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TB Outbreak in Grand Forks

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.

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TB Outbreak in Grand Forks

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  1. 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

  2. Late September 2012: 3 suspect TB cases were identified in Grand Forks County Early October 2012, Met with GFCCC, GFPH and Altru Team Timeline Overview

  3. 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 Timeline

  4. NORTH DAKOTA TB CASES 2000 - 2012

  5. Incidence Rate of TB/100,000in North Dakota 2009 - 2013

  6. TB Case Rates,* United States, 2012 D.C. <3.2 (2012 national average) >3.2 *Cases per 100,000.

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

  8. 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

  9. 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

  10. Investigative Tools • Case Interview • Electronic Medical Records • Name and Photo release forms • Facebook/Social Networks • Pictures of transmission locations • Genotyping

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

  12. TREATMENT CHALLENGESNursing Addiction

  13. TREATMENT CHALLENGESNursing • Transportation

  14. TREATMENT CHALLENGESNursing • Communication

  15. TREATMENT CHALLENGESNursing • Health Challenges

  16. TREATMENT CHALLENGESNursing Treatment Protocols

  17. TREATMENT CHALLENGESNursing • Compliance

  18. TREATMENT CHALLENGESNursing • Children

  19. TREATMENT CHALLENGESNursing • Relationship Building

  20. TREATMENT CHALLENGESNursing • Incentives

  21. TREATMENT CHALLENGESAdministrative • Budget

  22. TREATMENT CHALLENGESAdministrative • Resources

  23. TREATMENT CHALLENGESAdministrative • Coordination

  24. TREATMENT CHALLENGESAdministrative • Electronic Health Records

  25. Treatment Compliance • Housing • Provide Food • Transportation • Incentives

  26. 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)

  27. 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.

  28. 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

  29. TB Screening September 2012 - June 2013 June 2013 - June 2014 TST – 60 LTBI – 13 Lost of Follow-Up – 20? TST – 1650 LTBI – 69 53.7% of Named Contacts are LTBI

  30. 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

  31. Outbreak Age of Cases

  32. Gender of TB Cases

  33. TB Cases in North Dakota

  34. 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

  35. Whole Genome Sequencing Single-Nucleotide Polymporphism

  36. Five additional clustered isolates in GIMS

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