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TB Notes Newsletter

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No. 2, 2011


Using Components of the National Incident Management System (NIMS) Command Structure in TB Testing in Congregate Settings

The National Incident Management System (NIMS) Command Structure operates under specific concepts and principles. Using  components of NIMS can be of value to programs that are looking for a method for preparing for TB testing events that may require coordination with multiple jurisdictions, different agencies, existing and volunteer personnel, and financial arrangements or resource requests from one or more levels of government or community agencies. For the purpose of TB mass testing in this congregate setting, adapting some components of the NIMS command structure has been shown to be helpful.

In January 2010, a TB outbreak developed in a shelter in rural northwest Illinois. The origin of the TB outbreak is believed to have been traced back to April 2007 to a homeless shelter client who was diagnosed and treated for TB. However, only limited testing and treatment was offered to other contacts at the shelter. In October 2009 and January 2010, two clients living in the same homeless shelter were identified as having TB. The genotype pattern matched the 2007 case. Thereafter, 17 TB genotype-matched cases were identified through August 2010.

The TB clinic in the county health department where the shelter is located normally provides treatment for 15-20 TB cases a year for the entire county. The TB clinic normally is open 2 days a week and the doctor is only present for one half-day session.

As this TB outbreak continued to grow, it was decided that all the clients and staff of the shelter should be given TB tests during May 2010. To make this happen it was apparent that additional resources would be needed. County and state officials concluded that it would require resources from different sections of the County Health Department, along with requests for government assistance at the local, state, and federal levels to thoroughly address the outbreak. In addition, conducting such a large TB testing event would require staff beyond the TB department, including volunteer workers from the community (i.e., hospitals, health agencies, etc.).

The National Incident Management System (NIMS) structure identifies specific roles and responsibilities in response to an event. The elements of the NIMS command structure used during this event included five components. At the top was the Unified Command, consisting of the county health department lead, the state health department representative, and the director of the shelter. Lateral to the Unified Command was a Safety Officer, a Public Information Officer, and a Liaison Officer (coordinating with local, state, and other government officials).The planning team held many meetings (some at the shelter) to ensure everyone was fully informed and each section was progressing in their preparation for the upcoming event. The Public Information Officer was an active member of the team and was kept abreast of the current status of the TB outbreak as the numbers grew. This was helpful in that he was able to modify his statements to the press with the most up-to-date information.

The Operations Chief. For this event, the Operation Chief’s role was to oversee three main groups, the Nonmedical Group, the Medical Group, and the Medical Testing Group.

The Planning Chief. The Planning Chief worked for a different section in the health department, but because of a TB staff shortage was allowed to serve in this role before and after the event. The Planning Chief identified and acquired needed supplies, personnel, and contractors/vendors (i.e., for x-rays).

The Logistics Chief was on loan to the TB department from a different health department section as well. His role was to work closely with the Planning Chief in acquiring supplies, and in moving and setting up personnel, equipment, communications, and on-site supply and meal stations. This event testing site required set-up of nine tents, with tables and chairs, for registration and testing (sputum, QuantiFERON [QFT], diabetes [A1C], and HIV). Indoor testing supplies consisted of four portable chest x-ray units, an incentive table (McDonald’s coupons), and an exit table. At the end of the event, the Logistics Chief ensured transportation of QFT specimens to the lab and the return of personnel and all material back to the health department.

The Financial/Administration Chief. This activity was conducted through the existing accounting office. The Unified Command developed and managed the budget during this event.

A master checklist of supplies was developed weeks before the event. On the day before the event, a final confirmation of supplies and personnel was made and a 20-foot truck was rented and loaded. Local hospital emergency room directors, emergency medical service (EMS) staff, and police were notified of the event.

The set-up team arrived at the shelter site at 6:00 am. All tents, chairs, and supplies were in place by 6:30 am. The x-ray team members arrived at 6:30 am, and were ready by 7:00 am. The event started with a mass in-service training held in the cafeteria just after breakfast. It was stated that anyone who felt sick should see one of the nurses now before proceeding through the testing. Fortunately, everyone was fine that day. For testing, clients were first directed to a registration area. Here the client’s name was checked off a master shelter list, asked for demographic information, and given the forms needed for all testing that day.

Sputum was collected at the next station. The client was instructed to walk to the nearby fence and bring back a sputum specimen. The blood-draw was the next station for QFT and A1C (diabetes). Once the client completed all the stations, he or she was then given incentives (fast food coupon, and a choice of a personal item such as sunglasses or flip-flops) that were donated for the event. Over 300 clients were processed between 7 am and 5 pm.

NIMS structure oversight benefit during the event
To ensure that everything was running smoothly, or to address any problems as they occurred, the Chiefs met every 2 hours, or more often as needed, in the Unified Command tent throughout the day. For example, the lead person for the Medical Group noticed that the temperature was getting hot where some of the phlebotomists were sitting and made a request to the Operations Chief for assistance. The Operations Chief went to the Unified Command, and a meeting was quickly set up with the other Chiefs to discuss this matter. The shelter director provided two large fans for use in the phlebotomy area. The Safety Officer ensured the orange extension cords were put down and covered with duct tape so no one would trip. In addition, more frequent breaks for staff were discussed and scheduled. A cooling station/rest area was also designated in the First Aid tent.

At the end of the day, the logistics team, along with other health department staff, broke down all the stations, helped to load the truck, and left the site by 5:30 pm.

The following week an after-action review, or “Hot Wash,” was conducted. During the Hot Wash, all the participants of the event who could attend the meeting were asked for their suggestions for improvement if another event took place in the future. Many good suggestions were offered and were recorded by the Logistics Chief on a board.

Lessons Learned
There seemed to be good value in using the NIMS structure for this event. First, the existing infrastructure was not equipped with the necessary personnel, supplies, and financial resources to address this type of large-scale TB screening. The NIMS structure enabled the chiefs and their teams to plan and identify what resources were needed, and then meet with local government, community, state, and federal contacts for requests for assistance.

Second, the NIMS structure provided a template that equipped everyone with knowledge of their role during the event. The NIMS structure also clarified who participants could seek assistance from in case they needed help.  The personnel flow charts were developed for the first shift (morning) and second shift. I would strongly recommend developing and using a personnel flowchart for any program planning a similar event. It was extremely helpful.

Third, the long days of planning and management for events of this caliber can be very taxing on personnel. The NIMS structure provided a constant that permitted participants the ability to focus and execute despite the surrounding confusion and chaos.

On my return to Houston, I brought back this NIMS model and discussed it with the TB staff for use during some of our large shelter testing events. In September 2010, the Houston TB Program conducted a 4-day QFT testing event at a shelter using the NIMS structure. During this event, some personnel in the TB department performed duties and reported to individuals other than their normal supervisors. The TB Program developed and used a much-appreciated NIMS-style personnel flowchart. In addition, a template description of the transportation of personnel and QFT supplies/specimens to and from the lab was executed according to plan.

The director and the shift manager of the shelter were included in the unified command. Frequent communication between the commanders helped clarify if clients were still living in the shelter or the likelihood that they would return, as well as changes in set-up and storage of supplies and planning for the next day of testing.

Importantly, we asked for two director-approved shelter helpers to assist in finding clients throughout the shelter and guide them to the testing area. Some of the clients were found in their bunks or were just coming in the door from work. This made locating the clients much easier. Finally, the Houston TB program developed a future event-ready inventory system to store supplies in specific color-coded carrying cases. The testing went well, and the TB program plans to continue using the NIMS structure for applicable future events.

Using components of NIMS can be of value to programs looking for a method of preparing for TB events that may require coordination with multiple jurisdictions, different agencies, existing and volunteer personnel, and financial arrangements or resource assistance with one or more levels of government or community agencies.

Kudos to Mike Arbisi, TB Program Manager, Illinois Department of Public Health; Paul Kuehnert, Executive Director; and Claire Dobbins, Director, Health Protection Division, Kane County Health Department, as the principal architects of the design and adaptation of the NIMS command structure for the Illinois shelter mass testing event.

In addition, special thanks and acknowledgement to the staff at the Kane County Health Department and Illinois Department of Public Health for their extraordinary effort in the successful planning and response for this large shelter TB outbreak.

—Submitted by Ted Misselbeck
DTBE Public Health Advisor, Houston, Texas

New Mexico TB Control Program Collaborates with Navajo Nation and IHS in TB Education Campaign

The New Mexico (NM) Department of Health TB Program identified a high rate of TB-related mortality (13%-23%) during 2007–2009.  Dr. Burgos, the TB Medical Director, and the TB program staff conducted a retrospective study to identify the causes of death and missed opportunities in diagnosis and treatment of TB. It was determined that 68% of the deaths were due to TB-associated disease. The two prominent factors in the study were clinician delay in diagnosis and patient delay in seeking treatment for TB-related symptoms.  The primary groups of people affected by TB mortality were the Navajo population and Hispanics born in Mexico.

As a result of these alarming statistics, the NM TB program has collaborated with the Navajo Nation (NN) and Indian Health Services (IHS) on many projects to educate the general population within the NN of the signs and symptoms of TB disease and where they can receive treatment. A major educational campaign was undertaken within the NN to address these issues. (See previous issue of TB Notes for a related story.)  Recently two billboards were placed within the NN (at Gallup and Farmington) to reach out to the public about TB.

 Have you noticed a chanfge in your... Harmony? Breath? Energy? IT MAY BE TB 505-722-1589

There are plans to place a similar ad in the movie theater in Gallup to further inform about the signs and symptoms of TB.  It is hoped that increased awareness of the signs and symptoms of TB will encourage individuals to seek timely medical assistance. 

An important TB/HIV educational conference is held in this region each year in October, the TB/HIV Four Corners Conference.  This year, New Mexico will host the conference. The 17th Annual TB/HIV Four Corners Conference will provide TB and HIV education to clinicians and nurses in the four-state area (New Mexico, Arizona, Utah, and Colorado) and in the NN.  By providing TB-specific education, it is hoped that clinicians will consider TB in their differential diagnosis.

The NM TB program is also collaborating with the NM Office of Border Health to begin a similar educational effort in the southern part of New Mexico. On November 15–16, 2011, a binational TB conference, “UNIDOS: Managing Tuberculosis and its Co-morbidities along the U.S.-Mexico Border Region,” will be held in Las Cruces, NM, to address the TB educational interests of Mexican and U.S. clinicians in the border region.

Through these concerted efforts across New Mexico, the TB program hopes to see an increase in the number of TB cases that are successfully diagnosed and treated and ultimately a decrease in TB mortality.

—Diana Fortune RN, BSN
TB Nurse Consultant
Acting New Mexico TB Program Manager

Contact Investigation Among Liberian Refugees in Greensboro, North Carolina

In March 2010, an extensive contact investigation among a group of Liberian refugees in Greensboro, North Carolina, began with a call to Tuberculosis Control at the Guilford County Department of Public Health from a representative of the inpatient pediatric unit at University of North Carolina Hospitals.  We were informed that they were caring for a 7-month-old infant who had been referred from our community hospital. After 4 or 5 months of intermittent fever, heavy sweating, and cough, the child’s chest x-ray showed that his left lung was nearly opacified by consolidation and infiltrate. “Philip” had a positive TB skin test, and both bronchial washings and gastric aspirates were positive for acid fast bacillus.  PCR was positive for Mycobacterium tuberculosis, and he had been started on standard four-drug therapy for pulmonary tuberculosis.  The child had been born in the U.S., but his mother was a refugee from Liberia; his father, who did not live with the family, was from Sierra Leone. 

We began an immediate search to locate the source of Philip’s exposure and infection.  The father had a history of a prior positive TB skin test, but had completed treatment for latent TB infection; his chest x-ray showed that his lungs were clear, and he was asymptomatic.  The child lived in a household of nine people—himself, his mother, grandmother, aunt, and five cousins.  All those who had come as refugees had had negative TB skin tests on arrival to the U.S. in 2004, but now all were skin test positive.  The three adults and four of the children had negative chest x-rays and were asymptomatic.  A 2-year-old cousin had a cough and infiltrates and was also started on four-drug directly observed therapy (DOT) for tuberculosis; the other family members began preventive therapy for latent TB infection.  Since children themselves are almost never infectious but are infected by untreated adults, it was clear that every member of the household had had close and prolonged contact to an adult with infectious pulmonary tuberculosis.  The challenge was to identify that source case and stop the contagion. 

Many of the Liberian families that became a part of this contact investigation are headed by women who fled repeatedly from the violence, terror, and deprivation of civil war in Liberia.  Resettled in Greensboro, they are mutually supportive and protective; they are reluctant to share information that they believe should be kept in the family.  Coming from a country with a 75 percent illiteracy rate, few of the older women are able to read or write, and they have little understanding of the western concept of disease (“In Liberia, you cough, you die”). In addition, their Liberian English is difficult to understand for the unpracticed ear, and they, in turn, have difficulty understanding standard American English. 

Initially, the mother, aunt, and grandmother were reluctant to name people who were regular visitors to their home.  Instead, they would invite people just to show up when the nurse was there daily to medicate the children, making it necessary to be prepared to do skin testing and arrange chest x-rays at every visit.  Fortunately, the young woman who became identified as the source case was discovered in the first week. 

“Jennie” was 20, pregnant, and essentially homeless, living for periods with various friends and family.  Her sputum was strongly positive for acid fast bacillus making her highly infectious, so we arranged to isolate her in a motel room near the Health Department.  Sullen and uncommunicative, Jennie initially offered little information about contacts.  However, as trust built, members of the community were more forthcoming.  Ten separate Liberian households were tested.  A third child with pulmonary TB was uncovered by the Alamance County Health Department after it was discovered that Jennie had been a repeated visitor to the child’s home in Burlington.  In all, 89 people were evaluated for possible exposure to tuberculosis.  That number included contacts at Jennie’s African church plus social workers, counselors, and lawyers who participated in custody negotiations regarding Jennie’s two children, the foster family caring for her year-old son, and the teachers and other infants in Philip’s daycare nursery. 

The complete investigation yielded four cases of active TB and 31 newly identified cases of latent tuberculosis infection.  Twenty-nine people were started on isoniazid as chemoprophylaxis.  Philip completed 6 months of DOT and is now an active, robust toddler.  He gained 11 pounds and his grandmother refers to the TB drugs as his “eating medicine.”  Jennie gave birth to a healthy baby girl and completed 9 months of treatment.  Over the course of treatment, she bonded with her caregivers and became helpful in the investigation.

—Reported by Betty Rogers, RN
TB Control, Guilford County (NC) Department of Public Health

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