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

Pa Vang, RN, MSNWI TB Program

TB Summit, 2014

WI TB Program Update



Disclosures• None



WI TB Program Staff Lorna Will, RN, MA, Program Director

608-261-6319 [email protected] Wegner, RN, MPH, Nurse Consultant

608-266-3729 [email protected] Pa Vang RN, MSN, Nurse Consultant

608-266-9452 [email protected] Savitri Tsering, Refugee Health Coordinator

608-267-3733 [email protected] Denbrook, Interjurisdictional Coord.

608-261-6388 [email protected] Mercurio, TB Program Office Assistant

608-266-9692 [email protected] Cooper, Milwaukee Data Management

414-286-8630 [email protected] 3

mailto:[email protected]









WISCONSIN STATISTICS

4



TB Case Rates per 100,000 Population

2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

1

2

3

4

5

6

WIUS

5



† 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, 2013

Asian31%

Hispanic28%

Black22%

White15%

Other*2%

6



CDC National Data

7



2005 2006 2007 2008 2009 2010 2011 2012 20130

10

20

30

40

50

60

Number of TB Cases in U.S.-Born vs.. Foreign-Born Persons

Wisconsin, 2005-2013

US-BornForeign-Born

Year

Num

ber o

f Cas

es

8



TB Cases in Wisconsin by Place of Birth, 2005-2013

U.S. or Foreign Born Count Percent of Total

U.S.-Born 243 40.43%

Foreign-Born 358 59.57%

Total 601 100%

9



Tuberculosis DiseaseWisconsin 2001-2013

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

10

20

30

40

50

60

70

80

90

100

WI

10



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



The Two Most Common Factors Associated with TB Disease in Wisconsin are

Foreign-bornAnd/or

Known contact with someone with active TB disease

12



RISK-BASED TESTING

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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 2005. 14



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



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



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



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



Once You Test, What Do You Do With the

Results?• Handoutso 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



LTBI TREATMENT

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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



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 monthsoRifampin 600 mg daily X 4 monthso 4-drug therapy X 2 months (for patients

who are strong suspects for TB disease and for whom you are awaiting culture results)

22



TB PreventionPrevention is based upon

oComplete, effective, timely treatment for active disease

oComplete identification of contacts to TB cases Complete, effective, timely testing and

treatment of contacts for either TB infection or disease

oRisk-based testing, and subsequent treatment of TB infection, of non-contacts

23



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: http://www.dhs.wisconsin.gov/tb/forms/index.htm 24

http://www.dhs.wisconsin.gov/tb/forms/index.htm









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



Questions?

26

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.

Documents

wi tb program update

msn wi tb program tb

case of tb disease

tb program office assistant

active tb disease

mdrtb cases

low tb incidence state

program director