Partnerships for Success: Laboratories and Programs Meeting the Challenge. Partnerships During a TB Outbreak

Transcription

1 Partnerships for Success: Laboratories and Programs Meeting the Challenge Partnerships During a TB Outbreak 2015 National TB Conference Atlanta, GA David Warshauer, PhD., D(ABMM), Deputy Director, Communicable Diseases, Wisconsin State Laboratory of Hygiene Pa Vang, RN, MS, TB Nurse Consultant, Wisconsin Division of Public Health Tuberculosis Program Julie Tans-Kersten, MS, BS-MT (ASCP), TB Laboratory Program Coordinator, Wisconsin State Laboratory of Hygiene WISCONSIN STATE LABORATORY OF HYGIENE - UNIVERSITY OF WISCONSIN

2 Partnerships During a TB Outbreak Overview of the outbreak Program perspective of the outbreak Laboratory perspective of the outbreak Partnerships, communication, use of resources Accordance with Wisconsin Statute (7) Protecting and promoting the health and safety of the people of Wisconsin

3 Index Patient History 1994 and 1995 Immigrated to US in 1994, positive TST Completed 6 mo of INH for LTBI 1994 to Lived in WI and AK first sign of cough October 2011 to April 2012: multiple visits to health care provider and ER without definitive diagnosis Protecting and promoting the health and safety of the people of Wisconsin

4 Outline of Outbreak Events April 11, 2013 (Thursday) WI TB Program was notified of suspect TB patient. Patient has several children and large extended family. Patient isolated at hospital. April 15, 2013 (Monday) Lab confirms index patient has active TB (4+ smear, TB PCR positive). Patient started RIPE+MXF. April 16, 2013 Household contact investigation revealed additional active cases. One child is coughing. Three children have abnormal CXR and TB is suspected. All children are excluded from 2 different schools. Protecting and promoting the health and safety of the people of Wisconsin

5 Outline of Outbreak Events April 17, 2013 Index case: Molecular prediction of INH resistance INH stopped April 23, 2013 Total of 5 individuals diagnosed with active TB. April - May, 2013 Large contact investigation completed at 2 local schools. May 1, 2013 Index case: Molecular prediction of INH + rifampin resistance May 7, 2013 Index patient hospitalized and started on EMB, PZA, MXF, LZD, AMK, and ETH. Protecting and promoting the health and safety of the people of Wisconsin

6 Outline of Outbreak Events May June 2013 WI TB Program requested epidemiological assistance from CDC Epi-Aid. TB Nurse Consultants deployed to Sheboygan. June 2013 Index case transferred from hospital to Health Care Facility with negative pressure room. April -August 2013 A total of 11 secondary cases detected, 1 in a different county. Protecting and promoting the health and safety of the people of Wisconsin

7 Protecting and promoting the health and safety of the people of Wisconsin

8 Testing Time Line: Index Patient Date Result Turn-around Time (TAT) in days from receipt at WSLH 4/11/13 Diagnosis of tuberculosis 4/15/13 Smear +, TB PCR + 0 4/17/13 MDDR (CA): INH resistant 4/23/13 Culture confirmation 8 5/1/13 MDDR (CDC): INH + RIF resistant 5/2/13 Culture-based TB first-line DST 6/5, 6/6/15 Culture-based TB secondline DST WISCONSIN STATE LABORATORY OF HYGIENE - UNIVERSITY OF WISCONSIN

9 Initial MDDR Results 9

10 MDDR Results: CDC 10

11 11

12 Sheboygan Memorial Hospital Sheboygan Public Health Dept ACL (Milwaukee): smear, culture, MTD WSLH: smear, culture, TB PCR, conventional DST Marathon County Public Health Dept CDC: MDDR and Conventional second-line DST CA Public Health Lab: MDDR and conventional DST MI Public Health Lab: Genotyping 12

13 Sheboygan Memorial Hospital Sheboygan Public Health Dept ACL (Milwaukee): smear, culture, MTD WSLH: smear, culture, TB PCR, conventional DST Marathon County Public Health Dept CDC: MDDR and Conventional second-line DST CA Public Health Lab: MDDR and conventional DST MI Public Health Lab: Genotyping 13

14 14 WSLH Testing Volume, n=113 (April to July) Number of Specimens per week

15 Outbreak Patient Characteristics Clinical characteristics: Pulmonary Abnormal CXR Cavitary Lab Testing: Sputum smear-positive Sputum smear-negative PCR-positive Culture-positive MDDR + DST performed Genotyping performed Patients n (%) 12 (100) 12 (100) 3 (25) 7 (58) 3 (25) 11 (92) 12 (100) 12 (100) 12 (100) Protecting and promoting the health and safety of the people of Wisconsin

16 Fall 2013 Outline of Outbreak Events Another round of school testing is completed. November secondary cases completed tx. (PZA, EMB, AMK, MXF, LNZ) LTBI treated with Rifampin daily x 4 months DOT. July present Ongoing monitoring and case management. One close contact who completed LTBI tx and had a follow-up 6 month CXR showing abnormalities. She is currently being empirically treated for MDR-TB. TB work continues Protecting and promoting the health and safety of the people of Wisconsin

17 Evaluation of Family and Friends (Including the 10 cases dx with TB) Priority for Investigation High/Medium Risk Report Number of Contacts Identified 574 Number Evaluated 574 TB Disease 12 Window Treatment Previous Positive TST or IGRA 7 New Latent Infection ( 5 mm TST or IGRA positive) 31 Candidates for treatment of LTBI 31 Started Treatment 24 Completed Treatment n/a pending Preliminary data as of 9/25/13 Protecting and promoting the health and safety of the people of Wisconsin

18 Site Population Site-Based Screenings Contacts Identified 1 st Round 2 nd Round Contacts Tested Positive test for infection Hospital A Staff (2%) Hospital B Staff ( Clinic A Staff Contacts Tested Worksite 1 Same shift Worksite 2 Same shift School A Classmates School B Classmates School C Classmates School D Classmates Protecting and promoting the health and safety of the people of Wisconsin Positive test for infection Preliminary data as of 9/25/13

19 Activities between Partners Diagnosis of tuberculosis Identification of additional suspects/cases Logistics of specimen collection and transport Reporting, disseminating, interpreting test results Patient management Respiratory isolation Initiation of therapy Monitoring therapy Contact investigations: community, work place, schools, health care facility WISCONSIN STATE LABORATORY OF HYGIENE - UNIVERSITY OF WISCONSIN

20 Partnerships and Resources CDC Sheboygan Memorial Hospital Private Health Care Providers, Clinics ACL Laboratory Milwaukee CA Public Health Laboratory WSLH State TB Program Sheboygan Public Health Dept MI Public Health Laboratory Marathon County Public Health Dept 20

21 Specific Laboratory-Program Partnerships TB Program included WSLH in CDC Epi-Aid meetings and routine conference calls TB Program provided WSLH with information on new TB suspects and testing requested Continuous communication on specimens en-route, specimens received, quality of specimens, tests pending Optimization of specimen delivery to laboratory WISCONSIN STATE LABORATORY OF HYGIENE - UNIVERSITY OF WISCONSIN

22 Specific Laboratory-Program Partnerships Real-time summary of laboratory test results (smear, culture, PCR, MDDR, DST, genotyping) Effortless flow of information regarding testing algorithms turn-around times Test limitations Test interpretation WISCONSIN STATE LABORATORY OF HYGIENE - UNIVERSITY OF WISCONSIN

23 Challenges Delays in diagnosis of TB Submission of specimens from multiple facilities and providers Discordant test results Data management Large contact investigation 23

24 Successes Routine communication between all partners was invaluable Familiarity with partners and resources before the outbreak facilitated interactions during the outbreak Contact information Basic knowledge of roles and skills Understanding of information provided and needed Partnerships extend beyond the WSLH and TB Program to entire system 24

25 Acknowledgements Wisconsin State Lab of Hygiene Sheboygan Division of Public Health Wisconsin Division of Public Health CDC Division of Tuberculosis Elimination Mayo Clinic Center for Tuberculosis Treating clinicians Protecting and promoting the health and safety of the people of Wisconsin

26 Contact Information David Warshauer, Ph.D. D(ABMM) Deputy Director, Communicable Diseases Wisconsin State Laboratory of Hygiene Pa Vang TB Nurse Consultant WI Division of Public Health Julie Tans-Kersten Tuberculosis Laboratory Program Coordinator Wisconsin State Lab of Hygiene

27 Comments or Questions?? 27