1. Innovation   Collaboration   Accountability   Responsiveness   Excellence

2. Outline / Objectives What is TB? Duval TB Response Incident Command Public Information Accomplishing the mission Lessons learned for public health response

3. Innovation   Collaboration   Accountability   Responsiveness   Excellence What is TB? TB: short for Tuberculosis Globally, kills more people than HIV/AIDS Nationally on the decline

4. Innovation   Collaboration   Accountability   Responsiveness   Excellence Global Hot Spots

5. Innovation   Collaboration   Accountability   Responsiveness   Excellence National TB

6. Innovation   Collaboration   Accountability   Responsiveness   Excellence National Cases of TB

7. Innovation   Collaboration   Accountability   Responsiveness   Excellence TB Transmission Spread through coughing by air droplets

8. Innovation   Collaboration   Accountability   Responsiveness   Excellence TB Once infected, may have inactive (latent TB infection-LTBI) or active TB disease

9. Innovation   Collaboration   Accountability   Responsiveness   Excellence TB Symptoms

10. Innovation   Collaboration   Accountability   Responsiveness   Excellence How is TB Treated? Treatment of active cases requires months of antibiotics, not just 10 days TB drugs are old, subject to shortage Latent TB requires months of lesser doses of same antibiotics to kill hibernating TB germ

11. Innovation   Collaboration   Accountability   Responsiveness   Excellence Treatment of TB

12. Innovation   Collaboration   Accountability   Responsiveness   Excellence TB Funding TB allocation in the past across Florida related to five-year average number of active cases Duval had decreasing numbers of cases over last five years, yet “one of the most extensive TB outbreaks that CDC has been invited to…both in terms of its size and rapid growth.” (FL0046, that is)

13. Innovation   Collaboration   Accountability   Responsiveness   Excellence Duval County’s TB History 20082009201020112012 TB Cases 10289727183 0046 Cases 991030 % Geno- typed 25%64%100%

14. Innovation   Collaboration   Accountability   Responsiveness   Excellence TB Genotyping TB Genotyping is also known as Spligotyping or DNA fingerprinting 2005 - CDC initiates Universal TB Genotyping Program 2007 - Florida begins participation in Universal TB Genotyping Program

15. Innovation   Collaboration   Accountability   Responsiveness   Excellence

16. Duval’s TB Response Efforts Between July 12 and December 31, 2012: 4,067 individuals tested with T Spot Four active cases discovered by screen, others reported by docs/hospitals 476 individuals had LTBI (12% positive) All active cases treated; nearly all LTBI cases offered treatment to cure their TB 559 active, LTBI cases currently managed

17. Innovation   Collaboration   Accountability   Responsiveness   Excellence City Divided by Zone for Case Management

18. Innovation   Collaboration   Accountability   Responsiveness   Excellence Jacksonville’s System of Services for Homeless The good news: extensive meals/showers/clothing/beds in Jacksonville The challenge: dormitory style, 60 bunk beds in one room and face-to-face sleeping arrangements

19. Innovation   Collaboration   Accountability   Responsiveness   Excellence Jacksonville’s System of Services for Homeless, cont’d. The good news: a shared database among shelters in the city Another challenge: multiple aliases used by homeless lessens value of database

20. Innovation   Collaboration   Accountability   Responsiveness   Excellence Jacksonville’s System of Services for Homeless, cont’d. And more good news: the reluctance of shelters to deny anyone a bed And another challenge: coughing all night into shared air

21. Innovation   Collaboration   Accountability   Responsiveness   Excellence Jacksonville’s System of Services for Homeless, cont’d. The good news: Excellent cooperation among providers - the Jacksonville Community TB Coalition and health department More challenges: Available personnel to test every client seeking a bed Renewing 4,000 shelter clearance cards when they began expiring in 2013

22. Innovation   Collaboration   Accountability   Responsiveness   Excellence TB, The Homeless, and Shelter Guidelines TB, if untreated, can kill people Homeless people are at high risk for TB Guidelines are tools to help shelters: ID clients who may have TB Refer people with TB symptoms to health care Regularly test people we serve Ensure annual testing of staff, volunteers Identify ways to minimize risk of TB in facilities

23. Innovation   Collaboration   Accountability   Responsiveness   Excellence Quote “In order to create a complete community for our homeless population, they need a TB-free environment.” Cindy Funkhauser CEO IM Sulzbacher Center

24. Innovation   Collaboration   Accountability   Responsiveness   Excellence Incident Command System ICS was vital in managing TB response Assigned as Incident Commander in Sept of 2012 ICS experience included: E. coli outbreak at petting zoos H1N1 Numerous hurricanes, disasters

25. Innovation   Collaboration   Accountability   Responsiveness   Excellence Public Information

26. Innovation   Collaboration   Accountability   Responsiveness   Excellence Public Information, cont’d. Ability to communicate timely, accurate and accessible information on the incident’s cause, size and current situation to the public, responders, internal and external stakeholders.

27. Innovation   Collaboration   Accountability   Responsiveness   Excellence Public Information Team Florida Department of Health, Office of Communications Duval County Health Department PIO Volusia County Health Department PIO

28. Innovation   Collaboration   Accountability   Responsiveness   Excellence Risk Communication Strategies and Resources Development of core messages Identification of Subject Matter Experts, Spokespersons to deliver messaging Outreach to local governmental, state legislative representation, local organizations Weekly TB Update press calls Weekly data updates sent to media DOH Information Management Unit Virtual Joint Information Center (V-JIC) Public Records specialists

29. Innovation   Collaboration   Accountability   Responsiveness   Excellence Risk Communication Strategies and Resources, cont’d. Availability for in-person interviews Monthly Jacksonville TB Coalition updates Surgeon General Symposium on Crisis and Risk Communications in Public Health for community partners, public and media Risk communications training for all CHDs

30. Innovation   Collaboration   Accountability   Responsiveness   Excellence Mission Accomplished By the Numbers: 24 weeks of ICS in Duval in 2012 77 percent of the 2,100 priority contacts located 100 percent of TB cases treated, 90 plus percent of LTBIs Media appreciated regular updates, efforts continue

31. Innovation   Collaboration   Accountability   Responsiveness   Excellence Lessons Learned ICS works for prolonged cluster investigations-mimics pandemic response Integrated Florida DOH critical to address non-disaster events Important to build media relationships in advance of emergency Consistency of messages across CHDs in terms of reporting cases/contacts

32. Innovation   Collaboration   Accountability   Responsiveness   Excellence Public Health at Work

33. Innovation   Collaboration   Accountability   Responsiveness   Excellence Public Health at Work, cont’d.

34. Innovation   Collaboration   Accountability   Responsiveness   Excellence Questions? Bonnie Sorensen, MD, MBA Volusia County Health Department Bonita_Sorensen@doh.state.fl.us