The small rural Alabama town of Marion in Perry County is in the midst of an outbreak of tuberculosis (TB), with two additional cases identified February 4, according to the Alabama Department of Public Health (ADPH).

"This town historically has had no TB," Pam Barrett, director, Division of TB Control, ADPH, noted in an interview with Medscape Medical News.

"Since early 2014, we've had 29 cases of active TB that are either genotypically or epidemiologically linked to the town of Marion. A lot of those have completed treatment. We only have 11 currently being treated for active TB in Marion," Barrett said. Three adults with TB have died.

The latest two cases involve an adult and a child aged less than 15 years. "The child was diagnosed very early through the Health Department's screening program before having symptoms of TB disease. The child had been in very close contact with an adult who had TB disease. Both of the new patients and another adult patient whose TB disease was confirmed earlier are on TB medication and doing well," according to an ADPH press release.

As of February 2, 2016, ADPH had screened 2023 patients in Marion, Perry County. A total of 394 children were tested as part of the screening process and seven children were identified as being exposed to the TB bacteria. Altogether, a total of 151 patients have tested positive for TB. Most of these patients have received chest x-rays and have started treatment to prevent them from getting TB disease and spreading it.

The TB case rate in Marion (roughly 253 per 100,000) "far exceeds" the TB case rate for the entire state of Alabama, ADPH says, and many developing countries, according to the World Bank.

Screening in Marion a Challenge

Getting Marion (population < 3600) and surrounding Perry County residents to agree to be screened for TB hasn't been easy, Barrett said. "The problem has been that the cases in this town were very reluctant to give us their contacts. The population just would not give us their contacts so in turn people they had been around developed active TB and then those individuals wouldn't give us their contacts. So it kind of snowballed."

In November of 2014, Barrett said, ADPH attempted to do a health fair. "TB kind of drove it, but we didn't want to label it a TB health fair. We set up in a main neighborhood where a lot of TB had been found. The turnout was very bad. The phrase we kept hearing is, 'I don't want nobody knowing my business.' There is a huge stigma here with TB. It's more so than with any other disease that I've seen," Barrett said.

To encourage testing, the health department starting paying people to be tested. They offered $20 to anyone coming in to be screened for TB by the TSPOT blood test, another $20 for returning after 3 days to get the result, another $20 for keeping an appointment to get a chest x-ray if recommended, and an additional $100 to a patient if it is recommended he or she take medication and treatment is completed.

"On January 29, we stopped paying for people to be tested and opened it up to appointment only. We are still providing free screening," Barrett said. ADPH is offering an additional day for screening children at Francis Marion High School on Wednesday, February 10.

"That Is the Concern"

Aaron Glatt, MD, a spokesperson for the Infectious Diseases Society of America, told Medscape Medical News that the ongoing TB outbreak in Marion is "a concern like any disease outbreak is a concern. There have been other outbreaks of TB in the US and on a regular basis this type of thing happens."

"I don't know the inciting person in this situation, they probably identified someone with TB who unfortunately then potentially contaminated or infected a bunch of other people, so that is the concern," said Dr Glatt, division chief of infectious diseases at South Nassau Communities Hospital in New York.

ADPH has done a "good job of effectively identifying cases and putting a screening process in place" to contain the outbreak, he noted. "The typical thing to do in this situation is exactly what they have done, which is try to identify anybody who has been exposed and to treat them before they potentially get sick themselves and then become contagious."

"When a person first gets exposed to TB, the bacteria can set up shop and can cause infection in that person. At this point, they are not yet infective. It's only when they get disease themselves that they become capable of transmitting TB. So the trick is to identify those people before they become contagious themselves and treat them. The second important part is to identify those exposed and sick and treat them because those patients are contagious," Dr Glatt said.