TUBERCULOSISOUTBREAK

Sheboygan County 2013Sandy Muesegades, RN – Public Health Nurse

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Camp Ban Vinai,

Thailand

Immigrated toSan Francisco, CA from Laos

(2 children, no husband)TST 13mm

January – Moved to

SheboyganTook 6 weeks

of INH then pregnant

Completed 6 months INH - Sheboygan

No recall of prior TB treatment.

Offered Rifampin or INH, but

became pregnant

Again offered INH 7x.

Would follow-up in Alaska

Moved to Alaska

First sign of cough

March 2012Visited family for 1 month

in Thailand

October 2012 Moved to

Sheboygan continues with Sx

TIMELINE OF INDEX CASE

2012

2013

October 1Moved back to Sheboygan

October 23Dx with Pneumonia-ED

November Flight to Las Vegas

December 4Dx with Pneumonia-ED

December 20Dx bronchitis and treated for reflux-Office

April 3Went to clinic for depression, provider ordered CXR, cavitary lesions observed

April 11Dx with TB

February 25 - MarchWausau

February 22Dx with asthma by a pulmonologist

FebruaryED X2

January 4CXR interpreted as no active TB disease

OUTLINE OF EVENTS

April 11, 2013 - The Division of Public Health was notified of a patient with suspected TB. Patient has several children.

April 15, 2013- Labs confirm this patient has active tuberculosis. She was started on Rifampin, INH, Pyrazinamide, Ethambutol, and Moxifloxacin.

April 16, 2013- Investigation of family: One child is coughing. Four children have abnormal chest x-rays. Suspect with TB in these 4 children. Children are excluded from 2 different schools.

April 17, 2013- INH resistant detected and INH stopped

OUTLINE OF EVENTS

April 22, 2013- One more school child living outside the home is identified and found to have an abnormal chest x-ray.

April 23, 2013- Total of 6 individuals Dx with active TB. Incident Command System (ICS) activated. Contact investigation continues.

May 7, 2013- MDR TB Dx in Index Case. Resistant to both INH and Rifampin. Patient hospitalized and started on Ethambutol, Pyrazinamide, Moxifloxacin, Linezolid, Amikacin, and Ethionamide.

LIKELY TRANSMISSION AMONG CASES

Patient A’s House

8 kids

A9 kidsParents

Adult Child

Sister’s

Niece’s

OUTLINEOF EVENTS

By Early May 2013- We have the MDR Index Case, 5 of her children with active TB, and 3 extended family with active TB. Total 9 cases.

May 7-10, 2013- Centers for Disease Control, Mayo Clinic, State TB Program, Sheboygan Area School District Staff, Children’s Hospital and local Medical Providers conferenced with Public Health on the treatment and contact investigation recommendations. Incident Command is expanded.

OUTLINE OF EVENTS

May 13, 2013- Local Public Health abilities have exceeded capacity. Emergency Manager brought on board.

Requested IMT (Incident Management Team) assistance.

Conference call for mutual aid assistance from State, Regional and Local Health Departments.

May 16, 2013- Emergency Operations Center (EOC) opens. E-sponder activated.

OUTLINE OF EVENTS

May 20, 2013- Conference call with state legislators, seeking appropriations from joint finance committee.

June 3, 2013- Governor Walker and Department of Health Services issue a press release in support of funding the TB outbreak.

June 4, 2013- JFC approved 4.6 million for submission in the State biennial budget.

OUTLINE OF EVENTS

June 7, 2013- The CDC Epi-Aid team reported on the investigation, felt containment was met.

June 11, 2013- Index Case transferred from hospital to Rocky Knoll Health Care Facility.

June 26, 2013- Index Case returns to private single-family home in Sheboygan.

August 2013- Another school age child (Index case’s son) Dx with active TB. Child had LTBI and progressed to active TB. An additional active case was detected in Marathon County, Wausau, as well as, 4 new LTBI contacts.

September 2013- Another round of school testing concluded

CURRENT SITUATION Current case count, as of October 2013

Directly Observed Therapy (DOT) and Case Management needs will continue into 2014-15.

Sheboygan County Marathon County

TB Disease 10 active (1 with MDR-TB)(9 INH resistant)

1 active

Latent TB Infection (LTBI) 37 4

Contacts tested > 600

TREATMENT REGIMENTSFOR ACTIVE TB

TX REGIMENT MDR TBUndetermined length of treatment.

Ethambutol, Pyrazinamide, Moxifloxacin, Linezolid, Amikacin, and Ethionamide.

Daily Directly Observed Therapy

TX FOR INH RESISTANT TBCavitary (9 months) Non-Cavitary (6 months)Ethambutol, PZA, Moxifloxacin, and Rifampin.5-day a week Directly Observed Therapy Self-administered on weekends.

Treatment is extended if self-administered on weekends.

TREATMENT REGIMENTSFOR LTBI

CHILDREN- Rifampin Daily X6 months.

ADULTS- Rifampin Daily X4 months or

Ethambutol and MoxifloxacinDaily X6 months.

5-day a week Directly Observed Therapy Self-administered on weekends.Treatment is extended if self-administered on weekends.

All LTBI’s will have chest x-rays every 6 months for 2 years.

SHEBOYGANSITE-BASED SCREENINGS

Site PopulationContacts

IdentifiedContacts

Tested

1st RoundPositive Test for

infection

2nd RoundPositive Test for

infection

2 Hospitals Staff 158 119 4 2

Nursing Home Staff 32 30 0 N/A

2 Clinics Staff 51 43 1 0

2 Factories Same Shift 83 72 0 0

5 Gradesin 3 Schools

Classmates 204 196/103 1 0

Close Friends - 10 10/9 1 1

Family and Extended family

- 71 71 23 4

Preliminary data as of 6/4/2013Some 2nd Round Testing still pending