Interdisciplinary Public Health Intervention in a Multigenerational Tuberculosis (TB) Outbreak in Harris County, Texas: A Case Study with Implications for Disease Control Process Improvement and Transmission Cycle Interruption

Abstract

Background. Harris County Public Health (HCPH) is the health department for Harris County, Texas jurisdiction. Harris County as a whole is the nation's third most populous county, with 4.3 million residents, and a TB case rate more than double that of the USA. (7.6 cases per 100,000 pop). A total, 327 individuals were diagnosed with TB in Harris County during 2015, over two-thirds occurring in foreign-born individuals. In 2016, HCPH treated an immigrant female with active TB. Initial contact investigation (CI) yielded five household contacts (HHC). Two tested positive, but refused subsequent clinical evaluation by HCPH. Two months later, HCPH was notifed of a HHC hospitalized with TB. After hospital discharge, the sick HHC moved into a motel in attempts to self-isolate, but refused evaluation of additional HHC in the home, and banned home access, precluding adequate CI. After numerous phone calls, visits to motel and home, and multiple rescheduled appointments, legal action appeared inevitable. Days later, HCPH was notifed of another HHC diagnosed with active TB. Methods. With alarm regarding the family's adherence to control orders, TB staf implemented an innovative multidisciplinary team-based intervention in hopes of avoiding legal action. A site visit was paid to the motel by a local health authority, two TB staf, a county public investigator, and a refugee clinic outreach worker fuent in the family's language. Patients were presented with letters requesting immediate cooperation to avoid court flings. Questions were answered, misinformation corrected, and education provided. Results. Intermediary on-site intervention using a compassionate, frm multidis-ciplinary team approach resulted in 16 additional family members tested, yielding an infant with active TB (Case 4) and 8 with TB Infection (TBI). Isolation breaches were also discovered. Most importantly, TB transmission cycle was interrupted. Cultural and economic barriers hindering successful interaction with family were addressed, TB misconceptions corrected, and trusting relationship developed. Conclusion. This innovative multidisciplinary intervention avoided court proceedings and curtailed the TB transmission cycle. HCPH improved its non-adherence intervention process, and modified TB control orders for infectious patients residing in congregate settings.