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Tracy Agerton Director, Epidemiology Office Bureau of TB Control, NYC

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

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slide1

Inter-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

background
Background

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

background1
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
contacts at residence a
Contacts at Residence A
  • 109 close contacts
    • 33 current residents
    • 27 staff
    • 49 discharged residents
methods case finding discharged residents
Methods—Case FindingDischarged 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
methods case finding discharged residents1
Methods—Case FindingDischarged Residents
  • 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
slide7

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
slide8

Continual Case FindingDischarged 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
intra jurisdictional case surveillance and contact tracing efforts
Intra-jurisdictional Case Surveillance and Contact Tracing Efforts
  • 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
summary
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
lessons learned
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
acknowledgements
Acknowledgements

NYC DOHMH BTBCResidence ANYC DOHMH HIV/AIDS

Shameer Poonja Valentina Digrasso Judy Sackoff

Cindy Driver Pedro Gonzalez Lucia Torian

Ann Winters Lissette Rivas

Rachel Wiseman

Krishen Khemraj NJ TB ControlPHRI

Darrin Taylor Mark Wolman Barry Kreisworth

Christine Chuck Tom Privett

Kareen Joseph

Sonal Munsiff NYS TB Control

Diana Nilsen Margaret Oxtoby

Felicia Stubblefield

Abari Sulayman NYC DOHMH Correctional Health

Hope Campbell Woody Franklin

Tholief O’Flaherty Farah Parvez

Maria Gbur

slide13

NYC

STRAIN

W

NJ

Mark Wolman

NJMS Global TB Institute

background 1
Background-1
  • Patient FG was admitted to local hospital on September 13, 2005 with a diagnosis of suspected pulmonary TB
    • history of cough 1- 3 months
    • chest x-ray consistent with TB (non-cavitary)
    • sputum smear positive (4+)
background 2
Background-2
  • Infectious period established at March 1- September 13, 2005
  • During the infectious period the index patient indicated the following
      • single and homeless in Newark
      • address given to the hospital was a local flower shop
      • sat outside flower shop all day/every day
      • identified no family, friends nor social activities
      • identified no places of worship, employment, hangouts, shelters, hospitalizations, ED visits or incarceration
      • denied any local or extensive travel
background 3
Background-3
  • On September 19 initial culture collected on hospital admission identified as MTB
  • On November 8 susceptibility pattern indicated first line resistance
  • From this date forward new information collected identifying congregate setting exposures in two hospital settings during the infectious period moves to forefront of investigation
some early problem indicators
Some Early Problem Indicators……
  • Despite an order of airborne infection isolation on admission to one of the hospitals
    • early report by nursing station indicated that door to patient’s room left open and that the patient was seen occasionally leaving the room and walking the floor unmasked
    • airborne infection isolation discontinued later on the same day of admission for no apparent nor documented reason
  • During admission to the above hospital index patient was placed on same floor as high risk patients
  • Potential exposure to HCW’S and patients
patient time line march 1 december 17 2005
Patient Time LineMarch 1-December 17, 2005

12/17

3/1

6/1

6/15

6/16-22

6/30

7/4

7/6

7/12-15

7/23

7/24

7/25

8/13

8/17-22

9/5

9/13

9/19

11/8

11/10

11/28

12/2

12/14

Strain W

Linked to

Bronx

outbreak

NJ

Health

Alert

Hosp #1

In-pt

SP SM 4+

Aii

ordered

Drug

Resistance

Hosp #1

ED

Pneumonia

Hosp #1

ED

Rash

Hosp #2

In-pt

Rash

Hosp #2

ED

Rash

Hosp #2

ED

Rash

Hosp #2

ED

Rash

Watch List

to NJ

PT

Expired

Hosp #2

ED

Rash

Hosp #2

ED

Rash

Hosp #2

ED

Rash

PHRI

IS6110

Genotyping

MTB

Hosp #2

In-pt

Faint at B.S.

Pneumonia

Cough 1-2 mos

Aii d/c

Hosp #1

In-pt

Pneumonia

NYC

EXP

Hosp #1

ED

Cough

health alert 1
Health Alert-1
  • Issued by the Deputy Commissioner of the New Jersey Department of Health & Senior Services
    • alerting local health departments, clinicians and hospitals of Strain W cluster among HIV infected individuals in NYC
    • HIV infected homeless contacts linked to NYC investigation remain in the community and had not as yet been located
    • NJ and NYC DOH working closely to locate and medically assess the identified contacts
health alert 2
Health Alert-2
  • Medical providers urged to
    • isolate HIV infected homeless individuals who report a history of residing in NYC since January, 2005 and who present with symptoms of pulmonary TB
    • collect respiratory specimens
    • suspect drug resistance if these patients do not respond to standard TB therapy
diagnosis of hospitalized patients
Diagnosis of Hospitalized Patients

HIV/AIDS 18(42%)

Diabetes 7(16%)

Renal 3(7%)

Sickle Cell 3(7%)

Cancer 3(7%)

Pneumonia 3(7%)

Liver Disease 1(2%)

Cholecystitis 1(2%)

Gangrene 1(2%)

Cysts 1(2%)

Pituitary tumor 1(2%)

Alcohol 1(2%)

Total 43 (100%)

some early complications
Some Early Complications….
  • Identified patient contacts were themselves a very diverse medically complex group
  • If a second line latent treatment could be offered could these patients tolerate the medication?
    • Would they complete treatment?
summary of final assessment 1
Summary of Final Assessment -1
  • Throffer Diffuser Ventilation system
    • every 3 feet intake and outtake vents lined alongside ceiling lighting fixtures throughout the length and width of hospital floor
    • no shared or re-circulated air on floor
    • fresh air pumped in directly from roof to floor
    • environment air from floor pumped directly back to roof
    • provides 14 air exchanges per hour
    • isolation ante room has own intake and outtake vents
    • functional system as evidenced by testing provided by hospital engineering department
final assessment 2
Final Assessment - 2
  • Confirmation of initial nursing report of door to patient’s room left open
  • Initial report of patient walking the floor unmasked proved erroneous
outcomes to date
Outcomes To Date
  • All HCW’s identified and tested at both hospitals were TST negative
  • Based on the ventilation system that exists in the hospital coupled with the confirmation that the index patient did not leave his room during the July hospitalization the risk of transmission to patients had been reduced from high to low priority
    • No testing recommended for hospitalized patients
lessons learned and re learned 1
Lessons Learned…And Re-learned - 1
  • Maintain adherence to the basic principles of conducting congregate setting investigations
    • initiate and conduct on-site assessment of identified exposure environment(s)
    • collect information
    • confirm accuracy of information collected
    • review and analyze information collected
    • develop plan of action based on accurate information
lessons learned and re learned 2
Lessons Learned…And Re-learned - 2
  • As best as possible avoid decision-making that is driven by the perceived drama of the moment
  • Remain aware of the function and benefits of sharing information beyond geographic boundaries where there is frequent and easy access across state, county or city lines
      • watch lists
      • DNA fingerprinting results
slide31
The role in TB Control of institutions like PHRI is not only in the linking of patients through molecular epidemiology but in the linking of programs for the purpose of better understanding transmission and contact tracing of TB
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