Tuberculosis Outbreak

Responding to a Community Tuberculosis Outbreak: Public Health Nursing Interventions Debbie Swanson, RN, BSNGraduate Student, University of North Dakota November 4, 2013American Public Health Association Annual Meeting

Disclosure During the past 12 months I have had no financial, professional or personal relationships that might potentially bias and/or impact content of this educational session. Presentation Objectives At the end of the presentation, the learner will be able to: Describe social determinants that contribute to tuberculosis (TB). Identify public health interventions utilized by public health nurses to manage a local TB outbreak in the context of the Public Health Intervention Wheel. Discuss challenges to the successful treatment of TB in specific populations. TB Disease/ Active TB Mycobacteria multiply causing signs and symptoms of illness. Symptoms include night sweats, fever, weight loss, prolonged cough, and hemoptysis. Transmission potential varies greatly among individuals with active disease.Diagnostic tools include chest x-ray, blood testing, sputum tests, CT, bronchoscopy, lung biopsy. Treated with four front line medications and daily observed therapy (DOT). Latent TB Infection (LTBI) The individuals immune system is able to suppress the mycobacteria and small numbers become dormant. Activation of latent infection for most cases occurs within the first two years following exposure. Activation is impacted by other health factors Detected most often by TB skin test (TST). Treated with preventive therapy. Treatment for TB and LTBI TB disease - Treatment with four drug regimen isoniazid, (INH), rifampin (RIF), pyrazinamide (PZA) and ethambutol (EMB) Length of treatment may vary depending on clinical situationLatent TB infection treated with INH and B6 Current outbreak strain has low level resistance to INH so rifampin is indicated for LTBI Unexpected challenges nationwide shortage of medications and Tubersol used for testing Patients need frequent monitoring for side effects of medication and therapeutic effect

Social Risk Factors and TB TransmissionTransmission is affected by: Infectiousness of patient Environmental conditions Duration of exposure Exposure risks include:Low-income, medically underserved groupsChildren under age 5 exposed to high risk adultsCongregate settings, correctional institutions Immunosuppression

Transmission occurs when a person has prolonged (>2hrs) close contact with an infectious case of tuberculosis. Droplets expelled forcefully by coughing from an infectious person enter the lungs and can cause infection.

Transmission does not occur through casual contact such as the sharing of items, utensils, or cups. Children generally do not transmit TB. Individuals with latent infection cannot transmit disease.

7TB Outbreak Timeline 2010 2013 2010: two cases confirmed in Grand Forks in homeless individuals not living in a shelter.Early 2012: three confirmed cases identified and successfully treated with directly observed therapy. October November 2012: investigation identified more cases and the ND Dept. of Health requested visit from CDC Epi Aid Team.December 2012: CDC Epi Aid team arrives and spends three weeks on investigation. January April, 2013: total case count increases to 25, contact investigation continues, more visits by CDC advisors.

The initial cases did not have extensive contact investigation and reported very few contacts. The CDC Epi Aid team was able to link the early and late 2012 cases through interviews and later through genotyping. 8TB Outbreak TimelineMarch, 2013: therapeutic drug monitoring begun on outpatients. April September, 2013: one additional pediatric case identified, emphasis on case management and treatment of TB cases and LTBI cases. September, 2013: third CDC public health associate arrived to provide technical assistance and expertise. October, 2013: continuing to locate contacts needing testing and conducting follow up with LTBI cases.

Therapeutic drug monitoring had never been utilized at Grand Forks Public Health Dept. or ND Dept. of Health in the outpatient setting to determine effectiveness or length of treatment. The requirement to provide DOT 7 days per week was in response to the poor compliance by some clients and this proved to be very resource intensive. The visit by CDC associates was instrumental in providing education to staff, 9TB by the Numbers 26 TB cases includes both culture confirmed and clinical cases 8 pediatric cases ranging from 5 months 13 years at time of diagnosis 56 % male 44 % female84% American Indian, 12 % White, 4% Hispanic 9 cases completed treatment as of 10/15/2013

70 latent TB infections (LTBI) identified

1,800 individuals screened with TB skin testing

A large percentage of cases are treated for one year or more due to IHN resistant strain and irregular compliance with treatment. American Indians are largely over represented in the TB outbreak representing 84 % of cases yet American Indians represent less than 5% of total population in Grand Forks County. 10

Sample of results of contact investigation in the Grand Forks, ND TB outbreak. The complexity of the close social network provided challenges for the public health nurses involved. Social determinants in the affected population included poverty, unstable housing, drug and alcohol addiction, child abuse and neglect and their associated legal issues. 11North Dakota TB cases 2000 2012

ND Dept. of Health, 2013The TB outbreak in Grand Forks resulted in a very large increase in total cases in ND in 2012 compared to each year within the past decade. 12ND Dept. of Health, 2013The significant increase in cases per 100,000 for North Dakota changes the states status from low incidence area to moderate incidence, which may result in changed policies for routine TB testing in health care settings.

13North Dakota TB Rates per 100,000 Compared to United States TB Rates per 100,000

ND Dept. of Health, 2013Prior to 2012, ND TB rates per 100,000 were significantly lower than the U.S. rates. In 2012, North Dakota has a higher rate of TB cases per 100,000 people than the U.S. rate. This is related to the large number of cases identified in the TB outbreak and the relatively low population of the state. 14

North Dakota is one of 10 states with more than 3.2 cases per 100,000. We are a blue state. 15Public Health Intervention Wheel

Minnesota Dept. of Health, 2001 The Public Health Intervention Wheel was developed by the Minnesota Dept. of Health in the late 1990s to describe the work of public health nurses. It can also be used by other public health professionals. The model describes the interventions carried out at the individual, community or systems focus. The focus of my project was to describe with examples how the interventions in the public health intervention wheel were employed during a local TB outbreak. 16Interventions are actions that public health nurses take on behalf of individuals, families, systems, and communities to improve or protect health status.

Minnesota Dept. of Health, 2001 Public Health Intervention Wheel Application in TB Outbreak Very few articles describe public health nursing interventions during a TB outbreak in relationship to the Public Health Intervention Wheel.TB control most commonly described from medical and epidemiological models. Most common roles for PHNs described in literature are: screening and referral, nurse case management and contact investigation. It was difficult to find published articles that described TB outbreak control in the full context of the public health interventions. PHNs at Grand Forks Public Health Dept. have varying degrees of knowledge about the Public Health Wheel of Intervention and do not necessarily identify the activities in that context. They were simply responding to an overwhelming situation each day of the outbreak. 18Public Health Intervention Wheel Application in TB Outbreak Surveillance Disease investigationOutreach ScreeningReferral and follow up Case management Delegated functions

Health teaching CounselingConsultationCollaborationCoalition building Policy development and enforcement

13 public health interventions from The Wheel were employed in the TB outbreak response and the application included all three levels of intervention: individual, community and system. 19Examples of Public Health Interventions and PHN Roles Surveillance and disease event investigationTB lab reports, contact investigation, communication with health systemsUtilized photos and social media as investigative tools OutreachTargeted testing in three schools, seven worksites, and named contactsFlagging electronic health records The early reports of school aged children testing positive for TB created concern within the community and led to early testing of students in schools. There was ultimately no evidence of transmission in the school setting. A large percentage of clients with TB did not have health insurance coverage and thus primary care and hospitalization were not covered. During the outbreak, the PHNs assisted two adults and one child to obtain health care coverage. 20Examples of Public Health Interventions and PHN Roles Screening TB skin testing in the community, homes, public health officeIncreased screening in shelter population and correctional center Recommended blood testing for named contacts presenting in ER or urgent care

Examples of Public Health Interventions and PHN Roles Referral and follow upReferred clients for evaluation, follow up by phone or home visit to complete treatment Referred for other public health and primary care services Case management Appointment scheduling, transportation, incentives Housing supported for length of treatment Enrollment in health care coverage

Case management activities by public health nurses were the most time intensive. Clients experienced many barriers to treatment, which required creative solutions. Providing a $5.00 gift card each day to clients who were present for TB medication administration at their home or public health office proved to be the most effective way to ensure medication and treatment completion. 22Examples of Public Health Interventions and PHN RolesDelegated functions Medication compliance through DOT and DOPTMonitoring for medication side effects, and therapeutic drug levels

Directly observed therapy (DOT) five days per week is the standard for most cases of TB disease. Directly observed preventive therapy (DOPT) was initiated for children less than five years of age and certain cases where barriers to successful treatment were encountered. Very high doses of four drugs were ordered requiring some clients to take up to 12 pills at one time. 23Examples of Public Health Interventions and PHN Roles Health teachingTB disease education for clients and community Medication compliance Utilized electronic health record Counseling Four drug regimens resulted in side effects for clientsMotivational interviewing skills are necessary CollaborationWeekly TB case management meetings Bi-monthly case review meetings at local hospitalAgencies providing support services Presentations were made at several schools and worksites to explain transmission of TB. The length of treatment most frequently 12 months or more - made it challenging for clients and in some cases resulted in poorer compliance. Weekly case management meetings and bi-monthly case review meetings were essential to communication about the status of cases. Collaboration with community agencies was instrumental to securing support services to clients such as housing, transportation, clothing, food, and fuel assistance. Close collaboration with law enforcement entities and the court system was also required to ensure staff safety and compliance with treatment. 24Examples of Public Health Interventions and PHN Roles Coalition BuildingInitiated TB task force Developed media messages and talking points Consultation Correctional center nurses negative air pressure cellsCDC full genotyping linked cases from 2010 2013 Policy development and enforcement New recommendations for TB testing at shelter, correctional center, and health care organizationsLegal action related to isolation and treatment non-compliance

In late 2012 shortly after pediatric cases were identified, a TB Task Force was initiated to provide communication among all agencies responding to the TB outbreak and to provide information to the media. Consultation included a variety of tasks including consulting with engineers about HVAC requirements in the correctional facility to maintain negative air pressure space, consultations with the Regional Training and Consultation Centers for TB such as Mayo and Heartland, case consultation with Mayo Clinic, and technical assistance from the CDC and ND Dept. of Health. 25Ongoing Response to Outbreak Continued surveillance Populating a new TB database Robust case management for LTBI cases Increasing staff training on TB Provider education on TB Administrative tasks including increasing personnel, revising budgets, paying expenses, and communication activitiesProviding support to maintain morale Highlight the contributions of public health nurses

Controlling TB in a community after a large outbreak requires vigilance and sustained effort. Given that there was low concern among some contacts to be tested or treated for LTBI, the likelihood that TB will re-emerge in the community or elsewhere in the state remains very high. The intensity of effort without a significant infusion of resources is stressful for personnel and diverts attention from other important public health priorities. Public health nurses should describe the work involved in responding to a TB outbreak in terms of the public health interventions framework. 26PartnersThe response activities and dissemination of findings would not have been possible without the extraordinary efforts by professionals from these organizations.

Acknowledgements Grand Forks Public Health Dept. Personnel of Grand Forks Public Health Dept. Terri Keehr ,TB Program ManagerND Dept. of Health Shawn McBride, EpidemiologistDee Pritschet, HIV/AIDS and TB Surveillance CoordinatorLindsey Vanderbusch, HIV/AIDS and TB Program Manager Altru Health System James Hargreaves, Infectious DiseaseShannon Hansen, Infection Control Centers for Disease Control, Division of TB EliminationDiana Boothe, CDC Associate Nydia Palacios, Cindy Casteneda, CDC Consultants Courtney Yuen, Epi Aid Team University of North Dakota College of Nursing and Professional Disciplines Tracy Evanson, Associate Professor Lucy Heintz, Clinical Assistant Professor References Centers for Disease Prevention and Control. (2005). MMWR, Recommendations and Reports. December 16, 2005 /54(RR15);1-37. Guidelines for the investigation of contacts of persons with infectious tuberculosis. Recommendations from the National Tuberculosis Controllers Association and CDC. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htm

Centers for Disease Control and Prevention. Division of Tuberculosis Elimination (2007). Forging partnerships to eliminate tuberculosis: A guide and toolkit.

Centers for Disease Control and Prevention. (2013). Tuberculosis in the United States. National Tuberculosis Surveillance System Highlights from 2012. Retrieved from http://www.cdc.gov/tb/statistics/surv/surv2012/slides/surv1.htm.

Grand Forks Public Health Dept. (2013) TB Task Force Meeting Minutes, October, 2012 June, 2013.

References Jewett, B., (2012, October 24). Grand Forks County TB cases alarm officials. The Grand Forks Herald. A1, A8.

Keller. L. O., Strohschein, S., Lia-Hoagberg, B., Schaffer, M., (1998). Population-based public health nursing interventions: A model from practice. Public Health Nursing, 15 (3), 207-215.

Minnesota Dept. of Health. (2001). Public Health Interventions: Applications for Nursing Practice (The "Wheel" Manual). Retrieved from http://www.health.state.mn.us/divs/opi/cd/phn/wheel.html

North Dakota Department of Health. (2013). Epidemiology report. Retrieved from http://www.ndhealth.gov/Disease/NewsLetters/EpiArchives/CurrentEdition.pdf

Yuen, C. (2013, December 14). Tuberculosis Among American Indians Grand Forks, ND 2008 2012.Epi Aid report to the ND Dept. of Health, December 14, 2012.

Questions? Contact information: Debbie SwansonUniversity of North Dakota College of Nursing and Professional DisciplinesDeborah.Swanson.2@my.und.edu Grand Forks Public Health Dept. dswanson@grandforksgov.com