IM NOT HOMELESS

I AM NOT HOMELESSCSTE June 2013Dee Pritschet, TB Controller North Dakota Department of HealthShawn McBride, Epidemiologist North Dakota Department of HealthDiana Boothe, Public Health Associate Centers for Disease Control and PreventionAlicia Lepp, Epidemiologist North Dakota Department of HealthKirby Kruger, Division Director North Dakota Department of HealthTracy Miller, State Epidemiologist North Dakota Department of HealthKrissie Guerard, TB Program Manager North Dakota Department of Health

June 11, 2013It all started with a phone call

mddr

Molecular Detection of Drug Resistance

NORTH DAKOTA TB CASES 2000 - 2011NORTH DAKOTA TB CASES 2000 - 2012United States vs North Dakota TB Disease Rates/100,000Gender ND TB Cases 2008 - 2012

EthnicityND TB Cases 2008-2012

Timeline OverviewLate October: three confirmed cases had been identified in Grand Forks CountyNovember: Investigation identifies more cases and the State Health Dept. requests Epi AidDecember: Epi Aid team arrivesJanuary to Present: Investigation continues, linking cases, evaluating social network, locating and referring contacts for testing, managing active cases and latent infections, administering Directly Observed Therapy (DOT)

11Epidemiological LinksName-basedOne patient identifies another person by name and reports close contact with that individual during the patients infectious period (IP)

A third party names two individuals and reports close contact between them during ones infectious period and the others exposure period*adapted from CDC Epi Aid Team Exit Presentation December 2012Location-basedTwo patients known to have been present at the same time in a location in which they could have had close contact during one patients infectious period and the others exposure period

Investigative ToolsCase InterviewElectronic Medical RecordsName and Photo release formsFacebook/Social NetworksPictures of transmission locationsGenotyping

GenotypingSpoligotypingIdentifies the M. tuberculosis genotype based on presence or absence of spacer sequences found in a direct-repeat region of the M. tuberculosis genome where 43 identical sequences and 36 base pairs are interspersed by spacer sequences.

Spoligotype - 777776777760601 Miru - 224325153323Miru2 - 444234423337

CDC Epi Aid reviewed all cases with matching spoligotype as well as requested spoligotypes be run on culture positive cases with potential epi links

GENtype G00011

Sensitivity

Low Level Isoniazid (INH) ResistanceWhy is this important?Latent TB infection (LTBI) is treated with RifampinRifampin is a 4 month treatment in adultsRifampin is a 6 month treatment for childrenTreatment for Active TB Cases is 9 months vs 6 monthsINH shortage might lead to Rifampin shortage

Drug levels are imperative to ensure adequate drug levels are reached and maintained throughout the course of treatment

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

Couch SurfingPhoto and Name Release FormsRequested active cases sign an order to allow us to use their photo and/or name in investigation related activitiesUsed to verify suspected epi linksEstablished unknown epi linksLinked our genotypic match from another community who was demographically very different to the outbreak super spreaderExtended the super spreaders infectious period by 6 months

CDC used another method:Provided a name list to patients of random first names with other first names of cases, particularly those who did not sign a photo releaseFargo no known link until photo shown33Electronic Medical RecordsAllowed for further verification and identification of named contacts

Able to flag charts of patients

Streamlined gathering and sharing of clinical information and patient status

Using technologyProblem: Large amounts of information was being gathered, digesting and disseminating it was challengingComprehensive list of cases, contacts, and site screenings developed by Epi Aid team and based upon data base developed by Dept. of HealthDetailed case follow upInformation to action

Developed Secure access portal for case follow up and sharing of current informationControlled, secure accessLimited number of editorsEfficient communication

Sticky notes, Diana compiled all lists and developed a working spreadsheet35

Map of North DakotaGenotypingA case from early 2012 had matching spoligotype, however greatly varied demographically and geographically

Original contact investigation for either case was unable to identify name or location epi linkNew focus guided by genotyping established an epi link to the super spreaderPhoto release was critical in making the linkEstablished a time frame for the transmission eventExtended IP of super spreader from previous estimates by 6 monthsExpanded investigationCDC had this as a Minnesota caseNORTH DAKOTA CASES 2000 - 2013TB in North Dakota2002-20131 case in 2012 and 2 cases in 2013 are residing in Cass County39AGES OF Outbreak TB CASES

North Dakota Department of Health; data as of 1/25/13SCREENING1650Tuberculin Skin Tests (TSTs) Performed

69 LTBIs Identified

53.7% of Named Contacts are LTBIsOngoing workContinue to locate, refer, and follow cases, LTBI, and contactsAdminister directly observed therapy (DOT) to active casesManage social barriers to treatment complianceIsolation for infectious casesHousingfoodMedication and evaluation complianceContinue investigative workFull genotypingNew case identificationReinterviewsChallengesStaffing added Field Staff & Public Health AssociateHousing - Worked with Emergency Preparedness & ResponseDOT Compliance 7 day DOTDrug Levels Non-Therapeutic LevelsIndian Health ServicesBorder States and ProvincesINH ShortageTubersole Shortage

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