rendi murphree, phd cdr, usphs cdc epidemic intelligence service officer tennessee department of...
TRANSCRIPT
![Page 1: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/1.jpg)
Rendi Murphree, PhDCDR, USPHS
CDC Epidemic Intelligence Service Officer
Tennessee Department of Health
Communicable and Environmental Disease Services
Outbreak of Mycobacterium tuberculosis
Among Employees of an Elephant Refuge
![Page 2: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/2.jpg)
The Outbreak
• Notification– October 2009– 5 tuberculin skin test (TST) conversions among
employees of an elephant refuge
• Refuge– Known to house elephants previously exposed
to Mycobacterium tuberculosis– Rumors that one elephant had tuberculosis
disease
![Page 3: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/3.jpg)
Tuberculosis (TB)
• Caused by Mycobacterium tuberculosis (Mtb)
• Spread on airborne droplet nuclei
• Transmitted during close, prolonged contact
![Page 4: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/4.jpg)
TB in Humans and Elephants:Inactive Infection
Humans ElephantsDetection method
Symptoms
Infectious to others
Preventive therapy
![Page 5: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/5.jpg)
TB in Humans and Elephants:Inactive Infection
Humans ElephantsDetection method
Positive TST or IGRA
Symptoms No
Infectious to others
No
Preventive therapy
Recommended
![Page 6: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/6.jpg)
TB in Humans and Elephants:Inactive Infection
Humans ElephantsDetection method
Positive TST or IGRA
Validation needed
Symptoms No No
Infectious to others
No Probably not
Preventive therapy
Recommended Efficacy unknown
![Page 7: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/7.jpg)
TB in Humans and Elephants:Active Disease
Humans ElephantsDiagnosis
Symptoms
Infectious to others
Treatment
![Page 8: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/8.jpg)
TB in Humans and Elephants:Active Disease
Humans ElephantsDiagnosis Sputum or chest x-
ray
Symptoms Yes
Infectious to others
Yes
Treatment Required
![Page 9: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/9.jpg)
TB in Humans and Elephants:Active Disease
Humans ElephantsDiagnosis Sputum or chest x-
raySaline trunk wash
Symptoms Yes Rare
Infectious to others
Yes Yes
Treatment Required Recommended; efficacy unknown
![Page 10: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/10.jpg)
TB in Humans and Elephants:Treatment for Disease
Humans ElephantsAntibiotics
Duration
Delivery
Efficacious
![Page 11: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/11.jpg)
TB in Humans and Elephants:Treatment for Disease
Humans ElephantsAntibiotics Izoniazid, rifampin,
ethambutol, pyrazinamide
Duration 6 months
Delivery Oral
Efficacious Yes
![Page 12: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/12.jpg)
TB in Humans and Elephants:Treatment for Disease
Humans ElephantsAntibiotics Izoniazid, rifampin,
ethambutol, pyrazinamide
Izoniazid, rifampin, ethambutol,
pyrazinamide
Duration 6 months 12 months
Delivery Oral Oral or rectal
Efficacious Yes Unknown
![Page 13: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/13.jpg)
Important Literature
• 1998 Michalak et al. (EID)– TB outbreak among 4 elephants in Illinois– One employee had TB — isolate matched the elephants– 11 employees positive TST — timing of conversion
unknown– Prompted action from USDA — annual Mtb testing
required
![Page 14: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/14.jpg)
Captive Elephants in North America
270 Asian elephants12% infected with Mtb
220 African elephants2% infected with Mtb
![Page 15: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/15.jpg)
Elephant Refuge in Tennessee
• Established in 1995 with 1 elephant• Care of sick, old, or abused elephants• Nonprofit organization• Accredited and licensed • Closed to the public
![Page 16: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/16.jpg)
Elephant Refuge in Tennessee
• 2,700 acres and 14 elephants
• 3 areas with a barn and dedicated staff– African area — 2 African elephants– Asian area — 6 Asian elephants• 3 from Illinois herd
– Quarantine area — 7 Asian elephants • All from Illinois herd
![Page 17: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/17.jpg)
www.elephants.com
![Page 18: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/18.jpg)
![Page 19: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/19.jpg)
www.elephants.com
![Page 20: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/20.jpg)
The Outbreak
• Notification– October 2009– 5 TST conversions– 1 elephant with TB
• Response– Gained access to the refuge– Initiated onsite investigation– December 2009
![Page 21: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/21.jpg)
Investigation Objectives
• Determine extent of outbreak
• Identify risk factors for TST conversion in humans
• Prevent ongoing transmission
![Page 22: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/22.jpg)
Cohort Study
• Interviews
• Occupational health records– Preemployment and annual TST results– Respirator fit testing dates– Employment dates
• TST screening increased to quarterly
![Page 23: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/23.jpg)
TST Conversion
• Refuge employee or intern
• 2006–2009
• Documented negative (<10 mm) TST
• ≥10 mm increase in TST induration within 2 years
![Page 24: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/24.jpg)
Onsite Assessment
• Barn management
• Elephant husbandry practices
• Environmental sampling in targeted areas
• CDC National Institutes of Occupational Safety and Health (NIOSH)
![Page 25: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/25.jpg)
Record Review
• Refuge and TN Wildlife Resources Agency (TWRA)
• Timeline of events– Elephants– Employees
• Mtb culture results for respiratory secretions– Trunk wash– Participating elephants
![Page 26: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/26.jpg)
Employee Cohort, 2006–2009
• 57 current and former employees
• 46/57 (81%) interviewed– 30 caregivers– 11 administrators– 5 maintenance workers
• 9/46 (20%) had positive TST
![Page 27: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/27.jpg)
Characteristics of Employees with Positive TST (n=9)
• 7 female• Mean age 40 years (range 25–62 years)• TST ranged 12–24 mm induration• 1 conversion in 2006 – Prolonged exposure to a known source
of TB• 8 with documented conversion in 2009• 6 began preventive therapy • None have active TB disease
![Page 28: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/28.jpg)
Potential Risk Factors for TB Among
Refuge Employees, 2006–2009Potential risk factor Exposed Unexposed
Relative Risk
(95% CI)TST
+Tota
l%
TST+
Total
%
International travel 5 19 26 4 27 14 1.8 (0.6–
5.8)
Foreign-born 2 6 33 7 40 18 1.9 (0.5–
7.1)
Exposure to person(s)
with TB
0 4 0 9 42 21 –
Healthcare facility work 1 8 13 8 38 21 0.6 (0.1–
4.1)
Correctional facility work 0 4 0 9 42 21 –
Homeless shelter work 0 1 0 9 45 20 –
![Page 29: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/29.jpg)
Potential Risk Factors for TB Among
Refuge Employees, 2006–2009Potential risk factor Exposed Unexposed
Relative Risk
(95% CI)TST
+Tota
l%
TST+
Total
%
International travel 5 19 26 4 27 14 1.8 (0.6–
5.8)
Foreign-born 2 6 33 7 40 18 1.9 (0.5–
7.1)
Exposure to person(s)
with TB
0 4 0 9 42 21 –
Healthcare facility work 1 8 13 8 38 21 0.6 (0.1–
4.1)
Correctional facility work 0 4 0 9 42 21 –
Homeless shelter work 0 1 0 9 45 20 –
![Page 30: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/30.jpg)
Potential Risk Factors for TB Among
Refuge Employees, 2006–2009Potential risk factor Exposed Unexposed
Relative Risk
(95% CI)TST
+Tota
l%
TST+
Total
%
International travel 5 19 26 4 27 14 1.8 (0.6–
5.8)
Foreign-born 2 6 33 7 40 18 1.9 (0.5–
7.1)
Exposure to person(s)
with TB
0 4 0 9 42 21 –
Healthcare facility work 1 8 13 8 38 21 0.6 (0.1–
4.1)
Correctional facility work 0 4 0 9 42 21 –
Homeless shelter work 0 1 0 9 45 20 –
![Page 31: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/31.jpg)
Potential Risk Factors for TB Among
Refuge Employees, 2006–2009Potential risk factor Exposed Unexposed
Relative Risk
(95% CI)TST
+Tota
l%
TST+
Total
%
International travel 5 19 26 4 27 14 1.8 (0.6–
5.8)
Foreign-born 2 6 33 7 40 18 1.9 (0.5–
7.1)
Exposure to person(s)
with TB
0 4 0 9 42 21 –
Healthcare facility work 1 8 13 8 38 21 0.6 (0.1–
4.1)
Correctional facility work 0 4 0 9 42 21 –
Homeless shelter work 0 1 0 9 45 20 –
![Page 32: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/32.jpg)
Potential Risk Factors for TB Among
Refuge Employees, 2006–2009Potential risk factor Exposed Unexposed
Relative Risk
(95% CI)TST
+Tota
l%
TST+
Total
%
International travel 5 19 26 4 27 14 1.8 (0.6–
5.8)
Foreign-born 2 6 33 7 40 18 1.9 (0.5–
7.1)
Exposure to person(s)
with TB
0 4 0 9 42 21 –
Healthcare facility work 1 8 13 8 38 21 0.6 (0.1–
4.1)
Correctional facility work 0 4 0 9 42 21 –
Homeless shelter work 0 1 0 9 45 20 –
![Page 33: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/33.jpg)
Potential Risk Factors for TB Among
Refuge Employees, 2006–2009Potential risk factor Exposed Unexposed
Relative Risk
(95% CI)TST
+Tota
l%
TST+
Total
%
International travel 5 19 26 4 27 14 1.8 (0.6–
5.8)
Foreign-born 2 6 33 7 40 18 1.9 (0.5–
7.1)
Exposure to person(s)
with TB
0 4 0 9 42 21 –
Healthcare facility work 1 8 13 8 38 21 0.6 (0.1–
4.1)
Correctional facility work 0 4 0 9 42 21 –
Homeless shelter work 0 1 0 9 45 20 –
![Page 34: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/34.jpg)
Potential Risk Factors for TB Among
Refuge Employees, 2006–2009Potential risk factor Exposed Unexposed
Relative Risk
(95% CI)TST
+Tota
l%
TST+
Total
%
Close elephant contact 2 11 18 7 35 20 0.9 (0.2–
3.8)
![Page 35: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/35.jpg)
Potential Risk Factors for TB Among
Refuge Employees, 2006–2009Potential risk factor Exposed Unexposed
Relative Risk
(95% CI)TST
+Tota
l%
TST–
Total
%
Close elephant(s) contact 2 11 18 7 35 20 0.9 (0.2–
3.8)
Quarantine area exposure
2009
8 13 62 1 33 3 20.3
(2.8–
146.7)
![Page 36: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/36.jpg)
Potential Risk Factors for TB Among
Refuge Employees, 2006–2009Potential risk factor Exposed Unexposed
Relative Risk
(95% CI)TST
+Tota
l%
TST–
Total
%
Close elephant(s) contact 2 11 18 7 35 20 0.9 (0.2–
3.8)
Quarantine area exposure
2009
8 13 62 1 33 3 20.3
(2.8–
146.7)
![Page 37: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/37.jpg)
Quarantine Area
Quarantine Barn
AdminArea
www.elephants.com
![Page 38: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/38.jpg)
TST Conversion Timeline Among
Quarantine Area Employees, 2009
![Page 39: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/39.jpg)
TST Conversion Timeline Among
Quarantine Area Employees, 2009
![Page 40: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/40.jpg)
TST Conversion Timeline Among
Quarantine Area Employees, 2009
![Page 41: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/41.jpg)
TST Conversion Timeline Among
Quarantine Area Employees, 2009
![Page 42: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/42.jpg)
TST Conversion Timeline Among
Quarantine Area Employees, 2009
![Page 43: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/43.jpg)
TST Conversion Timeline Among
Quarantine Area Employees, 2009
![Page 44: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/44.jpg)
Characteristics of Quarantine Area Employees, 2009 (n = 13)
Conversion(n = 8)No. (%)
TST Negative(n = 5)No. (%)
PositionCaregiverAdministrativeMaintenance
5 (63) 3 (38) 0 ( 0)
3 (60) 0 ( 0) 2 (40)
Close contact with elephant(s) 1 (13) 2 (40)
Participated in elephant(s) trunk wash 0 ( 0) 1 (20)
Pressure washed 5 (63) 3 (60)
Annual N95 fit testing 2 (25) 3 (60)
“Always” compliant with N95 wear 2 (25) 3 (60)
![Page 45: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/45.jpg)
Characteristics of Quarantine Area Employees, 2009 (n = 13)
Conversion(n = 8)No. (%)
TST Negative(n = 5)No. (%)
PositionCaregiverAdministrativeMaintenance
5 (63) 3 (38) 0 ( 0)
3 (60) 0 ( 0) 2 (40)
Close contact with elephant(s) 1 (13) 2 (40)
Participated in elephant(s) trunk wash 0 ( 0) 1 (20)
Pressure washed 5 (63) 3 (60)
Annual N95 fit testing 2 (25) 3 (60)
“Always” compliant with N95 wear 2 (25) 3 (60)
![Page 46: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/46.jpg)
Characteristics of Quarantine Area Employees, 2009 (n = 13)
Conversion(n = 8)No. (%)
TST Negative(n = 5)No. (%)
PositionCaregiverAdministrativeMaintenance
5 (63) 3 (38) 0 ( 0)
3 (60) 0 ( 0) 2 (40)
Close contact with elephant(s) 1 (13) 2 (40)
Participated in elephant(s) trunk wash 0 ( 0) 1 (20)
Pressure washed 5 (63) 3 (60)
Annual N95 fit testing 2 (25) 3 (60)
“Always” compliant with N95 wear 2 (25) 3 (60)
![Page 47: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/47.jpg)
Characteristics of Quarantine Area Employees, 2009 (n = 13)
Conversion(n = 8)No. (%)
TST Negative(n = 5)No. (%)
PositionCaregiverAdministrativeMaintenance
5 (63) 3 (38) 0 ( 0)
3 (60) 0 ( 0) 2 (40)
Close contact with elephant(s) 1 (13) 2 (40)
Participated in elephant(s) trunk wash 0 ( 0) 1 (20)
Pressure washed 5 (63) 3 (60)
Annual N95 fit testing 2 (25) 3 (60)
“Always” compliant with N95 wear 2 (25) 3 (60)
![Page 48: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/48.jpg)
High Risk Work Practices
![Page 49: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/49.jpg)
Unrestricted Air Flow
![Page 50: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/50.jpg)
Environmental Sampling
• Barn housing the Mtb-infected elephant
• Standard methods
• Mtb not isolated– Elephant stool (n = 14)– Water (n = 12)– Barn surface swabs (n =
23)– Air filter (n = 3)
• M. fortuitum isolated from 6 specimens
![Page 51: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/51.jpg)
More on Elephant L Mtb Culture Isolation
• Transferred from Illinois herd in 2006 and housed in quarantine
• Respiratory secretions obtained by trunk-wash method annually
• Mtb culture-positive in 2009 – Susceptible to all 4 first-line antibiotics
– Mtb genotype PCR01621• 2004 CA human patient• 2005 TN elephant died with TB (Illinois herd)• 2006 TN elephant died with TB (Illinois herd)• 2008 MO elephant
![Page 52: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/52.jpg)
Summary
• Employees exposed to the quarantine area in 2009 were 20 times more likely to have TB infection– RR 20.3; 95% CI 2.8–146.7
• 8 TST conversion documented in 2009– 3 administrators without elephant contact
![Page 53: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/53.jpg)
Factors Contributing to Transmission
• Delayed response to Mtb isolation
• Inadequate infection control– Aerosol-generating work practices
– Inconsistent use of respirators
– Unrestricted air flow
![Page 54: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/54.jpg)
Immediate Interventions
• Relocate nonessential personnel
• Increase use of respirators
• Revise infection control practices
![Page 55: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/55.jpg)
Limitations
• 11 former employees not contacted– None employed during 2009
– 2 employed during 2008
![Page 56: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/56.jpg)
Conclusions
• Mtb transmitted from elephant to humans – Elephant L source of Mtb
• Indirect exposure associated with Mtb infection
• Inadequate infection control practices contributed
• Immediate interventions implemented
![Page 57: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/57.jpg)
Recommendations
• Reduce aerosol-generating work practices and restrict unfiltered air flow
• Educate workers and provide a comprehensive occupational health program
• Develop and comply with evidence-based TB control guidelines to protect employees working in the elephant industry
• Improve methods for diagnosis and treatment of Mtb infection in elephants
![Page 58: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/58.jpg)
Acknowledgments• Elephant refuge – Employees
– Leadership
• Tennessee Wildlife Resources Agency– Walter Cook
• TN South-central Regional Health Office– Lang Smith
– Joy Smith
• Lewis County Health Department
• Tennessee Department of Health– Jon V. Warkentin– John R. Dunn– Timothy F. Jones
• Vanderbilt University School of Medicine– William Schaffner
• CDC EIS Field Assignments Branch– W. Randolph Daley– Diana Bensyl– Kris Bisgard
• CDC Division of TB Elimination– Maryam Haddad– Adam Langer
![Page 59: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/59.jpg)
For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: [email protected] Web: www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
zazzle.com
![Page 60: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/60.jpg)
EXTRA SLIDES
![Page 61: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/61.jpg)
New Serologic Assays for Detecting Mtb Exposure in
Elephants• ElephantTB STAT-PAK® – Lateral-flow technology – Detects reactive antibody to M. tuberculosis and
Mycobacterium bovis antigens – Simple, rapid, and can be performed onsite
• MAPIA (multiantigen print immunoasay)– Detects reactive antibodies in serum specimens – After a STAT-PAK-positive result, MAPIA has been used
as a confirmatory test for M. tuberculosis – Monitoring the treatment of elephants with active TB
![Page 62: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/62.jpg)
Important Literature
• 1998 Michalak et al. (EID)– TB outbreak among 4 elephants in Illinois– One employee had TB — isolate matched the elephants– 11 employees positive TST — timing of conversion
unknown– Prompted action from USDA — annual Mtb testing
required
• 2002 Oh et al. (EID)– TB infection among multiple species at California zoo– 55 employees positive TST — 10 with probable
conversion
![Page 63: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/63.jpg)
Important Literature
• 1998 Michalak et al. (EID)– TB outbreak among 4 elephants in Illinois– One employee had TB — isolate matched the elephants– 11 employees positive TST — timing of conversion
unknown– Prompted action from USDA — annual Mtb testing required
• 2002 Oh et al. (EID)– TB infection among multiple species at California zoo– 55 employees positive TST — 10 with probable conversion
• 2002 Payeur et al. (Ann NY Acad Sci)– 5 Mtb genotypes circulating among 6 elephant herds
![Page 64: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/64.jpg)
Important Literature
• 1998 Michalak et al. (EID)– TB outbreak among 4 elephants in Illinois– One employee had TB — isolate matched the elephants– 11 employees positive TST — timing of conversion
unknown– Prompted action from USDA — annual Mtb testing required
• 2002 Oh et al. (EID)– TB infection among multiple species at California zoo– 55 employees positive TST — 10 with probable conversion
• 2002 Payeur et al. (Ann NY Acad Sci)– 5 Mtb genotypes circulating among 6 elephant herds
![Page 65: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/65.jpg)
Culture Isolation of Mtb from Elephant Respiratory
Secretions• Obtained by trunk-wash method– 30–60 mL of saline– Raise then lower trunk to collect saline– 3 samples collected over 1 week– Standard methods for mycobacterial species
• Method has low sensitivity– Mtb isolation confirms active TB disease– Negative result does not exclude active disease
![Page 66: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/66.jpg)
Trunk Wash Collection
![Page 67: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/67.jpg)
Trunk Wash Results
• Provided by TWRA
• 2006–2008, all trunk-wash results received were Mtb culture-negative
• 2009, Mtb isolated from 1 of 14 elephants
• Elephant L– Mtb culture-positive
– Housed in quarantine area
– Arrived in 2006
– Transferred from Illinois herd
![Page 68: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/68.jpg)
Elephant L Trunk Wash Timeline
• Dec 2008– Secretions collected
• Mar 2009 – Mtb isolated
• Jul 2009– Culture confirmed
• Oct 2009 – Heightened infection
control
![Page 69: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/69.jpg)
Elephant L Isolate
• Mtb susceptible to all 4 first-line antibiotics – Isoniazid, rifampin, ethambutol, pyrazinamide
• Genotype PCR01621– 2004 CA human patient– 2005 TN elephant died with TB– 2006 TN elephant died with TB– 2008 MO elephant
![Page 70: Rendi Murphree, PhD CDR, USPHS CDC Epidemic Intelligence Service Officer Tennessee Department of Health Communicable and Environmental Disease Services](https://reader035.vdocuments.net/reader035/viewer/2022062719/56649ed05503460f94bdeca0/html5/thumbnails/70.jpg)
Elephant L Isolate
• Mtb susceptible to all 4 first-line antibiotics – Isoniazid, rifampin, ethambutol, pyrazinamide
• Genotype PCR01621– 2004 CA human patient– 2005 TN elephant died with TB (exposure in IL)– 2006 TN elephant died with TB (exposure in IL)– 2008 MO elephant