An outbreak of tuberculosis in a middle school in Henan, China: Epidemiology and risk factors.

Background: In 2013, a tuberculosis (TB) outbreak occurred in a middle school in Henan province of China. An outbreak survey was carried out in the school.
Objectives: This study was undertaken to investigate the detection rate of TB cases and those with strong Mantoux positive (SMP), defined as tuberculin skin test (TST) indurations of 15mm or larger and/or blisters, necrosis or lymphangitis, and to identify their risk factors.
Methods: The TST, chest x-ray/radiography, and TB-suspicious symptoms interview were used to screen for TB cases. Their diagnosis was made by sputum smear microscopy, liquid culture, computed tomography (CT), and diagnostic therapy if necessary. We retrospectively analyzed the outbreak survey data of 4082 students and 278 staff in the school. Logistic regression models were used to identify the risk factors associated with SMP and TB disease.
Results: Approximately 3.55% of students and 16.55% of staff were SMP. SMP rate in students was significantly lower than that in staff (p<0.001). 55 TB cases in students and none in staff were identified in the school from February to November, 2013, with a detection rate of 1.35% for students. SMP and TB case detection rates were 20.29% and 41.77%, respectively, in the index class, both significantly higher than that in the other classes (3.26% and 0.55%, respectively; both p<0.001). In the index class, TB case detection rate over the study period in students with SMP was not significantly higher than that with TST indurations of <15mm (38.18% vs 21.43%, p = 0.24), but it was significantly higher in the other classes (7.81% vs 0.18%, p<0.001). Risk factors independently associated with SMP and TB cases shared the following with the index case: same dormitory-floor (adjusted odds ratio (AOR) 5.36, 95% CI 3.02-9.48, p<0.001 for SMP; AOR 2.67; 95% CI 1.03-6.96, p = 0.044 for TB cases), same classroom (AOR 4.01; 95% CI 1.95-8.26, p<0.001 for SMP; AOR 165.08; 95% CI 66.88-407.47, p<0.001 for TB cases), same teaching-floor in different classroom (AOR 5.41; 95% CI 3.02-9.71, p<0.001 for SMP; AOR 11.24; 95% CI 3.71-34.03, p<0.001 for TB cases) and same teaching-building on different floor (AOR 1.81; 95% CI 1.16-2.85, p = 0.009 for SMP; AOR 3.30; 95% CI 1.16-9.42, p = 0.025 for TB cases). The closer the contact was with the index case, the larger the AORs for SMP and TB cases were.
Conclusion: Same dormitory-floor, same classroom, same teaching-floor and same teaching-building with the index case were all risk factors for both TB infection and disease for students in the outbreak, and the closer the contact was with the index case, the higher the risk was observed. Attention should also be paid to students with TST indurations <15mm, as well as to those with that ≥15mm for the index class in dealing with the outbreak.
Competing Interests: The authors have declared that no competing interests exist.