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FL health chief criticizes CDC report on TB outbreak

Florida Department of Health Secretary Dr. John Armstrong says overstatements in a CDC report are partly to blame for a recent media frenzy about an outbreak of tuberculosis among the homeless population in Jacksonville. He also said there is no connection between the Duval cluster and cases in other counties.

In a telephone interview with Health News Florida on Tuesday night, Armstrong said some unfortunate phrases in the Centers for Disease Control report turned a manageable disease outbreak into a four-alarm media event that led to unnecessary concern among the public. He was referring to thePalm Beach Post reporton July 9 that bore the headline: "Worst TB outbreak in 20 years kept secret."

One of the phrases in the CDC reportthat Armstrong objected to was: “This outbreak represents one of the most extensive TB outbreaks that CDC has been invited to assist with since the early 1990s, both in terms of its size and rapid growth.”

He said the report failed to make clear that the 13 deaths and 99 illnesses associated with the cluster were spread over eight years, and that overall the number of TB cases in Florida has been going down.

"If you don't put context in, you create an opportunity for misunderstanding," he said. "That is unfortunate."

The report that Armstrong objected to was sent to Florida officials in April by the CDC team that studied the outbreak at the state's request. The author was Dr. Robert Luo,  a member of the CDC Epidemic Intelligence Service (EIS), a training ground for young disease-trackers.

Asked for a response to Armstrong's remarks, CDC press officer Jennifer Horvath wrote in an e-mail: "CDC stands behind the report, which reflects our findings, concerns, and recommendations to address unmet needs. We also stand ready to work with Florida to be supportive of their actions."

She also said that questions about the outbreak should be directed to the state DOH press office.

CDC does not launch an epidemiologic investigation – an “Epi-Aid” -- unless it is invited. Duval County and Florida health officials asked for the CDC’s help with the Jacksonville TB outbreak twice: in June 2009 and again in February 2012.

Luo was one of half a dozen CDC staff who worked on the February Epi-Aid. EIS officers are required to write a report at the conclusion of such investigations and send them to the state that requested the help.

According to his bio, Luo received his BA from Harvard University and MD and MPH from Johns Hopkins. He had a residency in anatomic and clinical pathology at Stanford University before joining the EIS in 2011.  He has worked on TB projects in many sites, including North Korea and Vietnam.

Answering other questions concerning the Jacksonville outbreak, Armstrong said:

--There is no  evidence that the tuberculosis outbreak in Jacksonville has spread to other areas of Florida. While two dozen cases of the same strain – FL 046 -- have been found in 17 other counties, only two of the patients had any contact with the Duval County cases, Armstrong said.

“This is random scatter,” he said, using epidemiology-speak for cases that have no connection.

The same strain has been found in 32 other states, he said. It appears to be latent in the environment, popping up from time to time for reasons that aren’t clear, he said.

--No new cases of the FL 046 strain have been diagnosed in Jacksonville since April.

--Those who work with the populations that are most vulnerable in the outbreak -- men in homeless shelters or jail, or who have mental illness or addictions -- have been successful in getting them to accept the testing and treament. No court orders have been necessary.

Earlier this week, as the Florida Times-Union reported, Armstrong and Duval County health officials met with the media in Jacksonville to talk about a new initiative that will be launched next week: mobile units that will look for people who need to be screened for TB.

Armstrong maintains that "risk communications" should be directed only to those who might be affected by an outbreak, the people who may be infected and those who spend time with them. In this case, the majority of cases have been found among persons who are homeless, mentally ill, substance abusers or in jail.

Armstrong's narrow definition of the audience for risk communications has drawn criticism. Some in the media and Legislature have accused DOH of trying to keep the TB outbreak secret so that it would be easier to downsize the health agency and close the state's TB hospital. That hospital, AG Holley in Lantana, was shut earlier this month.

--Health News Florida is an independent online publication dedicated to journalism in the public interest. Contact Editor Carol Gentry at 727-410-3266 or by e-mail.


Carol Gentry, founder and special correspondent of Health News Florida, has four decades of experience covering health finance and policy, with an emphasis on consumer education and protection.