Transcript Wisconsin eHealth Initiative

Epidemiology of
Multidrug-Resistant TB
in Wisconsin
Philip Wegner
TB Nurse Consultant
October 15, 2013
Background to Multidrug-resistant
Tuberculosis (MDR-TB)


Definition: drug-resistance to at least isoniazid (INH) and
Rifampin (RIF).
Normal treatment for TB is 6-9 months but for MDR-TB,
treatment is for 18-24 months post sputum culture
conversion and usually totals 24-30 months, plus the
recommended 2-year follow-up monitoring.
“Treatment must be more aggressive in situations where the patient has long-standing disease
(years), extensive disease, or multiple previous failed treatment efforts”
-from Drug-Resistant Tuberculosis: A Survival Guide for Clinicians 2nd edition, 2008 Francis J. Curry National TB
Center in San Francisco, CA
2
Protecting and promoting the health and safety of the people of Wisconsin
Standards in MDR-TB Treatment




3
MDR-TB expertise is needed to manage each case.
More frequent laboratory collection and analysis is needed than
with non-drug-resistant TB (second-line drug susceptibilities,
therapeutic drug monitoring, longer sputum collection is
needed to assess for treatment failure).
All treatment is individually based (medications, treatment
response, monitoring and duration).
Guidelines –Francis J Curry National TB Center in San
Francisco, CA 2nd edition Drug-Resistant Tuberculosis: A
Survival Guide for Clinicians, 2008.
Protecting and promoting the health and safety of the people of Wisconsin
MDR-TB in the United States




4
MDR-TB cases are 1.3% of all cases in the U.S. between 20072012 (638 cases).
States with the highest number of MDR-TB cases are:
California (162), New York (84), Texas (74) New Jersey (45).
States with the highest percentage of MDR-TB among their TB
cases are: 1. Utah (3.6%), 2. Wisconsin (3.24%), 3. Connecticut
(3.01%), 4. Hawaii (2.08%) and New Jersey (1.92%).
MDR-TB cases are 15.7% US-born and 84.3% Foreign-born.
Protecting and promoting the health and safety of the people of Wisconsin
MDR-TB in the U.S. 2007-2012
16
11
5
1
7
162
5
4
4
74
9
6
15
5
2
1
11
14
16
1
2
12
2
1
6
45
12
D.C.
1
8
5
5
5
1
9
84
13
2
3
10
34
10
States with no MDR-TB cases (10)
States with 1-10 MDR-TB cases (27 including D.C.)
5
States with >10 MDR-TB cases (14)
MDR-TB in
Wisconsin
Bayfield
2005-2013
Iron
Douglas
Ashland
Vilas
Washburn
Sawyer
Burnett
Price
Barron
Florence
Oneida
Rusk
Marinette
Forest
Polk
Lincoln
Taylor
Langlade
Dunn
Menominee
Marathon
3
Pepin
3-Counties with 2-3 MDR-TB
62-Counties with no MDR-TB
6
2
Outagamie
Wood
Brown
Waushara
Adams
Monroe
LaCrosse
Winnebago
Marquette
Green
Lake
Juneau
Vernon
Sauk
Richland
Columbia
Grant
LaFayette
4(5)
Green
Rock
Sheboygan
Fond du Lac
3
Dodge
Dane
Iowa
Manitowoc
Calumet
Jackson
Crawford
4-Counties with 1 MDR-TB case
Door
Jefferson
Ozaukee
2-Counties with >3 MDR-TB
Portage
Trempealeau
Buffalo
Shawano
Waupaca
Washington
Pierce
Oconto
Kewaunee
Clark
Eau Claire
Waukesha
Milwaukee
Chippewa
St. Croix
7
Walworth Racine
Kenosha
Protecting and promoting the health and safety of the people of Wisconsin
Where MDR-TB has occurred in
Wisconsin
Kenosha
4%
MDR-TB -2005-2013
Marathon
13%
Fox River Valley
17%
Sheboygan
13%
Milwaukee
31%
Madison/Dane
County
22%
7
Protecting and promoting the health and safety of the people of Wisconsin
Who has MDR-TB in Wisconsin?
Country of Origin for MDR-TB cases in
Wisconsin 2005-2012
China
Burma
Nepal
India
Laos
0
8
2
4
6
8
10
12
14
Protecting and promoting the health and safety of the people of Wisconsin
16
Average Age of MDR-TB patients in
Wisconsin (Hmong and non-Hmong)
70
# of cases
60
62
50
49
40
30
23
20
10
0
All
9
Hmong
Non-Hmong
Protecting and promoting the health and safety of the people of Wisconsin
MDR-TB Indicators (to date)






10
23 MDR-TB cases between 2005-2013 (2.5/year average)
All are foreign-born and Asian (15 Hmong, 8 non-Hmong)
Average number years in U.S. before diagnosis = 9.9 years
 Hmong =12.6 years (average age = 62)
 Non-Hmong = 4.8 years (average age = 23)
8 did not complete treatment (6 current, 2 died)
91.3% pulmonary (21)
1 clinical case (4.3%) and 1 extrapulmonary (4.3%)
Protecting and promoting the health and safety of the people of Wisconsin
More MDR-TB Indicators (to date)





11
Average length of treatment is 54 months (4.5 years) –
excluding those who died, average = 42 months (3.5 years)
13 with cavitation (56.5%) indicating extensive disease
Culture-conversion average of 79 days for all;
 For those with cavitation = 71 days
 For those without cavitation = 91 days
 Excluding one patient that was re-treated = 65 days
22 culture confirmed (1 by only a bronchoscopy), 1 clinical
2 died during treatment (8.6%), average of 77 years of age
Protecting and promoting the health and safety of the people of Wisconsin