Case Studies: Ann Kurth

Sam Clark    |    Jonathan Gorstein - Abstract    |    Jonathan Gorstein - Outline    |    Anne Marie Kimbal    |    Ann Kurth
Martina Morris    |    Beth Rivin    |    Bettina Shell-Duncan    |    Clarence Spigner    |    Joe Zunt    |    Combined

Outbreak of TB among a Social Network in Seattle, Washington

Abstract

In King County Washington a tuberculosis outbreak occurred among a group of friends and associates starting in late 2003. Most of the people affected were men of East African origin in their late teens and early twenties, most of whom came to the United States as babies or small children. Many had a history of incarceration at juvenile, adult, and INS detention facilities, and were involved in dealing and using drugs, especially marijuana and crack cocaine. The members of this group also ‘hot boxed’ (getting high in a car with the windows rolled up), which in part accounts for the high rate of transmission seen within the group. Most of these young men were homeless and couch surfed, staying in various apartments with friends for extended periods.

The index case was a twenty-one year old male from Somalia who was diagnosed with tuberculosis while in a detention facility. In late February of 2004, he complained of two weeks of fever and weight loss. A chest x-ray showed left hilar adenopathy. The source case was a twenty-year old male who came to the US from Ethiopia as an infant. He was hospitalized in early April of 2004. He had symptoms of cough, weight loss, and fever for several months. A chest x-ray revealed countless bilateral cavities and sputum smears were 4+ for acid-fast bacilli (AFB). This young man had sought treatment at an emergency department for the same symptoms in late December 2003, where a chest x-ray revealed cavitary tuberculosis. However, the diagnosis of tuberculosis was not recognized at the time, and the public health department TB control program was not notified.

Between April and September of 2004, ten more cases linked to this outbreak were found. Six of the twelve cases had cavitary tuberculosis and were 3+ to 4+ smear positive for AFB. Three of the twelve cavitary cases had normal chest x-rays two months prior to diagnosis. All eleven of these cases completed TB treatment. The twelfth case was identified as a contact early in the outbreak; he had a positive PPD and normal chest x-ray but he declined prophylactic treatment for latent TB infection in King County. He moved to another state, then became symptomatic for tuberculosis and was diagnosed there with clinical tuberculosis. He returned to King County and continued with TB treatment here. Eventually, he refused further treatment and was lost to follow-up.

In all, about 130 contacts were identified. Very few received prophylactic treatment for latent TB infection, because they have declined it. To date, no new cases have been identified in King County since September 2004, and the TB control program continues to monitor for evidence of any new cases. .

KEYWORDS::

Tuberculosis, outbreak, prophylaxis, social network, immigration, incarceration

LECTURES - OVERVIEW

WEEK 1: Intro to topic

I. Tuberculosis

• A. What is it?
• B. Why is this a priority?
• C. Transmission
• D. Prevention
  1. Isolation
  2. Treatment of active cases
  3. Identifying contacts of active cases
• E. Directly Observed Therapy (DOT)
  1. Why DOT
• F. Adherence to treatment and isolation
  1. Incentives
  2. Support
  3. Involuntary detention

What kind of evidence is needed (and available) to evaluate and address this case topic?

WEEK 2: How does institutional capacity affect the problem and the process?

II. Problem: Dealing with Latent TB infection

• A. LTBI treatment
• B. Barriers to treatment
  1. LTBI is optional
  2. “I’m not sick, so why should I take this medicine?”
  3. Over-estimation of the risks of medication side effects
  4. Long length of treatment for LTBI—9 months for self-administered treatment, 6 months for DOPT
  5. Drug and alcohol use
  6. Client fears
     • Jail/prison
     • INS/deportation
     • Government involvement
  7. Lack of funding/resources for LTBI treatment—extent of field based DOPT is very limited
  8. Cultural issues

WEEK 3: Conflicting Goals / Ethical & Human Rights Issues

• A. Solutions to these barriers
  1. Incentives
  2. Research study
  3. Social network of friends—if one comes for LTBI treatment, several come. But, if one drops out, they all drop out.
  4. Gaining trust
• B. Vulnerability to TB and TB control
• C. Human Rights issues: Patient and community responsibilities and rights
  1. Consensus documents
  2. Incarceration
• D. Ensuring adequate funding for TB control, locally = globally

READINGS & RESOURCES

Articles

Websites (public health, WHO, professional and legal associations, etc.)

Practice guidelines

Videos

LECTURES - DETAIL

WEEK 1: Intro to topic

Narrative

One Friday in April 2004, a Nurse Case Manager (NCM) at the local TB control program arrived at work, and the nursing supervisor informed her there were two new suspected cases of TB. The nurse would be assigned one of them. The NCM offered to take case of a twenty-year old male from Ethiopia. The nurse then reviewed the intake form, MD orders, ER notes, and lab work done so far. The intake form indicated the client was 4+ smear positive for AFB and was TST positive in jail one-year prior. The MD orders indicated a stat contact investigation was to be done. This request was very unusual, so the NCM looked at the chest x-ray (CXR) and report. The chest x-ray showed that the client had countless bilateral cavities.

A review of the notes also indicated the client had presented to the same hospital in late December of 2003 with cough, chest pain, fever, and weight loss. A CXR was done at the time, and it revealed likely cavitary TB. The client was discharged with a diagnosis of pneumonia and was given azithromycin and a follow up appointment in 2 weeks. The TB control program was not informed at the time. The client failed to come in for the scheduled follow up appointment.

The NCM went up to see the floor to see the client. She reviewed the chart first. It turned out the client was homeless and “couch surfed”, stayed with friends at a variety of apartments.

The nurse then went in to see the client, introduced herself, and asked if the client had any questions. He wanted to know when he could leave the hospital. The NCM let him know he could leave when the doctors had determined he was medically stable. As the client was homeless, the nurse offered to put the client up in a motel and provide food after hospital discharge. The client accepted this offer. The client and the nurse discussed that the client had been referred to the TB Control Program for treatment. The nurse gathered information from the client. He had come to the US as a baby from Ethiopia. Medical history and assessment were done. The client said he occasionally drank alcohol and smoked marijuana. He denied using other drugs. Medication teaching and DOT and TB counseling were done. DOT and TB counseling consists of discussion about DOT, isolation, importance of adherence with isolation and taking TB medications, and letting clients know up front that non-adherence with isolation and/or DOT can lead to involuntary detention.

The nurse explained the importance of identifying contacts, getting them screened, evaluated, and treated if needed. The nurse let the client know his confidentiality would be maintained. The client declined to give any contact information. The NCM spoke with the charge nurse and the shift nurse and requested that they inform all visitors to this client to follow-up with the TB clinic ASAP.

After leaving the client’s bedside, the nurse did a check of the jails in the county where the client lived and the surrounding counties. The nurse found out this client had been in jail in another county during his infectious period. The nurse informed the TB control program in that county.

Over time, the nurse was able to obtain a good rapport with the client. So, the nurse found out more information about the client; although, he never did name any contacts. He said he had traveled to Ethiopia with his family about 1½ years prior to diagnosis with active TB.

The request that the hospital staff inform any visitors who came to see the client to come into the TB clinic for evaluation was carried out and contacts started to come into the TB Clinic the following Monday. These contacts were also initially reluctant to give much information to the clinic staff. But, they said they would tell other contacts to come into the clinic.

The NCM realized she would need help with this contact investigation, so she asked the PHN and Disease intervention specialist (DIS) working on the CDC funded study for help. This collaboration would help the study obtain candidates and give these contacts a chance at a much shorter course of treatment—twelve weeks, and give an option of field based DOPT. The NCM also thought field based DOPT might lead to greater chance of identifying more contacts in this group. And, this is exactly what happened.

Many of the contacts went go to a Public Health clinic in the area where this group hung out for testing. That clinic was informed of the situation and referred contacts with positive skin tests to the TB clinic for CXRs. Nineteen days after the NCM spoke with the hospitalized client, one of these contacts came into the TB clinic, had a CXR, and turned out to have cavitary TB. This client had had a normal CXR two months prior. The NCM became concerned about the rapid progression to disease, and informed the Medical Director and Disease Control Officer (DCO).

One of the contacts was very open with the NCM and especially the study DIS and PHN. He had recently gotten out of jail and was having trouble with INS. He let them know that many members of the group “hot boxed”. Hot boxing is getting high in a car with the windows rolled up to maximize marijuana intake. This contact gave contact information about other contacts. One of the names mentioned sounded very familiar to the NCM. She figured out it was the name of a contact who was named by a case one of the other NCMs was managing. This twenty-one year old client was diagnosed and began treatment in February 2004 and completed treatment at a detention facility. It turned out he was a contact of the twenty-year old male from Ethiopia.

A few weeks after the NCM saw the twenty-year old male from Ethiopia in the hospital, another contact, who had come into the TB clinic for evaluation of positive TST, also turned out to have cavitary TB. There were other cases that were diagnosed in other medical facilities and one was diagnosed in jail. Another contact with a positive skin test that was placed and read in jail came into the TB clinic for evaluation and was diagnosed with pulmonary TB. In all, there were a total of eleven cases identified between April and September of 2004, for a total of twelve cases. Six of the cases had cavitary TB and were 3+ to 4+ sputum smear positive. One of the cases was HIV+. All of the cases who were culture positive for tuberculosis completed treatment for TB. All of the clients received field DOT. They were often difficult to find, so the outreach workers frequently had to really spend a lot of time looking for them. Most of these cases had cell phones, so the outreach workers would call them to find out where they were. One of the culture positive cases did come into the TB Clinic to get his medicine during the last part of his treatment..

One case, who was a clinical or culture negative case, was lost to follow up. A culture negative case is someone with TB symptoms, an abnormal CXR consistent with TB, negative cultures, resolution of symptoms after receiving treatment, and an improved CXR after two months of treatment. Involuntary detention is not an option in this situation because the person was never an infection risk. The risk of people not completing treatment, if they are culture negative cases, is that they may have a reactivation of illness and become infectious.

LECTURE 1

I. Tuberculosis (TB) --Tuberculosis disease and tuberculosis infection are caused by the acid fast bacillus mycobacterium tuberculosis.

• A. What is tuberculosis disease? Tuberculosis disease occurs when the TB germs of someone with latent TGB infection (LTBI) “wake up” and start to make the person sick. Tuberculosis disease can affect any part of the body except hair and nails. People are only infectious to others when they have active tuberculosis of the lungs or larynx.
• B. Tuberculosis is spread through the air when someone with tuberculosis disease in the lungs or larynx coughs, sneezes, talks, sings, etc. People around the person breath in the tuberculosis germs and can become infected and possibly develop active TB disease in the future.
• C. Prevention
  1. xiii. People with TB disease of the lungs must remain isolated from other people who have not been given the okay from the TB control program to spend time in doors with the person who is sick. This means the person with active TB must stay at home or at another designated place with no visitors. He or she cannot attend work, school, church, etc. while infectious.
  2. xiv. The person with active TB must take treatment for TB, which usually consists of isoniazid, rifampin, ethambutol, and pyrazinamide for at least 6 months and sometimes longer.
  3. xv. One of the most important parts of tuberculosis control is identifying contacts to active pulmonary TB cases and evaluating them for active and LTBI.
  4. xvi. Treatment of LTBI is optional. The treatment usually consists of 9 months of daily isoniazid self-administered. In isoniazid resistant cases, treatment may consist of daily rifampin for 4 months.

LECTURE 2

• D. Directly Observed therapy (DOT) It is recommended that people with active disease have their medicines provided to them by Directly Observed Therapy (DOT). In a DOT program, the person with active tuberculosis has medicines brought to him or her at least 5 days a week by an outreach worker, who watches the person take the medications. DOT is commonly recommended, because it is difficult to predict who will be adherent to taking TB medicines and who will not. If someone does not take TB medications, the disease will progress, the person will become more infectious, and the person will spread TB to more people. Also, if someone takes the medications for tuberculosis inconsistently, the person can develop drug resistant TB.

  Debate:

  DOT for active disease is considered standard of care, though the evidence base is mixed as to whether DOT shows more clinical benefit than self-administered therapy (see Cochrane reading). Does this raise an ethical concern about requiring all people with TB to interact with the health system, if they are capable or taking the medications consistently on their own? Does recommending DOT to all remove a sense of stigma for being singled out as “potentially non-compliant”? What about the ethical concerns of not providing DOT support, if a person with active disease stops taking treatment, develops multidrug-resistant TB, and/or continues to spread infection to others? If funds are limited for universal DOTS, how can public health systems equitably and optimally decide who needs DOT or not?

• E. Adherence
  1. xvii. Incentives are frequently used if necessary to help with adherence to treatment for clients with TB disease and with isolation. These incentives are often housing in a motel if a client is homeless, food, rental assistance, and sometimes cash.
  2. xviii. Emotional support from the Public Health Nurse (PHN) and the ORW are also very important. Being diagnosed with TB disease is often stigmatizing for clients. And, the isolation procedure can be a huge burden financially and emotionally for people.
  3. xix. If a client is non-compliant with isolation and especially taking TB medications, the Disease Control Officer can involuntarily detain a client through the court. In most counties, there is no hospital for clients to be detained in, so clients are usually detained in jail or placed on home detention with electronic monitoring.

READINGS:

2003. Trends in tuberculosis morbidity--United States, 1992-2002. MMWR Morb Mortal Wkly Rep 52:217-20, 222.

Volmink J, Garner P. Directly observed therapy for treating tuberculosis. Cochrane Database Syst Rev. 2003(1):CD003343.

Burman WJ, Reves RR. How much directly observed therapy is enough? Am J Respir Crit Care Med. Sep 1 2004;170(5):474-475.

Jasmer RM, Seaman CB, Gonzalez LC, Kawamura LM, Osmond DH, Daley CL. Tuberculosis treatment outcomes: directly observed therapy compared with self-administered therapy. Am J Respir Crit Care Med. Sep 1 2004;170(5):561-566.

Quarantine powers of health officers. http://healthlinks.washington.edu/nwcphp/wph/quarant.html

VIDEO:

RESOURCES:

Narrative:

There were a number of barriers to care with this group. Identification of contacts was difficult because many members of this group had incarceration histories at juvenile and adult detention, so they were very concerned about the health department notifying the police. Also, a few members of the group were having problem with INS, so some members of the group were worried they would be reported to INS by the health department. Several of the cases, who were diagnosed later in the out break, were very forth coming with contact information. The level of trust the members of the group had in the TB Program staff increased enormously over time.

The biggest barrier to care for the contacts was that most of them were really not interested in preventive therapy; they had other priorities in their lives. And, many of the contacts were involved in drug dealing and drug use.

One of the cases had been identified as a contact with a positive TST early in the investigation. He had obtained a CXR that was normal, but had declined preventive therapy. Two months later he became ill and was diagnosed with cavitary TB. When the NCM asked him why he had declined the preventive therapy, he said he believed he would not get sick, that it wouldn’t happen to him.

No new cases of tuberculosis have been identified since September of 2004. Monitoring by TB Control Program staff of high-risk members of the group continues. The continued surveillance includes collecting sputum on several high risk contacts with positive TSTs , who declined LTBI treatment and TST placement on a high risk contact who is TST negative and had contact with several active cases. These activities took place every six months through September of 2006, two years after the last case was diagnosed.

LECTURE 3

II. What is latent TB (LTBI)/TB infection?

Latent TB infection can occur when a person is around someone with TB disease of the lungs, has breathed in the TB germs, and become infected. The person may have a positive tuberculin skin test (TST), normal chest radiograph, and has no symptoms of active disease. People with latent TB are not infectious to others. Ten percent of latently-infected people with normal immune systems will go on to develop active TB in their lifetime. About 5% of people with latent TB infection will develop TB disease with in the first two years of becoming infected, if they do not receive treatment. Five percent more will develop TB disease at some point later in their lifetime.

• A. Treatment for LTBI usually consists of isoniazid everyday for 9 months. For contacts of active TB cases who have isoniazid resistant TB, rifampin everyday for 4 months.
• B. Barriers to LTBI treatment.
  1. i. LTBI treatment is optional.
  2. ii. Many people feel they don’t need to take medicine if they don’t feel sick
  3. iii. Many people over-estimate the risks medication side effects.
  4. iv. Treatment for LTBI is long—9 months everyday self-administered and 6 months of treatment two times a week observed therapy.
  5. v. Drug and alcohol abuse can be barriers to LTBI treatment, because of increased risk of side effects. Alcohol use increases the risk of hepatitis, and hepatitis B and C can also increase the risk of liver toxicity.
  6. vi. Many clients have fears of government involvement. They are afraid any illegal activity they may be participating in will be reported to the police by us.
  7. vii. Some undocumented clients also worry that they will be reported to INS.
  8. viii. Funding and resources for the treatment of LTBI are very limited. As a result, our ability to provide field based DOPT is extremely limited.
  9. ix. Cultural considerations (culture – within the social network, the families of origin, the larger East African immigrant community). The health department did encounter some stigmatization with the families of the TB cases. For example, the teenage sister of one of the cases was picked on at school because her older brother had TB. On the other hand, the group of friends that were exposed to the cases continued to spend time with the cases during their infectious periods even though they were aware the cases were still infectious.

Debate:

Discuss personal vs. community responsibility in supporting adherence with prophylactic treatment. What about role of systems barriers such as cultural norms and beliefs, health system, prison, immigration status, homelessness? What about role of cultural norms and beliefs, and those of the immediate social network if a cluster outbreak of socially-linked persons, as was the case here?

READINGS:

RESOURCES:

LECTURE 4

• A. Solving barriers in order to ensure both individuals and population-level health benefit
  1. i. The use of incentives can help to increase adherence with LTBI treatment. But, funding is very limited. McDonalds coupons and bus tokens are used.
  2. ii. During this outbreak, there was a CDC study taking place at this program. This study evaluated the effectiveness of 9 months of self-administered treatment or 6 months of biweekly DOPT vs. a 12 week-long ‘short course’ of one time per week INH and rifapentine. This program provided field based DOPT. The short course of treatment was much more successful than the standard regimen.
  3. iii. Some of these clients did receive clinic based DOPT. They would come into the clinic together to get their doses of medicine. When one stopped coming in, they all eventually stopped coming into the clinic (social network effect).
  4. iv. The most important thing that happened was that these clients eventually started to trust the health department staff and realized they were not going to turn them into the police or immigration. They started coming to the staff with questions about other healthcare matters. One of the clients had symptoms of schizophrenia on and off for about three years prior to diagnosis with active TB. He started to have symptoms again during treatment and told the NM about it. She was able to get him into mental health treatment, where he was diagnosed as having schizophrenia and started anti-psychotic medication. Another member of the group was exposed to a sexually transmitted disease while on treatment and came to the NM to find out what to do. She was able to get him into a clinic to be screened and treated, thus preventing transmission of another infectious disease.
  5. v. Many of King County’s East African immigrant community members face many constraints in trying to raise their children, or to adapt as first generation youth, in the Seattle/US culture. Ironically, some of the TB network clients’ general fears turned to reality when several of those involved in the outbreak were arrested for drug-related activities in spring of 2006 and were deported to their natal countries. The local Seattle papers described this as a bust of the “East African Posse”. Given the resource constraints in these settings, continued follow-up for development of active TB for these individuals is much less likely.

http://seattlepi.nwsource.com/local/266361_eastafrican12.html

LECTURE 5

• B. Global vulnerability to TB – Structural factors that are consistent across populations
  1. i. Poverty
  2. ii. Infrastructure
  3. iii. Social-cultural
  4. iv. Incarceration policies

LECTURE 6

• C. Ensuring adequate funding for TB control, locally = globally
  1. i. Advocacy campaigns

Debate:

DOT for active disease is considered standard of care, though the evidence base is mixed as to whether DOT shows more clinical benefit than self-administered therapy (see Cochrane reading). Does this raise an ethical concern about requiring all people with TB to interact with the health system, if they are capable or taking the medications consistently on their own? Does recommending DOT to all remove a sense of stigma for being singled out as “potentially non-compliant”? What about the ethical concerns of not providing DOT support, if a person with active disease stops taking treatment, develops multidrug-resistant TB, and/or continues to spread infection to others? If funds are limited for universal DOTS, how can public health systems equitably and optimally decide who needs DOT or not?

READINGS:

Lienhardt C, Rustomjee R. Improving tuberculosis control: an interdisciplinary approach. Lancet. 2006;367(9514):949-950.

McElroy PD, Rothenberg RB, Varghese R, et al. A network-informed approach to investigating a tuberculosis outbreak: implications for enhancing contact investigations. Int J Tuberc Lung Dis. 2003;7(12 Suppl 3):S486-493.

Rothenberg RB, McElroy PD, Wilce MA, Muth SQ. Contact tracing: comparing the approaches for sexually transmitted diseases and tuberculosis. Int J Tuberc Lung Dis. 2003;7(12 Suppl 3):S342-348.

Squire SB, Obasi A, Nhlema-Simwaka B. The Global Plan to Stop TB: a unique opportunity to address poverty and the Millennium Development Goals. Lancet. 2006;367(9514):955-957.

Dye C, Watt CJ, Bleed DM, Hosseini SM, Raviglione MC. Evolution of tuberculosis control and prospects for reducing tuberculosis incidence, prevalence, and deaths globally. JAMA. 2005; 293(22):2767-75.

Cultural competence in TB work

http://www.cdcnpin.org/scripts/population/culture.asp

Vulnerability and TB control

http://www.equi-tb.org.uk/uploads/tb_vulnerable.pdf

Advocacy

Deane J, Park W. Advocacy, communication and social mobilization to fight TB: a 10-year framework for action. WHO: Geneva, 2006.

http://www.stoptb.org/resource_center/assets/documents/TB-ADVOCACY.pdf

VIDEO:

Incaceration: Example of TB in Russian Prisons

http://www.pbs.org/wgbh/evolution/library/10/4/l_104_09.html

RESOURCES:

http://www.who.int/tb/publications/global_report/en/index.html

WHO Report 2006: Global tuberculosis control: surveillance, planning, financing.

International Standards for TB Care (downloadable pdf).

http://www.who.int/tb/publications/2006/istc_report.pdf

French and Spanish translations of this document will be available in 2006.

Chin J (ed). Control of Communicable Diseases Manual, 17th ed. Washington, D.C.:

American Public Health Association.

TB Behavioral and Social Science Listserv:

http://www.cdcnpin.org/scripts/listserv/tb_behavioral_science.asp

provides subscribers the opportunity to exchange information and engage in ongoing discussions about behavioral and social science issues as they relate to tuberculosis prevention and control; sponsored by the Division of Tuberculosis Elimination (DTBE) of the CDC.