Sheboygan County 2013
Sandy Muesegades, RN – Public Health Nurse
Completed 6 months
INH - Sheboygan
Immigrated to
San Francisco, CA from Laos
(2 children, no husband)
TST 13mm
March 2012
Visited family for 1 month
in Thailand
Again offered
INH 7x.
Would follow-up
in Alaska
Moved to Alaska
2013
2012
2011
2010
2009
2008
First sign
of cough
2007
2006
2005
2004
2003
2002
2001
2000
No recall of prior
TB treatment.
Offered Rifampin
or INH, but
became pregnant
1999
1998
1997
1996
1994
Prior to
1994
Camp Ban
Vinai,
Thailand
1995
January –
Moved to
Sheboygan
Took 6 weeks
of INH then
pregnant
October 2012
Moved to
Sheboygan
continues with Sx
January 4
October 1
Moved back to Sheboygan
2
0
1
2
October 23
Dx with Pneumonia-ED
November
Flight to Las Vegas
December 4
Dx with Pneumonia-ED
December 20
Dx bronchitis and treated for
reflux-Office
CXR interpreted as no active TB disease
2
0
1
3
February
ED X2
February 22
Dx with asthma by a pulmonologist
February 25 - March
Wausau
April 3
Went to clinic for depression, provider
ordered CXR, cavitary lesions observed
April 11
Dx with TB

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

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.
Sister’s
Parents
A
9 kids
Patient A’s House
8 kids
Adult Child
Niece’s

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.

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.

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.

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 case count, as of October 2013
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
Directly Observed Therapy (DOT) and Case
Management needs will continue into 2014-15.
TX REGIMENT MDR TB
Undetermined length of treatment.
Ethambutol, Pyrazinamide, Moxifloxacin, Linezolid,
Amikacin, and Ethionamide.
Daily Directly Observed Therapy
TX FOR INH RESISTANT TB
Cavitary (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.
CHILDREN- Rifampin Daily X6 months.
ADULTS-
Rifampin Daily X4 months or
Ethambutol and Moxifloxacin
Daily 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.
Site
Population
Contacts
Identified
Contacts
Tested
1st Round
Positive
Test for
infection
2nd Round
Positive
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 Grades
in 3 Schools
Classmates
204
196/103
1
0
Close Friends
-
10
10/9
1
1
Family and
Extended family
-
71
71
23
4