@JENNIFERGARDY

Using genomics to declare the end of a

TB outbreak

We handle ~300 TB cases each year.

One of our key strategies for stopping TB in BC is

UNDERSTANDING TRANSMISSION

~90-BED SHELTER & MEAL CENTRE

FRIENDSHIP CENTRE

DROP-IN CENTRE

PUB

DAY LABOUR AGENCY

outbreak

12a2B

3in summer 2011, we sequenced the tb genomes from the 33 outbreak cases that had occurred to date.

CASE 1, MAY 2008

CASE 5, DEC. 2008

CASE 2, JUNE 2008

WE FORGOT ABOUT WITHIN-HOST GENETIC DIVERSITY

IF YOU’RE GOING TO FACEPALM,

DO IT WITH (SMART) FRIENDS.

THE TRANSPHYLO METHOD (code.google.com/p/transphylo/)

USES BAYESIAN PHYLOGENETICS IN THE CONTEXT OF WITHIN-HOST GENETIC DIVERSITY .

USE BEAST TO BUILD A POOL OF TIME-LABELLED PHYLOGENIES AND USE TRANSPHYLO TO IDENTIFY AND TIME TRANSMISSION EVENTS.

BACK-CALCULATE THE SET OF PERSON-TO-PERSON TRANSMISSION EVENTS THAT COULD HAVE GIVEN RISE TO THE SUITE OF OBSERVED PHYLOGENIES.

AND REFINE THE NETWORK WITH WHATEVER EPIDEMIOLOGICAL DATA WE HAVE.

by 2014, the outbreak had grown to 52 cases and 2310 screened clients.

COULD THE OUTBREAK BE DECLARED OVER?2008 2009 2010 2011 2012 2013

7 7

11 12

86

1

outbreak

hangover

IN LATE 2014, WE SEQUENCED ADDITIONAL OUTBREAK GENOMES.

TRANSMISSION ENDED ~2012. THE OUTBREAK IS OVER.

MEMO

Bus: (250) 868-7818 Fax: (250) 868-7826 Kelowna Health Centre Email: sue.pollock@interiorhealth.ca 1340 Ellis Street www.interiorhealth.ca Kelowna, BC V1Y 9N1

Quality y Integrity y Respect y Trust

In 2008, an outbreak of Mycobacterium Tuberculosis (TB) was declared after a higher-than-expected number of TB cases were identified in the Central Okanagan. Between 2008 and 2014, 52 outbreak-related active TB cases were identified. Most cases were homeless and/or street-involved persons in Kelowna with a small linked cluster in Penticton, and several cases in Salmon Arm. Interior Health’s TB Outbreak Management Team, in partnership with community organizations and the BC Centre for Disease Control have used numerous strategies to identify and treat new cases and to minimize the public health risk. Epidemiological and genomics (genetic fingerprinting) data demonstrate that the peak of the outbreak occurred in late 2010/early 2011. There is currently no evidence of ongoing transmission and incidence of new TB cases has returned to baseline (pre-outbreak) levels.

The Central Okanagan TB outbreak is declared over as of January 29, 2015. We expect to see sporadic new TB diagnoses connected to the outbreak in the coming years; early detection of these cases will be critical to preventing another outbreak. The CD Unit will disseminate further information about next steps as the outbreak response is de-escalated. Outbreaks of TB among homeless persons are strongly related to social determinants of health such as employment, income, safe housing, and access to health care. Preventing and controlling future outbreaks requires continued attention to these inequities through comprehensive policies and programs that aim to reduce health disparities in our community. On behalf of the Office of the Medical Health Officers, we thank each of you for your hard work and collaboration in controlling this outbreak and for your continued dedication to TB prevention and control. If you have any questions, please contact the Communicable Disease Unit at 1-866-778-7736 or by email CDUnit@interiorhealth.ca.

To: CIHS Promotion & Prevention; Infection Control, Workplace Health & Safety, KGH Administrators, PRH Administrators, Senior Executive Team, CD Unit

From: Dr. Sue Pollock, Medical Health Officer & Medical Director, Communicable Disease

Date: February 4, 2015

RE: Central Okanagan TB Outbreak Declared Over

VARIOUS LESSONS LEARNED

I will not have uncleansed coffee cups in Pear Tree Productions.

The plague started from a mal-attended surface.

Let me tell you something about the Titanic, people forget, people forget that on the Titanic's maiden voyage there were over 1000 miles of uneventful, very pleasurable cruising before it hit the iceberg!

THANKS!