Transcript MTB OUTBREAK

MTB OUTBREAK
LOCAL LAB RESPONSE
Chris Partington MT(ASCP)
ACL MICROBIOLOGY LAB
LOCAL LAB RESPONSE
 ACL first specimens from outbreak:
04/20,21/2013 Sputums from daughter of index case
Ordered for AFB culture/smear and MTD
Both smear neg.
One specimen MTD neg, one MTD pos.
ACL unaware of “outbreak”, multiple contacts, relationship to index case.
All the index case’s children have a different last name than the mother.
Also unaware of probable resistant strain involved.
 Five more specimens from 3 patients arrive in the next 4 days.
All have the same last name, all children, all ordered for AFB culture/smear
and MTD.
At this point we have questions. We are informed by Sheboygan Public
Health and WSLH that this is a possible outbreak situation.
 ACL sends specimens (after decontamination and culture/smear performance)
directly to WSLH for TB PCR testing due to the high MTD workload.
 After the first week of May 2013:
The numbers of exposures, contacts and testing were exponentially
increasing so we made the next change in protocol: Sheboygan Hospital
would now send any samples related to the outbreak directly to WSLH.
 We at ACL kept all work cards, communications, history/physicals and reports
in a separate labeled folder for reference.
 We were in almost daily communication with WSLH TB Lab, Sheboygan Public
Health and Dr. Poursina (Infectious Disease) coordinating patients, specimens
and tests.
 We are still actively involved in all aspects because we have open accessions
from the “in-house” cultures.
MISTAKES MADE / PROBLEMS ENCOUNTERED
 Outbreak?! What outbreak?
We had no clue that we were dealing with a possible outbreak; we were just seeing more
than the usual orders for MTD. There were a few specimens with the same last name but
it is a common one and we didn’t know the patients were related. No one alerted us to
the possibility until we made some investigation.
 Sure, we can handle that! No problem!
We started with just a few specimens so we did it all: culture/smear and MTD. We were
doing MTD’s daily which threw out our routine. We changed protocol a number of times:
1) Did all orders in–house
2) Did cultures/smears only and sent processed specimen to WSLH for TB PCR
3) Received specimen at our lab, then sent on to WSLH via our courier for all tests
4) Instructed Sheboygan lab to send all specimens directly to WSLH for testing
This resulted in vast confusion: what tests are ours to result? how do we bill? who is
getting the reports?
 Is it Racial Profiling or Cultural Understanding?
Most of the offspring of the Index Case (“CM”) have a different last name from their mother.
We did not know who was considered an “outbreak” contact and who was excluded. We
received a tentative list of names from WSLH. We placed this list on the board in our
specimen receiving area. We did not want these specimens manipulated outside of the TB
room due to the MDR-TB designation. After a number of patient specimens came that
were “outbreak” related but not on the list, we decided to consider all Hmong names from
Sheboygan suspect.
We learned surnames are not necessarily shared between families in the Hmong
community. We learned a lot!
 Unnecessary testing encountered.
We had to watch the orders carefully. The children underwent bronchoscopies to obtain
suitable specimens. The orders should have been for AFB cultures only but the specimens
came with the “usual” bronch menu: AFB culture/smear, Fungus culture/smear, Routine
culture/gram, pneumocystis testing. Why would they order a pneumocystis on a 14 yr.old?
The explanation when questioned was that the pulmonologist just ordered his routine
testing protocol!
WHAT WE’LL DO NEXT TIME (NEXT TIME?!)
 Communication
If possible set up more communication with key players:
-Client (hospital Infection Control, outside lab personnel,
clinic, etc.)
-Public Heath
-WSLH TB lab
-appropriate Infectious Disease doc
-our own Micro personnel
 Education
Have in-services with the Micro personnel about tuberculosis, outbreak situations,
MDR-TB, the importance of carefully reviewing each specimen-name and test order.
Urge personnel to investigate questionable orders, names, etc. and communicate with
TB techs.
 Diligence/Assertiveness/Demanding(?)
Make sure everyone is doing their part. Don’t let the lab be the forgotten spoke of the
wheel. Ask to be included on all communication. Keep your personnel informed.
 Be mindful that specimens will keep coming for months (or years) for follow-up testing.
ACKNOWLEGEMENTS
Julie Tans-Kersten
WSLH TB Lab
Sandy Musegades
Sheboygan Public Health Dept.
Dr. Arash Poursina
Infectious Disease
Teri Hosterman
Sheboygan Memorial Infection Control
Nancy Kapellen
SMMC Lab Supervisor
Fetije Shabanoski
ACL Microbiology Supervisor