G07471: The TB Strain That Keeps On Giving Case Presentation.pdfNov 21, 2019 · G07471: The TB...
Transcript of G07471: The TB Strain That Keeps On Giving Case Presentation.pdfNov 21, 2019 · G07471: The TB...
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G07471: The TB Strain That Keeps On Giving
Kelly White, MPH, CPH, DirectorTB/Refugee Health
November 21, 2019
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May 2015: It Begins
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Case A• 19-year-old male high school student
went to ER on May 22− Originally from Democratic Republic of the
Congo• Cough, chest pain, night sweats, fever,
weight loss, fatigue since January • TST 0 mm• Abnormal, cavitary CXR and CT• Sputum was >50/field, PCR +, culture +
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Case A Genotype
• G07471: Not a match to any other Indiana cases
• Genotype associated with 10 other U.S. cases in past 10 years (as of 2015)
• Six of the 10 cases were non U.S.-born:− Four of the six from Democratic Republic of
the Congo
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Summer 2015: Just Another Contact Investigation, Right?
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Contact Investigation at School
• K-12 school:− Varsity basketball team− Senior bus trip− Basketball clinic for younger children
• Identified students with shared classes, activities and set up testing onsite at school− Letters sent to everyone
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Results of CI at School• First testing event: 294 TSTs placed:
− 50 positive (17.2% positivity)• Expanded to entire school:
− Additional 308 tested − 28 more positives (9.1% positivity)
• Where else has he been?
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Other Exposure Locations
• Teenager room at large church in neighboring county
• University basketball workout session the week before diagnosis
• Travel basketball league:− Two teams− Played games throughout Indiana
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What About Family?
• Lived with adoptive mother− TST negative x 2
• Wife lived in another county− TST negative x 1
• Adoptive mother’s family− Eight total tested, all negative
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Case A CI Summary
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Transmission from Case A• 54.4% positivity among high-risk contacts
− 67.7% among school contacts• 100% positivity among seniors on class trip• 70% positivity among JV/varsity BB players
• 88.9% among travel basketball contacts• 28.9% positivity among medium-risk
contacts• 13.4% among low-risk contacts
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Secondary Cases from Case A• 17-year-old U.S.-born male
− Played basketball with Case A at school− Completed RIPE therapy
• 15-year-old U.S.-born female− Attended school with Case A− Completed RIPE therapy
• 54-year-old U.S.-born male− Worked at school − Initiated RIPE, refused after 3 months of
therapy
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February 2016: It Ends … Right?
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Case A Wrap-Up• Pansensitive• Culture conversion occurred within 2
months of RIPE therapy• Moved to another county for school
during treatment• Completed therapy February 2016
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October 2016: Encore
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Case B• 19-year-old male U.S.-born college
student• Cough, night sweats, fever, weight loss,
chills since August 2016 • Positive TST and IGRA• Abnormal, cavitary CXR and CT• Sputum was 1-10/field, PCR +, culture +
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• No known risk factors or exposure• Pansensitive• RIPE therapy initiated and completed• Contact investigation conducted at school
and home, 5 LTBI• Genotyping returned as G07471
Case B
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Link Between Case A and Case B?
• Confirmed Case B was not a listed contact to Case A
• Case B’s father was a coach in the same travel basketball league as Case A
• No confirmed direct contact between cases
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March 2017: Third Time’s a Charm?
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Case C
• 67-year-old male U.S.-born businessman• Cough and loss of appetite since
February 2017 • Indeterminate IGRA• Abnormal, non-cavitary CXR and CT• Sputum was <1/field, PCR +, culture +
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• Diabetic, immunosuppression• Pansensitive• RIPE therapy initiated and completed• Contact investigation conducted at home
and work− Single positive, his son
• Genotyping returned as G07471
Case C
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Link Between Case A and Case C?
• Confirmed Case C was not a listed contact to Case A
• Case C’s son WAS a contact to Case A− Played on same travel basketball league− Son had not been evaluated
• Case C had minimal direct contact with Case A
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November 2018: This Seems Familiar …
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Case D• 23-year-old U.S.-born female presented
to ER in November • Cough, night sweats, fever, weight loss
since July 2018• Indeterminate IGRA• Abnormal, cavitary CXR and CT• Bronchoscopy was smear +, PCR +• RIPE started
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Link Between Case A and Case D?
• Case A is her husband!− One negative TST in 2015
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• Sputum was >50/field, PCR +, culture +• Pansensitive• Genotyping returned as G07471• Patient completed 9 months of therapy
with LHD• Larger contact investigation due to
progressed disease and length of infectious period
Case D
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Case D Contact Investigation• Household contacts included husband
(Case A) and 2-year-old son• Workplace contacts • Family/social contacts
− Case A’s adoptive family that had tested negative in 2015
− Exposure at birthday party and Thanksgiving
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Case D Contact Investigation, Continued
• Case A’s repeated CT remained stable• All of Case A’s family that was
previously negative in 2015 converted− Converted due to Case D or late reaction to
Case A?• Total of 31 contacts
− Nine new LTBI − What about the son?
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December 2018: Glimpse Into the Past
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Case E• 2-year-old U.S.-born male • Son of Case A and Case D• History of seizures• TST negative, QFT positive• CXR normal • Gastric aspirate, CSF negative on smear
and culture• TB meningitis• RIPE + levo started
− Remains on treatment through LHD
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March 2019: It Keeps Going and
Going …
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Case F• 72-year-old U.S.-born female • Adoptive mother of Case A • TST negative back in 2015• Cough dating back to December 2018• IGRA positive• CXR abnormal, non cavitary• Bronchoscopy done 2/1/19 became
culture + for MTB on 3/5/19
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• Completed RIPE therapy with LHD• Sputum was smear and culture negative• Genotyping returned as G07471• Contact investigation limited to
household and family − All also contacts to Case D− No testing at workplace due to limited
infectiousness
Case F
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Whole Genome SequencingG07471 in Indiana
Results received 5/28/2019
Case ACase C
Case B
Case D
Case F
*Four clinical cases not shown
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The Future: What Does It Hold
for This Strain?
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G07471 by the Numbers
932
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G07471 Points to Ponder• Is high transmission rate due to high
infectiousness of patients or virulence of this strain?
• Why are we seeing many TST negatives among cases?
• How many more cases will Indiana see?
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Acknowledgments
• Many thanks to all public health nurses and LHDs involved in these investigations
• These investigations have had every type of setback/difficulty seemingly possible, and the staff have persevered
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Questions?