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Tuberculosis Outbreak Identified at San Francisco High School Amid Rising US and Global Cases

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Tuberculosis Outbreak Identified at Archbishop Riordan High School Amidst Rising Global and US Cases

A tuberculosis (TB) outbreak has been identified at Archbishop Riordan High School in San Francisco, leading to confirmed active cases and a significant number of latent infections among the school community. Health officials have implemented specific measures to contain the spread, while broader discussions highlight an increase in TB cases in the United States and globally after decades of decline.

Outbreak Details at Archbishop Riordan High School

A student at Archbishop Riordan High School was diagnosed with tuberculosis in September, after experiencing a persistent cough. Two months later, in November, the San Francisco Department of Public Health (SFDPH) initiated an investigation following the identification of an initial active TB case within the school community.

Reports on the number of confirmed active cases vary. One source reported three confirmed active TB cases, while another stated four confirmed active cases and three additional suspected active cases as of February 24. Similarly, reports on latent TB infections differ, with one source indicating over 50 members of the school community tested positive for latent TB, and another reporting 207 members with latent TB.

School and Public Health Response

In response to the outbreak, Archbishop Riordan High School temporarily transitioned to remote learning until February 9, followed by a hybrid learning model through February 20. Following this period, campus access has been restricted to students and staff who have tested negative for TB. Participation in indoor off-campus activities, such as sports competitions, also requires a negative TB test result. The school required students to provide test and treatment information for in-person instruction. Testing efforts at the school are scheduled to continue every eight weeks until the outbreak is declared over.

The SFDPH issued an advisory, alerting healthcare providers to monitor for TB symptoms in individuals connected to the school. Individuals diagnosed with active TB are required to isolate at home. The SFDPH recommends that all individuals with latent TB infection (LTBI) complete treatment, noting that LTBI is not contagious. Public health officials have indicated that the risk to the broader San Francisco population and significant community transmission in the US is currently low. However, officials also noted that continued weakening of public health infrastructure and research funding could affect the ability to maintain low incidence rates. The school could not legally mandate medication for students.

Understanding Tuberculosis

Tuberculosis is a bacterial infection that primarily affects the lungs. It manifests in two forms:

Active TB

Individuals experience symptoms such as fever, chills, coughing, weight loss, and coughing up blood. Active TB is transmissible to others. An individual with active TB can infect up to 15 people annually.

Latent TB

Individuals are asymptomatic and not contagious, but the bacteria remain in the body and can progress to active TB at any time. Approximately 5 to 15 percent of latent cases progress to active disease if untreated.

Both latent and active TB are treatable with antibiotics, with treatment typically spanning several months. Some active cases may require hospitalization. The SFDPH reports a case fatality rate exceeding 10% in San Francisco. Diagnosing TB can be challenging as its symptoms, such as a chronic cough or night sweats, can resemble other conditions. Delays in diagnosis can lead to more severe patient outcomes, increased spread, and a higher risk of antibiotic resistance. Subclinical cases, where individuals are infectious without symptoms, may account for a portion of global transmission. Individuals cured of TB can be reinfected.

Broader Context of Tuberculosis Trends

Global Resurgence

Globally, TB regained its status in 2023 as the world's leading cause of death by infectious disease, infecting approximately 10 million people and causing 1.5 million deaths annually. Around a quarter of the global population may be infected with the bacteria. Robert Koch identified the cause of TB on March 24, 1882, an anniversary now observed as World Tuberculosis Day.

Rising Incidence in the United States

In the United States, TB incidence rates have been rising since 2022, following a 30-year period of decline. Recent cases have been reported in high schools in Long Island, New York, and Seattle, preceded by an outbreak in Kansas two years prior. California's TB incidence rate (5.4 cases per 100,000 people) is higher than the national average (approximately 3 cases per 100,000 in 2024). Outbreaks involving four or more people remain relatively uncommon in California, with 17 new or ongoing outbreaks reported in the state for 2024.

Contributing Factors and Challenges

Factors contributing to the persistence of TB in the US include:

  • Disinvestment in public health infrastructure.
  • Medication supply shortages.
  • Delays in diagnosis, partly exacerbated by the Covid-19 pandemic.
  • Challenges in detecting and treating latent cases.

Approximately 13 million people in the US have latent TB. The financial burden of TB treatment is substantial; latent TB treatment costs around $857 per patient, while active TB diagnosis and treatment costs over 50 times that amount. A widespread increase in TB or multidrug-resistant TB in the US could escalate annual treatment costs to over $11 billion. Cuts to international programs could also lead to millions of additional TB deaths globally and increased drug-resistant cases.

In the US, TB typically spreads in areas characterized by insufficient healthcare services, overcrowding, poor ventilation, and higher rates of malnutrition, such as prisons and homeless shelters, with marginalized populations identified as being at higher risk.

Path Forward

Infectious disease experts have noted the increase in U.S. TB cases since 2022. Developing new medications, improved diagnostics, adult vaccines, and ensuring sustained funding for TB research, prevention, and treatment are identified as essential tools for global TB control.