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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

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PURPOSE OF PRESENTATION To educate and collaborate with other professionals about my role as a public health tuberculosis case manager. T RAINING O BJECTIVES 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.

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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. TB CASE MANAGEMENT

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WHY RESILIENCE & NOT RESISTANCE? Being resilient doesnt 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-resiliencehttp://www.pbs.org/thisemotionallife/topic/resilience/what-resilience

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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

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HARDSHIP AND CHANGE Immigrated to the United States in 1990

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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.

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RESILIENCES STORY, CONT. April 2012 - Living with and Uncle & his wife and 4 children in Wausau for 6 months. June 18 th, 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.

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TIMELINE June 18, 2012 1 st 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 2 nd MD Office Visit Continued shortness of breath with exertion Chest X-ray ordered, but not followed up on

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TIMELINE, CONT. November 15, 2012 3 rd 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 4 th MD Office Visit Seen for elevated blood pressure Another Z-Pak ordered

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T IMELINE, 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 5 th MD Office Visit Chronic cough and non-responsive to antibiotics. Fever, chills, body aches, general malaise, productive cough Started on Levofloxacin

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T IMELINE, 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

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T IMELINE, 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.

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D EFINITIONS 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? 15

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P RE 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. 16

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WLSH T ESTING 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

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

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L ABORATORY T ESTING Specimen #DOCSmearPCRCulture 13mm41047/181-9/field (@WSLH) NEG(@WSLH)No AFB 13mm41057/193+ (@DTC)NEG(@WSLH)M. gordonae 13mm41037/22NEG (WSLH)Not doneM. tb Complex 13mm41217/23NEGNot doneM. tb Complex 13mm41487/24NEGNot doneNo AFB 13mm45238/151-9/100Not doneM. tb Complex 13mm45458/16NEGNot doneNo AFB 19

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L AB T ESTING #2 Specimen #DOCSmearPCRCulture 13mm45658/17QuestionableNot doneNo AFB 13mm45688/18NEGNot doneM. tb Complex 13mm47428/28NEGNot doneNo AFB 13mm47418/29NEGNot doneNo AFB 13mm49029/10NEGNot donePending 13mm49239/11NEGNot donePending 13mm49429/12NEGNot donePending 20

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

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MDDR T ESTING @ CDC Resistant to: Rifampin INH Ethambutol Kanamycin 22

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MDDR T ESTING @ CDC Cannot rule out resistance PZA (Mutation detected) Fluoroquinolone Other injectable drugs 23

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P HENOTYPIC 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 24

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CDC A GAR P ROPORTION RESULTS Resistance detected: Isoniazid 0.2/1.0/5.0 g/ml Rifampin 1.0 g/ml Ethambutol 5.0 g/ml Streptomycin 2.0/10.0 g/ml Rifabutin 2.0 g/ml Kanamycin 5.0 g/ml Capreomycin 10.0 g/ml Amikacin 4.0 g/ml

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CDC A GAR P ROPORTION RESULTS #2 Susceptible Ciprofloxacin 2.0 g/ml Ethionamide 10.0 g/ml PAS 2.0 g/ml Ofloxacin 2.0 g/ml

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O THER DST National Jewish Hospital in Denver MICs on individual drugs Linezolid Moxifloxacin Cycloserine Imipenem Azithromycin Clarithromycin

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T IMELINE, 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

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T IMELINE, 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 6 th MD Visit In negative pressure room MD against nursing home placement

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T IMELINE, CONT. October 4, 2013 7 th 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.

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

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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.

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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 Employees now asking how do we prevent further exposures to staff in the future?

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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

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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-resiliencehttp://www.pbs.org/thisemotionallife/topic/resilience/what-resilience

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Source: Curry International Tuberculosis Center Tuberculosis Drug Information Guide 2 nd edition 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.

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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

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