1. Sheboygan County 2013 Sandy Muesegades, RN – Public Health Nurse

2. Prior to 1994 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Camp Ban Vinai, Thailand Immigrated to San Francisco, CA from Laos (2 children, no husband) TST 13mm January – Moved to Sheboygan Took 6 weeks of INH then pregnant Completed 6 months INH - Sheboygan No recall of prior TB treatment. Offered Rifampin or INH, but became pregnant Again offered INH 7x. Would follow-up in Alaska Moved to Alaska First sign of cough March 2012 Visited family for 1 month in Thailand October 2012 Moved to Sheboygan continues with Sx

3. 20122012 20132013 October 1 Moved back to Sheboygan 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 April 3 Went to clinic for depression, provider ordered CXR, cavitary lesions observed April 11 Dx with TB February 25 - March Wausau February 22 Dx with asthma by a pulmonologist February ED X2 January 4 CXR interpreted as no active TB disease

4.  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

5.  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.

6. Patient A’s House 8 kids A 9 kids Parents Adult Child Sister’s Niece’s

7.  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.

8.  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.

9.  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.

10.  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

11.  Current case count, as of October 2013  Directly Observed Therapy (DOT) and Case Management needs will continue into 2014-15. Sheboygan CountyMarathon County TB Disease10 active (1 with MDR-TB) (9 INH resistant) 1 active Latent TB Infection (LTBI) 374 Contacts tested> 600

12. 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.

13. 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.

14. SitePopulation Contacts Identified Contacts Tested 1 st Round Positive Test for infection 2nd Round Positive Test for infection 2 HospitalsStaff1581194 2 Nursing HomeStaff32300N/A 2 ClinicsStaff514310 2 FactoriesSame Shift837200 5 Grades in 3 Schools Classmates204196/10310 Close Friends-1010/911 Family and Extended family -71 234 Preliminary data as of 6/4/2013 Some 2 nd Round Testing still pending