministry through the Uganda Public Health Fellowship Program has investigated the rumor to determine the existence of the outbreak, its scope and to recommend evidence-based control measures.
A total of 31 TB patients (11 confirmed) were identified; overall attack rate (AR) was 1.9 percent. All affected were senior four (S4) students with an AR equal to 20 percent. Male students (AR equal to 11 percent) were more affected than female students (AR equal to 6.4 percent). Among S4 students, students in stream E were more affected (AR equal to 21 percent) compared to stream S (AR equal to 18 percent). Residents of the S4 dormitory for men had an AR of 28 percent.
Chest x-rays suggestive of TB were 13 percent (25/191) [95 percent CI equal to (8.7 – 19)]. A total of 44 percent (11/25) had hilar consolidation; 32 percent (8/25) had upper zone pulmonary infiltrates; 8 percent (2/25) had lower lobe infiltrates; and 4 percent (1/25) had pleural effusion.
The epidemic curve showed a propagated outbreak. Residential space was 3.2 students per 10 square meters. Ventilation in residential cubicles was poor; only 4.5 percent of the cubicles had windows or air vents.
The investigating team concluded that exposure of students to open TB propagated this outbreak; low ventilation in residential cubicles/dormitories and congestion facilitated TB transmission. They recommended intensified TB case finding in the school community (screening with X-rays), Mantoux screening and giving isoniazid prophylaxis. Improving ventilation in cubicles/dormitories and increasing residential space for students will also aid in preventing future contagious diseases outbreaks.
All students who tested positive were started on the 1st line regimen. None had MDR TB [multidrug-resistant tuberculosis]. Latent TB infection in Uganda is not routinely diagnosed or treated; however, because of this outbreak we have recommended to the National TB Program to reconsider introducing routine testing.
All infants in Uganda are given BCG vaccine at birth.
—
Alex Riolexus Ario
Ag. Director
Uganda National Institute of Public Health
Ministry of Health, Uganda
<riolexus@musph.ac.ug>
[ProMED-mail thanks Alex Riolexus Ario for submission of the report of a tuberculosis (TB) outbreak in a boarding school in Uganda.
TB is transmitted primarily by the aerosol route from AFB (acid-fast bacilli)-positive cases of pulmonary or laryngeal tuberculosis. Transmission is facilitated, as in the Ugandan boarding school outbreak described above, by poor ventilation in overcrowded living spaces. Delay in diagnosis and in institution of appropriate therapy for TB can contribute to the continued spread of the infection.
Tuberculosis outbreaks in boarding schools have been previously reported in other countries, e.g., Israel (https://www.ncbi.nlm.nih.gov/pubmed/16807268) and China (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4427569/). The case finding in the Uganda outbreak identified apparently only cases in students; no teachers or other ancillary school staff were mentioned among the cases. Genotyping the clinical isolates would help identify transmission pathways (https://www.ncbi.nlm.nih.gov/pubmed/17192416/).
Those with recent exposure to a person with contagious TB should be evaluated immediately for latent TB infection (LTBI) because of the risk for progression to active TB disease, including miliary or meningeal tuberculosis. Testing for LTBI is done by either a tuberculin skin test (TST) or a blood test known as an interferon gamma release assay (IGRA). If the TST or IGRA result is positive, and there is no evidence of TB disease, they should be treated for LTBI. Those who initially have negative results should be retested for conversion of the TST or IGRA in 8-10 weeks after exposure has ended.
Treatment for LTBI, however, should be initiated in children 5 years of age and younger, who have close contact with contagious TB, even if the initial TST or IGRA is negative, because these young children are at high risk for progression to TB disease; and isoniazid is continued in these young children until the results of the 2nd TST or IGRA and other medical evaluation are known.
TST is the preferred method for testing children under the age of 5 years (http://www.cdc.gov/tb/publications/LTBI/diagnosis.htm) because of limited data on the use of IGRAs in this age group (http://www.cdc.gov/mmwr/PDF/rr/rr5905.pdf). However, TST will detect _M. tuberculosis_ infection as well as prior exposure to BCG vaccine or non-tuberculous environmental mycobacteria. IGRAs, however, are unaffected by BCG and most non-tuberculous, environmental mycobacteria. IGRAs should be used if there is a question of reactivity to TST because of prior BCG vaccination.
Mukono District is in the Central Region of Uganda, about 21 km (13 mi) by road east of Kampala, the capital and largest city of Uganda (https://en.wikipedia.org/wiki/Mukono_District). The town of Mukono is the district headquarters, located on the shores of Lake Victoria to the south. – Mod.ML
A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/1540.]
See Also
Tuberculosis – Syria: IDP 20170601.5076691
Tuberculosis – USA: (OK) high school 20161120.4642052
Tuberculosis – Spain (02): (CL) school, comment 20160529.4252860
Tuberculosis – Spain: (Castilla y León) school, RFI 20160516.4225012
2015
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Tuberculosis – Kenya: MDR, increasing incidence 20151119.3802924
2014
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Tuberculosis – USA (02): (CA) high school students 20140516.2477848
Tuberculosis – USA: children, foreign-born parents 20140212.2273349
2013
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Tuberculosis – France: (BD) school, Bejing strain 20130111.1493463
2005
—-
Tuberculosis, school – Sweden (Stockholm) 20051028.3140
Tuberculosis – Iraq (Missan) 20050613.1652
Tuberculosis, nursery school – Spain (Catalonia) 20050523.1416
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Background potential for the use of bioterrorism:
Boko Haram and the Lord’s Resistance Army: Brothers of Destruction
The religion may be different and separated by geographical and political boundaries, but the violent tactics and kidnappings are similar. The LRA is Boko Haram’s Christian doppelganger from northern Uganda. The similarities between the two organisations are remarkable. Boko Haram’s kidnap of schoolgirls is not without precedent. Eighteen years ago the LRA kidnapped 139 schoolgirls from St. Mary’s College in Northern Uganda.
“Islamist” movements like Boko Haram and others politico-religious extremists use the most powerful tool in their arsenal – not physical weapons, but the firm belief that their struggle (jihad) is sanctioned by their God – to provide justification for their illegal, horrifically violent and deplorable actions. Not only do they direct this tool inwards to their own psychological delusions, but they direct this tool outwards, to the rest of the world observing them, in order to intimidate and silence those around them or in opposition to them.
As in the case of Boko Haram, they disseminate propaganda pamphlets warnings private and secular schools to shut down female education or to face the consequences. The pamphlets declare female education as “haram,” an Islamic term referring to things forbidden in Islam. Similarly, groups like the Taliban shut down schools forbidding girls from pursuing their education.
Aside from kidnappings and atrocious levels of violence, the potential use of chemical or biological agents can be seen as another useful means in achieving their aims.
See Also: Boko Haram’s Devastating Toll on Students, Teachers, Schools in Northeast Nigeria
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