Contact tracing in TB incidents/outbreak investigation: Case study in an acute hospital setting

1. Contact tracing in TB incidents/outbreak investigation:Case study in an acute hospital setting Katie Hopgood Acting Consultant in Public Health katie.hopgood@phe.gov.uk

2. The TB strategy for England • Improving access and early diagnosis • High quality diagnostics • High quality treatment and care services • Contact tracing • Vaccination • Tackling drug resistance  • Tackling TB in underserved populations • New entrant screening for LTBI • Effective Surveillance and Monitoring • Workforce strategy

3. Contact Tracing What? • The systematic contact workup in a possible transmission setting Why? • To find an unknown source case • To detect active cases early • To prevent potential reactivation How? • Identify close contacts (stone in the pond) • Identify active cases and epi links • Identify and treat recently acquired LTBI • Compromise between effectiveness/ cost-effectiveness (=yield) • Public reassurance • Pragmatism Source: WHO 2016 http://www.who.int/tb/strategy/end-tb/en

4. NICE Pathway: TB Contact Tracing and Treatment Contact tracing in TB incidents/outbreak investigation

5. Ripple in a pond example Contact tracing in TB incidents/outbreak investigation

6. Case study – Contact tracing in an acute hospital 1 year attendance at local Dialysis unit 3 x 4h sessions per week, Taken by shared hospital transport (private company) ?8 month history of dry cough, no other symptoms reported ?Productive cough since July 24th Sept’17: Case taken by ambulance (SOB, general deterioration)in ED bay11pm-1am then GM ward 28th Sept’17: Direct PCR result received. MTB, smear positive. 4th Oct’17: Contact TB Nurse team to undertake risk assessment. (Retired, lived with wife, large number of extended family out of area – often stay when visiting) 16th Oct’17: Acute trust contact PHE to establish ICT 29th Sept’17: Massive haemoptysis, patient passed away Contact tracing in TB incidents/outbreak investigation

7. Dialysis unit Contact tracing in TB incidents/outbreak investigation

8. Small group exercise: • Handout details key events and contact definitions (5-10 mins) • In small groups of 4 think about applying the ‘ripple in a pond’ approach to this scenario. • Which key groups or individuals are you concerned might be at risk of infection? • Where do they sit in your risk stratification? Contact tracing in TB incidents/outbreak investigation

9. Risk stratification 1.1: Infectious period: Three months prior to diagnosis (24th June – admission), admission 24th-29th September. 1.2: Contact definitions: 1.2.1: Close contacts: Family, friends, staff and/or patients that have been in close proximity, or a confined area, with the case for a prolonged period of time (greater than 8 hours on a single occasion, or 8 hours cumulative exposure). 1.2.2: ‘Social contacts’: Family, friends, staff and patients that have had contact with the case, but not been in prolonged, frequent or intense contact. Immunocompromised social contacts require individual assessment based on proximity/duration and immune competence - may need to be treated as a close contact. Contributoryfactors: Disease: AFB+ve, haemoptysis, coughing since late July 2017 – although not noticed to have a cough by Cossham staff, outcomes of household contact screens not yet known Duration of contact: Individually assessed, dialysis sessions 4-5 hours in duration Proximity of contact: Individually assessed, use of PPE, wheelchair/limited mobility Air circulation: No confined spacesand/or unventilated spaces Immune competence: Immunocompromised contacts requiring individual assessment LTBI testing and treatment programme -data returns and IG

10. Highest Risk Higher Risk LTBI testing and treatment programme -data returns and IG

11. Medium Risk Low Risk LTBI testing and treatment programme -data returns and IG

12. Case study – Results A – Household contacts n=13 Active = 2 Latent = 1 Negative = 10 B –Dialysis unit close contacts n= 13 Active = 0 Latent = 0 Indeterminate – 2 Negative - 11 C – Hospital staff close contacts n=18 Active = 0 Latent =1 Negative = 17 D – Other dialysis unit users, ambulance crew, transport staff Warn and inform Contact tracing in TB incidents/outbreak investigation