PART II. Outbreak Investigation
A choir list was matched to the state TB registry and 2 additional confirmed cases of TB within the choir were identified and their information was added to the line listing below:
Table 3. Updated Line List of M tuberculosis Clinical Cases in Large Town Church Choir
|ID||TB Status||Name||Age/Sex||Smear/Culture||Phone #s||Address||Place of
|Symptoms/Chest X-ray||Date Onset||Med Hx|
|1||Confirmed||Ali Yusef||38/M||+/+||None||Homeless/ from Somalia||Church||Cough/+||April?||Pneumonia, malnutrition|
|2||Confirmed||Jack Gold||62/M||+/+||973-555-2233||87 Jefferson St.
Large Town, NJ
|Large Company X Large Town, NJ||Some unexpected weight loss, fever, cough/+||June 7||Bladder Cancer|
|33 Madison Ave., Large Town, NJ||Large Company Y Large Town, NJ||Unexpected weight loss, fever, night sweats, cough/+||June 1||Hypertension,
|4||Confirmed||James Jones||48/M||+/+||Unexpected weight loss, cough||June 20|
|5||Confirmed||Mark Carlen||52/M||+/+||June 25||Hypertension|
Table 3.— continued
|ID||TB Status||Name||Choir||Vocal Range||DNA testing||Other|
|1||Confirmed||Ali Yusef||8 a.m. and 11 a.m.||Tenor||African-continent strain|
|2||Confirmed||Jack Gold||11 a.m.||Tenor||African-continent strain|
|3||Confirmed||Marla Smith||11 a.m.||Alto||African-continent strain|
|4||Confirmed||James Jones||8 a.m.||Tenor||Not done||Commuted to choir practice with Case 1
|5||Confirmed||Mark Carlen||11 a.m.||Tenor
Are Cases 4 and 5 epidemiologically linked to the other cases? (Look at Table 3 above)
The suspected index case (Case 1) is a tenor in the 8 and 11a.m. church choirs. In the winter months, he was occasionally driven to church with Case 4, a tenor in the church choir. There were 5 different choir groups totaling approximately 300 to 500 members (per an outdated choir list). Aggregate and separate choir practices were held once a week in the church or in its basement with 3 separate choir groups singing together or in staggered time periods.
Choir groups were labeled as to the time the choir sang in church each Sunday (8 a.m. choir and 11 a.m. choir). Choir members’ ages ranged from 5 to 70 years. The adult choirs rehearsed together once a week; on average, rehearsal time was 1 hour. Many choir members lived in other urban or suburban communities away from the church location. Commuting together usually was sporadic and ad hoc. The church and choir members were largely working, middle class African-Americans.
Part III. Analysis
Can you develop a hypothesis regarding this outbreak?
Only 300 of the assumed total of 500 choir members were accessible and available for tuberculin testing. Nonchoir church members were not tested. The entire church building including the stage and basement where all the choirs rehearsed was inspected for contributory factors (such as ventilation outlets) to environmental transmission.
What was the response/cooperation rate of the choir members, assuming there were 500 choir members? Why is this important?
It could not be ascertained for certain where transmission occurred, but the main church’s choir loft, where most rehearsals occurred, was considered the most likely location for cases 1, 2, 3, and 5. Transmission to Case 4 could have occurred in the choir loft during joint practice or while commuting with Case 1. The basement, where some transmission could have occurred, had air conditioning units with 8 air outlets from a dropped ceiling. Air was re-circulated.
Of the 300 traced choir members tested, 120 belonged to the 11 a.m. choir; 25 members of the 120 11 a.m. choir members were TST reactors; 12 of the 25 reactors were tenors and 12 of 36 tenors were reactors.
Use the data from the 120 11 a.m. choir members who received TSTs to create a contingency table to look for an association between vocal range (as a proxy for location/exposure to the index case in the choir) and skin test result. Assume that the group has been assembled based on their exposure status and that level of exposure is stratified by vocal range (tenor vs nontenor) because the index case was a tenor. These 120 choir members received TSTs and when the data is available, populate this table.
|Vocal Range||+ (Reactor)||– (Nonreactor)||
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