Schools in the front line as killer TB creeps back
the phone call to Redwood Park secondary school last month was like a voice from another era. One of the school bus drivers had been diagnosed with tuberculosis and a Health Protection Agency response team was on its way.
Tony Cox, the headteacher of the Portsmouth school, was astonished. Like many, he thought TB had more or less died out with chimney sweeps and horse-drawn carriages.
"I thought it was something from the past and that BCG vaccinations had virtually wiped it out," he said. But the disease is back - and it is affecting schools. One outbreak a year has been reported since 2004, but this year there have been seven - so far.
Tuberculosis is the grim reaper of preventable diseases. Rife in Britain in previous centuries, it commonly affects the lungs and symptoms include fever, weight loss and coughing up blood. There are two million TB deaths worldwide every year. But until recently, it was thought to have been virtually wiped out in this country.
For most of the 1990s, the number of cases in England and Wales remained below 6,000 a year. But lately the figure has begun creeping up again. By 2005, it was 7,628, the highest in 20 years, with even more significant rises in Northern Ireland.
Because many staff and parents assume TB has been all but eradicated, schools can be caught unawares. Redwood Park secondary was lucky to get expert help. Half a dozen nurses from the Health Protection Agency arrived, with doctors and paediatricians, and started blood-testing the adults and children in the school.
The infected bus driver, from a local agency, had been taking children to the school for only 24 days but tests found traces of TB in 17 of his 33 young passengers. In Portsmouth, which has very low rates of TB, babies are not immunised as a matter of course.
Since the outbreak, the pupils have been permitted to return to school.
None of them showed symptoms of full-blown TB anddoctors judged they were not infectious.
The incident has prompted reanalysis of the Government's stance on tuberculosis, which was once called the White Plague or consumption. Two years ago, the Government's Joint Committee on Vaccination and Immunisation, an independent body of experts, recommended an end to universal immunisation.
Case figures had fallen steadily since the introduction of the BCG vaccine in 1953. Before the First World War there were more than 100,000 infections per year. By 1987, cases were at an all-time low of little over 5,000.
Health trusts adopted a policy of only immunising babies in high risk areas. These included much of London, Birmingham and Leicester. Immigrants from areas where TB is still common, such as Pakistan, Bangladesh and large parts of Africa, are also vaccinated.
But officials are concerned that the disease is being spread by immigration. One in five diagnoses are new arrivals.
Last month in England and Wales, at least four schools, a further and higher education college and a family centre reported TB outbreaks. In Wales, where there has been a spate of cases, teacher unions are calling for a return to universal immunisation.
At Southfield junior school in Luton, Bedfordshire, last month, seven children in one class were found to be infected. All pupils were screened and X-rayed for TB and antibiotics were administered where necessary. Yet Marilyn Redfern, the headteacher, was still criticised for refusing to close the school temporarily. Angry parents withdrew their children.
"I was following advice from the health authorities," she said.
Concerns were addressed by installing question boxes in classrooms for children to post worries. Some pupils are still taking medication and are asked to bring in snacks and water in case they feel tired or queasy.
"But the most important thing is to keep calm," said Ms Redfern.
Stuart Marson, head at Holywell high school in Flintshire, Wales, knows how difficult it is to balance the need to keep children safe with the desire not to create anxiety.
"It's important not to be complacent but on the other hand you don't want to fuel unnecessary speculation," he said.
He discovered a staff member had been hospitalised for TB before the recent summer half term and took advice from the local health trust. It helped him draft a detailed press release, which eased the media pressure, and organise a meeting with anxious parents. Next month 250 children judged to have come into frequent contact with the staff member will be tested. So far, none has exhibited symptoms.
Mr Marson said: "Parents and health staff have been brilliant. The most important thing is having a policy for these sorts of incidents drawn up.
It means you don't make an ill-judged decision."
TB is not highly infectious and can be treated easily with antibiotics if diagnosed quickly. Problems can follow if it is not - sometimes delay can be fatal.
Some cases end in tragedy. In Southampton, Hanif Khan is grieving the loss of his 13-year-old daughter, Uzma, in 2005.
"She was a young, bubbly little girl, full of life," he said. "There's everything to look forward to when you're young. You've got your whole life in front of you."
Mr Khan has nothing but praise for Uzma's teachers and, especially, the school nurse.
Like the family, the nurse was convinced that Uzma's coughing and breathing difficulties were symptoms of something more serious than a cold. Mr Khan said he and his family took Uzma to the doctors' surgery on six occasions and enlisted the assistance of the school nurse to phone the doctors to emphasise their concern.
In January 2005, Uzma's mother, Jamila Begum, took her to the health centre for the last time. When the doctor said her condition was not serious, Mrs Begum refused to leave.
"My wife said, 'I'm not leaving till we get seen or you send us to the hospital, because there's something seriously wrong with my child.' In the end the doctor gave in," Mr Khan said. "I always wonder if I could have done more. If I'd been more stubborn, earlier, would she still be here now?"
Uzma died in Southampton general hospital in February 2005, just across the road from the maternity unit in which she was born. Her parents took her body home to Pakistan for burial.
Like all government measures, the decision to end mass vaccination was the result of complex economic risk analysis. It was a matter of weighing costs against benefits.
These days Whitehall departments refuse to spend more than pound;1.43 million on measures that may save no more than a single human life. Earlier this month, following the school outbreaks, the Government's vaccinations committee reviewed the policy, but renewed its advice to immunise only babies in high-risk areas and some immigrants. The risk to the wider population remained low, the committee said.
The Department of Health said it was not complacent about TB, but that there were no shortcuts. It would take long-term concerted action for health authorities to win the battle against the disease.
Professionals believe combating TB is about those who work with children fully understanding that the biggest killer of the Victorian era is back.
White Plague returns
During the 19th century, up to a quarter of deaths in Europe were caused by TB, or consumption as it was often known. The bacterium has been around since at least Egyptian times, but because it is passed on by inhaling an infected person's breath, it caught hold in the crowded urban areas created by the industrial revolution.
It became known as the White Plague because of the pallor of its victims and because, when X-rays were used to confirm diagnosis, white specks appeared on the images of infected lungs.
The death toll began to fall at the start of the 20th century as living standards improved. From the start of the 1940s, effective medicines were developed.
But 2 million people will die from TB this year, mainly in poorer countries where there is overcrowding and malnutrition.
In the UK, the number of cases is rising. Most people's immune systems can fight it off, but drug users, those infected by HIV or heavy drinkers are among those more likely to encounter problems.
TB is not particularly prevalent in schools but, as with any infection, close contact between pupils may cause it to spread.