WI TB Program Update

1. WI TB Program Update Pa Vang, RN, MSN WI TB Program TB Summit, 2014

2. Disclosures • None

3. 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

4. Wisconsin statistics

5. TB Case Rates per 100,000 Population

6. TB Cases by Race/Ethnicity† — United States, 2013 † 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. 6

7. CDC National Data

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

10. Tuberculosis DiseaseWisconsin 2001-2013

11. 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%)

12. The Two Most Common Factors Associated with TB Disease in Wisconsin are Foreign-born And/or Known contact with someone with active TB disease

13. Risk-based testing

14. 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.

15. 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.

16. Assessing Risk • Employees: questionnaire, education • Issues: • Characteristics of your workforce; • TB stigma; • Ignorance. • Patients: Use risk factor list (next slides) • 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.

17. 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);

18. 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.

19. Once You Test, What Do You Do With the Results? • Handouts • Positive TST – What Next? • 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

20. LTBI treatment

21. 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.

22. TB Infection • Treatment options: • INH and Rifapentine, high dose, weekly via directly observed therapy X 12 weeks • INH 300 mg daily X 9 months • Rifampin 600 mg daily X 4 months • 4-drug therapy X 2 months (for patients who are strong suspects for TB disease and for whom you are awaiting culture results)

23. TB Prevention Prevention is based upon • Complete, effective, timely treatment for active disease • Complete identification of contacts to TB cases • Complete, effective, timely testing and treatment of contacts for either TB infection or disease • Risk-based testing, and subsequent treatment of TB infection, of non-contacts

24. 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

25. What’s Next or New? • State will supply Vitamin B6 and/or multivitamins • New drug for MDR TB: Bedaquiline (Sirturo™) • FDA approved • 12-dose regimen (3HP) is an equal option for treatment for LTBI • Community TB Control Efforts

26. Questions?