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I AM N
OT HOMELE
SS
CS
TE
JU
NE
20
13
Dee 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 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
MDDR
Mol
ecula
r Det
ectio
n of D
rug
Resis
tance
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110
5
10
15
20
25
30
Year
Num
ber o
f Cas
es
NORTH DAKOTA TB CASES 2000 - 2011
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120
5
10
15
20
25
30N
umbe
r of C
ases
NORTH DAKOTA TB CASES 2000 - 2012
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120
0.5
1
1.5
2
2.5
3
3.5
4
North Dakota TB Cases/100,0002000-2012
2008 2009 2010 2011 20120
0.5
1
1.5
2
2.5
3
3.5
4
4.5 US ND
United States vs North Dakota
TB Disease Rates/100,000
GENDER ND TB CASES 2008 -
2012
2008 2009 2010 2011 20120
2
4
6
8
10
12
14
16
Male Female
ETHNICITYND TB CASES 2008-
2012
2008 2009 2010 2011 20120
2
4
6
8
10
12
14
16Asian American Indian Black White
# o
f C
ases
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 LINKSName-basedOne 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-basedTwo 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 TOOLSCase Interview
Electronic Medical Records
Name and Photo release forms
Facebook/Social Networks
Pictures of transmission locations
Genotyping
GENOTYPINGSpoligotyping 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 - 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) 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 FORMSRequested 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 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 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
GENOTYPINGA 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
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130
5
10
15
20
25
30
Year
Num
ber o
f Cas
es
NORTH DAKOTA CASES 2000 - 2013
TB IN NORTH DAKOTA
2002-2013
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130
5
10
15
20
25
30
Rest of ND
Grand Forks County
AGES OF OUTBREAK TB CASES
0-10 11-20 21-30 31-40 41-50 51-60 60+0
1
2
3
4
5
6
North Dakota Department of Health; data as of 1/25/13
SCREENIN
G
1650Tuberculin Skin Tests (TST’s) Performed
69 LTBI’s Identified
53.7% of Named Contacts are LTBI’s
ONGOING WORKContinue 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
PARTNERSThe important work done and yet to do would not have been possible without the extraordinary efforts by professionals from these organizations