Kaiser Oakland Contact Kaiser Oakland Contact InvestigationInvestigation

CTCA ConferenceMay 6th, 2010

Tara Greenhow, MDPediatric Infectious Diseases

Kaiser Permanente San Francisco

ObjectivesObjectives

Discuss recent contact investigation at Kaiser Oakland

Describe elements of the public-private collaborative response that led to successful control of the TB outbreak

– Effective communication among all partners – Willingness of all partners to share

information – Getting an early start on the collaborative

response – Coordination across multiple jurisdictions

Index CaseIndex Case

12 yo girl with Trisomy 21 admitted on 1/12/09 for tracheostomy

She was well until winter 2006-2007 when she developed hoarse voice and cough

3/07 found to have vocal cord granulomas that showed noncasseating granulomas. AFB stain (-), culture not performed

4/07 PPD (-) 4/08 laryngoscopy continued to show

noncasseating granulomas. AFB stain and culture (-)

Index CaseIndex Case

7/08 steroids started for presumed sarcoid and transiently improved

10/08 – PPD 0mm – Chest CT with mediastinal

adenopathy and bilateral opacities RUL and RML

Index CaseIndex Case

Admitted 12/31/08 – 1/6/09 for bilateral UL pneumonia– Improved on IV

and oral antibiotics

Index CaseIndex Case

4mm airwayCXR bilateral infiltrates

1/12/09 1/13 1/22 1/24

Tracheostomy and bronchoscopy AFB stain (-)

Notified AFB culture (+)Airborne precautions

AFB confirmed as MTBStarted on RIPE therapySputum obtained 1/23 AFB smear (+) with many AFBAlameda TB controller notified

Evaluation of ExposedEvaluation of Exposed

1/24/09– Contacted local TB controller – Effective early communication

• Shared the patient’s history• Discussed beginning a contact

investigation

– Open communication thru email, office number and personal cell phone

“Fourth circle” - Exposed visitors

Assess TB Exposure RiskAssess TB Exposure Risk

“Inner circle” - those

with closest contact

(family members)

“Second circle” - Exposed staff with direct contact with patient

“Third circle” - Exposed staff without direct patient contact

- Exposed patients

Evaluation of ExposedEvaluation of Exposed

“First circle” – Family - Baseline– Sister is TST (+) 25mm (Last TST 2/04) – Mom's TST is 0mm (Last TST was

negative in 5/08) – Father h/o prior (+) TST with CXR (-)– 2 cousins from Mexico living in home

last 6 months both TST (-)

Evaluation of ExposedEvaluation of Exposed

“Second circle” – – Exposed staff with direct contact with

patient including 12/31-1/6 admission and current

– Air circulation data • PICU – 17 and 12.8• Private room 20

– Identified 94 employees

Evaluation of ExposedEvaluation of Exposed

“Third circle” – – 10 exposed patients [9 PICU and 1

hospital ward] including 3 mothers • 1 prior (+) – symptom screen and CXR (-)• 8 baseline (-) TST and CXR (-)• Ages 1 ½ y – 17y, only one

immunocompromised• 1 noncompliant with baseline testing

Evaluation of ExposedEvaluation of Exposed

On 2/26 (6 weeks after exposure) social worker with brief face-to-face exposure with 20mm TST (no baseline)

Exposure broadened to include all staff working in PICU including those without direct face-to-face contact– Employees to be screened now 195

EmployeesEmployees

Total to be screened 195

Total completed screening

195

% Complete 100%

Total Conversions 7

Total Positive Questionnaires

0

Employee converters– None from prior

admission– Ranged from no

direct contact to prolonged contact with secretions

– All but one asymptomatic

EmployeesEmployees

Respiratory therapist with close contact– Baseline TST 0mm– Follow-up TST 20mm– Abnormal CXR and chest CT– Sputum obtained x 8– All smear negative, 1 culture positive with

matching genotype to index case– Contact investigation of 8 co-workers – no

conversions

Patient ContactsPatient ContactsTotal to be screened 10

Total completed screening 8

1 symptom screen

Equals 9

% Complete 9/10 = 90%

Total Conversions 1 + 1 immunocompromised

Total Positive Questionnaires

0

Case #1Case #1

3yo, CE, resident of Oakland, Alameda CountyBaseline TST 0mm. Baseline CXR normal

TST on 4/6 (2 mo after exposure) 20mmCXR with hilar adenopathy &RML infiltrate

Case #1Case #1

Admitted to Kaiser SFO on 4/6-4/9 with cough

Gastric aspirates x3 obtained. Stain (-) culture (-)

Started on 3 drug INH/Rif/PZA DOT on 4/7

S/p 6 months therapy thru 10/7 CXR on 7/27: resolution of

RML infiltrate, continued right hilar adenopathy

Case #2Case #2

9yo, FV, resident of Tracy, San Joaquin County, with underlying spinal cancer – Baseline (-) PPD, (-) QTF-G and (-) CXR– Started on INH 2/8/09– Low grade fevers and cough early 2/09, LLL

pna and symptoms resolved on cefuroxime– Mother with PPD conversion [4/1/09 20mm

(last PPD 10/08)] and so continued on INH– 4/16 chest CT showing new RLL infiltrate

Case #2Case #2

– Admitted on 4/16 to Kaiser OAK• Repeat PPD (-)

• BAL and gastric aspirates x2 obtained. All stain (-) culture (-)

• Continued on INH. Rif/PZA/Eth added on 4/16• Discharged home on 4/20

– Repeat CXR on 4/29 and 5/26 negative– Plan

• 4 drug therapy for 6 months thru 10/16• Repeat PPD and QTF-G

Identifying all visitorsMass notification of visitors

– No communication by mail – All exposed contacted by team of

internists and pediatriciansHelp of local and state TB control with

coordination among different counties (Los Angeles, San Joaquin, Napa, Alameda, San Mateo, San Francisco, etc.)

LogisticsLogistics

Distributing information and documents– FAQ– Scripts for providers– Data collection forms

Noncompliant visitors– Sharing information with TBCB with

dissemination to all counties

LogisticsLogistics

VisitorsVisitorsTotal to be screened 92

Total completed screening

77

7 symptom screen prior PPD(+)

Equals 84

% Complete 84/92 = 91%

Total Conversions 4

Total Positive Questionnaires

0

Index CaseIndex Case

4mm airwayCXR bilateral infiltrates

1/12/09 1/13 1/22 1/24 2/1 3/2 4/1 4/13 5/18

Tracheostomy and bronchoscopy AFB stain (-)

Notified AFB culture (+)

AFB confirmed as MTB

Isolate pan-sensitive

Sputum culture (-)

Sputum smear (-) x 3

Trach removed

Discharged home

Index CaseIndex Case

S/P 9 months therapy due to cavitary lesions thru 10/24

9/09 CXR with continued

opacities