Jean Beinemann RN, Terri Boxrucker RN, and LT Dee Dee Downie MPH Outline The disease The outbreak The response The conclusions May 18, 2014 Wisconsin Public Health Association Annual Meeting Tuberculosis (TB) Mycobacterium tuberculosis Transmitted in air Usually affects the lungs, but also other sites Common symptoms: cough, fever, weight loss Medical Evaluation for TB Medical history (symptoms, exposure, past treatment, risk factors) Physical examination (overall condition) Test for TB infection i (TST and IGRAs) Chest radiograph (lesions suggest but not confirm) Bacteriologic examination (specimen collection, smear, culture identification, drug susceptibility) Chest Radiograph with Lower Lobe Cavity 1
Knowing the Difference Between Infection and Disease Takes Time Blood and skin tests only tell us if the person is infected. Genetic tests (PCR), if positive, ii mean that the person has TB. But a negative does NOT mean that the person doesn t have TB. Culture is the only gold standard for knowing if someone has TB; culture can take up to eight weeks. TB is Preventable and Curable Best prevention is to identify and treat active TB cases early, before transmission to others Once transmission occurs, detecting and treating LTBI helps prevent new cases of active TB Contagiousness greatly decreased within two weeks after start of effective treatment for TB disease 7 TB Morbidity (2007 2012) TB in Wisconsin About 70 cases per year X 10 years Increasing percent of cases are foreign born or children of foreign born parents 2013: 50 cases, 78% in foreign born or children of foreign born Between 3 and 10% of cases each year are multi drugresistant (MDR); all in people of Asian descent Source: CDC, http:/ / www.cdc.gov/ tb/ statistics/ reports/ 2011/, WI Division of Public Health, CDC, Trends in TB United States, 2012, MMWR, March 22, 2013. (2012 data provisional) 10 Multidrug resistant Tuberculosis (MDR TB) Definition: drug resistance to at least isoniazid (INH) and Rifampin (RIF). Normal treatment for TB is 6 9 months but for MDR TB, treatment is for 18 24 months post sputum culture conversion and usually totals 24 30 months, plus the recommended 2 year follow up monitoring. Standards in MDR TB Treatment MDR TB expertise is needed to manage each case. More frequent laboratory collection and analysis is needed than with non drug resistant TB (second line drug susceptibilities, therapeutic drug monitoring, longer sputum collection is needed to assess for treatment failure). All treatment is individually based (medications, treatment response, monitoring and duration). Guidelines Francis J Curry National TB Center in San Francisco, CA 2nd edition Drug Resistant Tuberculosis: A Survival Guide for Clinicians, 2008. 2
The Global Burden of TB 2012 All forms of TB HIV-associated TB Multidrug-resistant TB MDR TB in the United States MDR TB cases are 1.3% of all cases in the U.S. between 2007 2012 (638 cases). States with the highest number of MDR TB cases are: California (162), New York (84), Texas (74) New Jersey (45). MDR TB cases are 14% US born and 86% Foreignborn. Source: WHO Global Tuberculosis Report 2013 *Including deaths attributed to HIV/TB Source 2013 CDC: Report of Tuberculosis in the United States, 2012 MDR TB in Wisconsin MDR TB in Wisconsin Country of Origin for MDR TB Cases in Wisconsin 2005 2012 China Burma Nepal India Laos 0 2 4 6 8 10 12 14 16 Sheboygan County Population: 115,507. Rural/Urban mix. 95% of Sheboygan County residents born in the U.S. Increasing Diversity 2010 Census Data Hispanic/Latino 6,329 Asian 5,279 Black/African American 1,605 3
April 11, 2013 The Division of Public Health received report from the local Community Health Center of a patient with suspected TB. Patient has several children. April 15, 2013 Lab report confirms that this patient has tuberculosis disease. April 16, 2013 Investigation of family: One child is coughing. Four children have abnormal chest x rays. Children are excluded from school. April 22, 2013 More children living outside the home are identified and evaluated. April 23, 2013 Oldest child in the home is diagnosed with tuberculosis disease. This child attends South High School Case Count 2. Incident Command System (ICS) activated. 19 20 April 24 26, 2013 Met with SASD administration joint plans made. South High staff updated Letters sent home to South High parents Local news outlets contacted Joint press conference with SASD 21 Late April Early May Contact investigation expands. Additional suspect and confirmed cases identified. Case Count 8. May 6, 2013 Index case is found to have MDR TB. May 7 10, 2013 Phone conference Centers for Disease Control, Mayo Clinic, State TB Program, SASD staff, Children s Hospital, local Medical Providers and Public Health discuss recommendations of treatment and contact investigation. Outbreak affects two companies and two schools. Treatment to be provided via Directly Observed Therapy (DOT) and need IV antibiotic administration. 22 May 13, 2013 Determined that the Health Department has exceeded capacity. Emergency Manager brought on board. Requested IMT (Incident Management Team) assistance. Conference call for mutual aid assistance from State, Regional and Local Health Departments. LTE s to be hired. May 16, 2013 Emergency Operations Center (EOC) opens. E sponder activated. Conference call took place about declaring a State of Emergency. May 20, 2013 Conference call with state legislators, seeking appropriations from joint finance committee. May 28, 2013 The CDC Epi Aid team arrives. June 4, 2013 JFC approved $4.6 million for submission in the State biennial budget. (Projections for JFC request based expected # of MDR cases. Drug costs alone for MDR disease=$254,000/yr, to treat MDR infection=$8,760) June 7, 2013 The CDC Epi Aid team reported on the investigation, felt containment was met. 23 24 4
June 11, 2013 Final drug susceptibility tests show only Index Case with MDR TB, seven others INH resistant (mono resistant). June 25 2013 Another child found to have TB disease. Case Count is 9. June 26, 2013 Index case to move into rental house. August 2, 2013 Elementary school age child found to have TB disease Case Count 10, a third school is involved. August 5, 2013 Multidisciplinary team established to address long term stresses on Index case and family. September, 2013 School begins. LHD receives school assistance it with DOT (Directly Observed Therapy). Hot washes and AAR information gathering becomes a focus. October 17, 2013 Index case released from isolation following 27 weeks in hospital, LTCF and rental property. Able to reunite with children. Treatment to continue to 2015. 25 26 Winter 2013/2014 Contact investigation wraps up and individuals are completing medication therapy. AAR completed. Updating procedures and protocols based on lessons learned. Plans to further community education and screenings. Totals: 10 cases in Sheboygan County 2 cases ID d in another Wisconsin County 28 treated for TB infection in Sheboygan County 670 community members tested 7350 doses of medication given 27 Incident Command Structure (ICS) State ICS Structure Chief medical officers EIS officer Policy Public health incident coordinator CDC/DPH Liaison ICS advisor Liaison officer Regional office directors Public information officer Safety & security officer Operations Planning and Logistics Finance and Admin Intelligence 29 30 5
Sheboygan Fire and Police Dept Fire Safety Officer Daily Ops Mtg Fit Testing Transport Vent Police Daily Ops Mtg CAD Officer Safety ft Training/PPE Surveillance Incident Management Team (IMT) Used in Sheboygan Co previously Sent advance team Provided d organizational i support Filled Planning Section Documentation Filled a gap 31 32 Request Assistance: Folks are willing to help 33 AAR Lessons Technology Safety Protecting Healthcare Workers and Others Cell phones texting & dictation Conference call capabilities Streamline medication and finance protocols Assign lead to oversee contact investigation and request a healthcare liaison Assure pre and post exposure testing and mental health support of workers Reinforce ICS and train beyond the Health Department 35 36 6
Effective Communication Externally and Internally Public Information Officer crafts messages. Schedule Media Conferences. Use Joint Information System for community messages. Keep DHS and County Administration Updated. Emergency Manager can serve as an effective liaison. Schedule regular staff updates. Allow all staff a process to be heard. Step Back and Look at the Big Picture Understand that multiple internal and community providers are involved and have various levels of experience, expertise, expectations and roles. Everything isn t always Black or White. There are different approaches and treatment recommendations related to MDR TB. Keep your eye on the goal..early identification and successful treatment of cases with elimination of spread of disease. TB Elimination! Involve Finance Early in Process Time tracking and expense documentation critical. Projections for JFC request was based on past experience and expected # of cases. Having TB Dispensary Program in place was very helpful. Clients were largely uncertain regarding their health care coverage and struggled with Medicaid Application Process and understanding insurance statements. Funding does not magically appear! Logistical Lessons Technology Expand cell phones with texting availability, dictation use Post all meeting schedules and updates Streamline and centralize medication supply Two person team to manage medication refills and bubble packing. Use of Communication Logs for DOT workers Assure pre and post exposure testing of workers Develop consistent documentation standards Bring in support staff to act as runners, DOT workers, etc. Our Greatest Assets Strong support of elected officials and leadership Dedicated staff and community partners Staff with years of TB knowledge including previous experience with MDR TB and previous emergency preparedness training Trust within the Hmong Community Overall compliance of affected clients Best Approach: Prevent Outbreaks Engage the Hmong community in testing Engage the whole medical community in early identification of disease Early diagnosis i and treatment: relies on healthcare h provider awareness of possibility of TB May be enhanced if patient can identify risk to provider Targeted testing of high risk persons Education for clinicians and persons at risk 7
Additional Resources Tuberculosis Nursing: A Comprehensive Guide to Patient Care, National Tuberculosis Controllers Association Drug Resistant Tuberculosis; A Survival Guide for Clinicians, Francis J. Curry TB Center Core Curriculum on Tuberculosis: What the Clinician Should Know, CDC Sheboygan County TB Event After Action Report/Improvement Plan (Preparedness PCA Portal: https://share.health.wisconsin.gov/ph/pca/preparedness) 8