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Rural Indiana Outbreak County/State and CDC Response

Rural Indiana Outbreak County/State and CDC Response. Shameer Poonja MPH CDC Assignee Indiana State Department of Health TB Program. TB Incidence — United States, 2005. < 3.5 cases per 100,000. >3.5 cases per 100,000. Indiana Small Rural County. 2002

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Rural Indiana Outbreak County/State and CDC Response

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  1. Rural Indiana Outbreak County/State and CDC Response Shameer Poonja MPH CDC Assignee Indiana State Department of Health TB Program

  2. TB Incidence—United States, 2005 <3.5 cases per 100,000 >3.5 cases per 100,000

  3. Indiana Small Rural County

  4. 2002 School setting –linked to four secondary cases. One additional case linked to previous investigation in 1990’s. Social setting-four cases genetically linked to past case in three other counties. 2003 African American Community 25 cases in cluster Recent outbreaks

  5. TB Cases—County A, 1999–2004 1999 2000 2001 2002 2003 2004 2005

  6. Do we have a problem? • County- Spring 2005 • Noticed increase in cases • Placed call to state for recommendations • State- September/October 2005 • Noticed problem with DOT • Patient interviews revealed 3 potential sites of exposure • genotyping • CDC • TB news articles in 09/30 • Called State for update on issue

  7. Initial Response • State Health Department • Communicated with county health nurse • Provided staff persons • Provided emergency funding • Requested Epi-Aid team • CDC • Epi-Aid team arrives 11/9/05 -12/16/05 to re-interview, identify additional sites of exposure, screening contacts • 10/06 Requested (1999-2004) isolates be sent for genotyping

  8. CDC Epi- Aid Team Pre-Investigation DataOctober 2005 • 10 cases detected • All 10 genotypes matched • Archived isolate (1999–2004) genotypes matched

  9. TB Cases—County A, 1999–2005 Outbreak-related Not outbreak-related 1999 2000 2001 2002 2003 2004 2005

  10. Outbreak-Related Cases, 1999–2005 (N=23) Genotype-matched and epi-linked Epi-linked only Genotype-matched only 1999 2000 2001 2002 2003 2004 2005

  11. Outbreak Response • State • Continued to have staff available to interview, provide education • Medical residents • Pulmonary and ID consultation • Press release • CDC • Reviewed patient records • Interviewed patients diagnosed in 2005 and their contacts • Reviewed national TB genotyping data

  12. Patient Characteristics (N=23) Characteristicn Median age (range) 46 years (4–70) Male 17 White and US-born 23 HIV-infected 0 Diabetes 8 Heavy alcohol use 18 Methamphetamine use 1

  13. Disease Characteristics (N=23) Characteristicn Pulmonary 22 Cavitary 15 Smear positive 17 Culture positive 20 Drug susceptible 20 Fatal 2

  14. Risk Factors Delay (>60 days) n/N median (range) Diagnosis 11/18 135 days (74–389) Smear conversion 9/12 94 days (62–210) Culture conversion 10/15 96 days (63–141)

  15. Public Health Impact Additional Contacts 226 + 294 = 520 Contacts 109 LTBI 25 (23%) LTBI 25 + 24 = 49 Treatment Initiated 19 (76%) Treatment Initiated 41 (84%)

  16. Ongoing activities • County • Hired and trained additional staff • Establish ½ day TB clinic • State • Reorganization and build linkages with other programs • Resources (EPI, 2 Regional RN) • Requested public health advisor • Federal (CDC) • Deployed field staff (2/6-6/30) • Developed Data Management system

  17. Geographic Distribution* of Outbreak Strain—United States

  18. Acknowledgments • County A Health Department • Indiana State Department of Health • CDC Division of TB Elimination • CDC Experience and Epi Elective Programs

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