Cross-jurisdictional Efforts to Find Contacts to MDR TB

Outbreak Among HIV-infected Homeless, New York City, 2005

Tracy AgertonDirector, Epidemiology Office

Bureau of TB Control, NYCField Services Branch, DTBE, CDC

Background1/05 - 4/05Inf. period

4/05 - 7/05Inf. period

3/05 - 6/05Inf. period

Patient CRm 510

Patient BRm 505

Patient ARm 505

Stay in Residence

A

Infectious Period

6/2004 1/2006

1/05

6/2004 1/2006

1/05

6/2004 1/2006

1/05

1/05 - 6/05

3/05 - 7/05

9/04-4/05

Infectious period: 1/11/2005-7/5/2005 for all 3 cases

BackgroundResidence A• Transitional, harm-reduction residence • Primarily HIV-infected, homeless, drug users• 5-story building ~30 years old• 40 residents, 13 on each floor• Common rooms, ate meals together• Resident rooms with 1-6 person occupancy• No mechanical ventilation• Window A/C units, but not in Patient A’s room

Contacts at Residence A

• 109 close contacts– 33 current residents– 27 staff– 49 discharged residents

Methods—Case FindingDischarged Residents

• Reviewed residence records to obtain locating information

• 3 PHAs fulltime for 2 weeks• 3 home visits attempted• Phone calls to programs/next of

kin/home/providers

• Registry searches– TB– Prison– HIV/AIDS Services Administration (HASA)– Department of Homeless Services (DHS)– HIV/AIDS Surveillance

• Letters sent to providers of record– Nature of exposure– Recommendations for evaluation and treatment– F/u for results of evaluations

Methods—Case FindingDischarged Residents

Results—Case Finding• 109 close contacts

– 33 current residents• 100% evaluated• 1 additional case identified• 50% on TLTBI

– 27 staff• 85% evaluated • 58% on TLTBI

– 49 discharged residents• 23 located and evaluated• 39% on TLTBI

Continual Case FindingDischarged Residents

• 26 discharged residents not found• Monthly registry checks

– HASA– Prison– HIV/AIDS

• November: PHRI and NJ DOH notified BTBC of Strain W case diagnosed in NJ– Discharged resident from Resident A– Homeless in NJ since June 2005

Case Surveillance and Contact Tracing Efforts Across Jurisdictions

• HAN alert (NYC: AIDS Institute, Inter- City ID Rounds, NYS DOH, NJ DOH, CDC, PR TB Control, NTCA)

• Watch list of all HIV-infected contacts (NYC TB surveillance, NYS DOH, NJ DOH)

• Continue monthly registry checks (NYC prison, DHS/HASA, TB registry, NYC death registry)– Found 1 d/c resident found through NYC death

registry match• Cause of death: metastatic esophoegeal cancer 11/05

• NYS prison search – Found 2 more d/c residents

• Both fully evaluated and on TLTBI with MXF

Summary• Extensive transmission • Rapid progression to disease• Active case finding identified one additional

MDR TB case• Home visits and contact with providers

proved effective• Registry match with HIV surveillance was

useful• Shared genotyping and outbreak information

with other jurisdictions vital

Lessons Learned• Case finding activities should be initiated in settings

for HIV-infected individuals where TB transmission is evident

• Alerts to neighboring jurisdictions should occur earlier– Confidentiality and privacy issues

• Expansion to other jurisdictions for contact tracing extremely useful– Routine information sharing around outbreaks

• Partnering with other DOHMH Bureaus (HIV, Correctional Health) very helpful

AcknowledgementsNYC DOHMH BTBC Residence A NYC DOHMH HIV/AIDSShameer Poonja Valentina DigrassoJudy SackoffCindy Driver Pedro Gonzalez Lucia TorianAnn Winters Lissette RivasRachel Wiseman Krishen Khemraj NJ TB Control PHRIDarrin Taylor Mark Wolman Barry KreisworthChristine Chuck Tom PrivettKareen JosephSonal Munsiff NYS TB ControlDiana Nilsen Margaret OxtobyFelicia StubblefieldAbari Sulayman NYC DOHMH Correctional HealthHope Campbell Woody FranklinTholief O’Flaherty Farah Parvez

Maria Gbur