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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