1. WISCONSIN STATE LABORATORY OF HYGIENE 1 State Lab Perspective Julie Tans-Kersten, MS, BS-MT (ASCP) Tuberculosis Laboratory Program Coordinator Wisconsin State Laboratory of Hygiene tanskejl@mail.slh.wisc.edu (608) 263-5364

2. WISCONSIN STATE LABORATORY OF HYGIENE Testing Timeline, Index Patient 4/12/13 (Saturday): sputum specimens collected 4/15/13: smear result: 4+ positive 4/15/13: TB PCR positive 4/15/13: sent sediment for MDDR testing –California Public Health Laboratory: pyrosequencing for detection of mutations that confer INH and rifampin resistance 4/23/13: Culture confirmation of MTBC 2

3. WISCONSIN STATE LABORATORY OF HYGIENE Initial Molecular Results 3

4. WISCONSIN STATE LABORATORY OF HYGIENE Testing Timeline 4/12/13: WSLH received specimens from index case ACL started receiving specimens from contacts about 1 week later Specimens from index case collected by the public health department (to WSLH) Specimens from contacts collected at community hospital (to ACL) 4

5. WISCONSIN STATE LABORATORY OF HYGIENE Discordant Molecular Results: CA (pyrosequencing) 5

6. WISCONSIN STATE LABORATORY OF HYGIENE Discordant Molecular Results: CDC (Sanger Sequencing) 6

7. WISCONSIN STATE LABORATORY OF HYGIENE Testing Timeline Learned of drug resistance and possible outbreak at about the same time 4/29/13: started receiving bloody specimens from ACL for TB PCR 5/7/13: 7 contacts with active TB, most specimens had been going to ACL 5/8/13: ACL begins forwarding specimens to WSLH 5/10/13: community hospital starts sending specimens directly to WSLH 7

8. WISCONSIN STATE LABORATORY OF HYGIENE Significance of discordant Results Sequencing of KatG locus gave “clean” results Sequencing of rpoB locus gave “heterogenous” results Genotyping for index patient was “heterogenous” Genotype results between index case and contacts did not match. 8

9. WISCONSIN STATE LABORATORY OF HYGIENE Discordant Results Discovery that the index patient is infected with two strains of TB: –INH-resistant Beijing strain –INH and rifampin resistant Manila strain 9

10. WISCONSIN STATE LABORATORY OF HYGIENE Significance of discordant Results Sequencing of KatG locus gave “clean” results Sequencing of rpoB locus gave “heterogenous” results Genotyping for index patient was “heterogenous” Genotype results between index case and contacts did not match. 10

11. WISCONSIN STATE LABORATORY OF HYGIENE 11

12. WISCONSIN STATE LABORATORY OF HYGIENE WSLH Testing Volume (Specimens per week), n=113 12

13. WISCONSIN STATE LABORATORY OF HYGIENE 13 Sheboygan Public Health Dept Sheboygan Memorial Hospital Marathon County Public Health Dept ACL: smear, culture, MTD WSLH: smear, culture, TB PCR, conventional DST CDC: MDDR and Conventional second-line DST MI Public Health Lab: Genotyping CA Public Health Lab: MDDR and conventional DST Submitters and Health Care Providers Local Public Health Departments State TB Program CDC

14. WISCONSIN STATE LABORATORY OF HYGIENE Lessons Learned It is difficult to keep track of TB suspects, test results and test volumes when specimens are submitted to multiple labs Discordant results can cause confusion and delay appropriate patient management Data management is critical (everyone has a spreadsheet). Routine conference calls were invaluable This outbreak highlights partnerships between local laboratories, WSLH, Local Public Health Departments, WI State Division of Public Health and CDC. 14

15. WISCONSIN STATE LABORATORY OF HYGIENE Thank You Wisconsin TB Program Sheboygan public health Department Marathon County Public Health Department ACL Laboratories St. Vincent Lab, Green Bay (800 QFTs) 15

16. WISCONSIN STATE LABORATORY OF HYGIENE Contact Information Julie Tans-Kersten Tuberculosis Laboratory Program Coordinator Wisconsin State Lab of Hygiene (608) 263-5364 Fax: (608) 890-2548 julie.tanskersten@slh.wisc.edu TB (Mycobacteriology) Lab: (608) 262-1618

17. WISCONSIN STATE LABORATORY OF HYGIENE 17 Dave Julie TK Julie B. Nate Youngmi and Ana WSLH Laboratory Team Don