1. TB in Tennessee The Good, the Bad, and the Ugly Jason Cummins, MPH April 30, 2014

2. The Good

3. Tuberculosis Case Rates Tennessee and United States, 2000-2013 Case Rate per 100,000 Population Year

4. Reported Tuberculosis Cases Tennessee, 2000-2013 Year Number of Cases

5. Statewide Implementation of QFT-GIT QuantiFERON-TB Gold In-Tube (QFT-GIT ® ) was implemented statewide in October 2013 HIV testing done as part of the QFT-GIT process using the “opt out policy” To date, every county has drawn at least one QFT since October 2013. Ability to run QFTs at the State Lab

6. TST vs. QFT TST Patients must visit clinic twice (placing and reading) Previous BCG vaccination may lead to false-positive False positives range from 3-65% in all persons tested An initial TST may cause future TSTs to be subject to boosting QFT QFT is performed in one visit QFT is not affected by BCG vaccination QFT is >99% specific QFT is not subject to boosting, eliminating the need for two-step testing

7. Revised Risk Assessment Tool (TB RAT) Further clarification of risk factors for exposure vs. risk factors for progression to active disease if exposed Terminology and risk factors more closely align with that of CDC Addition of QFT testing and results

8. The Bad

9. Pediatric TB Meningitis Case 28 month-old Hispanic male Source case: maternal grandmother Brain tissue was AFB smear-positive and culture positive for TB Sequelae: o Patient is a quadriplegic Deaf and blind Has a permanent trach Has a permanent PEG No cognitive response

10. TB in High Schools Shelby County (2) Cheatham County (1)

11. Multidrug Resistant Case 35 year-old Burmese man Wife diagnosed with TB of the colon in 2013 Patient was lost to follow-up as a contact to his wife in 2013 and never fully evaluated for TB vs. TBI Drug susceptibility results: resistant to Isoniazid, Rifampin, Streptomycin, Rifabutin, and Ethionamide Different genotypes from his wife

12. Long-Term Care Facility CI 49 year-old “floater” housekeeper at a nursing home Infectious period began August 1, 2013 Contact investigation involves 30+ employees and at least 60 residents Contact investigation in household: four persons tested with QFT and all four were positive o To date: two contacts are TB suspects

13. Cluster Investigations in Memphis Notified by CDC about 4 genotype “clusters of concern” that should be further investigated Clusters with recent cases in the cluster represent ongoing transmission Process of investigating clusters o Re-interviewing patients o Identifying contacts to cases in the cluster that were not fully evaluated and/or did not complete treatment for TBI o Extensive chart abstraction

14. The UGLY