Tracy Agerton Director, Epidemiology Office Bureau of TB Control, NYC

1. Cross-jurisdictional Efforts to Find Contacts to MDR TB Outbreak Among HIV-infected Homeless, New York City, 2005 Tracy Agerton Director, Epidemiology Office Bureau of TB Control, NYC Field Services Branch, DTBE, CDC

2. Background Infectious period: 1/11/2005-7/5/2005 for all 3 cases

3. Background Residence A • Transitional, harm-reduction residence • Primarily HIV-infected, homeless, drug users • 5-story building ~30 years old • 40 residents, 13 on each floor • Common rooms, ate meals together • Resident rooms with 1-6 person occupancy • No mechanical ventilation • Window A/C units, but not in Patient A’s room

4. Contacts at Residence A • 109 close contacts • 33 current residents • 27 staff • 49 discharged residents

5. Methods—Case FindingDischarged Residents • Reviewed residence records to obtain locating information • 3 PHAs fulltime for 2 weeks • 3 home visits attempted • Phone calls to programs/next of kin/home/providers

6. Methods—Case FindingDischarged Residents • Registry searches • TB • Prison • HIV/AIDS Services Administration (HASA) • Department of Homeless Services (DHS) • HIV/AIDS Surveillance • Letters sent to providers of record • Nature of exposure • Recommendations for evaluation and treatment • F/u for results of evaluations

7. Results—Case Finding • 109 close contacts • 33 current residents • 100% evaluated • 1 additional case identified • 50% on TLTBI • 27 staff • 85% evaluated • 58% on TLTBI • 49 discharged residents • 23 located and evaluated • 39% on TLTBI

8. Continual Case FindingDischarged Residents • 26 discharged residents not found • Monthly registry checks • HASA • Prison • HIV/AIDS • November: PHRI and NJ DOH notified BTBC of Strain W case diagnosed in NJ • Discharged resident from Resident A • Homeless in NJ since June 2005

9. Case Surveillance and Contact Tracing Efforts Across Jurisdictions • HAN alert (NYC: AIDS Institute, Inter- City ID Rounds, NYS DOH, NJ DOH, CDC, PR TB Control, NTCA) • Watch list of all HIV-infected contacts (NYC TB surveillance, NYS DOH, NJ DOH) • Continue monthly registry checks (NYC prison, DHS/HASA, TB registry, NYC death registry) • Found 1 d/c resident found through NYC death registry match • Cause of death: metastatic esophoegeal cancer 11/05 • NYS prison search • Found 2 more d/c residents • Both fully evaluated and on TLTBI with MXF

10. Summary • Extensive transmission • Rapid progression to disease • Active case finding identified one additional MDR TB case • Home visits and contact with providers proved effective • Registry match with HIV surveillance was useful • Shared genotyping and outbreak information with other jurisdictions vital

11. Lessons Learned • Case finding activities should be initiated in settings for HIV-infected individuals where TB transmission is evident • Alerts to neighboring jurisdictions should occur earlier • Confidentiality and privacy issues • Expansion to other jurisdictions for contact tracing extremely useful • Routine information sharing around outbreaks • Partnering with other DOHMH Bureaus (HIV, Correctional Health) very helpful

12. Acknowledgements NYC DOHMH BTBCResidence ANYC DOHMH HIV/AIDS Shameer Poonja Valentina Digrasso Judy Sackoff Cindy Driver Pedro Gonzalez Lucia Torian Ann Winters Lissette Rivas Rachel Wiseman Krishen Khemraj NJ TB ControlPHRI Darrin Taylor Mark Wolman Barry Kreisworth Christine Chuck Tom Privett Kareen Joseph Sonal Munsiff NYS TB Control Diana Nilsen Margaret Oxtoby Felicia Stubblefield Abari Sulayman NYC DOHMH Correctional Health Hope Campbell Woody Franklin Tholief O’Flaherty Farah Parvez Maria Gbur