tb outbreak in grand forks
DESCRIPTION
TB Outbreak in Grand Forks. Shawn McBride, Field Epidemiologist – North Dakota Department of Health Terri Keehr , RN – Grand Forks Public Health Delbert Streitz , Emergency Preparedness Coordinator – Grand Forks Public Health Dee Pritschet, TB Controller – North Dakota Department of Health. - PowerPoint PPT PresentationTRANSCRIPT
TB Outbreak in Grand ForksShawn McBride, Field Epidemiologist – North Dakota Department of HealthTerri Keehr, RN – Grand Forks Public HealthDelbert Streitz, Emergency Preparedness Coordinator – Grand Forks Public HealthDee Pritschet, TB Controller – North Dakota Department of Health
TIMELINE OVERVIEW
• Late September 2012: 3 suspect TB cases were identified in Grand Forks County
• Early October 2012, Met with GFCCC, GFPH and Altru Team
DV1-4-2011
2010ND000201012
DV6-4-2010
2010ND000201004
GJWS
Not Treated
HH3-7-2012
2012ND000201204
LPgirlfriend
SHdaughter
KH3 y/o son
2012ND000201210
SM4-24-2012
2012ND000201206
TEson
AMbrother
TEson
JDnephew
RLboyfried Treatment dc'd liver problem
EF
PD9-21-2012
2012ND000201212
RCMom
CDsister 10 y/o
RDsister 10 y/o
CCsister 8 y/o
SRFCCJ sister
RPMaint Jail
CDIT County
BACorrections Officer
LV9-27-2012
2012ND000201213
RPfriend
QSinmate
GPfriend
MPfriend
DFfriend
DPFriend
DDson
DFGirlfriend
ED5 month old
TH9-28-2012
2012ND000201214
RP25# weight loss,
Night Sweats
GHNot Tested
PP
PPdaugher
APdaughter
TDgrand-daugher
DDgrandson
CMgirlfriend
AMson
MGgirlfriend
JDmom
SRsister
CCfriend
SJfriend
DJfriend
ABfriend
DHfriend
JHfriend
MBfriend
DMfriend
BPfriend
JKfriend
DKfriend
SEfriend
Daniel Knowels friend
MF
DHGrafton ? tested
JHGrafton
KPJohnny's Bar
MGJohnny's Bar
RGJohnny's Bar
BSJohnny's Bar
MRJohnny's Bar
JVJohnny's Bar
WH
MD
brother
Northland Rescue Mission 19 tested
ADContact? Altru DL
JScontact ? Altru ER
Negative TST
Positive TST, CXR Pending
Positive Culture
Cultures Pending
Not Tested
LTBI
Other
TIMELINE
October 2012: 3 suspect cases were confirmed as cases; 3 additional cases added to the outbreak
November 2012: Investigation identifies 7 more cases, CDC Epi-Aid requested
December 2012: Epi Aid team arrives, 3 more cases
NORTH DAKOTA TB CASES 2000 - 2012
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120
5
10
15
20
25
30
56 6 6
46
10
7
35
12
7
26
Reporting Year
Num
ber o
f Cas
es
June 1, 2012
Incidence Rate of TB/100,000in North Dakota 2009 - 2013
TB Case Rates,* United States, 2012
*Cases per 100,000.
< 3.2 (2012 national average)>3.2
D.C.
*from CDC Epi Aid Exit Presentation 12/11/12
Investigation Methods• Any laboratory
confirmed or clinically diagnosed cases investigated
• Establish infectious period
• Identification of named contacts and transmission sites
• Prioritization of contacts• Household contacts• High risk contacts• Location
screenings/targeted testing
• Locate and refer contacts
• Medical treatment for contacts with LTBI
Epidemiological Links• Name-based
• One patient identifies another person by name and reports close contact with that individual during the patient’s infectious period
• A third party names two individuals and reports close contact between them during one’s infectious period and the other’s exposure period
• Location-based• Two 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
*adapted from CDC Epi Aid Team Exit Presentation December 2012
Investigative Tools
• Case Interview• Electronic Medical Records• Name and Photo release forms• Facebook/Social Networks• Pictures of transmission locations• Genotyping
North Dakota Department of Health; data as of 1/25/13
TREATMENT CHALLENGESNursing
• Addiction
TREATMENT CHALLENGESNursing
• Transportation
TREATMENT CHALLENGESNursing
• Communication
TREATMENT CHALLENGESNursing
• Health Challenges
TREATMENT CHALLENGESNursing
Treatment Protocols
TREATMENT CHALLENGESNursing
• Compliance
TREATMENT CHALLENGESNursing
• Children
TREATMENT CHALLENGESNursing
• Relationship Building
TREATMENT CHALLENGESNursing
• Incentives
TREATMENT CHALLENGESAdministrative
• Budget
TREATMENT CHALLENGESAdministrative
• Resources
TREATMENT CHALLENGESAdministrative
• Coordination
TREATMENT CHALLENGESAdministrative
• Electronic Health Records
Treatment Compliance
• Housing
• Provide Food
• Transportation
• Incentives
Why Genotype?• Discover unsuspected transmission relationships between TB patients
• Identify unknown or unusual transmission settings, such as bars or clubs, instead of traditional settings like home and workplace
• Uncover inter-jurisdictional transmission• Establish criteria for outbreak-related case definitions • Identify additional persons with TB disease involved in an outbreak• Determine completeness of contact investigations• Detect laboratory cross-contamination event• Distinguish recent infection (with development of disease) from
activation of an old infection
*CDC TB genotyping fact sheet (www.cdc.gov)
Additional Cases Linked
• Cases from 2010 linked, index case identified
• Cases from early 2012 were linked to outbreak – delay in linking cases to 2010
• A case from early 2012 had matching spoligotype, however greatly varied demographically and geographically
• A case in another city when interviewed did not provide any information that would lead us to believe he was linked to the outbreak.
Shortages• PPD
• State set aside PPD for contact screening• Hospital staff screening
• INH• RIF prescribed due to low level INH resistance• Approximately $50.00 per bottle/9 months = $450.00• RIF at $30.00/4 month = $120.00• Better completion rates with RIF
TB Screening
September 2012 - June 2013
TST – 1650
LTBI – 69
53.7% of Named Contacts are LTBI
June 2013 - June 2014
TST – 60
LTBI – 13
Lost of Follow-Up – 20?
Number of Cases• 2010 – 2 cases• 2012 – 20 cases• 2013 – 5 cases• 2014 – 2 cases
• Culture Confirmed – 18 cases• Clinical Diagnosis – 11 cases
• Under 18 years of age - 8 cases
Outbreak Age of Cases
0-9 10-19 20-29 30-39 40-49 50-59 60+0
1
2
3
4
5
6
6
2
6
2
5 5
3
Age
Num
ber o
f Cas
es
Gender of TB Cases
17
12
Males
Females
TB Cases in North Dakota
2010 2011 2012 2013 20140
5
10
15
20
25
30
9
5 6 74
2
20
5
22
2
OutbreakGF CountyRest of ND
Year of Diagnosis
Num
ber o
f Cas
es
Working with Other Agencies• Fargo Cass Public Health Unit
• Minnesota Department of Health• Interjurisdictional Notifications• Contact Investigation• Testing• Treatment
• Indian Health Services• Chart Reviews• Flagged Charts
Whole Genome Sequencing
Single-Nucleotide Polymporphism
Five additional clustered isolates in GIMS
In the News
Cohort Review• Attended by Altru Staff, GFPHU Staff and NDDoH staff
• Review each case
• Lessons learned• Contact Investigation – not just once• On-going genotype surveillance• Drug Levels
Successes• Use of Photo and Name Release
• Flagging Altru charts
• 27 cases treatment completed• 2 cases on-going
TB Cases in North Dakota
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 418520
5
10
15
20
25
30
56 6 6
4
6
10
7
3
5
11
7
26
12
8
Reporting Year
Num
ber o
f Cas
es
2014• 2 cases linked to outbreak
• 1 case is the index case• 1 case was never identified through the numerous interviews as a
person of interest• Contact investigations continue
Renewed interest in 321 address
Follow-Up exams done on active cases due to symptoms
Ongoing work
• Continue 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
Collaboration• Grand Fork Public Health Unit• Altru Healthcare• Grand Forks County Correctional Center• Indian Health Services• Fargo Public Health Unit• Fargo Cass County Jail• CDC• Mayo - Regional Training Center• Minnesota Department of Health