Responding to a TB Event Bismarck, North Dakota June 24-25, 2008 TB & Outbreak Management Douglas B. Hornick, MD June 25, 2008 TB & Outbreak Management Douglas B. Hornick, MD Professor University of Iowa Carver College of Medicine Figure from FJ Curry National TB Center Website 1
Objectives Highlight Epidemiology of TB in large group, Low-Incidence area (substantial portion of US) Review recent TB outbreak in rural Iowa Illustrate 2 main lessons learned: 1. unique TB presentation uncovered during screening/contact investigation; 2. Establish effective local TB screening Walk through the steps/stages of Fairfield TB outbreak investigation How do Rural TB rates compare to the National TB rates? 2
US vs. Foreign-Born TB Cases Iowa 2006 45 40 35 30 25 20 US: 4.6 TB cases/100,000 Iowa: 1.3 TB cases/100,000 ~1/yr drug resistant 28 15 12 10 5 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 U.S Non - U.S. There s a good reason why some talent remains undiscovered 3
Transcendental Meditation & Yogic Flying First stage demonstrated above: the body lifts up in a series of spontaneous hops then practice leads to second stage, hovering for a short time, then third stage, complete mastery of the sky This profound mind-body coordination produces high levels of brain wave coherence resulting in the radiation of powerful waves of harmony & coherence throughout society extensively validated through rigorous, peer - reviewed scientific research. [taken from TM website] Pandits Come to Fairfield IA Pandits: Peaceful quiet men, all wearing white cotton dhotis & shawls, none that I met spoke English Priests advanced Yogic Flyers, treated w/ great reverence Age range 23-36 yrs; All Brahman class None smoke, drink EtOH, do illicit drugs, & no HIV detected Called by Maharishi Mahesh Yogi Concentrate in Fairfield IA, a/w Maharishi U of Management Goal: 1000 Pandits (1 st 400 arrived 11/07, attrition 15) All meditate at least 8 hours/day Reduce conflict & aggression in war-torn world Once established in Iowa, next 1000 to be located San Diego, CA Screened in India for communicable disease at highly reputable hospital just prior to coming to US 4
Pandits: The Invincible American Assembly --Maharishi Mahesh Yogi This compound will hold 1050 Pandits all praying for world peace Calculations: Reduce violence throughout world by 20% Pandits Daily Gathering Group 1, 385 Pandits Arrived in Fairfield IA 11/06 Group 2, 105 Pandits Arrived 4/07 housed separately, new campus All Pandits are sequestered from Fairfield & Maharishi U population 5
Outbreak Statistics March-June 2007: 8 cases active TB among group 1 Pandits (N=385) 3 Pulmonary (includes index case ) 5 Extra-pulmonary (3 Cx adenitis; 1 Cx & Axillary adenitis; 1 T12-L2 & psoas abscess) 6/8 M. tuberculosis isolated All pan susceptible DNA fingerprinting: none related All treated successfully by standard 4 drug DOT regimens. Index Case Radiographs Sputum smear: 3+ AFB; M. tuberculosis direct (MTD) test + 6
Five Extra-Pulmonary TB Cases Sporadically turned up in 3 months after index case All 4 adenitis cases underwent resection/biopsy w/ histopath, culture & susceptibilities All had negative chest x-ray & sputum (AFB, MTD, cultures) All biopsies grew pan-susceptible M. tuberculosis Spinal (T12-L2) and Psoas TB, stable pleural changes, nodular RUL infiltrate on chest CT Pleural bx aborted and AM sputa all AFB/MTD/culture negative Spinal changes resolved/stabilized on 4 drug DOT x6 months Screening Contacts in Pandit Groups Group 1 Skin testing completed 4/07 291/385 (76%) TST positive!!...suspect TB transmission Chest x-rays on all 291 The 2 additional pulmonary cases detected this way (asymptomatic) 1 AFB positive/mtd positive, pan-susceptible 1 AFB neg/mtd negative (ultimately culture negative, 4 mos Rx) 22 w/ chest x-ray changes c/w TB changes (eg, upper lobe nodular hard densities, upward hilar retraction, pleural effusion/thickening which didn t layer) 5 started on 4-drug DOT awaiting additional data All sputa smear negative/mtd negative/ culture negative 8 week films unchanged (prior films from India confirm pre-existing lesions) Group 2 Skin testing completed 4/07 (no contact w/ Group 1) 32/95 (30%) TST positive Chest x-rays on 32: no active pulmonary cases found 4 w/ chest x -ray changes c/w old TB changes which were confirmed & not treated All TST positive (N=323): INH 900 mg 2x/week DOT x 9 months 9% dropped out d/t LFT elevation or other toxicity (eg, hives) 7
Two Significant Lessons Learned TB screening among pandits (& students) from highly TB endemic areas will turn up early active asymptomatic TB cases Unique TB presentation TB screening of new arrivals from TB endemic areas must be done on site using proven, effective measures. Examples of Early TB Cases Detected Through Screening TST +, asymptomatic, CXR abnormal, sputum AFB smear negative (culture positive) General: Less severe disease, easier to cure Yield of screening varies (case detection/screened): Immigrants/refugees B1, B2 classification: 2-14% Homeless shelter (outbreak): 3.1, 4.3 % Contact investigations: 1-3% Inner City residents seeking SS: 0.5% Homeless Shelter (routine): 0.18, 0.36% Correctional facility intake: 0.07, 0.17% University intake foreign born students:???? 1998-2001 Seattle-King County: 11% of TB cases identified via screening CDC: MMWR Rec & Reports 54(RR12) 2005 8
Screening Early TB (or Hawkeye TB) Comprehensive TB screening of Pandits or newly enrolled foreign-born students Active cases occasionally surface: +TST, asymptomatic, BCG, Balky Subtle, non-cavitary Chest x-ray infiltrate Smear negative, culture positive (AM sputum x3) Bronchoscopy in many but not all Note: Smear negative, culture negative uncommon Often faster response to treatment (small organism burden) Successful management: Teamwork Vigilant/Supportive Student/Pandit Health Service University Administration ($ for testing, QFT-G) Department of Public Health R Upper Lobe Bronchus Intermedius Viet Nam Korea Philippines Screening Early TB Latest Active Pandit Case Screening Group 3 Argentina Malaysia Smear-, Culture- India 9
Screening Early TB +TST, BCG hx, Subtle CXR infilt., Smear-, Culture+ Comprehensive TB screening of Pandits or enrolled foreignborn students Active cases occasionally surface: +TST, asymptomatic, BCG, Balky Subtle, non-cavitary chest x-ray infiltrate Smear negative, culture positive (AM sputum x3) Bronchoscopy in many but not all Note: Smear negative, culture negative uncommon Often faster response to treatment (small organism burden) Successful management: Teamwork Vigilant/Supportive Student/Pandit Health Service University Administration ($ for testing, QFT-G) Department of Public Health Unique TB Presentation Proactive instead of Passive Process Two Significant Lessons Learned TB screening among pandits (& students) from highly TB endemic areas will turn up early active asymptomatic TB cases unique TB presentation TB screening of new arrivals from foreign TB endemic areas must be done on site using proven, effective measures. 10
Maharishi U Pandit Screening Contract with one of the finest hospitals in India All pandits: Chest x-ray, complete H&P, screen for communicable diseases (no TSTs done ) Examples of evaluation Maharishi U administration responded: We will contract for two separate evaluations in India Ultimately convinced to establish on-site TB screening program Two nurses hired & local MD supervision established 1 nurse Pandits screening & treatment of LTBI 1 nurse Maharishi U (new students from countries with highly endemic TB) Training by UI Student Health nurse in charge of TB screening & modeled program after that at UI India Evaluation of Index Case March 2007 India CXR report 11/06:? Pulmonary Koch s Please assess clinically Clinical assessment 11/06: I certify he is fit for travel to US 11
India Evaluation of Another Pulmonary TB Case Fairfield 4/07 India CXR report 11/06: R upper zone infiltrate w/ R CP blunting Clinical assessment 11/06: I certify he is fit for travel to US Fairfield 4/07: TST+, asymptomatic, but sputum AFB positive Maharishi U Pandit Screening Contract with the finest hospital in India All pandits: Chest x-ray, complete H&P, screen for communicable diseases (no TSTs done ) Examples of evaluation Maharishi U administration responded: We will contract for two separate evaluations in India Ultimately convinced to establish on-site TB screening program Two nurses hired & local MD supervision established 1 nurse Pandits TB screening & treatment of LTBI 1 nurse Maharishi U (new students from countries with highly endemic TB) Training by UI Student Health nurse in charge of TB screening & modeled program after that used at UI 12
TB Outbreak Definition Outbreak Definition (any of the following): Increase in TB cases above expected During contact investigation, 2 contacts identified with active TB Missed during initial contact investigation: 2 cases w/in one year of each other found to be linked Genotyping cluster leads to 1 verified transmission w/in prior 2 years Contact investigation turns up more cases than local PH can handle & outside help required Ongoing transmission documented despite control efforts Adapted from FJ Curry National TB Center Website TB Outbreak General Response Plan Outbreak team: ID or Pulm MD oversight; local, regional, or state public health officials; local medical personnel; PH laboratory; CDC consultant Confirm TB Outbreak Identify roles/authority Review legal issues Establish communication mechanism & data management among team members (action plans, lab data, data about suspect and active cases, contact investigation data) Agree upon guidelines for diagnosis/treatment of active, suspect & latent cases; guidelines for isolation; guidelines contact investigation Identify need for additional resources & training Provide basic TB education to PH staff & other health care providers Contact & enroll community partners Plan for media press releases and questions from community Adapted from FJ Curry National TB Center Website 13
Outline Pandit TB Outbreak Response Outbreak Team: Hornick (pulm MD) oversight; State TB control officer; State TB control nurse; County Public Health Nurse; Local ER Doc & Maharishi U nurse (hired to cover outbreak) Communication via email, cell, pager, fax data and all data entered into spreadsheet (Hornick) County PHN, Maharishi nurse, State TB control nurse & TB control officer performed contact investigation (TSTs on all Pandits) over 2 weeks in April 2007; repeat in June on few negatives from 1 st cycle Provided basic TB re-education to local PHN, ER Doc, Maharishi nurse (introduced UI student health screening program for foreign students) Local ER doc on Pandit site 3x/week to address medical issues, TB treatment prescriptions (communication nearly daily w/ Hornick); also arranged for 320+ chest x-rays at local hospital Outline Pandit TB Outbreak Response II Maharishi U administrators personally drove batches of abnormal chest x-rays to UIHC daily for secondary reading & advice (Hornick) Established separate weekly clinic at UIHC (Hornick) to evaluate suspect & active cases (required sputa x3 for AFB negative, if positive, on Rx x1wk), other issues (eg, drug toxicities, non-tb abnormal x-rays) Meeting w/ local medical community, Maharishi U administration, Fairfield hospital administration w/in two weeks of index case to provide information & garner cooperation Media inquiries handled through usual state public health mechanism 14
Pandit TB Outbreak Response Challenges/Barriers Cultural/linguistic: No pandits speak English; Resistance to western medical Rx of infectious disease; TB drug Vedic therapy interactions Prolonged discussion/debate over establishing Student Health paradigm for screening TB among all new arrivals from India & other foreign countries where TB endemic Surge in cases tested limited capacity of County Public Health resources/personnel/experience (TB nurse retiring coincided w/ outbreak) Oil water MUM Local Medical Community MUM administration = Business model mindset Ostrich solutions Outsourcing to India aspects of screening/tb management High rate of extra-pulmonary TB Unique clinical management lessons (Oto, G surg). Conclusions Reviewed Epidemiology of TB in Low- Incidence areas (most of US) Highlighted unique aspects of a TB outbreak among Pandits in Fairfield Iowa (Maharishi University) & two major lessons learned: 1. Unique early TB presentation uncovered during screening/contact investigation 2. Establish effective local TB screening Walked through the steps/stages of TB outbreak investigation generally & this one 15