Wisconsin Mycobacteriology Laboratory Network Conference

1. Wisconsin Mycobacteriology Laboratory Network Conference Tuesday, October 15, 2013

2. PRE-EXTENSIVELY DRUG RESISTANT (XDR) TB IN WISCONSIN • Marathon County • Population 134,700 • 1,545 square miles • Marathon County Health Department • 53 employees • Tuberculosis in Marathon County • 1-3 active annual cases • Case “Resilience”

3. PURPOSE OF PRESENTATION • To educate and collaborate with other professionals about my role as a public health tuberculosis case manager. Training Objectives • To increase participant knowledge of public health nurse case management role. • To tell a story and give a voice to Resilience. • To collaborate with my colleagues by answering questions and sharing knowledge & experiences.

4. TB CASE MANAGEMENT • The primary goals of TB case management are to render the client non-infectious by ensuring appropriate treatment, prevent additional transmission and development of additional disease, identify and remove barriers to adherence, and identify and address other urgent health needs. • The health department role includes case management, contact investigation, determination of infectiousness (including release from isolation and return to normal activity/locations), and oversight of treatment plan and outcome.

5. WHY RESILIENCE & NOT RESISTANCE? • “Being resilient doesn’t mean going through life without experiencing stress and pain. People feel grief, sadness, and a range of other emotions after adversity and loss. The road to resilience lies in working through the emotions and effects of stress and painful events.” • Resilience defined: “We all experience adversity, from everyday changes and challenges to serious losses. Fortunately, people are able to adapt.” • Source: http://www.pbs.org/thisemotionallife/topic/resilience/what-resilience

6. MEET RESILIENCE? • Resilience is a 69 year old Asian female living in Marathon County with limited resources. • Birthplace: Laos • Family: Eldest of 7 children • Occupation: Farmer • Spouse and Children

7. HARDSHIP AND CHANGE • Immigrated to the United States in 1990

8. THE CHAIN OF INFECTION • Resilience visited a granddaughter for 1-2 weeks in March 2012. The father-in-law to this granddaughter was diagnosed with active TB. Resilience reported she was not screened for TB as she had only a small amount of exposure and no symptoms.

9. RESILIENCE’S STORY, CONT. April 2012 - Living with and “Uncle & his wife and 4 children in Wausau for 6 months.” June 18th, 2012 - Resilience was diagnosed with right upper lobe pneumonia and put on Azithromycin. November 2012 -Follow-up chest x-ray showed improvement but not complete resolution of the infiltrate. - Resilience traveled to California via plane to stay with family. She had developed a cough and night sweats. - TST performed came back negative. No follow up or additional testing performed. February 2013 - Resilience lived on her own in 2 different apartments in Marathon County since her return from California.

10. TIMELINE • June 18, 2012 – 1st MD Office Visit • Shortness of breath with minimal exertion • Abnormal chest X-ray (patchy and linear opacity projecting over the right upper lobe, which was new from prior exam from 01/18/2004) • No fever, cough, or chills • June 19, 2012 – treated with a Z-Pak • July 31, 2012 – 2nd MD Office Visit • Continued shortness of breath with exertion • Chest X-ray ordered, but not followed up on

11. TIMELINE, CONT. • November 15, 2012 – 3rd MD Office Visit • Right breast pain x1 week • Repeat chest X-ray, which was abnormal (mild persistent infiltrate in the right upper lobe, which does not seem as prominent as on the prior exam [06/18/2012]) • Another Z-Pak ordered • April 19, 2013 – 4th MD Office Visit • Seen for elevated blood pressure • Another Z-Pak ordered

12. Timeline, cont. • July 1, 2013 – Seen in Urgent Care • Reports history of headache and cough, both which have been ongoing for a long time, with occasional productive cough • Chest X-ray, which was abnormal (right upper lobe segmental consolidation, suspected malignancy; suggested CT scan) • Sputum samples ordered for fungus, etc. • Primary provider follow-up suggested • July 9, 2013 – 5th MD Office Visit • Chronic cough and non-responsive to antibiotics. Fever, chills, body aches, general malaise, productive cough • Started on Levofloxacin

13. Timeline, cont. • July 11, 2013 – CT Scan • Significantly abnormal CT Scan (fairly extensive area of opacity involving the anterior segment of the right upper lobe) • “TB cannot be excluded” • July 19, 2013 – Pulmonary Consult • Everything completed in a negative pressure room. • Positive QuantiFERON test

14. Timeline, cont. • July 22, 2013 – Health Department Notified • Diagnostic & Treatment Center positive smears on 07/18/13 & 07/19/2013 • Client placed in isolation by Health Department • Education provided, sputum samples collected & labs • Consulted with grandchildren, masks provided • Contact investigation started • July 25, 2013 – Removed from Isolation “A patient can be presumed to have an infection with non-tuberculosis mycobacteria pending culture results, if a second specimen is smear positive and PCR negative.”

15. Definitions • Multi-drug resistant (MDR): • TB that is resistant to at least INH and Rifampin • Extensively drug resistant (XDR): • TB that is MDR • Also resistant to any fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin). • Pre XDR-TB?

16. Pre XDR-TB TB disease caused by a TB strain resistant to isoniazid and rifampin and either a fluoroquinolone or a second-line injectable drug, but not both.

17. WLSH Testing • Initial specimens received at WSLH • Referred smear POS specimen submitted from Diagnostic and Treatment Center in Weston. • Sputum specimen (DOC: 7/19/13) • 3+ smear POS at DTC • PCR negative at WSLH • Primary specimen also submitted at same time • Sputum. • Smear POS @WSLH (1-9/oil immersion field) • PCR negative

18. Culture POSITIVE • 4th Sputum specimen collected on 7/23/13 • SMEAR NEGATIVE at WLSH • MGIT tube is POS on 8/12/13 • HPLC shows M. tuberculosis Complex

19. Laboratory Testing

20. Lab Testing #2

21. MDDR Testing @ CDC • 13mm4121 • M. tuberculosis Complex reported on 8/14/13. • Sent to CDC on 8/16/13 • MDDR result received on 8/20/13

22. MDDR Testing @ CDC • Resistant to: • Rifampin • INH • Ethambutol • Kanamycin

23. MDDR Testing @ CDC • Cannot rule out resistance • PZA (Mutation detected) • Fluoroquinolone • Other injectable drugs

24. Phenotypic DST testing • Began in-house • Problematic due to presence of M. gordonae in specimen • IIRE results pending • CDC: Agar proportion testing • First and second line drugs

25. CDC Agar Proportion results • Resistance detected: • Isoniazid 0.2/1.0/5.0 µg/ml • Rifampin 1.0 µg/ml • Ethambutol 5.0 µg/ml • Streptomycin 2.0/10.0 µg/ml • Rifabutin 2.0 µg/ml • Kanamycin 5.0 µg/ml • Capreomycin 10.0 µg/ml • Amikacin 4.0 µg/ml

26. CDC Agar Proportion results #2 • Susceptible • Ciprofloxacin 2.0 µg/ml • Ethionamide 10.0 µg/ml • PAS 2.0 µg/ml • Ofloxacin 2.0 µg/ml

27. Other DST • National Jewish Hospital in Denver • MICs on individual drugs • Linezolid • Moxifloxacin • Cycloserine • Imipenem • Azithromycin • Clarithromycin

28. Timeline, cont. • August 16, 2013 – Placed back into Isolation • Positive sputum culture collected on 07/23/2013 showing Microbacterium Tuberculosis complex (WSLH specimen number 13MM4121). • September 1, 2013 – Emergency Room Visit • Ambulance • Provider & Hospital • No family in the area • Concerns about isolation • Negative pressure room

29. Timeline, cont. • September 6, 2013 – Program Manager Visit • Concerns about isolation • Nursing home? • Clan/Family • Health Department 4 visits/day x1 week, 3 visits/day ongoing; isolation surveillance checks • Family member to stay with client in the evening • September 9, 2013 – 6th MD Visit • In negative pressure room • MD against nursing home placement

30. Timeline, cont. • October 4, 2013 – 7th MD Visit • Client with increased back and leg pain. • Flu shot provided • October 16, 2013 - Update • Isolation Compliance improved • Judicare • Energy Assistance • Stable at home waiting for treatment plan and then ID will do a direct admit so a line can be placed and treatment started in the hospital.

31. TIMELINE SUMMARY • Total Primary Provider Visits: 5 • X-Rays: 4 • 06/2012 – 07/2013 before TB was suspected

32. CONTACT INVESTIGATION • Home Care employees tested 8/20 (2 adults) • Neighbor tested 8/22 (2 adults) • Wausau Family tested 8/23 negative (4 adults and 1 child) • Wausau Family tested 8/28 negative (2 adults and 4 children) • Sacramento County Family referral 8/27 (2 adults and 3 children) • Professional staff at Marshfield Clinic.

33. CONTACT INVESTIGATION, CONT. • Released from isolation 07/25/2013 – 08/14/2013 • New exposure 07/25/13 referral made to Green Bay (1 adult and 1 child) • New exposure 07/25/13 & 08/02/2013 2 staff members • Hospital visit grandson appendectomy 07/25/13 • Health Department Employee’s now asking how do we prevent further exposures to staff in the future?

34. HELPING RESILIENCE IDENTIFY WITH HER NAME • Factors that contribute to Resilience: • Close relationships with family and friends • A positive view of yourself and confidence in your strengths and abilities • The ability to manage strong feelings and impulses • Good problem-solving and communication skills • Feeling in control • Seeking help and resources

35. HELPING RESILIENCE IDENTIFY WITH HER NAME • Factors that contribute to resilience: • Seeing yourself as resilient, rather than as a victim. • Coping with stress in healthy ways and avoiding harmful coping strategies, such as substance abuse. • Helping others. • Finding positive meaning in your life despite difficult or traumatic events. • Source: http://www.pbs.org/thisemotionallife/topic/resilience/what-resilience

36. A WORD ABOUT TREATING DRUG-RESISTANT TUBERCULOSIS • “Hard data are often lacking to assist clinicians in the management of drug-resistant TB. Many of the drugs used to treat drug-resistant TB are not Food and Drug Administration (FDA) licensed for these indications. Examples include amikacin, all of the fluoroquinolones, and rifabutin. • Much-needed research is currently underway to more thoroughly document the clinical efficacies of various treatment regimens for drug-resistant TB and multidrug-resistant (MDR)-TB. Managing drug-resistant TB is extremely challenging, and national guidelines call for treatment of drug-resistant TB to be provided by or in close consultation with experts.” Source: Curry International Tuberculosis Center Tuberculosis Drug Information Guide 2nd edition

37. QUESTIONS/COMMENTS Mary Hackel, R.N., B.S.N. Public Health Nurse Marathon County Health Dept. Phone: 715-261-1945 Email:mary.hackel@co.marathon.wi.us

38. Nathan Woolever B.A. Senior Microbiologist Wisconsin State Laboratory of Hygiene Phone: 608-262-1618 Email: nathan.woolever@slh.wisc.edu