Having baseline results helps UConn avoid panic
New screening program buys some peace of mind
It had the makings of a student health director's worst nightmare. A foreign-born student at the University of Connecticut was diagnosed with multidrug-resistant tuberculosis. It was the end of the regular school year, so along with regular classes, the student had attended lots of crowded social events, including graduation ceremonies.
But instead of expensive mass screenings, scores of phone calls from parents, and a massive contact investigation, the university's student health services had the problem taken care of in practically no time.
The reason? UConn, as the campus is known locally, has baseline skin-test results and health histories on all of the 14,900 American students and 1,100 international students on the sprawling rural campus in Storrs.
Plus, even though most international students come from countries where TB is endemic, and many have had BCG vaccinations, student health staff have little anxiety about the accuracy of the students' TB-related data. No wonder: The foreign-born students' skin tests were all placed and read by student health staff themselves, who also took the health histories, referred students for chest X-rays when indicated, and provided follow-up and monitoring for prophylaxis.
"We had the data," says David Kurland, MPH, director of UConn student health services and head of the New England College Health Association. "We already had records on all the student's friends and close contacts. So we never had to go into one of these mass screening programs."
State adopts university's guidelines
Guidelines based on UConn's TB screening program have recently been adopted and promulgated as the state standard for colleges and universities, and the program is the envy of many universities.
Still, Kurland is forthright about his program's shortcoming. "It's expensive," he says. "You simply cannot say that a program like this is cost-effective. We're very fortunate to have the resources to do it, but this program may not be right for everyone. We just decided it was the right program for us."
The American College Health Association (ACHA) recommends targeted screening of two groups: foreign-born students from high-incidence areas and American students from high-incidence areas. Many administers from small universities decide they don't have the time or resources to do even that much, says Claire Verdier, APRN, a nurse practitioner at student health service and a member of the school's TB Action Team. "Most schools do require immunizations [for measles, mumps, and rubella], but don't have any TB screening requirements," she says. "For such a long time, TB just wasn't an issue."
That's changed, of course. But it wasn't TB's resurgence that got UConn officials thinking about a new screening program for the disease, Kurland says; it was a measles scare.
"This was around the time [in the early 1990s] when we were having problems nationwide with measles outbreaks," he says. The University of Hartford had several cases of measles, with the result that the whole campus had been quarantined.
When UConn officials learned that a Yale student with measles had visited their campus, "We literally had to audit 10,000 charts," he says. "We decided that kind of scare was something we never wanted to go through again."
The state health department moved quickly to implement new immunization requirements for all university students. Almost as an after-thought, UConn officials decided to throw in a requirement for TB screening. "We figured, as long as we were doing it, why not the whole banana?" says Kurland.
At first, UConn's screening requirements were anything but stringent. "It was like, you have to be tested for TB, and will you please tell us about it," says Kurland.
But meeting even that requirement proved dicier than expected. Among places most of the school's international students called home - namely, countries in Latin America, Africa, and Asia - there was too much variation in skin testing and in policy related to BCG (bacille Calmette-Guerin) vaccination and prophylaxis. "In some countries you have a 21 mm induration, and they consider you kosher," says Kurland.
Trying to target only students from high incidence areas posed another set of problems. "It's hard to isolate out just the foreign-born, since not all foreign-born students are international; a lot of them are U.S. citizens," says Kurland. "And we're an active research university; our students go back and forth, spending a year here, three years there, a year someplace else." What kind of questionnaire could take into account so many variables?
Student health staff rejected as patently offensive the notion of asking students to single out those from high-incidence areas in the United States, whether they hailed from a neighborhood where there were lots of drug users, homosexuals, or homeless people, Kurland adds.
Finally, even though most TB cases at UConn occur among international students, there was the danger of offending foreign-born students by requiring only them to be skin tested, says Kurland. "There was a sentiment that we'd be discriminating against international students," he says.
The answer? Screen everybody!
The only answer seemed to be to mandate TB screening for everyone; it was decided. To make sure there were no offended students (and, not incidentally, to be sure evaluations were done according to U.S standards), student health offered to screen international students for free. American students, by comparison, would have to go to their own health care providers and pay for skin testing.
The commitment to screen all international students results in a lot of work. The program's success was only possible because UConn already had abundant health care resources, Kurland emphasizes. Storrs is located in a rural setting, 20 minutes from the nearest town or hospital, leaving it reliant on its own resources. As a result, student health services are "almost like a small hospital," says Verdier. On-campus amenities include a laboratory, a pharmacy, and radiology services.
There's an in-patient unit where sick students can stay overnight, plus speciality clinics for women, emergency care, mental health, and walk-in services, all staffed by four full-time physicians, 10 nurse practitioners, and assorted clerical and part-time support staff.
Still, the screening was a labor-intensive operation, says Verdier. Between 30% and 50% of foreign students are skin-test positive; about half of all Chinese students, who make up a big contingent, test positive; and many are chronically infected with hepatitis B virus as well, making liver function tests especially important if students must take INH.
Plus, every positive test means an exhaustive health history must be gathered, says Kurland. "That's where the real fun begins."
To cover the cost of chest X-rays, state TB control pays for a small portion; the radiology group that reads the X-rays has agreed to provide its services at Medicaid rates; and the health insurance the university provides to all students who lack their own coverage covers some costs as well.
About 60 to 80 students need prophylaxis at any given time, with student health providing the monitoring and follow-up, including letters, phone calls, and monthly evaluations. (The state TB control office provides the isoniazid, along with skin-testing reagents, for free.)
"I'm incredibly proud of our staff," says Kurland. "Not only have they developed great guidelines, they've also come up with a great logistical process." A detailed policy manual, for instance, provides meticulous lists of all the supplies - how many clipboards, pens, pencils, fans, photocopiers - are needed for fall orientation, when as many as 200 international students crowd into the student union, says Verdier.
"They've really got it down to a science," says Kurland.
Educating doctors, as well as students
As the program has evolved over the years, one of the biggest changes has been in attitudes toward the requirements, says Verdier. In the beginning, clinicians would fire off angry letters accusing the school of malpractice for putting students with BCG vaccinations on INH. Parents and students often resisted what felt like another country's heavy-handed and chauvinistic health practices, Verdier adds.
"We had to educate a lot of physicians," she says. As for the students, Verdier invites everyone who is a candidate for prophylaxis to come in for a talk, where she patiently explains the rationale behind skin testing and preventive therapy.
"It's hard for them," she says. "They've done everything required of them in their own country. Then they get here, and suddenly they have to cope with health insurance and all these other differences." In the end, she says, about half of all candidates complete a course of INH.
Inevitably, about once a year or so, someone breaks down with active TB. When that happens, Kurland adds, the good news is that UConn is ready.
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