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 outbreaks2002–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 recommendationsState- September/October 2005–Noticed problem with DOT–Patient interviews revealed 3 potential sites of exposure –genotypingCDC–TB news articles in 09/30–Called State for update on issueInitial ResponseState Health Department–Communicated with county health nurse–Provided staff persons–Provided emergency funding –Requested Epi-Aid teamCDC–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 detectedAll 10 genotypes matchedArchived 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 ResponseState–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 activitiesCounty–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 advisorFederal (CDC) –Deployed field staff (2/6-6/30)–Developed Data Management systemGeographic Distribution* of Outbreak Strain—United StatesAcknowledgmentsCounty A Health DepartmentIndiana State Department of HealthCDC Division of TB EliminationCDC Experience and Epi Elective
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