H-BLUE 07/12-15/2005

1
NYC
STRAIN W
NJ
Mark Wolman NJMS Global TB Institute
2
Background-1

• Patient FG was admitted to local hospital on
  September 13, 2005 with a diagnosis of suspected
  pulmonary TB
• history of cough 1- 3 months
• chest x-ray consistent with TB (non-cavitary)
• sputum smear positive (4)

3
Background-2

• Infectious period established at March 1-
  September 13, 2005
• During the infectious period the index patient
  indicated the following
• single and homeless in Newark
• address given to the hospital was a local flower
  shop
• sat outside flower shop all day/every day
• identified no family, friends nor social
  activities
• identified no places of worship, employment,
  hangouts, shelters, hospitalizations, ED visits
  or incarceration
• denied any local or extensive travel

4
Background-3

• On September 19 initial culture collected on
  hospital admission identified as MTB
• On November 8 susceptibility pattern indicated
  first line resistance
• From this date forward new information collected
  identifying congregate setting exposures in two
  hospital settings during the infectious period
  moves to forefront of investigation

5
Some Early Problem Indicators

• Despite an order of airborne infection isolation
  on admission to one of the hospitals
• early report by nursing station indicated that
  door to patients room left open and that the
  patient was seen occasionally leaving the room
  and walking the floor unmasked
• airborne infection isolation discontinued later
  on the same day of admission for no apparent nor
  documented reason
• During admission to the above hospital index
  patient was placed on same floor as high risk
  patients
• Potential exposure to HCWS and patients

6
Patient Time LineMarch 1-December 17, 2005
12/17
3/1
6/1
6/15
6/16-22
6/30
7/4
7/6
7/12-15
7/23
7/24
7/25
8/13
8/17-22
9/5
9/13
9/19
11/8
11/10
11/28
12/2
12/14
Strain W Linked to Bronx outbreak
NJ Health Alert
Hosp 1 In-pt SP SM 4 Aii ordered
Drug Resistance
Hosp 1 ED Pneumonia
Hosp 1 ED Rash
Hosp 2 ED Rash
Hosp 2 In-pt Rash
Hosp 2 ED Rash
Hosp 2 ED Rash
Hosp 2 ED Rash
Hosp 2 ED Rash
PT Expired
Watch List to NJ
Hosp 2 ED Rash
PHRI IS6110 Genotyping
MTB
Hosp 2 In-pt Faint at B.S. Pneumonia Cough 1-2
mos Aii d/c
Hosp 1 In-pt Pneumonia
NYC EXP
Hosp 1 ED Cough
7
Health Alert-1

• Issued by the Deputy Commissioner of the New
  Jersey Department of Health Senior Services
• alerting local health departments, clinicians and
  hospitals of Strain W cluster among HIV infected
  individuals in NYC
• HIV infected homeless contacts linked to NYC
  investigation remain in the community and had not
  as yet been located
• NJ and NYC DOH working closely to locate and
  medically assess the identified contacts

8
Health Alert-2

• Medical providers urged to
• isolate HIV infected homeless individuals who
  report a history of residing in NYC since
  January, 2005 and who present with symptoms of
  pulmonary TB
• collect respiratory specimens
• suspect drug resistance if these patients do not
  respond to standard TB therapy

9
Hospital AssessmentJuly 12-15, 2005 Admission- 1
10
Diagnosis of Hospitalized Patients

• HIV/AIDS 18(42)
• Diabetes 7(16)
• Renal 3(7)
• Sickle Cell 3(7)
• Cancer 3(7)
• Pneumonia 3(7)
• Liver Disease 1(2)
• Cholecystitis 1(2)
• Gangrene 1(2)
• Cysts 1(2)
• Pituitary tumor 1(2)
• Alcohol 1(2)
• Total 43 (100)

11
Some Early Complications.

• Identified patient contacts were themselves a
  very diverse medically complex group
• If a second line latent treatment could be
  offered could these patients tolerate the
  medication?
• Would they complete treatment?

12
Hospital Assessment - 2
13
Hospital Assessment - 3
14
Summary of Final Assessment -1

• Throffer Diffuser Ventilation system
• every 3 feet intake and outtake vents lined
  alongside ceiling lighting fixtures throughout
  the length and width of hospital floor
• no shared or re-circulated air on floor
• fresh air pumped in directly from roof to floor
• environment air from floor pumped directly back
  to roof
• provides 14 air exchanges per hour
• isolation ante room has own intake and outtake
  vents
• functional system as evidenced by testing
  provided by hospital engineering department

15
Final Assessment - 2

• Confirmation of initial nursing report of door to
  patients room left open
• Initial report of patient walking the floor
  unmasked proved erroneous

16
Outcomes To Date

• All HCWs identified and tested at both hospitals
  were TST negative
• Based on the ventilation system that exists in
  the hospital coupled with the confirmation that
  the index patient did not leave his room during
  the July hospitalization the risk of transmission
  to patients had been reduced from high to low
  priority
• No testing recommended for hospitalized patients

17
Lessons LearnedAnd Re-learned - 1

• Maintain adherence to the basic principles of
  conducting congregate setting investigations
• initiate and conduct on-site assessment of
  identified exposure environment(s)
• collect information
• confirm accuracy of information collected
• review and analyze information collected
• develop plan of action based on accurate
  information

18
Lessons LearnedAnd Re-learned - 2

• As best as possible avoid decision-making that is
  driven by the perceived drama of the moment
• Remain aware of the function and benefits of
  sharing information beyond geographic boundaries
  where there is frequent and easy access across
  state, county or city lines
• watch lists
• DNA fingerprinting results

19

• The role in TB Control of institutions like PHRI
  is not only in the linking of patients through
  molecular epidemiology but in the linking of
  programs for the purpose of better understanding
  transmission and contact tracing of TB