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

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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

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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 (77s) 5 7(height).
• Case ?noncompliant and uncooperative.

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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.

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CDCs 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.

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GCHDs 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.

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Outcome

• Cases 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 patients 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).

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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.

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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.

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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

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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

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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?

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Region map
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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?

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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).

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Lessons Learned

• PIO information calls not well coordinated due to
  unclear jurisdiction issues.
• Initial use of terminology uncooperative and
  non-compliant ? court order needed.

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Lesson Learned

• LHDs 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.

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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.

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Court Order Protocol
Person Identified as a Public Health Threat and
Non-Compliant
LHA write medical affidavit based on patients
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
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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
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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.