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MTB OUTBREAK

MTB OUTBREAK. LOCAL LAB RESPONSE Chris Partington MT(ASCP) ACL MICROBIOLOGY LAB. LOCAL LAB RESPONSE ACL first specimens from outbreak: 04/20,21/2013 Sputums from daughter of index case Ordered for AFB culture/smear and MTD Both smear neg. One specimen MTD neg, one MTD pos.

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MTB OUTBREAK

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  1. MTB OUTBREAK LOCAL LAB RESPONSE Chris Partington MT(ASCP) ACL MICROBIOLOGY LAB

  2. LOCAL LAB RESPONSE • ACL first specimens from outbreak: • 04/20,21/2013 Sputums from daughter of index case • Ordered for AFB culture/smear and MTD • Both smear neg. • One specimen MTD neg, one MTD pos. • ACL unaware of “outbreak”, multiple contacts, relationship to index case. • All the index case’s children have a different last name than the mother. • Also unaware of probable resistant strain involved. • Five more specimens from 3 patients arrive in the next 4 days. • All have the same last name, all children, all ordered for AFB culture/smear • and MTD. • At this point we have questions. We are informed by Sheboygan Public Health and WSLH that this is a possible outbreak situation. • ACL sends specimens (after decontamination and culture/smear performance) directly to WSLH for TB PCR testing due to the high MTD workload.

  3. After the first week of May 2013: • The numbers of exposures, contacts and testing were exponentially increasing so we made the next change in protocol: Sheboygan Hospital would now send any samples related to the outbreak directly to WSLH. • We at ACL kept all work cards, communications, history/physicals and reports in a separate labeled folder for reference. • We were in almost daily communication with WSLH TB Lab, Sheboygan Public Health and Dr. Poursina (Infectious Disease) coordinating patients, specimens and tests. • We are still actively involved in all aspects because we have open accessions from the “in-house” cultures.

  4. MISTAKES MADE / PROBLEMS ENCOUNTERED • Outbreak?! What outbreak? • We had no clue that we were dealing with a possible outbreak; we were just seeing more than the usual orders for MTD. There were a few specimens with the same last name but it is a common one and we didn’t know the patients were related. No one alerted us to the possibility until we made some investigation. • Sure, we can handle that! No problem! • We started with just a few specimens so we did it all: culture/smear and MTD. We were • doing MTD’s daily which threw out our routine. We changed protocol a number of times: • 1) Did all orders in–house • 2) Did cultures/smears only and sent processed specimen to WSLH for TB PCR • 3) Received specimen at our lab, then sent on to WSLH via our courier for all tests • 4) Instructed Sheboygan lab to send all specimens directly to WSLH for testing • This resulted in vast confusion: what tests are ours to result? how do we bill? who is • getting the reports?

  5. Is it Racial Profiling or Cultural Understanding? • Most of the offspring of the Index Case (“CM”) have a different last name from their mother. • We did not know who was considered an “outbreak” contact and who was excluded. We • received a tentative list of names from WSLH. We placed this list on the board in our • specimen receiving area. We did not want these specimens manipulated outside of the TB • room due to the MDR-TB designation. After a number of patient specimens came that • were “outbreak” related but not on the list, we decided to consider all Hmong names from • Sheboygan suspect. • We learned surnames are not necessarily shared between families in the Hmong • community. We learned a lot! • Unnecessary testing encountered. • We had to watch the orders carefully. The children underwent bronchoscopies to obtain • suitable specimens. The orders should have been for AFB cultures only but the specimens • came with the “usual” bronch menu: AFB culture/smear, Fungus culture/smear, Routine • culture/gram, pneumocystis testing. Why would they order a pneumocystis on a 14 yr.old? • The explanation when questioned was that the pulmonologist just ordered his routine • testing protocol!

  6. WHAT WE’LL DO NEXT TIME (NEXT TIME?!) • Communication • If possible set up more communication with key players: • -Client (hospital Infection Control, outside lab personnel, • clinic, etc.) • -Public Heath • -WSLH TB lab • -appropriate Infectious Disease doc • -our own Micro personnel • Education • Have in-services with the Micro personnel about tuberculosis, outbreak situations, • MDR-TB, the importance of carefully reviewing each specimen-name and test order. • Urge personnel to investigate questionable orders, names, etc. and communicate with • TB techs. • Diligence/Assertiveness/Demanding(?) • Make sure everyone is doing their part. Don’t let the lab be the forgotten spoke of the • wheel. Ask to be included on all communication. Keep your personnel informed. • Be mindful that specimens will keep coming for months (or years) for follow-up testing.

  7. ACKNOWLEGEMENTS Julie Tans-Kersten WSLH TB Lab Sandy Musegades Sheboygan Public Health Dept. Dr. ArashPoursina Infectious Disease Teri Hosterman Sheboygan Memorial Infection Control Nancy Kapellen SMMC Lab Supervisor Fetije Shabanoski ACL Microbiology Supervisor

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