NICU CI. Tools For TB Elimination April 22, 2015 Curry International Tuberculosis Center. CI in Healthcare Facilities 1. Case Summary.

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1 NICU CI Michael Stacey MD, MPH CMO/Dep Health Officer/TB Controller Solano County Public Health Case Summary Index Case: Pregnant 34 yo Filipino descent sent to Sacramento County hospital from a Solano County hospital for high risk delivery on March 13 th March 14 th delivered baby and mother was d/c d March 18 th. Baby stayed in NICU in Sacramento. March 31 st baby was transferred to Solano County hospital to be closer to mother. Case Summary April 21 st mother seen in ER for cough and bloody sputum. Treated for PNA CXR was abnormal. Thought to have pneumonia, but CXR was also concerning for possible recurrence of lymphoma. Seen by oncologist as outpatient with continued cough. Sputums ordered on May 11 th. May 14 th oncologist sent pt to hospital due to concern of a postobstructive PNA. May 15 th sputum results from May 11 th smear positive and NAAT positive. Infectious period? 3 months before symptom onset (February 21 at latest) 1

2 Why Contact Investigation? Find TB Disease: In the case possible transmission in a NICU we want to figure this out as quickly as possible Find TB Infection: Complicated by the decreased reliability of TB diagnostics in infants Crisis Communication 1. Be Right 2. Be First 3. Be Credible Who is in charge? YOU! Getting Organized Quickly set up a teleconference meeting with hospital leadership, public relations, infection control, employee health, Sacramento PH and TBCB. Determined infectious period Got agreement and buy-in on criteria for determining priority of contacts Generated lists of contacts Determined how contacts will be evaluated and treated Agreed on messaging to contacts and to media. Created joint press release Kept index patient informed at all times 2

3 SOLANO COUNTY County Administrator s Office SOLANO COUNTY County Administrator s Office FOR IMMEDIATE RELEASE Contact: Stephen Pierce Health TB Program staff, who receive new active TB disease cases regularly each month. TB is preventable and curable, said Olivia Kasirye, MD, MS, Health Officer for Sacramento County. May 22, 2012 (707) slpierce@solanocounty.com For general TB information, visit During business hours, Solano County residents with questions can call Solano Public Health at Sacramento County Contact: Michael Stacey, MD, Chief Medical Officer/Deputy Health Officer, Solano residents can contact Sacramento County Public Health at County Health & Social Services, Solano Public Health, Laura McCasland, Communication and Media Officer, Sacramento County Public ### Health, Sacramento, Solano Health Officials Work with Local Hospitals on TB Case SOLANO COUNTY Sacramento and Solano County public health agencies are working with NorthBay Medical Center in Fairfield and Sutter Medical Center, Sacramento to investigate potential exposures to an individual with active tuberculosis (TB) who spent time in both facilities. The Solano County resident is currently isolated and receiving treatment to prevent the spread of TB. Health officials are working with both medical centers, in consultation with California Department of Public Health, to assess patients, visitors, and staff to determine who may have been exposed to the TB germ. There were periods of exposure in the Sacramento neonatal intensive care unit (NICU) from March 14-March 31 and the Solano NICU from March 31 to April 2 and from April 11 to April 19 of Parents of exposed babies will be contacted within 24 hours, while others potentially exposed will be contacted within the next few days. In accordance with State and Federal laws that protect patient confidentiality, no specific information about the individual with active TB will be released. From the medical evidence we have reviewed so far, we believe that the risk of infection with TB in this particular case is low, said Michael Stacey, MD, Chief Medical Officer for Solano County. We will take the necessary measures to ensure that all those with significant levels of exposure are tested and, if necessary, treated with antibiotics. Contact investigations, like this one currently under way, are an important step in stopping the spread of TB. Patients, visitors or staff determined to have TB infection will be given medication to prevent progression to TB disease. Although it may be a new experience for the patients, visitors and staff to the NICU, contact investigations are a regular activity for Solano Public Health and Sacramento County Public EDITORS: ADDITIONAL BACKGROUND INFORMATION Tuberculosis (TB) is a serious, treatable, and slow-growing bacterial lung disease. It is transmitted person-to-person through microscopic droplets that enter the air while coughing, sneezing, talking or singing. The most common way to become infected with TB germs is by spending a lot of time in enclosed air spaces with a person who has active TB disease. TB is a disease that, by law, must be reported to the local Public Health Department. Upon notification of the TB disease diagnosis, public health nurses act immediately working with the patient and family members to list all of the places they have spent time and all people with whom they have been in close contact. Public health staff will identify and test individuals who may have come in contact with the TB germ. Infection with TB can occur with prolonged indoor contact in an enclosed air space with the person who has active TB. There is a difference between TB infection and active TB disease. Most people who test positive for TB have TB infection. People with TB infection: Do not have disease and are not sick because the germ is inactive Do have the TB germ in their body Cannot spread the germ to others Over their lifetime, adults with TB infection have about a 10% risk of developing active TB disease if untreated. The risk of developing active TB is much higher in infants and immunocompromised persons. People with Active TB disease: Develop active TB from untreated TB infection Are ill from the germs that are active in their body May cough a lot, feel weak, have a fever, lose weight, cough up blood, or sweat a lot at night Are contagious and are capable of giving the infection to others, until they are treated, have repeated tests, and are cleared for public contact by a doctor Tuberculosis: 25 Babies in California Possibly Exposed to TB ABCNews Health officials: TB patient had reason to be in NICUs KCRA Solano Health Officials Work With Local Hospitals On TB Case A unidentified Solano County resident is being treated for tuberculosis. Suisun City Patch Calif. babies tested for TB exposure in neonatal ICU NBCNews Person visited neonatal units before TB diagnosis Washington Times CA health officials testing 35 babies for TB CBSNews NICU Infant Exposure Sacramento: March Solano: March 31- April 2; April Pt stopped visiting NICU because she was sick and worried about exposing infants. 3

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5 Baby Contacts NB NICU CONTACT LIST Note A Contact remains in NICUremains in NICU * Exposure likely over 240 minutes Index's Baby MRN Admission Discharge Factors for Exposure >240 or + 3 Non Contact DOB Date Date exposure minutes + visits visits Letters Date of Visit 1 4/17/2012 4/17/2012 4/17/2012 No exposre 0 needs 2 3/23/2012 4/16/2012 isolette only MD contacted 3 4/14/2012 4/14/2012 4/25/2012 open crib /13/2012 4/13/2012 4/16/2012 open crib 95 1 needs 3/14/2012 3/31/2012 Mother index /21/2012 3/21/2012 4/10/2012 open crib /22/ /21/2012 3/21/2012 4/10/2012 open crib /22/ /23/2012 3/23/2012 4/11/2012 open crib /23/ /11/2012 4/11/2012 4/14/2012 open crib 23 2 needs 10 3/27/2012 3/31/2012 4/3/2012 open crib /22/2012 3/22/2012 4/8/2012 open crib /23/ /29/2012 3/29/2012 4/2/2012 open crib /12/2012 4/17/ MD contacted 14 4/12/2012 4/17/ MD contacted 15 4/7/2012 4/7/ /13/2012 4/13/2012 5/12/2012 open crib /19/2012 4/19/2012 No exposre 0 MD contacted 18 4/11/2012 4/11/2012 4/11/2012 No exposre 0 needs 19 3/31/2012 3/31/2012 4/16/2012 open crib /14/2012 4/14/2012 4/27/2012 open crib /13/2012 3/13/2012 4/26/2012 open crib /18/2012 2/7/2012 4/3/2012 open crib /10/2012 4/3/2012 unknown isolette only needs 20 5 Contacting Parents SCRIPT FOR PARENTS OF EXPOSED INFANTS You are being contacted today because your baby was exposed to an active case of TB, tuberculosis, while in the neonatal intensive care unit in NorthBay Medical Center. If it is determined that you or other family members also have been exposed, then you will be contacted in the next few days by someone with the Solano County TB Program. TB is serious, but curable. So it is very important that you contact your provider right away to schedule an appointment no later than the end of the week. Your baby will need to be evaluated with a chest x-ray, skin test, a physical exam to determine what medication your baby will need and for how long. Once you have set the appointment, please immediately call the NICU at NorthBay Medical Center, , and let them know the time and date you have scheduled with your primary care doctor. Solano County health officials are working very closely with your healthcare provider to coordinate care for your baby. You can expect a phone call from Solano County Public Health in the next few days. Window Prophylaxis TST less reliable for infants under 6 months Initial TSTs done on infants regardless of age Window prophylaxis (INH) started and repeat TST done at 8 weeks post exposure or 6 months, whichever came last If > 6 month TST was < 5mm then INH was stopped Adult TST data was useful for determining how infectious the index case was 5

6 CI Data Cohort Solano NICU Sac NICU Solano Employe es Sac Employe es Total Total Number Number of Number of Number Number Number Comments Number Contacts Not TB ll New Prior Started Started Complet of Evaluated Infected Positives Positives on LTBI ed LTBI Contacts Window * *Neg TST/QFT Index case s baby * 2* *neg TST/QFT Family ( 7 new, US Born =7 2 All 0 mm converters) CI Outcomes Fortunate in this situation not to have any secondary cases Strengthened partnerships with local hospitals Confidentiality of patient was maintained Patient successfully completed treatment Baby of index case was not able to complete full INH treatment due to ongoing GI problems in NICU Monitored baby Media messaging was successful Summary General principles of CI apply to all situations For example: Determining period of infectiousness, prioritizing contacts, evaluation of contacts, etc. Certain CIs may require working closely with community partners Certain situations are likely to attract media attention and this needs to be considered from the beginning and it is important to be proactive Public Health official is usually the most qualified to be the primary media contact 6

7 QUESTIONS Michael Stacey, MD, MPH 7