Policy and Programmatic Implications to Tuberculosis control in Schools following a Tuberculosis out-break in a Secondary School in Mukono District, Oct. 2017

Summary

On 5 October 2017, the Ministry of Health National TB and Leprosy Program was notified of a possible tuberculosis (TB) outbreak in a boarding secondary school in Mukono District. Investigations revealed several students with TB disease in the school. Non-isolation of infectious students, poor ventilation, and congestion in residential dormitories and lack of treatment could have propagated this outbreak. We recommended improvement in TB infection control in the school, improved ventilation, reduced congestion, identification and isolation of infectious students and offering treatment support to individuals with TB in school.

Introduction

TB remains a major public health problem in Uganda and the country is considered by the World Health Organization among the 30 high burden TB/HIV countries [1]. A national TB prevalence survey conducted in 2015/16 revealed TB prevalence of 253/100000 and incidence of 234/100000 [2] compared to previously estimated TB prevalence of 159/100000 [3]. With a TB notification of 43413 in 2016, the country missed about half of the estimated incident TB cases [1].

TB case finding remains a major challenge in the country despite efforts by Ministry of Health and partners; case finding is even harder among children and adolescents age 15 years and below. The country notifies only about 8% of all TB as children as opposed to the estimated 15-20%. Evidence from the national TB prevalence survey identified a TB notification to prevalence ratio of 2.0 among individuals aged 15-24, implying that for every one individual diagnosed with TB in that age group, two are missed.

On 5 October 2017; a rumor about a tuberculosis outbreak in a secondary school in Mukono District was received by Ministry of Health National TB and Leprosy Program (NTLP), via the NTLP’ whatsApp platform. Initial investigations by Mukono District Health Team (DHT) revealed that in a span of one year, the school had recorded 4 students with confirmed TB. Tuberculosis is an infectious disease spread from one person to another through droplet transmission from an infected individual via the respiratory route.

Approaches and Results

We investigated this TB outbreak to determine the scope, risk factors for transmission and to recommend evidence-based interventions. We defined a suspected TB case as onset of fever or night sweats, plus cough, chest pain, fatigue or weight loss in a School X student. A probable case was a suspected case with chest X-rays (CXR) suggestive of TB or diagnosed clinically. A confirmed case was a suspected or probable case testing positive by Xpert MTB/RIF. We found cases by reviewing medical records at the school dispensary, Mukono HC IV, medical records kept by students and performed CXR and screening among close contacts (i.e., sharing dormitories or in the same grade) of the initially- reported confirmed cases for signs and symptoms. We evaluated risk factors for developing TB disease, including dormitory crowding and ventilation.

Of the 224 close contacts investigated, We found 30 cases (10 con- firmed, 20 probable) (attack rate [AR]=13%(30/224). The primary case-student diagnosed mid-2015 started on 1^st line TB treatment but was lost to follow-up two months later. Neither he nor subsequent case-students were ever isolated. Cases at School X occurred among Senior 4 (23/145, AR=16%) and Senior 5 students (7/79, AR=8.9%). Males (AR=20%) were more affected than females (AR=5.7%). Among CXR performed, 13% (25/191) were suggestive of TB. In dormitories, average per-student living space was 3.1m² (Recommended is > 3.5m²). The window-to-living-space area ratio was 4.5% (Recommended is20%).

Currently efforts by the Ministry of Health and partners towards TB control in congregate settings have focused on prisons and urban slums, where dedicated projects exist. TB control in schools and other institutions of higher learning has not had much attention yet evidence shows that TB exists in schools and other institutions.