NJMS Global TB Institute NYC STRAIN W NJ Mark Wolman NJMS Global TB Institute

Background-1 Patient FG was admitted to local hospital on September 13, 2005 with a diagnosis of suspected pulmonary TB history of cough 1- 3 months chest x-ray consistent with TB (non-cavitary) sputum smear positive (4+)

Background-2 Infectious period established at March 1- September 13, 2005 During the infectious period the index patient indicated the following single and homeless in Newark address given to the hospital was a local flower shop sat outside flower shop all day/every day identified no family, friends nor social activities identified no places of worship, employment, hangouts, shelters, hospitalizations, ED visits or incarceration denied any local or extensive travel

Background-3 On September 19 initial culture collected on hospital admission identified as MTB On November 8 susceptibility pattern indicated first line resistance From this date forward new information collected identifying congregate setting exposures in two hospital settings during the infectious period moves to forefront of investigation

Some Early Problem Indicators…… Despite an order of airborne infection isolation on admission to one of the hospitals early report by nursing station indicated that door to patient’s room left open and that the patient was seen occasionally leaving the room and walking the floor unmasked airborne infection isolation discontinued later on the same day of admission for no apparent nor documented reason During admission to the above hospital index patient was placed on same floor as high risk patients Potential exposure to HCW’S and patients

Patient Time Line March 1-December 17, 2005 3/1 6/1 6/15 6/16-22 6/30 7/4 7/6 7/12-15 7/23 7/24 7/25 8/13 8/17-22 9/5 9/13 9/19 11/8 11/10 11/28 12/2 12/14 12/17 Hosp #1 ED Pneumonia Hosp #1 ED Rash Strain W Linked to Bronx outbreak NJ Health Alert Hosp #2 ED Rash Hosp #2 ED Rash Hosp #2 ED Rash Hosp #2 In-pt Rash Hosp #1 In-pt SP SM 4+ Aii ordered Drug Resistance Hosp #2 ED Rash Hosp #2 ED Rash Watch List to NJ PT Expired NYC EXP Hosp #1 In-pt Pneumonia Hosp #1 ED Cough Hosp #2 In-pt Faint at B.S. Pneumonia Cough 1-2 mos Aii d/c Hosp #2 ED Rash MTB PHRI IS6110 Genotyping

Health Alert-1 Issued by the Deputy Commissioner of the New Jersey Department of Health & Senior Services alerting local health departments, clinicians and hospitals of Strain W cluster among HIV infected individuals in NYC HIV infected homeless contacts linked to NYC investigation remain in the community and had not as yet been located NJ and NYC DOH working closely to locate and medically assess the identified contacts

Health Alert-2 Medical providers urged to isolate HIV infected homeless individuals who report a history of residing in NYC since January, 2005 and who present with symptoms of pulmonary TB collect respiratory specimens suspect drug resistance if these patients do not respond to standard TB therapy

Hospital Assessment July 12-15, 2005 Admission- 1

Diagnosis of Hospitalized Patients HIV/AIDS 18(42%) Diabetes 7(16%) Renal 3(7%) Sickle Cell 3(7%) Cancer 3(7%) Pneumonia 3(7%) Liver Disease 1(2%) Cholecystitis 1(2%) Gangrene 1(2%) Cysts 1(2%) Pituitary tumor 1(2%) Alcohol 1(2%) Total 43 (100%)

Some Early Complications…. Identified patient contacts were themselves a very diverse medically complex group If a second line latent treatment could be offered could these patients tolerate the medication? Would they complete treatment?

Hospital Assessment - 2

Hospital Assessment - 3

Summary of Final Assessment -1 Throffer Diffuser Ventilation system every 3 feet intake and outtake vents lined alongside ceiling lighting fixtures throughout the length and width of hospital floor no shared or re-circulated air on floor fresh air pumped in directly from roof to floor environment air from floor pumped directly back to roof provides 14 air exchanges per hour isolation ante room has own intake and outtake vents functional system as evidenced by testing provided by hospital engineering department

Final Assessment - 2 Confirmation of initial nursing report of door to patient’s room left open Initial report of patient walking the floor unmasked proved erroneous

Outcomes To Date All HCW’s identified and tested at both hospitals were TST negative Based on the ventilation system that exists in the hospital coupled with the confirmation that the index patient did not leave his room during the July hospitalization the risk of transmission to patients had been reduced from high to low priority No testing recommended for hospitalized patients

Lessons Learned… And Re-learned - 1 Maintain adherence to the basic principles of conducting congregate setting investigations initiate and conduct on-site assessment of identified exposure environment(s) collect information confirm accuracy of information collected review and analyze information collected develop plan of action based on accurate information

Lessons Learned… And Re-learned - 2 As best as possible avoid decision-making that is driven by the perceived drama of the moment Remain aware of the function and benefits of sharing information beyond geographic boundaries where there is frequent and easy access across state, county or city lines watch lists DNA fingerprinting results

The role in TB Control of institutions like PHRI is not only in the linking of patients through molecular epidemiology but in the linking of programs for the purpose of better understanding transmission and contact tracing of TB