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Rural Indiana Outbreak County/State and CDC Response

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Rural Indiana Outbreak County/State and CDC ResponseSlide 2Indiana Small Rural CountyRecent outbreaksTB Cases—County A, 1999–2004Do we have a problem?Initial ResponseCDC Epi- Aid Team Pre-Investigation Data October 2005TB Cases—County A, 1999–2005Outbreak-Related Cases, 1999–2005 (N=23)Outbreak ResponsePatient Characteristics (N=23)Disease Characteristics (N=23)Risk FactorsPublic Health ImpactOngoing activitiesGeographic Distribution* of Outbreak Strain—United StatesAcknowledgmentsRural Indiana Outbreak County/State and CDC ResponseShameer Poonja MPHCDC AssigneeIndiana State Department of HealthTB ProgramTB Incidence—United States, 2005>3.5 cases per 100,000<3.5 cases per 100,000Indiana Small Rural CountyRecent outbreaks2002–School setting –linked to four secondary cases. One additional case linked to previous investigation in 1990’s.–Social setting-four cases genetically linked to past case in three other counties.2003–African American Community•25 cases in clusterTB Cases—County A, 1999–20041999 2000 2001 2002 2003 2004 2005Do we have a problem?County- Spring 2005 –Noticed increase in cases –Placed call to state for recommendationsState- September/October 2005–Noticed problem with DOT–Patient interviews revealed 3 potential sites of exposure –genotypingCDC–TB news articles in 09/30–Called State for update on issueInitial ResponseState Health Department–Communicated with county health nurse–Provided staff persons–Provided emergency funding –Requested Epi-Aid teamCDC–Epi-Aid team arrives 11/9/05 -12/16/05 to re-interview, identify additional sites of exposure, screening contacts–10/06 Requested (1999-2004) isolates be sent for genotypingCDC Epi- Aid Team Pre-Investigation DataOctober 2005 10 cases detectedAll 10 genotypes matchedArchived isolate (1999–2004) genotypes matchedTB Cases—County A, 1999–20051999 2000 2001 2002 2003 2004 2005Outbreak-relatedNot outbreak-related1999 2000 2001 2002 2003 2004 2005Genotype-matched and epi-linkedOutbreak-Related Cases, 1999–2005 (N=23)Genotype-matched onlyEpi-linked onlyOutbreak ResponseState–Continued to have staff available to interview, provide education–Medical residents–Pulmonary and ID consultation–Press release CDC–Reviewed patient records–Interviewed patients diagnosed in 2005 and their contacts–Reviewed national TB genotyping dataPatient Characteristics (N=23)Characteristic nMedian age (range) 46 years (4–70)Male 17White and US-born 23HIV-infected 0Diabetes 8Heavy alcohol use 18Methamphetamine use 1Disease Characteristics (N=23)Characteristic nPulmonary 22 Cavitary 15 Smear positive 17Culture positive 20 Drug susceptible 20Fatal 2Risk Factors Delay (>60 days) n/N median (range)Diagnosis 11/18 135 days (74–389)Smear conversion 9/12 94 days (62–210)Culture conversion 10/15 96 days (63–141)Public Health ImpactContacts 109 LTBI25 (23%)Treatment Initiated 19 (76%)Additional Contacts 226 + 294 = 520 LTBI25 + 24 = 49 Treatment Initiated 41 (84%)Ongoing activitiesCounty–Hired and trained additional staff–Establish ½ day TB clinic State–Reorganization and build linkages with other programs–Resources (EPI, 2 Regional RN)–Requested public health advisorFederal (CDC) –Deployed field staff (2/6-6/30)–Developed Data Management systemGeographic Distribution* of Outbreak Strain—United StatesAcknowledgmentsCounty A Health DepartmentIndiana State Department of HealthCDC Division of TB EliminationCDC Experience and Epi Elective


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