TB Outbreak in Grand Forks Shawn McBride, Field Epidemiologist – North Dakota Department of Health Terri Keehr, RN – Grand Forks Public Health Delbert Streitz, Emergency Preparedness Coordinator – Grand Forks Public Health Dee Pritschet, TB Controller – North Dakota Department of Health

Late September 2012: 3 suspect TB cases were identified in Grand Forks County Early October 2012, Met with GFCCC, GFPH and Altru Team Timeline Overview

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 Timeline

NORTH DAKOTA TB CASES 2000 - 2012 June 1, 2012

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

TB Case Rates,* United States, 2012 D.C. < 3.2 (2012 national average) >3.2 *Cases per 100,000.

*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 Discuss concentric circles guiding testing and expansion of testing

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 CHALLENGES Nursing Addiction

TREATMENT CHALLENGES Nursing Transportation

TREATMENT CHALLENGES Nursing Communication

TREATMENT CHALLENGES Nursing Health Challenges

TREATMENT CHALLENGES Nursing Treatment Protocols

TREATMENT CHALLENGES Nursing Compliance

TREATMENT CHALLENGES Nursing Children

TREATMENT CHALLENGES Nursing Relationship Building

TREATMENT CHALLENGES Nursing Incentives

TREATMENT CHALLENGES Administrative Budget

TREATMENT CHALLENGES Administrative Resources

TREATMENT CHALLENGES Administrative Coordination

TREATMENT CHALLENGES Administrative 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 INH 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 TST – 1650 LTBI – 69 53.7% of Named Contacts are LTBI September 2012 - June 2013 June 2013 - June 2014 TST – 1650 LTBI – 69 53.7% of Named Contacts are LTBI TST – 60 LTBI – 13 Lost of Follow-Up – 20?

Number of Cases 2010 – 2 cases 2012 – 20 cases 2013 – 5 cases Culture Confirmed – 18 cases Clinical Diagnosis – 11 cases Under 18 years of age - 8 cases

Outbreak Age of Cases

Gender of TB Cases

TB Cases in North Dakota

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 A and B homeless, social contact, jail A G visited home of B. G often visited with son F. G prolonged infectious period (11 month), multiple social TB risk factors, superspreader G stayed in home of P and R G stayed in home of Q G&F stayed in home of E G&F visited Q, L, K G&F visited M, N, O, T G visited I, S, H J vistited I (doesn’t say if G was there) C and D no social links to F& G but stayed in upper level of same duplex as Q Single-Nucleotide Polymporphism

Five additional clustered isolates in GIMS A and B homeless, social contact, jail A G visited home of B. G often visited with son F. G prolonged infectious period (11 month), multiple social TB risk factors, superspreader G stayed in home of P and R G stayed in home of Q G&F stayed in home of E G&F visited Q, L, K G&F visited M, N, O, T G visited I, S, H J vistited I (doesn’t say if G was there) C and D no social links to F& G but stayed in upper level of same duplex as Q 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

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