title: Outbreak of drug-resistant tuberculosis with second-generation transmission in a high school in California.
abstract: BACKGROUND
  In spring 1993, four students in a high school were diagnosed with tuberculosis resistant to isoniazid, streptomycin, and ethionamide.
  
  
  METHODS
  To investigate potential transmission of drug-resistant tuberculosis, a retrospective cohort study with case investigation and screening by tuberculin skin tests and symptom checks was conducted in a high school of approximately 1400 students. Current and graduated high-school students were included in the investigation. DNA fingerprinting of available isolates was performed.
  
  
  RESULTS
  Eighteen students with active tuberculosis were identified. Through epidemiologic and laboratory investigation, 13 cases were linked; 8 entered 12th grade in fall 1993; 9 of 13 had positive cultures for Mycobacterium tuberculosis with isoniazid, streptomycin, and ethionamide resistance, and all 8 available isolates had identical DNA fingerprints. No staff member had tuberculosis. One student remained infectious for 29 months, from January 1991 to June 1993, and was the source case for the outbreak. Another student was infectious for 5 months before diagnosis in May 1993 and was a treatment failure in February 1994 with development of rifampin and ethambutol resistance in addition to isoniazid, streptomycin, and ethionamide. In the fall 1993 screening, 292 of 1263 (23%) students tested had a positive tuberculin skin test. Risk of infection was highest among 12th graders and classroom contacts of the two students with prolonged infectiousness. An additional 94 of 928 (10%) students tested in spring 1994 had a positive tuberculin skin test; 22 were classroom contacts of the student with treatment failure and 21 of these had documented tuberculin skin test conversions.
  
  
  CONCLUSIONS
  Extensive transmission of drug-resistant tuberculosis was documented in this high school, along with missed opportunities for prevention and control of this outbreak. Prompt identification of tuberculosis cases and timely interventions should help reduce this public health problem.
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
authors.forename: R
authors.initials: R
authors.lastname: Ridzon
authors.forename: J H
authors.initials: JH
authors.lastname: Kent
authors.forename: S
authors.initials: S
authors.lastname: Valway
authors.forename: P
authors.initials: P
authors.lastname: Weismuller
authors.forename: R
authors.initials: R
authors.lastname: Maxwell
authors.forename: M
authors.initials: M
authors.lastname: Elcock
authors.forename: J
authors.initials: J
authors.lastname: Meador
authors.forename: S
authors.initials: S
authors.lastname: Royce
authors.forename: A
authors.initials: A
authors.lastname: Shefer
authors.forename: P
authors.initials: P
authors.lastname: Smith
authors.forename: C
authors.initials: C
authors.lastname: Woodley
authors.forename: I
authors.initials: I
authors.lastname: Onorato
mesh_terms: D000293:Adolescent; D002140:California / Q000453:epidemiology; D015331:Cohort Studies; D004196:Disease Outbreaks / Q000517:prevention & control / Q000706:statistics & numerical data*; D018432:Drug Resistance, Multiple; D004977:Ethambutol / Q000008:administration & dosage; D005000:Ethionamide / Q000008:administration & dosage; D005260:Female; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control / Q000706:statistics & numerical data*; D007538:Isoniazid / Q000008:administration & dosage; D008297:Male; D008403:Mass Screening; D009169:Mycobacterium tuberculosis / Q000187:drug effects / Q000302:isolation & purification; D012189:Retrospective Studies; D012293:Rifampin / Q000008:administration & dosage; D012574:Schools / Q000706:statistics & numerical data; D012882:Skin Tests; D013183:Sputum / Q000382:microbiology; D013307:Streptomycin / Q000008:administration & dosage; D014376:Tuberculosis / Q000175:diagnosis / Q000453:epidemiology* / Q000517:prevention & control / Q000635:transmission*
chemical_list: D004977:Ethambutol; D005000:Ethionamide; D007538:Isoniazid; D012293:Rifampin; D013307:Streptomycin