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Tuberculosis Outbreak Shakes Wisconsin City

Dale Hippensteel, manages the Sheboygan County health department. (For NPR)

Looking crisp and official in his khaki-colored sheriff's department polo shirt, Steve Steinhardt says Sheboygan, Wis., is a pretty good place to be a director of emergency services.

"Nothing bad happens here," he says, knocking on wood. Unless, that is, you count the tuberculosis outbreak that struck the orderly Midwestern city of 50,000 this spring and summer.

"I never expected TB to be one of the bigger emergencies I'd face when I got into this field," Steinhardt says.

How contagious is tuberculosis? How could one-third of the world's population be infected with the bacteria? We recently chatted with Dr. Mel Spigelman, of TB Alliance's, and he answered five common questions about the infectious disease.

Sheboygan County officials have had to scramble to contain it. At the height of the crisis, the county activated its emergency operation center — a step usually reserved for major fires, floods and tornadoes.

The county has had to borrow personnel from other jurisdictions, calm parents of schoolchildren, find housing to isolate infected families and appeal to the state for millions of dollars in extra money to deal with the situation.

It's a reminder that TB — a disease most Americans may view as a relic of the 19th century — is still an insidious threat that can pop up anywhere.

In its advanced stages, tuberculosis can destroy lungs, damage other organs and cause death.

The Sheboygan outbreak came to light on April 11. The first case was a woman at the center of a large, close-knit family. Health officials decline to identify the family, but they say the people were part of an immigrant community, a common theme in most current TB outbreaks in the U.S.

Sheboygan is home to sizable populations from Mexico and Southeast Asia, where TB is common. Asian immigrants make up half of Wisconsin's recent TB cases. Refugees among the Hmong people of Laos and Thailand have been among the most difficult-to-treat cases.

Public health nurse Jean Beineman says the first case in the current outbreak is a middle-aged mother who had suffered from TB for many months. "[She] had symptoms since at least last August — weight loss, cough, just feeling poorly," Beinemann says.

By early May, Sheboygan County health workers found active TB in three other family members, spread over several households. And others had symptoms and abnormal chest X-rays.

Ominously, several were schoolchildren.

"Once the families were identified, we knew we had a tiger by its tail," says Dale Hippensteel, Sheboygan County's public health manager.

But the really bad news was that the woman at the epidemic's center had a TB strain resistant to at least two of the main drugs used to treat the infection. That's known as multidrug-resistant tuberculosis, or MDR-TB. It's especially hard to cure. The antibiotics can cost around $300,000 for a single case.

Officials worried the MDR bacteria had spread to a lot of other people in town.

Epidemiologists predicted Sheboygan could end up with 15 symptomatic MDR-TB cases and up to 200 people infected with the resistant strain but not yet showing symptoms. Asymptomatic, or latent, TB isn't contagious. But it has to be treated with antibiotics for six months to a year.

The kids in the family with active TB infections attended a Sheboygan high school and middle school. One big priority was to see if they had transmitted the disease to their classmates.

"We tested about 130 students and teachers who had very close contacts with the affected individuals," Beinemann says. The results of a second round of testing aren't yet known.

More than three months after the outbreak first came to light, there have been nine confirmed cases of active TB among five households. Fortunately, none of the other cases is as drug-resistant as the first one.

It's not clear yet how many other people in Sheboygan will turn out to be infected. Officials think it will be in the dozens.

That may not sound like such a big deal. But treating TB infections of any kind is complex and labor-intensive. Every day, without exception, a nurse must watch each person take medication. A lapse in treatment could cause them to develop a multidrug-resistant strain.

Active TB has to be treated until it's no longer contagious. That can take up to a year.

Officials recently moved the woman with MDR-TB into an apartment paid for by the county. Keeping her and the others apart from everyone while they're contagious requires continuous monitoring and education.

And the cost of all this is enormous. When officials feared they faced a wider epidemic of highly resistant TB, they projected it would cost the county $17 million to bring it under control.

In the end, Sheboygan dodged that worst-case scenario. But it had to persuade the governor and state legislature to appropriate around $5 million to deal with the situation.

Still, Lorna Will, Wisconsin's TB control director, says Sheboygan has avoided a much higher number of TB infections than it might have had. "That's because we jumped on them and got them right away," she says.

But across the nation, the ability to jump on these outbreaks is eroding fast.

TB in the U.S. is at an all-time low, with less than 10,000 cases each year. But a recent survey by the National TB Controllers Association shows 60 percent of states have cut their TB control budgets. Many health workers say cases of TB are being missed and they can't investigate outbreaks the way they used to.

This reminds Dr. Richard Chaisson of what happened in the early 1990s. Funding cuts in TB programs led to a resurgence of the disease.

"We corrected that mistake, and we've had great results,"says Chaisson, who directs TB research at Johns Hopkins University. "Now we're making that same mistake all over again, which is declaring victory and withdrawing from the fight before the disease is controlled."

"Overall TB rates won't go back to the 1992 level, Chaisson says. "But outbreaks like Sheboygan's will start popping up more often ... and stopping them will cost a lot more than keeping TB under control."

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Transcript

DAVID GREENE, HOST:

Our series on tuberculosis has taken us all over the world. We began in Boston with the story of an African-American family tragically touched by the disease.

RENEE MONTAGNE, HOST:

We then learned how the disease is affecting Moldova and Tajikistan, where medical care can't keep up with the challenges of drug-resistant forms of TB.

GREENE: Last week we heard reports about drug-resistant TB in Siberia.

MONTAGNE: This morning we're returning to this country to learn about a TB outbreak in America's heartland. Local and state officials in Wisconsin have had to scramble to contain it and stretch to pay the bill.

GREENE: NPR's Richard Knox has this morning's report.

RICHARD KNOX, BYLINE: Are you a Sheboygan native?

STEVE STEINHARDT: Sheboygan County native, not a city of Sheboygan.

KNOX: Steve Steinhardt, who works with the county's sheriff's department, is taking me on a quick tour of Sheboygan. It's a well-ordered city of 50,000 on the western shore of Lake Michigan.

STEINHARDT: I forgot we have a little construction going on back there.

KNOX: Normally Steinhardt is called on to deal with fire, floods or tornadoes. But usually it's pretty quiet.

STEINHARDT: As the emergency manager director, you can't find a better place to live. Nothing bad happens here. It's a good place...

KNOX: With the occasional TB outbreak.

STEINHARDT: That's what I'm learning. I never expected TB to be one of the bigger emergencies I'd face when I got into this field.

KNOX: Nurse Jean Beineman, who oversees the county's communicable disease control program, says it began on April 11.

JEAN BEINEMAN: I was working late in the afternoon and received a call from a nurse practitioner in the community. She had seen someone with tuberculosis.

KNOX: It was a woman at the center of a large close-knit family. State and local officials declined to identify the family, but they say like most TB outbreaks in this country these days, it involves an immigrant community. Sheboygan is home to sizeable populations from Mexico and from Laos in Thailand, where TB is common. Asian immigrants make up half of Wisconsin's recent TB cases. Refugees from the Hmong people of Laos have been the most difficult-to-treat cases. If it's not treated, TB can destroy lungs, damage other organs and kill. Beineman says the first case in this outbreak is a middle-aged mother who had suffered from TB for many months.

BEINEMAN: Had symptoms since at least last August - weight loss, cough, just feeling poorly.

KNOX: In fact, she probably first got sick more than a year ago. She went to doctors but her illness wasn't recognized as TB.

BEINEMAN: That's not at all unusual, so it was a long period of time.

KNOX: By early May, county health workers found active TB in three other family members spread over several households. And others had TB symptoms and abnormal chest X-rays. Ominously, several were schoolchildren.

DALE HIPPENSTEEL: Once the families were identified, we knew we had the tiger by its tail.

KNOX: That's Dale Hippensteel, Sheboygan County's public health manager. He says the really bad news was that the woman at the epidemic's center had a TB strain resistant to at least two of the main drugs used to treat the infection. That's known as multidrug-resistant, or MDR, tuberculosis. Officials worried that hard-to-treat MDR-TB had spread to a lot of other people in town.

HIPPENSTEEL: We thought we were going to have 15 of these multi-drug-resistant folks. And we thought from those we might have up to 200 cases of latent TB. That's kind of the data they had that says if you have one of these cases, you're going to have 10 or 15 people who have been infected.

KNOX: Latent TB isn't contagious, but it has to be treated with antibiotics every day for six months to a year. One big priority was to see if the kids with active TB who attended a Sheboygan high school and a middle school had transmitted the disease to their classmates. Again, nurse Jean Beineman.

BEINEMAN: We tested about 130 students and teachers who had very close contacts with the affected individuals, those that were diagnosed as having tuberculosis. We really looked at the individuals that spent a lot of time, had more than one class together.

KNOX: Officials assured parents and teachers that TB is not easily caught and that when someone gets infected it can be cured. That seemed to keep people calm.

BEINEMAN: Really, I think the level of panic in the community was held at bay. We did not see panic.

KNOX: Today, more than three months after the outbreak first came to light, there have been nine confirmed cases of active TB in the extended family. But fortunately none of the other cases is as drug-resistant as the first one. It's not clear yet how many other people in Sheboygan will turn out to be infected. Officials think it will be in the dozens.

BEINEMAN: When we put it all together, we probably will end up treating anywhere between 30 and 40 individuals for infection.

KNOX: That may not sound like such a big deal. But treating TB is complex and labor-intensive. People with latent TB infections have to be treated so they don't become sick and spread it. Every day a nurse must watch them take antibiotics. A lapse in treatment could cause them to develop a multidrug-resistant germ. Active TB has to be treated until it's no longer contagious. And that can take up to a year. And the woman with multidrug-resistant TB needs to be treated with a toxic cocktail of drugs for two years - maybe more. That may cost something like $300,000 for the antibiotics alone. Officials recently moved her into an apartment paid for by the county.

HIPPENSTEEL: We're talking about some folks that don't have very much. They're low-income folks. They didn't have a phone. They couldn't afford those things.

KNOX: She and the eight others with active TB in the family must be kept apart from everyone until they're no longer contagious.

HIPPENSTEEL: They were isolated from work, school, any public contact. You know, we had to reinforce that a number of times - and no, you can't just get in the car and go to the big box store. You know, you have to stay home.

KNOX: The cost of all this is enormous. When officials feared there might be 15 active cases and 200 latent cases of highly drug-resistant TB, they projected it would cost the county $17 million to bring the outbreak under control. Sheboygan dodged that worst-case scenario. But it had to persuade the state legislature to appropriate around $5 million to deal with the situation. That's almost 10 times the state's normal TB control budget. Still, Lorna Will, the state's TB control director, says Sheboygan has avoided a much higher number of TB infections than it might have had.

LORNA WILL: And that's because we jumped on them and got them right away. If this was the sort of leisurely contact investigation where, well, next week I'll go talk to this family and the next week after that I'll get the other - you know, if you didn't have the manpower to jump in and essentially do everything at once, this could be looking very different.

KNOX: But the ability to jump on these outbreaks is eroding fast. A recent survey by the National TB Controllers Association shows 60 percent of states have cut their TB control budgets. So have nine major cities with the biggest TB problem. Many say cases of TB are being missed and they can't investigate outbreaks the way they used to. This reminds TB expert Richard Chaisson of Johns Hopkins of what happened in the early 1990s. Funding cuts in TB programs led to a resurgence of the disease.

DR. RICHARD CHAISSON: We corrected that mistake, and we've had great results. And now we're making that same mistake all over again, which is declaring victory and withdrawing from the fight before the disease is controlled. And that's a huge mistake that will come back to haunt us.

KNOX: Overall TB rates won't go back to the 1992 level, Chaisson says, but outbreaks like Sheboygan's will start popping up more often and stopping them will cost a lot more than keeping TB under control. Richard Knox, NPR News. Transcript provided by NPR, Copyright NPR.

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