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Galveston County Health District Perspectives on Handling TB Aboard a Cruise Line

Galveston County Health District Perspectives on Handling TB Aboard a Cruise Line Contributors: Dana Beckham, DVM H. Mark Guidry, MD, MPH Cassandra Arceneaux, MD, MPH Syed Haidry, MD, MPH Case Scenario

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Galveston County Health District Perspectives on Handling TB Aboard a Cruise Line

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  1. Galveston County Health District Perspectives on Handling TB Aboard a Cruise Line Contributors: Dana Beckham, DVM H. Mark Guidry, MD, MPH Cassandra Arceneaux, MD, MPH Syed Haidry, MD, MPH

  2. Case Scenario • June 29, 2007 GCHD was notified by CDC of a highly suspected TB case on board a cruise line. • Case boarded from Galveston on Sunday, (6/24) for 7 day cruise and return on Sunday (7/1) am. • Suspect has HX of alcohol and nicotine abuse; weighs 35 kilos (77#s); 5’ 7”(height). • Case noncompliant and uncooperative.

  3. Case Scenario • Case presented to infirmary with (V/D); placed in isolation, then released. • Later presented to infirmary with coughing, sweats, wt. loss, bloody sputum. • Ships radiographs revealed right apical lung cavitation.

  4. CDC’s Plan of Action • CDC notified Border Patrol, Coast Guard, DSHS-Austin. • Start contact investigation. • Recommend N-95 mask or above for PPE. • CDC initial plan: voluntarily quarantine, but if not, recommend local/state to enforce quarantine pending confirmation of TB.

  5. GCHD’s Plan of Action • Notify internal (LHA, TB, EMS, PIO) and external partners (UTMB, DSHS-Region, Co. Judge & Legal). • Coordinate logistics of transport – Ship to UTMB. • Determine residency of case & notify appropriate health authority. • Provide technical assistance if out of county jurisdiction. • Determine best way to prevent “uncooperative and noncompliant” case from exposing others.

  6. Outcome • Case’s Residence in Howard County, DSHS Region 9/10. • Email and telephone communications: DSHS (CO, Reg. 6/5S & 9/10), GCHD, ship MD, CDC, UTMB. • Question on pursing court-order to quarantine patient • Security clearance to enter ship. • Correction on patient’s disposition: compliant and cooperative (“did not have a good grasp on basic health issues”). • Contact tracing: 8 exposed (3 stewards, 5 medical, 1 travel companion).

  7. Outcome (continued) • Case stayed in room. • Travel companion declined PPD pending DX. • Air circulation flow outside. • Consider number of exposures when boarding, standing in line, and also prior to boarding.

  8. Outcome (continued) • Ship MD did PPD test on 8 staff: • For 4 (+) tests, GCHD suggested Chest X-ray and LTBI Treatment, per CDC guidelines. • GCHD-TB/EMS, DSHS regional, CDC met ship Sunday am (7/1). • Region issued health authority letter to case. • GCHD assured safe transport to hospital and follow-up with UTMB MDs.

  9. Outcome (continued) • UTMB Evaluation • AFB X 3 = negative • PPD = negative • X-ray = cavitary lesion near mass • CT scan = cystic cavities (most consistent w/ infectious process - TB or necrotizing pneumonia) • TB eventually ruled out

  10. Issues • Weekend; case on ship and isolated; CDC temp. confine case. • International issues who is the authority. • Person on cruise ship in water w/ infectious disease not Galveston County resident. • Role of GCHD, State, CDC • Email communication (GCHD server down). • Confusion on terminology: court order versus Local Health Authority letter. • Confusion on who should issue the order. • Turned out to be LHA letter

  11. What if? This Howard County resident left Galveston county (against advice of health authority letter) and began driving back to Howard County…. Question 1: How many counties would she cross in her drive back home? How many stops for gas, food, water, or hotel accommodations?

  12. Region map

  13. What if? Suppose the Howard County resident drove to Hobby Airport or Bush Intercontinental (Harris County) to fly back…. Question 2: How many passengers in how many states throughout the country might be expose?

  14. Jurisdictional Interest/Authorities • GCHD – residents of Galveston County. • DSHS – residents of Texas – multiple counties (254). • CDC – residents of US – multiple states (50) or other countries in the world (international).

  15. Lessons Learned • PIO information calls not well coordinated due to unclear jurisdiction issues. • Initial use of terminology “uncooperative and non-compliant”  court order needed.

  16. Lesson Learned • LHD’s are not funded for cost of responding to health threats of state, national, or international interest (e.g., personnel, law enforcement for 24/7 if order is issued, supplies, transport, etc.). • CDC was reluctant to quarantine on ship until a local court order could be obtained. • There was confusion between a LHA letter vs. a court-ordered quarantine (which one has the enforcement authority?). • Local Quarantine process is not immediate and more challenging on weekend.

  17. Local Health Authority Letter • A notice given to case. • Include statement of case being infected or highly suspected of being infectious to others & why. • Informs case on recommended action (e.g., get treatment at….). • Informs case of consequences if recommendations not followed (e.g., penalties & court-ordered quarantine). • Does NOT have enforcement authority from law enforcement.

  18. Court Order Protocol Person Identified as a Public Health Threat and Non-Compliant LHA write medical affidavit based on patient’s medical chart Medical affidavit sent to DSHS for commissioner/designee Agree Disagree Stop Issue a concurrence & designate facility/ies to confine patient for temp. and long term TX County Legal review Judge set date and time for court hearing LHA testify Judge makes decision to sign and issue order to temporarily confine patient Law enforcement is ordered to enforce temporary court-order

  19. Court Order Protocol contd. Long Term confinement Patient gets an attorney Judge sets hearing Agree to Trial Waive Right to Trial Set trial, pick jurors, set date Judge issue order for long term TX facility decided upon by DSHS Outcome depends on verdict Patient transported from temp facility to long term facility

  20. Unresolved Issues • Best way to quickly obtain a court-ordered quarantine for a “uncooperative” person on a weekend who resides in an outside county. • County legal questioned if Judge would issue court order for person out of jurisdiction. • If quarantine on ship; ship needs to leave dock? • If LHA initiates & acquires a court-ordered quarantine on a resident of another county, there are fiscal and legal implications… cost, lawsuits, open records requests, etc.

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