1. Cross-jurisdictional Efforts to Find Contacts to MDR TB Outbreak Among HIV-infected Homeless, New York City, 2005 Tracy Agerton Director, Epidemiology Office Bureau of TB Control, NYC Field Services Branch, DTBE, CDC

2. Background Infectious period: 1/11/2005-7/5/2005 for all 3 cases

3. Background Residence A Transitional, harm-reduction residence Primarily HIV-infected, homeless, drug users 5-story building ~30 years old 40 residents, 13 on each floor Common rooms, ate meals together Resident rooms with 1-6 person occupancy No mechanical ventilation Window A/C units, but not in Patient A’s room

4. Contacts at Residence A 109 close contacts –33 current residents –27 staff –49 discharged residents

5. Methods—Case Finding Discharged Residents Reviewed residence records to obtain locating information 3 PHAs fulltime for 2 weeks 3 home visits attempted Phone calls to programs/next of kin/home/providers

6. Registry searches –TB –Prison –HIV/AIDS Services Administration (HASA) –Department of Homeless Services (DHS) –HIV/AIDS Surveillance Letters sent to providers of record –Nature of exposure –Recommendations for evaluation and treatment –F/u for results of evaluations Methods—Case Finding Discharged Residents

7. Results—Case Finding 109 close contacts –33 current residents 100% evaluated 1 additional case identified 50% on TLTBI –27 staff 85% evaluated 58% on TLTBI –49 discharged residents 23 located and evaluated 39% on TLTBI

8. Continual Case Finding Discharged Residents 26 discharged residents not found Monthly registry checks –HASA –Prison –HIV/AIDS November: PHRI and NJ DOH notified BTBC of Strain W case diagnosed in NJ –Discharged resident from Resident A –Homeless in NJ since June 2005

9. Case Surveillance and Contact Tracing Efforts Across Jurisdictions HAN alert (NYC: AIDS Institute, Inter- City ID Rounds, NYS DOH, NJ DOH, CDC, PR TB Control, NTCA) Watch list of all HIV-infected contacts (NYC TB surveillance, NYS DOH, NJ DOH) Continue monthly registry checks (NYC prison, DHS/HASA, TB registry, NYC death registry) –Found 1 d/c resident found through NYC death registry match Cause of death: metastatic esophoegeal cancer 11/05 NYS prison search –Found 2 more d/c residents Both fully evaluated and on TLTBI with MXF

10. Summary Extensive transmission Rapid progression to disease Active case finding identified one additional MDR TB case Home visits and contact with providers proved effective Registry match with HIV surveillance was useful Shared genotyping and outbreak information with other jurisdictions vital

11. Lessons Learned Case finding activities should be initiated in settings for HIV-infected individuals where TB transmission is evident Alerts to neighboring jurisdictions should occur earlier –Confidentiality and privacy issues Expansion to other jurisdictions for contact tracing extremely useful –Routine information sharing around outbreaks Partnering with other DOHMH Bureaus (HIV, Correctional Health) very helpful

12. Acknowledgements NYC DOHMH BTBCResidence ANYC DOHMH HIV/AIDS Shameer PoonjaValentina DigrassoJudy Sackoff Cindy DriverPedro GonzalezLucia Torian Ann WintersLissette Rivas Rachel Wiseman Krishen Khemraj NJ TB ControlPHRI Darrin Taylor Mark WolmanBarry Kreisworth Christine ChuckTom Privett Kareen Joseph Sonal MunsiffNYS TB Control Diana NilsenMargaret Oxtoby Felicia Stubblefield Abari Sulayman NYC DOHMH Correctional Health Hope CampbellWoody Franklin Tholief O’FlahertyFarah Parvez Maria Gbur