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No. 3, 2011

HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS

North Carolina TB and Respiratory Disease Meeting Summary

The 61st Annual Tuberculosis and Respiratory Disease (TB/RD) Institute meeting was held in Raleigh, North Carolina, July 27-29, 2011. It is affectionately known to many as the “Black Mountain Conference,” a reference to a long history of having the conference in the mountains not far from the old Black Mountain Sanatorium outside Asheville, NC. The TB/RD Institute brings together nurses, physicians, and other allied health professionals for the purpose of providing education and training about current trends in TB treatment and management. Past programs have explored TB research, including vaccine development and genetic sequencing, new laboratory testing methods, and the threat of multidrug-resistant (MDR) TB.

Officially kicking off the conference was the Herman F. Easom Distinguished Guest Lecture. The key note speaker for this session was Dr. John Hamilton from Duke University Medical Center. Dr. Hamilton provided attendees with a timeline illustrating events and persons responsible for the development of TB research and support at Duke University. A returning favorite, Dr. Eric Brenner, steered participants through a short course entitled “Epidemiological Aspects of Tuberculosis and TB Control” in which he challenged them to think critically about how epidemiological studies inform public health practice. One of the meeting highlights was the presentation of “difficult” cases by local TB nurses and clinicians. These presentations emphasize the diversity of experience that working a TB investigation can bring to public health. This year’s presentations included a large investigation in an urban homeless shelter; a multilayered prison investigation with delayed diagnosis contributing to ongoing transmission; and MDR TB in a foreign adoptee. The presentations underscored the need for rapid, accurate diagnostics; consultation with treatment experts; and enhanced communication between all concerned parties to ensure successful outcomes.

The planning committee members from North Carolina and South Carolina, the Southeastern National TB Center, and CDC collaborated with Martha Bogdan, President and CEO of the ALA of the Southeast, and her “right-hand woman” Candy Holloway, Director of Medical Education. Without the support of ALA of the Southeast, the meeting would not have been possible. The speakers delivered wonderful information on topics including Tuberculosis in Internationally Adopted Children and Refugees, Pharmacokinetics Studies of Levofloxacin in Children Exposed to MDR TB, Radiographic Manifestations of Tuberculosis, and CDC’s DGMQ Do Not Board Process among others. The 78 attendees were from North Carolina, South Carolina, Florida, Georgia, and Puerto Rico. While budget cuts definitely had an effect on overall attendance, those able to join the meeting professed themselves very satisfied overall with the quality of the learning experience.

—Reported by Elizabeth Zeringue, RN, BSN, MPH
NC TB Control Program

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Cluster Investigation on TB Row: Field Investigations and TB-GIMS Converge in Detroit

Background
From the mid 1960s to late 2010, the Detroit TB program managed a cluster of Mycobacterium tuberculosis (M. tuberculosis) case patients and contacts with latent TB infection (LTBI) known as “TB Row.” This name was given by the Senior Public Health Nurse, who has served for many years as the case manager and field investigative historian for the TB control program. She has provided directly observed therapy (DOT), contact investigations, treatment and care, and follow-up services since 2001. During this time, the TB program has experienced many changes in field contact investigation protocols and procedures. In the past 2 years, a focus has been placed on finding missed contacts from previous field efforts. Several generations of TB cases and suspects were identified from the main cluster. In 2010 the “TB Row” cluster was identified through the Tuberculosis Genotyping Information Management System (TB-GIMS) as a high-level concern for investigation. This particular cluster yielded eight historic multidrug-resistant cases, as well as 43 drug-sensitive cases among a local family and their contacts during the period of 1998 through 2009.

Purpose of Activity
The concept of incorporating TB-GIMS data into proactive case management was the main objective for this investigation. The idea of utilizing TB-GIMS to highlight what the program did not already know about the current cases was not the only challenge. More important was the idea that TB-GIMS could help confirm what we already suspected from the field in regard to epi-links. While the epi-links could provide clues as to where to direct and focus our contact investigation in the field, this tool would help us determine how the cluster investigation would be applied. TB-GIMS and active case management would help determine the extent of continued transmission, identify risk factors, and show negative factors that prevent the completion of therapy. The most important purpose of this investigation was to identify the positive outcomes in field contact investigation work. We also wanted to investigate the level of effort required to conduct a good cluster investigations. We had to be sure not to exceed the capacity of the TB program while performing the investigations.

Description of Program and Progress
Step 1: Evaluate and review both TB-GIMS and individual medical health records for completeness and missing variables for locating contacts. Field staff used genotyping PCR or ID numbers to make a positive match for all cases within the identified cluster. We followed up to find any missing variables from each case contact roster. This would include data on first and second skin test results, starting or stopping treatment, treatment completion, and loss to follow-up. Demographic data were reviewed and verified to locate persons who could assist in our interviews, usually family and friends.

Step 2: Scrutinize common contacts found on each contact roster. This data would show any obvious epi-links between cases and add to what we already suspected with the DNA match.

Step 3: Identify contacts to all epi-linked persons via phone and/or field visit for associate interviews. Field staff solicited any information that would link additional associates, contacts, high-risk persons, family or friends – generally, anyone who would benefit from a TB skin test. The associate interviews would elicit the names and locations of persons with a history of TB. Education and training on TB signs and symptoms from the Public Health Field Nurses and Disease Intervention Specialists would help the contacts identify possible missed persons for testing.

Step 4: Perform a field tour with the contact to show staff where missed at-risk contacts reside or hang out. The field staff would also elicit any nicknames or other information that would help locate the at-risk persons.

Step 5: Provide incentives and enablers to contacts and cluster interviewees for their help in locating and providing demographic data for potential at-risk contacts. Incentives and enablers included gift cards, bus tickets, clothes, shoes, and food. And a simple “Thank you! We really appreciate your help” further ensured that the health department developed a good rapport and credibility in the community.

Step 6: Provide verbal feedback to all persons involved in the associate interview process. Maintain the standard of care for persons with TB disease and latent TB infection as recommended.

Results of Activity
The cluster investigation involved 43 persons who had active TB diagnosed during the time period of 1966-2010. Most persons were members of one extended family, their close contacts, or neighbors. Others resided in nearby homeless shelters or lived on the local area streets. Of the 43 cases, 13 were identified using traditional “gum-shoe epi”; an additional 25 cases were linked using TB-GIMS genotyping data; and 5 cases were linked by both methods.  The cluster investigation found 15 infected contacts to known TB cases that otherwise would have been missed in traditional contact investigations. All persons were evaluated for disease and symptom history, and recommended for LTBI treatment if appropriate.

The cohort of 43 patients in this cluster consisted of U.S.-born African Americans. Following are additional demographic data:

Male = 26 (60.5%)
History of homelessness = 13 (30.2%)
History of drug use = 17 (39.5%)
History of alcohol use = 19 (44.2%)
HIV infected = 10 (23.3)
Multidrug-resistant TB = 10 (23.3%)
Required court commitment to complete treatment = 5 (11%)

Lessons Learned
Transmission of tuberculosis in this cluster remained localized for many generations. Multigenerational and neighborhood transmission yielded several missed opportunities for prevention among this high-risk population. Homelessness, drug use, alcohol use, HIV infection, and male social gathering rituals appear to be overwhelming factors for the propagation of TB, not to mention high unemployment! Real-time case management, surveillance, contact investigations, and proper treatment of persons with active TB and latent infections are keys to reducing transmission. Although the overall field investigations were conducted well, the use of TB-GIMS and DNA fingerprinting did help bridge a wide gap and provides another realistic tool for TB control and prevention. The use of DOT for high-risk persons with LTBI (e.g., children, homeless, medically complicated patients, HIV-infected and other immune-compromised persons) all assist to increase completion of therapy rates and to reduce the future risk of TB disease.

Future Plans
Incorporate active surveillance, DNA genotyping data, and focused contact investigations as a daily case management plan. Develop a reproducible protocol for evaluating cluster investigations for the future. Use the resources stated to help “lessen the sting” of reduced funding and staffing woes as we become more efficient with new technologies. Continue the progress towards DOT for not only high-risk persons with LTBI, but for all contacts that start LTBI treatment. Consider the implementation of a 4-month rifampin regimen with DOT as an effective programmatic protocol for contacts with LTBI.

—Reported by Vernard D. Green, MSPH
CDC SPHA, Lansing, Michigan

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