TB cases linked to Castro bars
by Matthew S. Bajko
San Francisco health officials have traced several cases of tuberculosis to patrons of Castro gay bars, with one of the people infected a bartender in the area. The discovery has prompted them to ask 140 employees of businesses in the gay neighborhood who may have been exposed to an active case of TB to get screened for the potentially deadly disease.
To handle the large number of people being asked to cooperate with the request, the health department has set up a special screening site at Magnet, the gay men's community health center in the Castro, that will be open over the first two weeks of January. Those screened will be given an advanced blood test for TB, and people who are HIV-positive, and particularly at risk for TB, will also be given a chest X-ray.
The screenings are meant to identify anyone who is at risk for developing TB and provide them with follow up treatment necessary to control the disease. More than 50 people have reportedly already been tested.
"What we are trying to achieve is 100 percent participation from the bars in getting all staff who have face-to-face relations with the public screened. Without all data, we can't come to accurate conclusions," said Dr. Masae Kawamura, director of the health department's tuberculosis control section. "TB can affect anyone. It is an equal opportunity disease. You don't have to be HIV to get infected."
This week the health department also notified service providers with gay and HIV patients in the city to be on the lookout for signs of TB infections.
The screenings were prompted after health officials last month were able to link the same strain of TB found since 2007 to five men in their early 20s suspected to be gay or bisexual who frequent Castro bars. One of the cases was found last summer in an employee at a Castro bar, which they declined to name due to privacy issues.
According to a fact sheet handed out to bar owners, obtained by the Bay Area Reporter, the health department is concerned that the "cluster of highly infectious TB cases" may be "working its way through the SF gay community."
As detailed in the fact sheet, the first two cases to emerge were linked to a retail commercial establishment in the South of Market neighborhood where one individual worked and the other was a patron. After testing 32 employees at the site, a total of five were infected with TB, "despite a low-risk, indoor gymnasium-like setting with good ventilation," stated the notice.
Then last January, a third case of TB was discovered in a patient who lived near the commercial business, but had no physical link to it. In the summer, a fourth case emerged in a person who works at "a popular nightclub" in the Castro and had no connection to the SOMA business.
In late November a fifth U.S.–born patient was hospitalized with a cough, night sweats and a 40-pound weight loss, stated the fact sheet. In early December, the state's genotyping laboratory notified the health department that it had matched all five cases of TB to the same strain.
Four of the five cases were in openly gay men in their 20s, with three HIV infected. All but one of the individuals were U.S. born and would not be considered at risk for TB by "usual standards," stated the fact sheet.
"After repeat interviews, contacts of the fifth and third case admitted to going to bars in the Castro and named the bar/club employing the fourth index patient. All three of these individuals frequented many of the bars in the Castro during their infectious periods," according to the document. "This outbreak in young gay men who are highly social is a cause for concern for the community."
In interviews this week, health officials stressed that, to date, they have found no evidence to suggest that other patrons of Castro bars are at risk. And they also noted that, if discovered early, TB is a preventable and curable disease.
"We don't want to cause panic in the community. We are targeting staff of the bars because they would have the most exposure than patrons," said Kawamura. "TB takes quite a bit of exposure to catch it."
TB is an airborne disease and is easily spread when a person who is infected coughs, sneezes, or spits. Due to the poor ventilation in many bars, employees are more susceptible to TB exposure, said Kawamura.
"You don't get it from sex or sharing food or beer bottles. It is spread by someone who has it in their lungs who either sneezes or coughs," explained Kawamura. "Bars are notorious sites of transmission. There is a higher risk of breathing in contaminated air."
Supervisor Bevan Dufty, who was notified of the TB concerns last month, helped coordinate a meeting of Castro bar owners at Magnet prior to the holidays to alert them to the situation. He said customers should not be concerned about patronizing the bars in the Castro, noting he spent New Year's Eve at various locations in the neighborhood.
"We are going to move fairly quickly. Members of the public are at extremely low risk and there is nothing to demonstrate there are additional cases generating with connections to Castro bars," said Dufty. "I was at the bars on New Year's and I will continue to go out and I encourage people to continue to go out."
Bar owner Greg Bronstein, who has been spearheading an effort to formally organize Castro bar owners into their own association, said he assigned one of his managers to facilitate the screenings of his employees at his businesses.
"We are doing the best we can to work with city officials," said Bronstein. "We want to protect our staff and make sure everyone is safe but not overplay it."
Kawamura said she has been impressed with the cooperation her staff has received from Castro bar owners in responding to the situation.
"We are getting full cooperation from the community, which is really refreshing. Often we get a pushback or people feel stigmatized or concerned about their business," she said. "We didn't get any of that from this situation."
But the screenings have raised concerns among some bartenders in the Castro, one of whom contacted the Bay Area Reporter to complain about the invasiveness of the screenings and to question why only employees at gay businesses were being targeted.
"Why are the bartenders in the Castro being FORCED to take TB tests, and not the rest of the SF service industry?" asked the bartender, who preferred to remain anonymous. "Along with the tests there are many many personal questions we are to answer."
Health officials described the screenings as "business as usual" for the TB control section, noting that in 2008 they conducted similar testing for the disease in schools, on college campuses, a hospital, restaurants, and retail stores. The questioning is also part of the protocol the health department uses to pinpoint patterns of transmission.
Depending on their risk for exposure, some friends and family members of the Castro employees are also being screened, said Kawamura. Once the test results come back later this month Kawamura said she would then have a better picture on if the TB outbreak in the Castro is widespread or isolated to a few cases.
"If we find high rate of infections that shouldn't be there, then we would have to take it from there and determine what sites we feel transmissions have occurred and if there is any pattern," she said. "After that we would begin targeting HIV-positive individuals who frequent bars in the Castro if transmission is found."
HIV is the biggest risk factor for not only contracting TB but for perpetuating and amplifying transmission, said Kawamura. It can also be deadly for HIV-positive individuals if the TB goes untreated.
"Our big concern here, and certainly we do not want to stigmatize the community, but the Castro is most vulnerable because of high rates of HIV among workers and patrons who go there," said Kawamura. "For the public there is no need for alarm, not yet anyway."
Last year there were 118 TB cases reported in San Francisco. It marked the lowest number of active TB cases recorded in the city since health officials started tracking the disease. In 2007, there were 143 TB cases.
The majority of cases are found in foreign-born individuals coming to the U.S. from countries with severe TB outbreaks. Kawamura said the city has rarely found a cluster of TB cases among gay or bi men, and among people living with HIV, the number of cases has been steadily dropping.
Last year marked an all-time low of cases among individuals with HIV, with only 11 people, almost half of whom were homeless, contracting TB. The number presents 7.7 percent of the total cases.
The cluster of TB cases in the Castro should therefore be a red flag for gay and bi men, Kawamura said.
"Another big concern for the gay community, with the rise in syphilis and unprotected sex, is we are going to see a rise in HIV among young men. What we are seeing now is HIV and TB, and we shouldn't be seeing it in this population, the Castro population," she said.
Symptoms most associated with TB include chronic cough, unexplained weight loss, night sweats, and low-grade fevers.
"If they have any of these symptoms, especially if they are HIV-positive, or a chronic cough that is not improving after three weeks, they should see their doctor," said Kawamura.
For more information about TB, the health department has set up a fact sheet online at www.sfdph.org.