I AM N

OT HOMELE

SS

CS

TE

JU

NE

20

13

Dee Pritschet, TB Controller – North Dakota Department of HealthShawn McBride, Epidemiologist – North Dakota Department of

HealthDiana Boothe, Public Health Associate – Centers for Disease

Control and PreventionAlicia Lepp, Epidemiologist – North Dakota Department of Health

Kirby Kruger, Division Director – North Dakota Department of Health

Tracy Miller, State Epidemiologist – North Dakota Department of Health

Krissie Guerard, TB Program Manager – North Dakota Department of Health

June 11, 2013

IT ALL STARTED WITH A PHONE CALL

MDDR

Mol

ecula

r Det

ectio

n of D

rug

Resis

tance

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110

5

10

15

20

25

30

Year

Num

ber o

f Cas

es

NORTH DAKOTA TB CASES 2000 - 2011

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

5

10

15

20

25

30N

umbe

r of C

ases

NORTH DAKOTA TB CASES 2000 - 2012

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

0.5

1

1.5

2

2.5

3

3.5

4

North Dakota TB Cases/100,0002000-2012

2008 2009 2010 2011 20120

0.5

1

1.5

2

2.5

3

3.5

4

4.5 US ND

United States vs North Dakota

TB Disease Rates/100,000

GENDER ND TB CASES 2008 -

2012

2008 2009 2010 2011 20120

2

4

6

8

10

12

14

16

Male Female

ETHNICITYND TB CASES 2008-

2012

2008 2009 2010 2011 20120

2

4

6

8

10

12

14

16Asian American Indian Black White

# o

f C

ases

TIMELINE OVERVIEW• Late October: three confirmed cases had been

identified in Grand Forks County

• November: Investigation identifies more cases and the State Health Dept. requests Epi Aid

• December: Epi Aid team arrives

• January to Present: Investigation continues, linking cases, evaluating social network, locating and referring contacts for testing, managing active cases and latent infections, administering Directly Observed Therapy (DOT)

EPIDEMIOLOGICAL LINKSName-basedOne patient identifies another person by name and reports close contact with that individual during the patient’s infectious period (IP)

A third party names two individuals and reports close contact between them during one’s infectious period and the other’s exposure period

*adapted from CDC Epi Aid Team Exit Presentation December 2012

Location-basedTwo patients known to have been present at the same time in a location in which they could have had close contact during one patient’s infectious period and the other’s exposure period

INVESTIGATIVE TOOLSCase Interview

Electronic Medical Records

Name and Photo release forms

Facebook/Social Networks

Pictures of transmission locations

Genotyping

GENOTYPINGSpoligotyping Identifies the M. tuberculosis genotype based on presence or absence of

spacer sequences found in a direct-repeat region of the M. tuberculosis genome where 43 identical sequences and 36 base pairs are interspersed by spacer sequences.

Spoligotype - 777776777760601 Miru - 224325153323Miru2 - 444234423337

CDC Epi Aid reviewed all cases with matching spoligotype as well as requested spoligotypes be run on culture positive cases with potential epi links

GENtype G00011

SENSITIVITY

LOW LEVEL ISONIAZID (INH) RESISTANCE

Why is this important?• Latent TB infection (LTBI) is treated with Rifampin

• Rifampin is a 4 month treatment in adults

• Rifampin is a 6 month treatment for children

• Treatment for Active TB Cases is 9 months vs 6 months

• INH shortage might lead to Rifampin shortage

Drug levels are imperative to ensure adequate drug levels are reached and maintained throughout the course of treatment

*from CDC Epi Aid Exit Presentation 12/11/12

Couch Surfing

PHOTO AND NAME RELEASE FORMSRequested active cases sign an order to allow us

to use their photo and/or name in investigation related activities

Used to verify suspected epi links

Established unknown epi links Linked our genotypic match from another community who was demographically

very different to the outbreak super spreader Extended the super spreader’s infectious period by 6 months

CDC used another method: Provided a name list to patients of random first names with other first names

of cases, particularly those who did not sign a photo release

ELECTRONIC MEDICAL RECORDSAllowed for further verification and identification

of named contacts

Able to “flag” charts of patients

Streamlined gathering and sharing of clinical information and patient status

USING TECHNOLOGYProblem: Large amounts of information was being

gathered, digesting and disseminating it was challenging

Comprehensive list of cases, contacts, and site screenings developed by Epi Aid team and based upon data base developed by Dept. of Health Detailed case follow up Information to action

Developed Secure access portal for case follow up and sharing of current information

Controlled, secure access Limited number of editors Efficient communication

MAP OF NORTH DAKOTA

GENOTYPINGA case from early 2012 had matching spoligotype,

however greatly varied demographically and geographically

Original contact investigation for either case was unable to identify name or location epi link

New focus guided by genotyping established an epi link to the super spreader

Photo release was critical in making the link Established a time frame for the transmission event Extended IP of super spreader from previous estimates by 6 months Expanded investigation

CDC had this as a Minnesota case

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

5

10

15

20

25

30

Year

Num

ber o

f Cas

es

NORTH DAKOTA CASES 2000 - 2013

TB IN NORTH DAKOTA

2002-2013

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

5

10

15

20

25

30

Rest of ND

Grand Forks County

AGES OF OUTBREAK TB CASES

0-10 11-20 21-30 31-40 41-50 51-60 60+0

1

2

3

4

5

6

North Dakota Department of Health; data as of 1/25/13

SCREENIN

G

1650Tuberculin Skin Tests (TST’s) Performed

69 LTBI’s Identified

53.7% of Named Contacts are LTBI’s

ONGOING WORKContinue to locate, refer, and follow cases, LTBI, and contacts

Administer directly observed therapy (DOT) to active cases

Manage social barriers to treatment compliance Isolation for infectious cases

Housing food

Medication and evaluation compliance

Continue investigative work Full genotyping New case identification Reinterviews

CHALLENGES

Staffing – added Field Staff & Public Health Associate

Housing - Worked with Emergency Preparedness & Response

DOT Compliance – 7 day DOT Drug Levels – Non-Therapeutic Levels Indian Health Services Border States and Provinces INH Shortage Tubersole Shortage

PARTNERSThe important work done and yet to do would not have been possible without the extraordinary efforts by professionals from these organizations