2014 WI TB Update WI TB Program Wisconsin Department of Health Services Pa Vang, RN, MSN WI TB Program TB Summit, 2014 WI TB Program Update

2014 WI TB Update WI TB Program Wisconsin Department of Health Services Disclosures None

2014 WI TB Update WI TB Program Wisconsin Department of Health Services WI TB Program Staff Lorna Will, RN, MA, Program Director Philip Wegner, RN, MPH, Nurse Consultant Pa Vang RN, MSN, Nurse Consultant Savitri Tsering, Refugee Health Coordinator Norma Denbrook, Interjurisdictional Coord Jo Mercurio, TB Program Office Assistant Michael Cooper, Milwaukee Data Management

2014 WI TB Update WI TB Program Wisconsin Department of Health Services WISCONSIN STATISTICS 4

2014 WI TB Update WI TB Program Wisconsin Department of Health Services TB Case Rates per 100,000 Population 5

2014 WI TB Update WI TB Program Wisconsin Department of Health Services † Persons identified as white, black, Asian, or of other race are all non-Hispanic. Persons identified as Hispanic might be of any race. * Persons included in this category are American Indian/Alaska Native, Native Hawaiian or other Pacific Islander, or multiple race. Data are updated as of 3/21/14 and are provisional. TB Cases by Race / Ethnicity † — United States,

2014 WI TB Update WI TB Program Wisconsin Department of Health Services CDC National Data 7

2014 WI TB Update WI TB Program Wisconsin Department of Health Services 8

2014 WI TB Update WI TB Program Wisconsin Department of Health Services TB Cases in Wisconsin by Place of Birth, U.S. or Foreign BornCountPercent of Total U.S.-Born % Foreign-Born % Total601100% 9

2014 WI TB Update WI TB Program Wisconsin Department of Health Services Tuberculosis Disease Wisconsin

2014 WI TB Update WI TB Program Wisconsin Department of Health Services 2013 Data Total cases = 50 (down 30% from 2012) Pulmonary = 37 (74%, all = 78%) Extra-pulmonary = 11 (22%, all = 26%) Both pulmonary & extra-pulmonary = 2 (4%) Children = 12% (6) Foreign-born = 29 (58%) U.S.-born = 21 (42%) MDR-TB cases = 3 (6%) 11

2014 WI TB Update WI TB Program Wisconsin Department of Health Services The Two Most Common Factors Associated with TB Disease in Wisconsin are Foreign-born And/or Known contact with someone with active TB disease 12

2014 WI TB Update WI TB Program Wisconsin Department of Health Services RISK - BASED TESTING 13

2014 WI TB Update WI TB Program Wisconsin Department of Health Services Risk - based vs.. Routine Testing Wisconsin is a low TB incidence state. Many areas of the state have not had a case of TB disease in years. Repeat testing in a low incidence area results in many false positive tests – and associated unnecessary treatment for TB infection. Risk-based testing recommended by CDC since

2014 WI TB Update WI TB Program Wisconsin Department of Health Services Implications for TB Testing Testing people in low-prevalence areas will result in a lot of false positive tests Positive tests have implications – required follow-up testing, costs (in dollars, in work, in worry) Therefore, testing on the basis of actual risk for TB is preferred in low-prevalence areas. 15

2014 WI TB Update WI TB Program Wisconsin Department of Health Services Assessing Risk Employees: questionnaire, education o Issues:  Characteristics of your workforce;  TB stigma;  Ignorance. Patients: Use risk factor list (next slides) o Although there is little TB in Wisconsin, the last generation of those routinely exposed to TB is now in our assisted living and long-term care facilities. 16

2014 WI TB Update WI TB Program Wisconsin Department of Health Services Who’s at Risk for TB Infection ? Close contacts of persons known or suspected to have active tuberculosis; Foreign-born persons from areas that have a high incidence of active tuberculosis ( e.g., Africa, Asia, Eastern Europe, Latin America, and Russia); Persons who visit areas with a high prevalence of active tuberculosis, especially if visits are frequent or prolonged; Residents and employees of congregate settings whose clients are at increased risk for active tuberculosis ( e.g., correctional facilities, long-term care facilities, and homeless shelters); 17

2014 WI TB Update WI TB Program Wisconsin Department of Health Services Who’s at Risk for TB Infection ? Health-care workers who serve clients who are at increased risk for active tuberculosis; Populations defined locally as having an increased incidence of latent M. tuberculosis infection or active tuberculosis, possibly including medically underserved, low-income populations, or persons who abuse drugs or alcohol; and Infants, children, and adolescents exposed to adults who are at increased risk for latent M. tuberculosis infection or active tuberculosis. 18

2014 WI TB Update WI TB Program Wisconsin Department of Health Services Once You Test, What Do You Do With the Results ? Handouts o Positive TST – What Next? o Positive IGRA – What Next? Local public health and state TB program happy to assist with interpretation and decisions Test with intent to treat positives – not much benefit in random TB testing result 19

2014 WI TB Update WI TB Program Wisconsin Department of Health Services LTBI TREATMENT 20

2014 WI TB Update WI TB Program Wisconsin Department of Health Services Treatment for TB Infection Treat those most likely to progress from infection to disease. Treatment available free from local public health if necessary. Usually covered by insurance. Three separate regimens available (12-week, 4- month, 9-month), plus custom regimens if persons unable to take the most common medications. 21

2014 WI TB Update WI TB Program Wisconsin Department of Health Services TB Infection Treatment options: o INH and Rifapentine, high dose, weekly via directly observed therapy X 12 weeks o INH 300 mg daily X 9 months o Rifampin 600 mg daily X 4 months o 4-drug therapy X 2 months (for patients who are strong suspects for TB disease and for whom you are awaiting culture results) 22

2014 WI TB Update WI TB Program Wisconsin Department of Health Services TB Prevention Prevention is based upon o Complete, effective, timely treatment for active disease o Complete identification of contacts to TB cases  Complete, effective, timely testing and treatment of contacts for either TB infection or disease o Risk-based testing, and subsequent treatment of TB infection, of non-contacts 23

2014 WI TB Update WI TB Program Wisconsin Department of Health Services What’s New in WI New rapid resistance testing available through CDC (must go thru State Lab and DPH) As of August 1, 2013, State Lab started performing MAC PCR on all smear positive respiratory specimens Development of a health care provider toolkit Updated State Prescription forms available on-line at: 24

2014 WI TB Update WI TB Program Wisconsin Department of Health Services What’s Next or New ? State will supply Vitamin B6 and/or multivitamins New drug for MDR TB: Bedaquiline (Sirturo™) o FDA approved 12-dose regimen (3HP) is an equal option for treatment for LTBI Community TB Control Efforts 25

2014 WI TB Update WI TB Program Wisconsin Department of Health Services Questions? 26