{ tb outbreak 2013 sheboygan tb outbreak 2013 april 24, 2014 lessons learned – a local health...
TRANSCRIPT
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Sheboygan TB Outbreak 2013
April 24, 2014
Lessons Learned – A Local Health Department
Perspective
Amy Betke, RN Public Health NurseDeb Schmidt, RN Public Health NurseMiva Yang, RN Public Health Nurse
None
Disclosures
PRESENTATION OBJECTIVES
Overview of index case and outline of
outbreak events
Lessons Learned – Sheboygan
County Public Health
Department Perspective
Lessons Learned – TB Nurse Case
Management Strike Team Perspective
TIMELINE OF INDEX CASEP
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Camp Ban
Vinai, Thailan
dHad 2
children
Immigrated toUSA from Laos
(1 child, no husband)TST 13mm
September – Moved to Sheboygan
Took 6 weeks of INH then pregnant
Completed 6 months INH -
Sheboygan
No recall of prior TB
treatment.Offered
Rifampin or INH, but became
pregnant
Again offered INH 7x.
Moved to
Alaska
First sign of cough
March 2012Visited family for 1 month in Thailand
October 2012 Moved to
Sheboygan continues with
cough
TIMELINE OF INDEX CASE
2012
2013
October 1Moved back to Sheboygan
October 23Dx with Pneumonia-ED
November Flight to Las Vegas
December 4Dx with Pneumonia-ED
December 20Dx bronchitis and treated for reflux-Office
April 3Went to clinic for depression, provider ordered CXR, cavitary lesions observed
April 11Dx with TB
February 25 - MarchWausau
February 22Dx with asthma by a pulmonologist
FebruaryED X2
January 4CXR interpreted as no active TB disease
April 11, 2013 - The Division of Public Health was notified of a patient with suspected TB. Patient has several children.
April 15, 2013- Labs confirm this patient has active tuberculosis. She was started on Rifampin, INH, Pyrazinamide, Ethambutol, and Moxifloxacin.
April 16, 2013- Investigation of family: One child is coughing. Three children have abnormal chest x-rays. Suspect with TB in these 3 children. Children are excluded from 2 different schools.
April 17, 2013- INH resistant detected and INH stopped.
OUTLINE OF EVENTS
April 22, 2013- One more school child living outside the home is identified and found to have an abnormal chest x-ray.
April 23, 2013- Total of 5 individuals Dx with active TB. Incident Command System (ICS) activated. Contact investigation continues.
April 24-26, 2013- Meeting with SASD Administration to develop joint plan.
April - May 2013- Targeted testing was completed at 2 local schools.
May 7, 2013- MDR TB Dx in Index Case. Resistant to both INH and Rifampin. Patient hospitalized and started on Ethambutol, Pyrazinamide, Moxifloxacin, Linezolid, Amikacin, and Ethionamide.
OUTLINE OF EVENTS
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LIKELY TRANSMISSION AMONG CASES
PatientA’s House
8 kids
A9 kids
Parents
Adult Child
Sister’s
Niece’s
1 active2 infected
1 infected
4 active8 infected
1 active3 infected
May 7-10, 2013- Centers for Disease Control, Mayo Clinic, State TB Program, Sheboygan Area School District Staff, Children’s Hospital and local Medical Providers conferenced with Public Health on the treatment and contact investigation recommendations. Incident Command is expanded.
OUTLINEOF EVENTS
May 20, 2013- Conference call with state legislators, seeking appropriations from Joint Finance Committee (JFC).
June 3, 2013- Governor Walker and Department of Health Services issue a press release in support of funding the TB outbreak.
June 4, 2013- JFC approved 4.6 million for submission in the State biennial budget.
OUTLINE OF EVENTS
June 7, 2013- The CDC Epi-Aid team reported on the investigation, felt containment was met.
June 11, 2013- Index Case transferred from hospital to Rocky Knoll Health Care Facility negative-pressure room with no visitation. Final drug susceptibility tests show only Index case with MDR; other 7 cases INH resistant only.
June 26, 2013- Index Case returns to private single-family home in Sheboygan. Client remained in isolation. County purchasing agent secured home, as a rental property and obtained furnishing/necessary household items.
August 2013- Another school age child (Index case’s nephew) Dx with active TB. Case count at 10, child had LTBI and progressed to active TB. An additional active case was detected in Marathon County as well as, 4 new LTBI contacts.
OUTLINE OF EVENTS
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Fall, 2013 – School begins. LHD receives school assistance with DOT for students and faculty affected by outbreak. Another round of school testing is completed.
October 17, 2013- Index case released from isolation following 27 weeks spent in hospital, LTCF and rental property. Able to reunite with children.
November 2013 – TB work continues. Incident Command modified as contact investigation wraps up and individuals are beginning to complete directly observed therapy for active as well as latent TB.
Outline of Events
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Lessons Learned-Our Agency Perspective
Greatest Assets During Outbreak Dedicated Staff and Community Healthcare Partners
Staff Members Including PHN’s, Support Staff, HHS Interpreter with
strong TB knowledge including previous experience with MDR TB
Staff members willing to learn and do
Previous Emergency Preparedness Training
Compliance of the majority of clients with prescribed TB treatment
Strike Team Case Management
One Year Later…What Have We
Learned?
Greatest Assets During Outbreak (cont.) Interdisciplinary Team
DOT Workers
Collaboration with SASD for DOT
Interdisciplinary Meeting with ASMMC.
Rocky Knoll Health Care Facility
Strong Support of Elected Officials and Leadership
One Year Later…What Have We
Learned?
Local Capacity Was ExceededEarly in Outbreak
Staff Assignedto Assist
Request Mutual Aid and Obtain
Approval toHire Limited
Term Employees
Logistical Lessons Technology – Expand cell phones with
texting availability and dictation use
Streamline and centralize medication supply – Two person team to manage medication refills and bubble packing.
Use of Communication Logs for DOT workers
Bring in support staff to act as runners, DOT workers, etc.
Development of Communication Cards
Card for Clinic Use
INTERDISCIPLINARYTEAM FORMATION
Complex needs of the family-financial, mental health,family dynamics, and school-related issues.
TB NURSECASE MANAGEMENT
STRIKE TEAM PERSPECTIVE
Amy, Deb, Miva, Mai Kou pic
Additional Strike Teams
DPH Sub Teams
Medication Monitoring Team
Business/School Investigation Team
DOT Team
Cultural Competency-Lessons Learned
Assign Hmong Nurse and Support Staff as part of the Strike Team from the start
Consider the gender and age of the interpreter
Education with the index case as to the importance of naming close contacts was a priority
Cultural Competency-Lessons Learned
Involve family into the treatment plan decisions
Importance of nutritional needs/ethnic food preference
Birth control and its challenges in relation to TB treatment
Tips for Providing Culturally Competent Tuberculosis Services to Hmong Persons
Interactions with Hmong clients and Family Members Avoid speaking loudly Avoid making direct eye contact Avoid outwardly complimenting Hmong children Avoid refusing refreshments that may be offered at a Hmong
client’s home Be aware that a Hmong client may present with unusual
physical markings as well as wearing red cloth necklace or bracelets
Be sure to ask clients about their understanding of their illness and its cause
Tips for Providing Culturally Competent Tuberculosis Services to Hmong Persons
Family and Cultural Issues Before making a decision, family members are consulted
Mental Health (Worries) Hmong may be ashamed or avoid discussion of mental health
issues
Social Stigma TB is often a cause for shame among the Hmong
Active TB vs. LTBI
Tips for Providing Culturally Competent Tuberculosis Services to Hmong Persons
Tuberculosis Diagnosis and Treatment Hmong language lacks words for many medical terms
Hmong may delay or avoid seeking care
Deliver clear, consistent messages
Two-way communication and equal exchange between provider, client, and family
Tips for Providing Culturally Competent Tuberculosis Services to Hmong Persons
Summary
http://www.cdc.gov/tb/publications/guidestoolkits/EthnographicGuides/Hmong/chapters/tips.pdf Promoting Cultural Sensitivity: A Practical Guide for Tuberculosis Programs That Provide Services to Persons from Somalia
Francis J. Curry National Tuberculosis Center and California Department of Public Health (2008). Drug-Resistant Tuberculosis A Survival Guide for Clinicians, Second edition
References
Any Questions?