TB Outbreak in Grand ForksShawn McBride, Field Epidemiologist – North Dakota Department of HealthTerri Keehr, RN – Grand Forks Public HealthDelbert Streitz, Emergency Preparedness Coordinator – Grand Forks Public HealthDee Pritschet, TB Controller – North Dakota Department of Health

TIMELINE OVERVIEW

• Late September 2012: 3 suspect TB cases were identified in Grand Forks County

• Early October 2012, Met with GFCCC, GFPH and Altru Team

DV1-4-2011

2010ND000201012

DV6-4-2010

2010ND000201004

GJWS

Not Treated

HH3-7-2012

2012ND000201204

LPgirlfriend

SHdaughter

KH3 y/o son

2012ND000201210

SM4-24-2012

2012ND000201206

TEson

AMbrother

TEson

JDnephew

RLboyfried Treatment dc'd liver problem

EF

PD9-21-2012

2012ND000201212

RCMom

CDsister 10 y/o

RDsister 10 y/o

CCsister 8 y/o

SRFCCJ sister

RPMaint Jail

CDIT County

BACorrections Officer

LV9-27-2012

2012ND000201213

RPfriend

QSinmate

GPfriend

MPfriend

DFfriend

DPFriend

DDson

DFGirlfriend

ED5 month old

TH9-28-2012

2012ND000201214

RP25# weight loss,

Night Sweats

GHNot Tested

PP

PPdaugher

APdaughter

TDgrand-daugher

DDgrandson

CMgirlfriend

AMson

MGgirlfriend

JDmom

SRsister

CCfriend

SJfriend

DJfriend

ABfriend

DHfriend

JHfriend

MBfriend

DMfriend

BPfriend

JKfriend

DKfriend

SEfriend

Daniel Knowels friend

MF

DHGrafton ? tested

JHGrafton

KPJohnny's Bar

MGJohnny's Bar

RGJohnny's Bar

BSJohnny's Bar

MRJohnny's Bar

JVJohnny's Bar

WH

MD

brother

Northland Rescue Mission 19 tested

ADContact? Altru DL

JScontact ? Altru ER

Negative TST

Positive TST, CXR Pending

Positive Culture

Cultures Pending

Not Tested

LTBI

Other

TIMELINE

October 2012: 3 suspect cases were confirmed as cases; 3 additional cases added to the outbreak

November 2012: Investigation identifies 7 more cases, CDC Epi-Aid requested

December 2012: Epi Aid team arrives, 3 more cases

NORTH DAKOTA TB CASES 2000 - 2012

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

5

10

15

20

25

30

56 6 6

46

10

7

35

12

7

26

Reporting Year

Num

ber o

f Cas

es

June 1, 2012

Incidence Rate of TB/100,000in North Dakota 2009 - 2013

TB Case Rates,* United States, 2012

*Cases per 100,000.

< 3.2 (2012 national average)>3.2

D.C.

*from CDC Epi Aid Exit Presentation 12/11/12

Investigation Methods• Any laboratory

confirmed or clinically diagnosed cases investigated

• Establish infectious period

• Identification of named contacts and transmission sites

• Prioritization of contacts• Household contacts• High risk contacts• Location

screenings/targeted testing

• Locate and refer contacts

• Medical treatment for contacts with LTBI

Epidemiological Links• Name-based

• One patient identifies another person by name and reports close contact with that individual during the patient’s infectious period

• A third party names two individuals and reports close contact between them during one’s infectious period and the other’s exposure period

• Location-based• Two patients known to have been present at the same

time in a location in which they could have had close contact during one patient’s infectious period and the other’s exposure period

*adapted from CDC Epi Aid Team Exit Presentation December 2012

Investigative Tools

• Case Interview• Electronic Medical Records• Name and Photo release forms• Facebook/Social Networks• Pictures of transmission locations• Genotyping

North Dakota Department of Health; data as of 1/25/13

TREATMENT CHALLENGESNursing

• Addiction

TREATMENT CHALLENGESNursing

• Transportation

TREATMENT CHALLENGESNursing

• Communication

TREATMENT CHALLENGESNursing

• Health Challenges

TREATMENT CHALLENGESNursing

Treatment Protocols

TREATMENT CHALLENGESNursing

• Compliance

TREATMENT CHALLENGESNursing

• Children

TREATMENT CHALLENGESNursing

• Relationship Building

TREATMENT CHALLENGESNursing

• Incentives

TREATMENT CHALLENGESAdministrative

• Budget

TREATMENT CHALLENGESAdministrative

• Resources

TREATMENT CHALLENGESAdministrative

• Coordination

TREATMENT CHALLENGESAdministrative

• Electronic Health Records

Treatment Compliance

• Housing

• Provide Food

• Transportation

• Incentives

Why Genotype?• Discover unsuspected transmission relationships between TB patients

• Identify unknown or unusual transmission settings, such as bars or clubs, instead of traditional settings like home and workplace

• Uncover inter-jurisdictional transmission• Establish criteria for outbreak-related case definitions • Identify additional persons with TB disease involved in an outbreak• Determine completeness of contact investigations• Detect laboratory cross-contamination event• Distinguish recent infection (with development of disease) from

activation of an old infection

*CDC TB genotyping fact sheet (www.cdc.gov)

Additional Cases Linked

• Cases from 2010 linked, index case identified

• Cases from early 2012 were linked to outbreak – delay in linking cases to 2010

• A case from early 2012 had matching spoligotype, however greatly varied demographically and geographically

• A case in another city when interviewed did not provide any information that would lead us to believe he was linked to the outbreak.

Shortages• PPD

• State set aside PPD for contact screening• Hospital staff screening

• INH• RIF prescribed due to low level INH resistance• Approximately $50.00 per bottle/9 months = $450.00• RIF at $30.00/4 month = $120.00• Better completion rates with RIF

TB Screening

September 2012 - June 2013

TST – 1650

LTBI – 69

53.7% of Named Contacts are LTBI

June 2013 - June 2014

TST – 60

LTBI – 13

Lost of Follow-Up – 20?

Number of Cases• 2010 – 2 cases• 2012 – 20 cases• 2013 – 5 cases• 2014 – 2 cases

• Culture Confirmed – 18 cases• Clinical Diagnosis – 11 cases

• Under 18 years of age - 8 cases

Outbreak Age of Cases

0-9 10-19 20-29 30-39 40-49 50-59 60+0

1

2

3

4

5

6

6

2

6

2

5 5

3

Age

Num

ber o

f Cas

es

Gender of TB Cases

17

12

Males

Females

TB Cases in North Dakota

2010 2011 2012 2013 20140

5

10

15

20

25

30

9

5 6 74

2

20

5

22

2

OutbreakGF CountyRest of ND

Year of Diagnosis

Num

ber o

f Cas

es

Working with Other Agencies• Fargo Cass Public Health Unit

• Minnesota Department of Health• Interjurisdictional Notifications• Contact Investigation• Testing• Treatment

• Indian Health Services• Chart Reviews• Flagged Charts

Whole Genome Sequencing

Single-Nucleotide Polymporphism

Five additional clustered isolates in GIMS

In the News

Cohort Review• Attended by Altru Staff, GFPHU Staff and NDDoH staff

• Review each case

• Lessons learned• Contact Investigation – not just once• On-going genotype surveillance• Drug Levels

Successes• Use of Photo and Name Release

• Flagging Altru charts

• 27 cases treatment completed• 2 cases on-going

TB Cases in North Dakota

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 418520

5

10

15

20

25

30

56 6 6

4

6

10

7

3

5

11

7

26

12

8

Reporting Year

Num

ber o

f Cas

es

2014• 2 cases linked to outbreak

• 1 case is the index case• 1 case was never identified through the numerous interviews as a

person of interest• Contact investigations continue

Renewed interest in 321 address

Follow-Up exams done on active cases due to symptoms

Ongoing work

• Continue to locate, refer, and follow cases, LTBI, and contacts• Administer directly observed therapy (DOT) to active cases• Manage social barriers to treatment compliance

• Isolation for infectious cases• Housing• Food

• Medication and evaluation compliance• Continue investigative work

• Full genotyping• New case identification• Reinterviews

Collaboration• Grand Fork Public Health Unit• Altru Healthcare• Grand Forks County Correctional Center• Indian Health Services• Fargo Public Health Unit• Fargo Cass County Jail• CDC• Mayo - Regional Training Center• Minnesota Department of Health