Marijean Day BScN, RN -- Nursing in a TB Outbreak

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Nursing in a TB Outbreak

• TB Outbreak Kelowna, BC
• Marijean Day BScN

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TB Outbreak in the Urban Homeless

• TB Outbreaks in the homeless population can be
  very challenging
• A harm reduction and social determinants of
  health approach required
• Significant health sector and public health
  resources
• Collaboration necessary
• Outbreak management team

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Natural History of TB infection
Exposure
Latent Disease
Risk Factors
95
Primary Infection
Susceptible
Active Disease
Risk Factors
5
4
Homelessness and Tuberculosis
Latent Disease
Risk Factors
95
MalnutritionSmokingAlcohol AbuseHIVMedical
co-morbiditiesHealth care accessInhalational
exposuresMental health- med adherence
Poor ventilationCrowded environmentHigh risk
social networkLow health literacyProlonged
infectious periodsInhalational exposures
Primary Infection
Risk Factors
Susceptible
Active Disease
Risk Factors
5
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How to most effectively approach an urban
homeless outbreak

• Primordial prevention social determinants of
  health housing, nutrition, health care, income
  harm reduction.
• Primary Prevention shelter design and
  ventilation isolation education active case
  finding monitoring patients with LTBI.
• Secondary prevention treatment of LTBI harm
  reduction addressing medical co-morbidities.
• Tertiary Prevention early treatment of active
  disease DOT

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IH TB Outbreak Management Team
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Guidelines and Surveillance

• The outbreak management team / CD Unit provided
  specific guidelines specifically for the Kelowna
  TB Outbreak
• Surveillance guidelines used for all LTBI clients
  which consisted of chest x-rays and sputum
  collection for AFB X 2 years
• Spreadsheet developed used to help assist in the
  management of outbreak

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Outreach Urban Health

• Primary Care facility in the downtown core
  accessible to the Kelowna street involved and
  homeless population
• Physicians
• Social Worker
• Nurses
• Drug Alcohol Counsellor
• Chiropractor
• Podiatrist
• Acupuncturist
• Ministry of Social Development liaison

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Beginnings

• The Kelowna Outbreak began in early May 2008
• An adult 20 year old male travelled to Kelowna
  from the VDTES
• Stayed at the Kelowna Gospel Mission for 9 nights
• Chest x-ray on May 13th showed a cavitating
  lesion
• Admitted to KGH on May 24th
• Sputum results on May 27th 4 AFB smear positive.

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Contact Tracing

• The key is early case findings
• 5-10 of those infected will go to have active TB
  within the first 2 years
• Higher in the marginalized urban homeless related
  to the social determinants of health
• Detailed social networking questionnaire developed

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Traditional Contact Tracing
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Problem patient interviews and contact tracing
do not reveal all relationships that could be
associated with transmission.
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Kelowna Gospel Mission Sleeping Quarters
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Screenings

• TSTs done on those identified through case
  interviews bed lists
• MHO determines the closeness slept to case and
  of nights as criteria
• Ongoing screenings done q6 monthly in several
  locations six months
• Sputum sweeps
• Identified LTBI clients encouraged preventative
  therapy
• Less LTBI identified the recent use of IGRAs
  have reduced the number over the past year

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The social network demonstrated
the outbreak was location-based
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Status from 2008-2012

• Current Outbreak Status (as of February 29, 2012)
• Active Pulmonary TB Cases
  39
• required hospitalization in IH facilities
  27
• receiving treatment
  5
• completed treatment
  28
• died 2
• Screening
• potentially exposed and investigated  - 1764
• fully assessed with no further follow-up -
  1120
• with TB screening in process - 238
• not completing TB screening process
  - 98
• receiving or completed preventative
  treatment (PT) - 91
• not on PT but being monitored for health status
  - 96
• recommended for PT but refused PT and
  monitoring - 11
• recommended for PT but lost to follow-up - 21
• other - 36

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Nursing Strategies

• Screenings at meal times or when most residents
  present
• Everyone encouraged to be tested including staff
• 5 Safeway cards given at the read as incentive
  to return
• Bus tickets supplied for those who need it to
  return
• Assessed for symptoms and collected sputums if
  symptomatic
• Drove clients with symptoms or a positive TST to
  the hospital and stayed with them to get their
  chest x-ray
• Sputum sweeps
• Educate, educate, educate.about latent and
  active TB infection in clear understandable
  language

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Strategies

• Engage and establish trusting relationships
  with the population when ever possible
• Lots of outreach and support including easily
  understandable TB education
• Identify support their needs, housing or social
  work support, mental health issues, other health
  concerns, getting treatment or detox,
• Encourage support those newly diagnosed latent
  infection to take preventative therapy
• Facilitate engagement with services at Outreach
  Urban Health
• Assist them to get 40 a month from social
  assistance while on therapy (another incentive)

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Managing Preventative Therapy in this population

• Sensitivities 0.1 Isoniazid resistance 0.4
  Isoniazid sensitive
• This became the resistance pattern with only a
  couple of exceptions
• Initially Isoniazid used for preventative therapy
  
• High rate of ongoing substance abuse, Hepatitis C
  length of treatment made INH use quite
  challenging
• Decreased toxicity to liver 0.1 INH resistance
  pattern lead to using rifampin for 4 months.

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Medication Management

• DOT
• Medications blister packed
• Frequent monitoring of liver enzymes side
  effects as
• Supplied and found ways to have medications like
  benadryl or dioval paid for if effective for some
  side effects
• Texting effective for some hard to contact
  clients - phone cards supplied
• Monthly bus passes supplied to enable clients to
  come to OUH for DOT or med pickup
• Met clients in places like the park or shelters
  for DOT

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Active Case Management Strategies

• Frequent visits from outreach staff will in KGH
  for extended periods
• Shop for these clients and rented movies
• Accompany them out for fresh air break
• Free TV, phone, Wii game, exercise mat or
  stationary bike
• Find housing
• Buy groceries isolation
• Provide free recreation passes
• Connect clients with community workers to help
  with taxes, documents social assistance

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IH TB 2008-2010
5
15
5
5
5
12
51
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Molecular Fingerprinting

• MIRU analysis is the type of molecular (DNA)
  fingerprinting used in BC
• This has confirmed the link in 38 cases in the
  Okanagan or with known links to the Okanagan thus
  far.
• Two current cases show the same resistance
  pattern but MIRU results not yet available
• Genomics investigation

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Spreading Out

• 2 of these cases on Vancouver Island. Both cases
  had stayed at the Kelowna Gospel Mission in the
  fall of 2009
• 5 cases who reside in Penticton as very
  infectious active case who spent time with
  friends the local soup kitchen in 2009
• 1 case who was skin tested at the Gospel Mission
  but did not take preventative therapy became an
  active case in Alberta
• 1 case with the same MIRU pattern was found in
  northern BC with no known link to Kelowna
• 6 cases with matching MIRU in the Vancouver DTES
  that have no links to Kelowna

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Further field and molecular epidemiological work
revealed more cases.
1
38
6
2
26
2012-2016
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Summary

• Outbreak Management Team required
• Specific outbreak guidelines
• Primary, secondary, tertiary primordial
  prevention strategies
• Public health nursing team that can focus on the
  outbreak
• Nursing strategies specifically focused on the
  urban homeless population
• Collaboration is key!