1. { TB Outbreak 2013 Sheboygan TB Outbreak 2013 April 24, 2014 Lessons Learned – A Local Health Department Perspective Amy Betke, RN Public Health Nurse Deb Schmidt, RN Public Health Nurse Miva Yang, RN Public Health Nurse

2. None Disclosures

3. PRESENTATION OBJECTIVES Overview of index case and outline of outbreak events Lessons Learned – Sheboygan County Public Health Department Perspective Lessons Learned – TB Nurse Case Management Strike Team Perspective

4. TIMELINE OF INDEX CASE Prior to 1994 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Camp Ban Vinai, Thailand Had 2 children Immigrated to USA from Laos (1 child, no husband) TST 13mm September – Moved to Sheboygan Took 6 weeks of INH then pregnant Completed 6 months INH - Sheboygan No recall of prior TB treatment. Offered Rifampin or INH, but became pregnant Again offered INH 7x. Moved to Alaska First sign of cough March 2012 Visited family for 1 month in Thailand October 2012 Moved to Sheboygan continues with cough

5. TIMELINE OF INDEX CASE 20122012 20132013 October 1 Moved back to Sheboygan October 23 Dx with Pneumonia-ED November Flight to Las Vegas December 4 Dx with Pneumonia-ED December 20 Dx bronchitis and treated for reflux-Office April 3 Went to clinic for depression, provider ordered CXR, cavitary lesions observed April 11 Dx with TB February 25 - March Wausau February 22 Dx with asthma by a pulmonologist February ED X2 January 4 CXR interpreted as no active TB disease

6.  April 11, 2013 - The Division of Public Health was notified of a patient with suspected TB. Patient has several children.  April 15, 2013- Labs confirm this patient has active tuberculosis. She was started on Rifampin, INH, Pyrazinamide, Ethambutol, and Moxifloxacin.  April 16, 2013- Investigation of family: One child is coughing. Three children have abnormal chest x-rays. Suspect with TB in these 3 children. Children are excluded from 2 different schools.  April 17, 2013- INH resistant detected and INH stopped. OUTLINE OF EVENTS

7.  April 22, 2013- One more school child living outside the home is identified and found to have an abnormal chest x-ray.  April 23, 2013- Total of 5 individuals Dx with active TB. Incident Command System (ICS) activated. Contact investigation continues.  April 24-26, 2013- Meeting with SASD Administration to develop joint plan.  April - May 2013- Targeted testing was completed at 2 local schools.  May 7, 2013- MDR TB Dx in Index Case. Resistant to both INH and Rifampin. Patient hospitalized and started on Ethambutol, Pyrazinamide, Moxifloxacin, Linezolid, Amikacin, and Ethionamide. OUTLINE OF EVENTS

8. { Patient A’s House 8 kids A 9 kids Parents Adult Child Sister’s Niece’s 1 active 2 infected 1 infected 4 active 8 infected 1 active 3 infected

9.  May 7-10, 2013- Centers for Disease Control, Mayo Clinic, State TB Program, Sheboygan Area School District Staff, Children’s Hospital and local Medical Providers conferenced with Public Health on the treatment and contact investigation recommendations. Incident Command is expanded. OUTLINE OF EVENTS

10.  May 20, 2013- Conference call with state legislators, seeking appropriations from Joint Finance Committee (JFC).  June 3, 2013- Governor Walker and Department of Health Services issue a press release in support of funding the TB outbreak.  June 4, 2013- JFC approved 4.6 million for submission in the State biennial budget. OUTLINE OF EVENTS

11.  June 7, 2013- The CDC Epi-Aid team reported on the investigation, felt containment was met.  June 11, 2013- Index Case transferred from hospital to Rocky Knoll Health Care Facility negative-pressure room with no visitation. Final drug susceptibility tests show only Index case with MDR; other 7 cases INH resistant only.  June 26, 2013- Index Case returns to private single-family home in Sheboygan. Client remained in isolation. County purchasing agent secured home, as a rental property and obtained furnishing/necessary household items.  August 2013- Another school age child (Index case’s nephew) Dx with active TB. Case count at 10, child had LTBI and progressed to active TB. An additional active case was detected in Marathon County as well as, 4 new LTBI contacts. OUTLINE OF EVENTS

12.  Fall, 2013 – School begins. LHD receives school assistance with DOT for students and faculty affected by outbreak. Another round of school testing is completed.  October 17, 2013- Index case released from isolation following 27 weeks spent in hospital, LTCF and rental property. Able to reunite with children.  November 2013 – TB work continues. Incident Command modified as contact investigation wraps up and individuals are beginning to complete directly observed therapy for active as well as latent TB. Outline of Events 12

13. Lessons Learned- Our Agency Perspective 13

14. Greatest Assets During Outbreak  Dedicated Staff and Community Healthcare Partners  Staff Members Including PHN’s, Support Staff, HHS Interpreter with strong TB knowledge including previous experience with MDR TB strong TB knowledge including previous experience with MDR TB  Staff members willing to learn and do  Previous Emergency Preparedness Training  Compliance of the majority of clients with prescribed TB treatment  Strike Team Case Management One Year Later… What Have We Learned?

15. Greatest Assets During Outbreak (cont.)  Interdisciplinary Team  DOT Workers  Collaboration with SASD for DOT  Interdisciplinary Meeting with ASMMC.  Rocky Knoll Health Care Facility  Strong Support of Elected Officials and Leadership One Year Later… What Have We Learned?

16. Local Capacity Was Exceeded Early in Outbreak Staff Assigned to Assist Request Mutual Aid and Obtain Approval to Hire Limited Term Employees

17. Logistical Lessons  Technology – Expand cell phones with texting availability and dictation use  Streamline and centralize medication supply – Two person team to manage medication refills and bubble packing.  Use of Communication Logs for DOT workers  Bring in support staff to act as runners, DOT workers, etc.  Development of Communication Cards

18. Card for Clinic Use

19. INTERDISCIPLINARY TEAM FORMATION Complex needs of the family-financial, mental health, family dynamics, and school-related issues.

20. TB NURSE CASE MANAGEMENT STRIKE TEAM PERSPECTIVE  Amy, Deb, Miva, Mai Kou pic

21. Additional Strike Teams Additional Strike Teams

22. DPH Sub Teams Medication Monitoring Team Business/School Investigation Team DOT Team

23. Cultural Competency- Lessons Learned  Assign Hmong Nurse and Support Staff as part of the Strike Team from the start  Consider the gender and age of the interpreter  Education with the index case as to the importance of naming close contacts was a priority

24. Cultural Competency- Lessons Learned  Involve family into the treatment plan decisions  Importance of nutritional needs/ethnic food preference  Birth control and its challenges in relation to TB treatment

25. Tips for Providing Culturally Competent Tuberculosis Services to Hmong Persons

26. Interactions with Hmong clients and Family Members   Avoid speaking loudly   Avoid making direct eye contact   Avoid outwardly complimenting Hmong children   Avoid refusing refreshments that may be offered at a Hmong client’s home   Be aware that a Hmong client may present with unusual physical markings as well as wearing red cloth necklace or bracelets   Be sure to ask clients about their understanding of their illness and its cause Tips for Providing Culturally Competent Tuberculosis Services to Hmong Persons

27. Family and Cultural Issues   Before making a decision, family members are consulted Mental Health (Worries)   Hmong may be ashamed or avoid discussion of mental health issues Social Stigma   TB is often a cause for shame among the Hmong   Active TB vs. LTBI Tips for Providing Culturally Competent Tuberculosis Services to Hmong Persons

28. Tuberculosis Diagnosis and Treatment   Hmong language lacks words for many medical terms   Hmong may delay or avoid seeking care   Deliver clear, consistent messages   Two-way communication and equal exchange between provider, client, and family Tips for Providing Culturally Competent Tuberculosis Services to Hmong Persons

29. Summary

30. http://www.cdc.gov/tb/publications/guidestoolkits/EthnographicGuides/ Hmong/chapters/tips.pdfhttp://www.cdc.gov/tb/publications/guidestoolkits/EthnographicGuides/ Hmong/chapters/tips.pdf Promoting Cultural Sensitivity: A Practical Guide for Tuberculosis Programs That Provide Services to Persons from Somalia Francis J. Curry National Tuberculosis Center and California Department of Public Health (2008). Drug-Resistant Tuberculosis A Survival Guide for Clinicians, Second edition References

31. Any Questions?