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

2. 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+)

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. Hospital Assessment July 12-15, 2005 Admission- 1

10. 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%)

11. 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?

12. Hospital Assessment - 2

13. Hospital Assessment - 3

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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