1. 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

2. 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

4. 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

5. NORTH DAKOTA TB CASES
June 1, 2012

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

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

21. *from CDC Epi Aid Exit Presentation 12/11/12

22. 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

23. 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

24. Investigative Tools Case Interview Electronic Medical Records
Name and Photo release forms
Facebook/Social Networks
Pictures of transmission locations
Genotyping

25. North Dakota Department of Health; data as of 1/25/13

26. TREATMENT CHALLENGES Nursing
Addiction

27. TREATMENT CHALLENGES Nursing
Transportation

28. TREATMENT CHALLENGES Nursing
Communication

29. TREATMENT CHALLENGES Nursing
Health Challenges

30. TREATMENT CHALLENGES Nursing
Treatment Protocols

31. TREATMENT CHALLENGES Nursing
Compliance

32. TREATMENT CHALLENGES Nursing
Children

33. TREATMENT CHALLENGES Nursing
Relationship Building

34. TREATMENT CHALLENGES Nursing
Incentives

35. TREATMENT CHALLENGES Administrative
Budget

36. TREATMENT CHALLENGES Administrative
Resources

37. TREATMENT CHALLENGES Administrative
Coordination

38. TREATMENT CHALLENGES Administrative
Electronic Health Records

39. Treatment Compliance
Housing
Provide Food
Transportation
Incentives

40. 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 (

41. 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.

42. 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

43. TB Screening TST – 1650 LTBI – 69 53.7% of Named Contacts are LTBI
September June 2013
June June 2014
TST – 1650 LTBI – % of Named Contacts are LTBI
TST – 60
LTBI – 13
Lost of Follow-Up – 20?

44. 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

45. Outbreak Age of Cases

46. Gender of TB Cases

47. TB Cases in North Dakota

48. 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

49. 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

50. 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

51. In the News

52. 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

53. Successes Use of Photo and Name Release Flagging Altru charts
27 cases treatment completed
2 cases on-going

54. TB Cases in North Dakota

55. 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

56. 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

57. 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