Rural Indiana Outbreak County/State and CDC Response

Shameer Poonja MPHCDC Assignee

Indiana State Department of HealthTB Program

TB Incidence—United States, 2005

>3.5 cases per 100,000

<3.5 cases per 100,000

Indiana Small Rural County

Recent outbreaks 2002

– School setting –linked to four secondary cases. One additional case linked to previous investigation in 1990’s.

– Social setting-four cases genetically linked to past case in three other counties.

2003– African American Community

•25 cases in cluster

TB Cases—County A, 1999–2004

0

1

2

3

4

5

Year by quarter

Cou

nt

1999 2000 2001 2002 2003 2004 2005

Do we have a problem? County- Spring 2005

– Noticed increase in cases – Placed call to state for recommendations

State- September/October 2005– Noticed problem with DOT– Patient interviews revealed 3 potential sites of

exposure – genotyping

CDC– TB news articles in 09/30– Called State for update on issue

Initial Response State Health Department

– Communicated with county health nurse– Provided staff persons– Provided emergency funding – Requested Epi-Aid team

CDC– Epi-Aid team arrives 11/9/05 -12/16/05 to

re-interview, identify additional sites of exposure, screening contacts

– 10/06 Requested (1999-2004) isolates be sent for genotyping

CDC Epi- Aid Team Pre-Investigation Data

October 2005 10 cases detected

All 10 genotypes matched

Archived isolate (1999–2004) genotypes matched

TB Cases—County A, 1999–2005

0

1

2

3

4

5

Year by quarter

Cou

nt

1999 2000 2001 2002 2003 2004 2005

Outbreak-relatedNot outbreak-related

0

1

2

3

4

5

Year by quarter

Cou

nt

1999 2000 2001 2002 2003 2004 2005

Genotype-matched and epi-linked

Outbreak-Related Cases, 1999–2005 (N=23)

Genotype-matched onlyEpi-linked only

Outbreak Response State

– Continued to have staff available to interview, provide education

– Medical residents– Pulmonary and ID consultation– Press release

CDC– Reviewed patient records– Interviewed patients diagnosed in 2005

and their contacts– Reviewed national TB genotyping data

Patient Characteristics (N=23)

Characteristic nMedian age (range) 46 years (4–70)Male 17White and US-born 23HIV-infected 0Diabetes 8Heavy alcohol use 18Methamphetamine use 1

Disease Characteristics (N=23)

Characteristic nPulmonary 22 Cavitary 15 Smear positive 17Culture positive 20 Drug susceptible 20Fatal 2

Risk Factors

Delay (>60 days) n/N median (range)

Diagnosis 11/18 135 days (74–389)

Smear conversion 9/12 94 days (62–210)

Culture conversion 10/15 96 days (63–141)

Public Health Impact

Contacts 109

LTBI25 (23%)

Treatment Initiated 19 (76%)

Additional Contacts 226 + 294 = 520

LTBI25 + 24 = 49

Treatment Initiated 41 (84%)

Ongoing activities County

– Hired and trained additional staff– Establish ½ day TB clinic

State– Reorganization and build linkages

with other programs– Resources (EPI, 2 Regional RN)– Requested public health advisor

Federal (CDC) – Deployed field staff (2/6-6/30)– Developed Data Management

system

Geographic Distribution* of Outbreak Strain—United States

Acknowledgments

County A Health Department

Indiana State Department of Health

CDC Division of TB Elimination

CDC Experience and Epi Elective Programs