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
WISCONSIN STATE
LABORATORY OF HYGIENE
1
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
WISCONSIN STATE
LABORATORY OF HYGIENE
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Initial Molecular Results
WISCONSIN STATE
LABORATORY OF HYGIENE
3
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)
WISCONSIN STATE
LABORATORY OF HYGIENE
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Discordant Molecular Results: CA
(pyrosequencing)
WISCONSIN STATE
LABORATORY OF HYGIENE
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Discordant Molecular Results: CDC
(Sanger Sequencing)
WISCONSIN STATE
LABORATORY OF HYGIENE
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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
WISCONSIN STATE
LABORATORY OF HYGIENE
7
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.
WISCONSIN STATE
LABORATORY OF HYGIENE
8
Discordant Results
• Discovery that the index patient is
infected with two strains of TB:
–INH-resistant Beijing strain
–INH and rifampin resistant
Manila strain
WISCONSIN STATE
LABORATORY OF HYGIENE
9
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.
WISCONSIN STATE
LABORATORY OF HYGIENE
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WISCONSIN STATE
LABORATORY OF HYGIENE
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WSLH Testing Volume (Specimens
per week), n=113
Number of Specimens per week
14
12
10
8
6
4
2
0
1
2
3
4
WISCONSIN STATE
LABORATORY OF HYGIENE
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
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Sheboygan
Public
Health Dept
Submitters
and Health
Care
Providers
WSLH:
smear,
culture, TB
PCR,
conventional
DST
Sheboygan
Memorial
Hospital
Local Public
Health
Departments
State TB
Program
ACL:
smear,
culture,
MTD
Marathon
County
Public
Health Dept
CDC
CDC:
MDDR and
Conventional
second-line
DST
WISCONSIN STATE
LABORATORY OF HYGIENE
CA Public
Health Lab:
MDDR and
conventional
DST
MI Public
Health Lab:
Genotyping
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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.
WISCONSIN STATE
LABORATORY OF HYGIENE
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Thank You
• Wisconsin TB Program
• Sheboygan public health Department
• Marathon County Public Health
Department
• ACL Laboratories
• St. Vincent Lab, Green Bay (800 QFTs)
WISCONSIN STATE
LABORATORY OF HYGIENE
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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
WISCONSIN STATE
LABORATORY OF HYGIENE
WSLH Laboratory
Team
Nate
Dave
Julie B.
WISCONSIN STATE
LABORATORY OF HYGIENE
Don
Youngmi and Ana
Julie TK
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