1. Kaiser Oakland Contact Investigation CTCA Conference May 6 th, 2010 Tara Greenhow, MD Pediatric Infectious Diseases Kaiser Permanente San Francisco

2. Objectives Discuss recent contact investigation at Kaiser Oakland Describe elements of the public-private collaborative response that led to successful control of the TB outbreak –Effective communication among all partners –Willingness of all partners to share information –Getting an early start on the collaborative response –Coordination across multiple jurisdictions

3. Index Case 12 yo girl with Trisomy 21 admitted on 1/12/09 for tracheostomy She was well until winter 2006-2007 when she developed hoarse voice and cough 3/07 found to have vocal cord granulomas that showed noncasseating granulomas. AFB stain (-), culture not performed 4/07 PPD (-) 4/08 laryngoscopy continued to show noncasseating granulomas. AFB stain and culture (-)

4. Index Case 7/08 steroids started for presumed sarcoid and transiently improved 10/08 –PPD 0mm –Chest CT with mediastinal adenopathy and bilateral opacities RUL and RML

5. Index Case Admitted 12/31/08 – 1/6/09 for bilateral UL pneumonia –Improved on IV and oral antibiotics

6. Index Case 4mm airway CXR bilateral infiltrates 1/12/09 1/13 1/22 1/24 Tracheostomy and bronchoscopy AFB stain (-) Notified AFB culture (+) Airborne precautions AFB confirmed as MTB Started on RIPE therapy Sputum obtained 1/23 AFB smear (+) with many AFB Alameda TB controller notified

7. Evaluation of Exposed 1/24/09 –Contacted local TB controller –Effective early communication Shared the patient’s history Discussed beginning a contact investigation –Open communication thru email, office number and personal cell phone

8. “Fourth circle” - Exposed visitors Assess TB Exposure Risk “Inner circle” - those with closest contact (family members) “Second circle” - Exposed staff with direct contact with patient “ Third circle” - Exposed staff without direct patient contact - Exposed patients

9. Evaluation of Exposed “First circle” – Family - Baseline –Sister is TST (+) 25mm (Last TST 2/04) –Mom's TST is 0mm (Last TST was negative in 5/08) –Father h/o prior (+) TST with CXR (-) –2 cousins from Mexico living in home last 6 months both TST (-)

10. Evaluation of Exposed “Second circle” – –Exposed staff with direct contact with patient including 12/31-1/6 admission and current –Air circulation data PICU – 17 and 12.8 Private room 20 –Identified 94 employees

11. Evaluation of Exposed “Third circle” – –10 exposed patients [9 PICU and 1 hospital ward] including 3 mothers 1 prior (+) – symptom screen and CXR (-) 8 baseline (-) TST and CXR (-) Ages 1 ½ y – 17y, only one immunocompromised 1 noncompliant with baseline testing

12. Evaluation of Exposed On 2/26 (6 weeks after exposure) social worker with brief face-to-face exposure with 20mm TST (no baseline) Exposure broadened to include all staff working in PICU including those without direct face-to-face contact –Employees to be screened now 195

13. Employees Total to be screened195 Total completed screening 195 % Complete100% Total Conversions7 Total Positive Questionnaires 0 Employee converters –None from prior admission –Ranged from no direct contact to prolonged contact with secretions –All but one asymptomatic

14. Employees Respiratory therapist with close contact –Baseline TST 0mm –Follow-up TST 20mm –Abnormal CXR and chest CT –Sputum obtained x 8 –All smear negative, 1 culture positive with matching genotype to index case –Contact investigation of 8 co-workers – no conversions

15. Patient Contacts Total to be screened10 Total completed screening8 1 symptom screen Equals9 % Complete9/10 = 90% Total Conversions1 + 1 immunocompromised Total Positive Questionnaires 0

16. Case #1 3yo, CE, resident of Oakland, Alameda County Baseline TST 0mm. Baseline CXR normal TST on 4/6 (2 mo after exposure) 20mm CXR with hilar adenopathy & RML infiltrate

17. Case #1 Admitted to Kaiser SFO on 4/6-4/9 with cough Gastric aspirates x3 obtained. Stain (-) culture (-) Started on 3 drug INH/Rif/PZA DOT on 4/7 S/p 6 months therapy thru 10/7 CXR on 7/27: resolution of RML infiltrate, continued right hilar adenopathy

18. Case #2 9yo, FV, resident of Tracy, San Joaquin County, with underlying spinal cancer –Baseline (-) PPD, (-) QTF-G and (-) CXR –Started on INH 2/8/09 –Low grade fevers and cough early 2/09, LLL pna and symptoms resolved on cefuroxime –Mother with PPD conversion [4/1/09 20mm (last PPD 10/08)] and so continued on INH –4/16 chest CT showing new RLL infiltrate

19. Case #2 –Admitted on 4/16 to Kaiser OAK Repeat PPD (-) BAL and gastric aspirates x2 obtained. All stain (-) culture (-) Continued on INH. Rif/PZA/Eth added on 4/16 Discharged home on 4/20 –Repeat CXR on 4/29 and 5/26 negative –Plan 4 drug therapy for 6 months thru 10/16 Repeat PPD and QTF-G

20. Identifying all visitors Mass notification of visitors –No communication by mail –All exposed contacted by team of internists and pediatricians Help of local and state TB control with coordination among different counties (Los Angeles, San Joaquin, Napa, Alameda, San Mateo, San Francisco, etc.) Logistics

21. Distributing information and documents –FAQ –Scripts for providers –Data collection forms Noncompliant visitors –Sharing information with TBCB with dissemination to all counties Logistics

22. Visitors Total to be screened92 Total completed screening 77 7 symptom screen prior PPD(+) Equals84 % Complete84/92 = 91% Total Conversions4 Total Positive Questionnaires 0

23. Visitors of Patient #1 Total to be screened13 Total completed screening 12 N/A symptom screen Equals12 % Complete12/13 = 92% Total Conversions1

24. Visitors of Patient #2 Total to be screened50 Total completed screening 44 4 symptom screen Equals48 % Complete48/50 = 96% Total Conversions3 Total Positive Questionnaires 0

25. Index Case 4mm airway CXR bilateral infiltrates 1/12/09 1/131/221/24 2/13/24/1 4/13 5/18 Tracheostomy and bronchoscopy AFB stain (-) Notified AFB culture (+) AFB confirmed as MTB Isolate pan-sensitive Sputum culture (-) Sputum smear (-) x 3 Trach removed Discharged home

26. Index Case S/P 9 months therapy due to cavitary lesions thru 10/24 9/09 CXR with continued opacities