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. 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.

4.  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

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-resiliencehttp://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 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.

10. 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

11. 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

12. 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

13. 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

14. 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.”

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

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

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

24. 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

25. CDC A GAR P ROPORTION 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 A GAR P ROPORTION RESULTS #2  Susceptible  Ciprofloxacin 2.0 µg/ml  Ethionamide 10.0 µg/ml  PAS 2.0 µg/ml  Ofloxacin 2.0 µg/ml

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

28. 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

29. 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

30. 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.

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

36. 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.”

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