Transcript I’M NOT HOMELESS

Dee Pritschet, TB Controller – North Dakota Department of Health
Shawn McBride, Epidemiologist – North Dakota Department of Health
Diana Boothe, Public Health Associate – Centers for Disease Control and Prevention
Alicia Lepp, Epidemiologist – North Dakota Department of Health
Kirby Kruger, Division Director – North Dakota Department of Health
Tracy Miller, State Epidemiologist – North Dakota Department of Health
Krissie Guerard, TB Program Manager – North Dakota Department of Health
June 11, 2013
IT ALL STARTED WITH A PHONE CALL
30
Number of Cases
25
20
15
10
5
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year
NORTH DAKOTA TB CASES 2000 - 2011
30
Number of Cases
25
20
15
10
5
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
NORTH DAKOTA TB CASES 2000 - 2012
North Dakota TB Cases/100,000
2000-2012
4
3.5
3
2.5
2
1.5
1
0.5
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
US
4.5
ND
4
3.5
3
2.5
2
1.5
1
0.5
0
2008
2009
2010
2011
2012
United States vs North Dakota
TB Disease Rates/100,000
16
Male
14
Female
12
10
8
6
4
2
0
2008
2009
2010
2011
2012
GENDER
ND TB CASES 2008 - 2012
16
14
Asian
American Indian
Black
White
12
# of Cases
10
8
6
4
2
0
2008
2009
2010
2011
2012
ETHNICITY
ND TB CASES 2008-2012
TIMELINE OVERVIEW
• Late October: three confirmed cases had been
identified in Grand Forks County
• November: Investigation identifies more cases
and the State Health Dept. requests Epi Aid
• December: Epi Aid team arrives
• January 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)
EPIDEMIOLOGICAL LINKS
Name-based
 One patient identifies another person by name and
reports close contact with that individual during the
patient’s infectious period (IP)
 A third party names two individuals and reports close
contact between them during one’s infectious period
and the other’s exposure period
*adapted from CDC Epi Aid Team Exit Presentation December 2012
Location-based
 Two patients known to have been present at the same
time in a location in which they could have had close
contact during one patient’s infectious period and the
other’s exposure period
INVESTIGATIVE TOOLS
Case Interview
Electronic Medical Records
Name and Photo release forms
Facebook/Social Networks
Pictures of transmission locations
Genotyping
GENOTYPING
Spoligotyping
 Identifies 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 - 224325153323
Miru2 - 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)
RESISTANCE
Why is this important?
•
Latent TB infection (LTBI) is treated with Rifampin
•
Rifampin is a 4 month treatment in adults
•
Rifampin is a 6 month treatment for children
•
Treatment for Active TB Cases is 9 months vs 6 months
•
INH 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 Surfing
PHOTO AND NAME RELEASE FORMS
Requested active cases sign an order to allow us
to use their photo and/or name in investigation
related activities
Used to verify suspected epi links
Established unknown epi links
 Linked our genotypic match from another community who was demographically
very different to the outbreak super spreader
 Extended the super spreader’s 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 release
ELECTRONIC MEDICAL RECORDS
Allowed 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 TECHNOLOGY
Problem: Large amounts of information was being
gathered, digesting and disseminating it was
challenging
 Comprehensive list of cases, contacts, and site screenings developed by Epi Aid
team and based upon data base developed by Dept. of Health
 Detailed case follow up
 Information to action
Developed Secure access portal for case follow up and
sharing of current information
 Controlled, secure access
 Limited number of editors
 Efficient communication
MAP OF NORTH DAKOTA
GENOTYPING
A 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 link
 New focus guided by genotyping established an epi link to the
super spreader
 Photo release was critical in making the link
 Established a time frame for the transmission event
 Extended IP of super spreader from previous estimates by 6
months
 Expanded investigation
CDC had this as a Minnesota case
30
Number of Cases
25
20
15
10
5
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year
NORTH DAKOTA CASES 2000 - 2013
30
25
20
Rest of ND
Grand Forks
County
15
10
5
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
TB IN NORTH DAKOTA
2002-2013
6
5
4
3
2
1
0
0-10
11-20
21-30
31-40
41-50
51-60
60+
AGES OF OUTBREAK TB CASES
North Dakota Department of Health; data as of 1/25/13
1650Tuberculin Skin Tests
(TST’s) Performed
69 LTBI’s Identified
53.7% of Named Contacts
are LTBI’s
ONGOING WORK
Continue to locate, refer, and follow cases, LTBI, and contacts
Administer directly observed therapy (DOT) to active cases
Manage social barriers to treatment compliance
 Isolation for infectious cases
 Housing
 food
 Medication and evaluation compliance
Continue investigative work
 Full genotyping
 New case identification
 Reinterviews
CHALLENGES
 Staffing – added Field Staff & Public Health
Associate
 Housing - Worked with Emergency Preparedness
& Response
 DOT Compliance – 7 day DOT
 Drug Levels – Non-Therapeutic Levels
 Indian Health Services
 Border States and Provinces
 INH Shortage
 Tubersole Shortage
PARTNERS
The important work done
and yet to do would not have
been possible without the
extraordinary efforts by
professionals from these
organizations