1. MTB OUTBREAK LOCAL LAB RESPONSE Chris Partington MT(ASCP) ACL MICROBIOLOGY LAB

2. LOCAL LAB RESPONSE  ACL first specimens from outbreak: 04/20,21/2013 Sputums from daughter of index case Ordered for AFB culture/smear and MTD Both smear neg. One specimen MTD neg, one MTD pos. ACL unaware of “outbreak”, multiple contacts, relationship to index case. All the index case’s children have a different last name than the mother. Also unaware of probable resistant strain involved.  Five more specimens from 3 patients arrive in the next 4 days. All have the same last name, all children, all ordered for AFB culture/smear and MTD. At this point we have questions. We are informed by Sheboygan Public Health and WSLH that this is a possible outbreak situation.  ACL sends specimens (after decontamination and culture/smear performance) directly to WSLH for TB PCR testing due to the high MTD workload.

3.  After the first week of May 2013: The numbers of exposures, contacts and testing were exponentially increasing so we made the next change in protocol: Sheboygan Hospital would now send any samples related to the outbreak directly to WSLH.  We at ACL kept all work cards, communications, history/physicals and reports in a separate labeled folder for reference.  We were in almost daily communication with WSLH TB Lab, Sheboygan Public Health and Dr. Poursina (Infectious Disease) coordinating patients, specimens and tests.  We are still actively involved in all aspects because we have open accessions from the “in-house” cultures.

4. MISTAKES MADE / PROBLEMS ENCOUNTERED  Outbreak?! What outbreak? We had no clue that we were dealing with a possible outbreak; we were just seeing more than the usual orders for MTD. There were a few specimens with the same last name but it is a common one and we didn’t know the patients were related. No one alerted us to the possibility until we made some investigation.  Sure, we can handle that! No problem! We started with just a few specimens so we did it all: culture/smear and MTD. We were doing MTD’s daily which threw out our routine. We changed protocol a number of times: 1) Did all orders in–house 2) Did cultures/smears only and sent processed specimen to WSLH for TB PCR 3) Received specimen at our lab, then sent on to WSLH via our courier for all tests 4) Instructed Sheboygan lab to send all specimens directly to WSLH for testing This resulted in vast confusion: what tests are ours to result? how do we bill? who is getting the reports?

5.  Is it Racial Profiling or Cultural Understanding? Most of the offspring of the Index Case (“CM”) have a different last name from their mother. We did not know who was considered an “outbreak” contact and who was excluded. We received a tentative list of names from WSLH. We placed this list on the board in our specimen receiving area. We did not want these specimens manipulated outside of the TB room due to the MDR-TB designation. After a number of patient specimens came that were “outbreak” related but not on the list, we decided to consider all Hmong names from Sheboygan suspect. We learned surnames are not necessarily shared between families in the Hmong community. We learned a lot!  Unnecessary testing encountered. We had to watch the orders carefully. The children underwent bronchoscopies to obtain suitable specimens. The orders should have been for AFB cultures only but the specimens came with the “usual” bronch menu: AFB culture/smear, Fungus culture/smear, Routine culture/gram, pneumocystis testing. Why would they order a pneumocystis on a 14 yr.old? The explanation when questioned was that the pulmonologist just ordered his routine testing protocol!

6. WHAT WE’LL DO NEXT TIME (NEXT TIME?!)  Communication If possible set up more communication with key players: -Client (hospital Infection Control, outside lab personnel, clinic, etc.) -Public Heath -WSLH TB lab -appropriate Infectious Disease doc -our own Micro personnel  Education Have in-services with the Micro personnel about tuberculosis, outbreak situations, MDR-TB, the importance of carefully reviewing each specimen-name and test order. Urge personnel to investigate questionable orders, names, etc. and communicate with TB techs.  Diligence/Assertiveness/Demanding(?) Make sure everyone is doing their part. Don’t let the lab be the forgotten spoke of the wheel. Ask to be included on all communication. Keep your personnel informed.  Be mindful that specimens will keep coming for months (or years) for follow-up testing.

7. ACKNOWLEGEMENTS Julie Tans-Kersten WSLH TB Lab Sandy Musegades Sheboygan Public Health Dept. Dr. Arash Poursina Infectious Disease Teri Hosterman Sheboygan Memorial Infection Control Nancy Kapellen SMMC Lab Supervisor Fetije Shabanoski ACL Microbiology Supervisor