Wisconsin Department of Health Services
WI TB Program Update
Pa Vang, RN, MSN
WI TB Program
TB Summit, 2014
2014 WI TB Update
WI TB Program
Wisconsin Department of Health Services
Disclosures
• None
2014 WI TB Update
WI TB Program
Wisconsin Department of Health Services
WI TB Program Staff
Lorna Will, RN, MA, Program Director
608-261-6319 lorna.will@wi.gov
Philip Wegner, RN, MPH, Nurse Consultant
608-266-3729 philip.wegner@wi.gov
Pa Vang RN, MSN, Nurse Consultant
608-266-9452 pa.vang@wi.gov
Savitri Tsering, Refugee Health Coordinator
608-267-3733 savitri.tsering@wi.gov
Norma Denbrook, Interjurisdictional Coord.
608-261-6388 norma.denbrook@wi.gov
Jo Mercurio, TB Program Office Assistant
608-266-9692 joann.mercurio@dhs.wisconsin.gov
Michael Cooper, Milwaukee Data Management
414-286-8630 michael.cooper@wi.gov
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Wisconsin Department of Health Services
WISCONSIN STATISTICS
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Wisconsin Department of Health Services
TB Case Rates
per 100,000 Population
6
5
4
WI
3
US
2
1
0
2004
2005
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2006
2007
2008
2009
2010
2011
2012
2013
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Wisconsin Department of Health Services
TB Cases by Race/Ethnicity† —
United States, 2013
White
15%
Other*
2%
Asian
31%
Black
22%
Hispanic
28%
† 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.
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Wisconsin Department of Health Services
CDC National Data
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Wisconsin Department of Health Services
Number of TB Cases in U.S.-Born vs.. Foreign-Born
Persons
Wisconsin, 2005-2013
Number of Cases
60
50
40
30
US-Born
20
Foreign-Born
10
0
2005 2006 2007 2008 2009 2010 2011 2012 2013
Year
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Wisconsin Department of Health Services
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
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100%
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Wisconsin Department of Health Services
Tuberculosis Disease
Wisconsin 2001-2013
100
90
80
70
60
50
WI
40
30
20
10
0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
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Wisconsin Department of Health Services
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%)
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Wisconsin Department of Health Services
The Two Most Common Factors Associated
with TB Disease in Wisconsin are
Foreign-born
And/or
Known contact with someone with
active TB disease
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Wisconsin Department of Health Services
RISK-BASED TESTING
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Wisconsin Department of Health Services
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.
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Wisconsin Department of Health Services
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.
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Wisconsin Department of Health Services
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.
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Wisconsin Department of Health Services
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);
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Wisconsin Department of Health Services
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.
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Wisconsin Department of Health Services
Once You Test, What Do You Do
With the Results?
• Handouts
o 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
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Wisconsin Department of Health Services
LTBI TREATMENT
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Wisconsin Department of Health Services
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, 4month, 9-month), plus custom regimens if persons
unable to take the most common medications.
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Wisconsin Department of Health Services
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 months
o Rifampin 600 mg daily X 4 months
o 4-drug therapy X 2 months (for patients who are
strong suspects for TB disease and for whom
you are awaiting culture results)
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Wisconsin Department of Health Services
TB Prevention
Prevention is based upon
o Complete, effective, timely treatment for
active disease
o Complete identification of contacts to TB
cases
 Complete, effective, timely testing and treatment
of contacts for either TB infection or disease
o Risk-based testing, and subsequent treatment
of TB infection, of non-contacts
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Wisconsin Department of Health Services
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
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Wisconsin Department of Health Services
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
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Wisconsin Department of Health Services
Questions?
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