Possible Transmission of a New TB Strain in A

ABSTRACT 1

Possible Transmission of a New TB Strain in a

New York City Hospital Emergency Department

Jillian Knorr, MPH; Bianca R. Perri, MPH; Shama D. Ahuja, PhD, MPH;

Douglas C. Proops, MD, MPH; Jeanne Sullivan Meissner, MPH

New York City Department of Health and Mental Hygiene, New York, New York

Rationale: Since 2001, the New York City (NYC) Bureau of Tuberculosis Control (BTBC) has conducted universal genotyping to better understand tuberculosis (TB) transmission. In 2012, BTBC identified a new strain of TB in NYC and conducted an outbreak investigation.

Methods: BTBC defines a genotype cluster as two or more TB patients who have isolates with matching genotypes (spoligotype and IS6110-based restriction fragment length polymorphism results). Clusters are routinely investigated to establish epidemiologic links between patients and identify possible sites of TB transmission. This investigation entailed data collection, medical chart review, and patient re-interview.

Results: From January 2010 to May 2012, four patients with matching TB genotypes were identified. All were United States (US)-born, non-Hispanic black males between the ages of 52 and 56. Three patients had pulmonary disease. Two patients had a history of homelessness and three had a history of substance abuse. Patient A was evaluated for TB in 2010 while incarcerated but was released before TB culture confirmation and treatment initiation. He was found one year later but died without starting TB treatment. Three patients were diagnosed from March to May 2012. Patients did not name each other during contact investigation or re-interview. During the outbreak investigation, BTBC learned that Patient A and another cluster patient frequently visited a NYC hospital emergency department (ED) for medical care, including treatment for alcohol withdrawal. Patient A had multiple ED visits during the year that he was lost and infectious, two of which overlapped with the other patient’s ED visits. Both patients and a third cluster patient also spent considerable time in the same two-block area during several years before TB diagnosis.

Conclusions: Strong epidemiologic links among these US-born patients indicate recent transmission in NYC of a new TB strain. Homelessness and substance abuse are known TB risk factors, and EDs are frequently a source of care for individuals with these risk factors. While transmission of this strain in the ED is not definitive, this investigation highlights the need for providers to be vigilant for TB, particularly in recurrent ED patients or patients with TB risk factors.

ABSTRACT 2

Changes in the TB Care System during the Economic

Downturn in Washington State 2009 – 2013

S. Carlson; S. Allen; S. Lindquist

Washington State Department of Health

Objective: To examine how capacity for TB care within Washington State local health jurisdictions (LHJs) has changed at a time when public health resources are decreasing.

Method: In 2009, a survey was sent to the 35 local health jurisdictions (LHJs) in Washington State to determine the current capacity that was being utilized in caring for tuberculosis in their community. In 2013, a slightly revised version of the same survey was sent to the same LHJs. The surveys were then compared to see how capacity for TB care in public health has in Washington State changed over the past 4 years.

Results and Findings: The 2009 survey received an 83% response rate from LHJs, compared to 70% in 2013. Of those who responded, in 2009 95% of Washington State’s population was represented, while 2013 yielded a 90% representation. Some of the significant findings from the survey include: Nursing staff dedicated to TB decreased 44% from 2009 to 2013; In 2013, 83% of LHJs shared their TB program staff with other programs within the LHJ; LHJs referring patients to community health centers for LTBI care increased 37% from 2009 to 2013; IGRAs are more commonly used in foreign-born and those who have BCG than in 2009. Limited resources are being focused on mainly: management of pulmonary disease, MDR, DOT for smear positive pulmonary cases and LTBI testing of contacts to active cases. Cost and reimbursement for IGRAs remain a problem. There are a lack of isolation resources for active TB cases. There remains a need for provider oversight of patients with both LTBI and TB disease at the LHJ level that includes: examination of each patient, standing orders, and protocols for dealing with adverse events.

Conclusions: The information gathered from this survey is shared with our Local Health Officers in each of the LHJs. The intention is for the LHJs to be aware of what the trends in TB care are in Washington, how their organization compares to what is being done around the State and how it has changed over the past few years. At the State level, we intend to take the information gathered from the survey to focus education efforts around issues LHJs are experiencing in their work to eliminate TB within their communities.

ABSTRACT 3

Increasing Treatment Completion of LTBI in High-Risk International University Students

Sue Madeja, RN, MSN; Amy Anderson, RN, BS-N

Bethlehem Health Bureau

Medication compliance and regimen completion are common issues for latent tuberculosis (TB) treatment in patients. Latent tuberculosis infection (LTBI) requires 9 months of isoniazid (INH) and the one most commonly used by local TB clinics for LTBI treatment. New CDC approved treatment regimens are of significantly shorter duration, making treatment initiation more successful and treatment completion more possible. A better solution was needed, and with the 2011 CDC approval of a 12-week INH/rifapentine regimen, another treatment option for this group of patients existed that could increase treatment compliance and completion rates.

Conversations were held between the state and local health departments and university staff, a catalyst for discussions about implementation of the new 12- week regimen for university students. Meetings in 2012 with the state department of health, TB program, local health department nursing staff and the university health center began. It was decided that the new university students would have two voluntary options: the new CDC approved 12 week regimen and the traditional 9 month regimen resulting in better completion rates. The new treatment regimen had a slightly more successful completion rate but a higher initiation rate meaning more high-risk students completed treatment. Satisfaction with the new regimen was positive for most students. All students in 2012 chose the new CDC approved 12- week regimen despite the requirement for weekly appointments for directly observed therapy. Completion of LTBI treatment is an important goal for this high-risk population ensuring a reduction in TB disease in these individuals.

ABSTRACT 4

TB Screening in Oregon Healthcare Workers: Coming to Consensus

Heidi Behm, RN, MPH TB Control, Oregon Health Authority; Stephanie Ryan, MPH Oregon Health and Science University; Lindsey Lane, MPH TB Control, Oregon Health Authority; Trung Vu, Oregon Health and Science University; Kevin Winthrop, Oregon Health and Science University

TB Control, Oregon Health Authority (TBOHA) has received an increasing number of calls over the past few years from health care facilities regarding implementation of TB testing programs for health care workers (HCWs) and the interpretation of individual employee TB test results. Despite the high volume of phone calls, TBOHA did not have complete information on who facilities were testing or how TB testing was being conducted.

To learn more, a 29 question survey was emailed to employee health and infection control programs at hospitals, clinics and long term care facilities. 56 individuals responded. 83.9% (47) were from inpatient settings, 48.2% (27) outpatient settings and 10.7% (6) other settings. The number of beds per facility ranged from 19‐554 with a good representation of large and small as well as rural and urban facilities. Most (53) of the reporting facilities stated they are in a low risk classification for TB and accordingly only 5.8% (3) still test employees annually.

100% (54) of respondents screen new employees for TB upon hire with 58.5% (31) utilizing a risk factor questionnaire with baseline screening. For baseline screening, 59 % (31) use a TB skin test (TST), 32% (17) QuantiFERON, and 0% T‐SPOT. 15% (8) reported using both TST and QuantiFERON for baseline screening. In the comments sections, a number of respondents expressed concern regarding false positive tests with QuantiFERON and confusion on how IGRAs may best be utilized.

Accepting tests from other facilities was another area where practices varied. 90% (45) of respondents stated their facility accepts prior negative TB screening results from other facilities and negative chest x-ray results, but the age of the results acceptable varied greatly among respondents. Comments also indicated confusion about testing requirements for groups such as contractors, vendors and credentialed non employees.

After results were tabulated and disseminated, 5 stakeholder group meetings were commenced to discuss key areas of discordance in practice among facilities as found in the survey. A set of guidelines addressing these specific areas were developed which are unique to Oregon that reflect the survey findings and the concerns of the stakeholder groups.

ABSTRACT 5

Implications of Decreased Funding for Domestic TB Programs: NTCA Survey Findings

S Burkholder1, S Saephan2, J Kanouse3, J Flood2, M Lobato4, M Burgos5, J Warkentin3, 6, D Nilsen7, J Rodman8, K Farrell9

1Indiana State Department of Health, TB/ Refugee Health Division, Indianapolis, IN; 2California Department of Public Health, Center for Infectious Diseases, Division of Communicable Disease Control, Tuberculosis Control Branch, Richmond, CA; 3National Tuberculosis Controllers Association, Atlanta, GA; 4 Division of TB Elimination, Centers for Disease Control and Prevention, Hartford, CT; 5University of New Mexico, Department of Internal Medicine; TB Program, New Mexico Department of Health; 6 Tennessee Department of Health, TB Elimination Program; 7NewYork City Department of Health and Mental Hygiene, Bureau of TB Control, Queens, NY; 8Delaware’s Division of Public Health TB Elimination Program, Dover, DE; 9TB Control Section, Bureau of Communicable Diseases, Division of Disease Control & Health Protection Department of Health, Delray Beach, FL.

Background: To describe capacity changes of TB programs across the nation since 2009, the National TB Controllers Association (NTCA) conducted a survey of state and local public health TB program staff in January 2013. The survey measured changes in staffing, funding, TB cases, program capacity, services, and patient outcomes.

Methods: An electronic survey was distributed to TB Controllers of all 50 states. A snowball sampling method was used to further distribute the survey to jurisdictions within each state.

Results: A total of 277 survey responses were collected. Respondents included all 50 states, 23 regions, 187 counties, and 17 cities including 9 federally-funded cities.

Since 2009, 57% (27 of 47) of states reported decreased budgets and decreased staffing. Among federally funded cities, 100% (7 of 7) had decreased budgets as well as decreased staffing. Of the 27 states with deceased budgets, 17 (63%) experienced increases in TB cases at any time during the 2010-2012 year-period. Seventy-nine percent (34 of 43) of states reported an increase in the proportion of complex cases (i.e., homelessness, HIV infection, diabetes, drug resistance, substance abuse, refugee, and non-English speaking).

Nearly 20% (7 of 38) of states reported decreased ability to provide directly observed therapy (DOT) to pulmonary TB patients while 46% (15 of 33) had a decreased ability to provide DOT to high-risk patients with latent TB infection. One-third (14 of 42) of states reported decreased capacity to conduct contact investigations; approximately 27% (12 of 45) of states reported decreased capacity to perform outbreak investigations. Thirty responses described sub-optimal care by private providers leading to one or more of the following patient outcomes: delays in diagnosis, misdiagnosis, ongoing TB transmission, ineffective treatment, outbreaks, and death.

Conclusion: The majority of U.S. TB programs have experienced a decrease in TB control resources since 2009. Reduced resources and staffing, coupled with increases in complex cases, has put a strain on TB programs across the nation. The impact of these reductions has resulted in reduced capacity for important interventions such as contact investigations.

ABSTRACT 6

Can New York City Meet the National Target for TB Treatment Completion by 2015?

Darlene Bhavnani, PhD, MPH1,2; Nicola Lancki, MPH1,2; Iris Winter2; Michelle Macaraig, DrPH, MPH2

1Centers for Disease Control and Prevention (CDC), Council for State and Territorial Epidemiologists, Applied Epidemiology Fellowship

2New York City (NYC) Department of Health and Mental Hygiene (DOHMH) Bureau of Tuberculosis Control, New York, NY, USA

Background: One of the national TB program indicators established by the CDC is treatment completion within 12 months for 93% of eligible patients by 2015.

Objective: To examine treatment completion among TB patients in NYC.

Methods: We reviewed TB cases counted in NYC between January 2009 and June 2010. Patients were excluded if they failed to start treatment, died before diagnosis or during treatment, had meningeal TB or a rifampin resistant strain, or were <14 years old with disseminated TB per CDC recommendations. Patient treatment outcomes were categorized as completed treatment in ≤12 months (timely completion), completed treatment after 12 months (delayed completion) or incomplete treatment. Patients with timely completion were compared to patients with delayed completion and incomplete treatment. Poisson regression with robust error variance was used to measure adjusted risk ratios (aRR) for dichotomous outcomes.

Results: Timely treatment completion occurred in 91% (921/1008) of eligible patients, while 5% (48/1008) had delayed treatment, and 4% (39/1008) had incomplete treatment. Of 804 patients with timely completion and known provider, 477 (59%) were treated by a DOHMH-provider. Compared to patients with timely completion, patients with delayed completion were less likely to have a DOHMH-provider (aRR: 0.5, 95%CI 0.3-0.9), and more likely to have extra-pulmonary TB only (aRR: 2.3, 95%CI 1.1-4.9), history of TB disease (aRR: 4.5, 95%CI 1.8-11.4), non-rifampin drug resistant TB (aRR: 4.5, 95%CI 1.4-15.0), and multiple hospitalizations (aRR: 1.1, 95%CI 1.0-1.2). Seventy-nine percent (723/921) of patients with timely completion were on directly observed therapy (DOT). Compared to patients with timely completion, patients with incomplete treatment were less likely to be on DOT (aRR: 0.4, 95%CI 0.2-0.8) and more likely to have extra-pulmonary TB only (aRR: 3.0, 95%CI 1.5-6.2). Nearly half (40/87) of all patients with delayed completion or incomplete treatment were explained by patient refusal to continue treatment.

Conclusions: In NYC, timely TB treatment completion is high. However, increased efforts to enroll patients on DOT and educate patients on the importance of treatment adherence, particularly those managed by non-DOHMH providers, are needed to achieve the national target.