1. I AM NOT HOMELESS CSTE JUNE 2013 Dee Pritschet, TB Controller – North Dakota Department of Health Shawn McBride, Epidemiologist – North Dakota Department of Health Diana Boothe, Public Health Associate – Centers for Disease Control and Prevention Alicia Lepp, Epidemiologist – North Dakota Department of Health Kirby Kruger, Division Director – North Dakota Department of Health Tracy Miller, State Epidemiologist – North Dakota Department of Health Krissie Guerard, TB Program Manager – North Dakota Department of Health June 11, 2013

2. IT ALL STARTED WITH A PHONE CALL

3. MDDR Molecular Detection of Drug Resistance

5. NORTH DAKOTA TB CASES 2000 - 2011

6. NORTH DAKOTA TB CASES 2000 - 2012

8. United States vs North Dakota TB Disease Rates/100,000

9. GENDER ND TB CASES 2008 - 2012

10. ETHNICITY ND TB CASES 2008-2012

11. TIMELINE OVERVIEW Late October: three confirmed cases had been identified in Grand Forks County November: Investigation identifies more cases and the State Health Dept. requests Epi Aid December: Epi Aid team arrives January to Present: Investigation continues, linking cases, evaluating social network, locating and referring contacts for testing, managing active cases and latent infections, administering Directly Observed Therapy (DOT)

12. EPIDEMIOLOGICAL LINKS Name-based  One patient identifies another person by name and reports close contact with that individual during the patient’s infectious period (IP)  A third party names two individuals and reports close contact between them during one’s infectious period and the other’s exposure period * adapted from CDC Epi Aid Team Exit Presentation December 2012

13. Location-based  Two patients known to have been present at the same time in a location in which they could have had close contact during one patient’s infectious period and the other’s exposure period

14. INVESTIGATIVE TOOLS Case Interview Electronic Medical Records Name and Photo release forms Facebook/Social Networks Pictures of transmission locations Genotyping

15. GENOTYPING Spoligotyping  Identifies the M. tuberculosis genotype based on presence or absence of spacer sequences found in a direct-repeat region of the M. tuberculosis genome where 43 identical sequences and 36 base pairs are interspersed by spacer sequences. Spoligotype - 777776777760601 Miru - 224325153323 Miru2 - 444234423337  CDC Epi Aid reviewed all cases with matching spoligotype as well as requested spoligotypes be run on culture positive cases with potential epi links GENtype G00011

17. SENSITIVITY

18. LOW LEVEL ISONIAZID (INH) RESISTANCE Why is this important? Latent TB infection (LTBI) is treated with Rifampin Rifampin is a 4 month treatment in adults Rifampin is a 6 month treatment for children Treatment for Active TB Cases is 9 months vs 6 months INH shortage might lead to Rifampin shortage Drug levels are imperative to ensure adequate drug levels are reached and maintained throughout the course of treatment

31. *from CDC Epi Aid Exit Presentation 12/11/12

32. Couch Surfing

33. PHOTO AND NAME RELEASE FORMS Requested active cases sign an order to allow us to use their photo and/or name in investigation related activities Used to verify suspected epi links Established unknown epi links  Linked our genotypic match from another community who was demographically very different to the outbreak super spreader  Extended the super spreader’s infectious period by 6 months CDC used another method:  Provided a name list to patients of random first names with other first names of cases, particularly those who did not sign a photo release

34. ELECTRONIC MEDICAL RECORDS Allowed for further verification and identification of named contacts Able to “flag” charts of patients Streamlined gathering and sharing of clinical information and patient status

35. USING TECHNOLOGY Problem: Large amounts of information was being gathered, digesting and disseminating it was challenging  Comprehensive list of cases, contacts, and site screenings developed by Epi Aid team and based upon data base developed by Dept. of Health  Detailed case follow up  Information to action Developed Secure access portal for case follow up and sharing of current information  Controlled, secure access  Limited number of editors  Efficient communication

36. MAP OF NORTH DAKOTA

37. GENOTYPING A case from early 2012 had matching spoligotype, however greatly varied demographically and geographically  Original contact investigation for either case was unable to identify name or location epi link  New focus guided by genotyping established an epi link to the super spreader  Photo release was critical in making the link  Established a time frame for the transmission event  Extended IP of super spreader from previous estimates by 6 months  Expanded investigation CDC had this as a Minnesota case

38. NORTH DAKOTA CASES 2000 - 2013

39. TB IN NORTH DAKOTA 2002-2013

40. AGES OF OUTBREAK TB CASES

41. North Dakota Department of Health; data as of 1/25/13

42. SCREENING 1650Tuberculin Skin Tests (TST’s) Performed 69 LTBI’s Identified 53.7% of Named Contacts are LTBI’s

43. ONGOING WORK Continue to locate, refer, and follow cases, LTBI, and contacts Administer directly observed therapy (DOT) to active cases Manage social barriers to treatment compliance  Isolation for infectious cases  Housing  food  Medication and evaluation compliance Continue investigative work  Full genotyping  New case identification  Reinterviews

44. CHALLENGES  Staffing – added Field Staff & Public Health Associate  Housing - Worked with Emergency Preparedness & Response  DOT Compliance – 7 day DOT  Drug Levels – Non-Therapeutic Levels  Indian Health Services  Border States and Provinces  INH Shortage  Tubersole Shortage

45. PARTNERS The important work done and yet to do would not have been possible without the extraordinary efforts by professionals from these organizations