1. Epidemiology of Multidrug-Resistant TB in Wisconsin Philip Wegner TB Nurse Consultant October 15, 2013

2. Protecting and promoting the health and safety of the people of Wisconsin 2  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. Background to Multidrug-resistant Tuberculosis (MDR-TB) “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 2 nd edition, 2008 Francis J. Curry National TB Center in San Francisco, CA

3. Standards in MDR-TB Treatment  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 2 nd edition Drug-Resistant Tuberculosis: A Survival Guide for Clinicians, 2008. Protecting and promoting the health and safety of the people of Wisconsin 3

4. 4 MDR-TB in the United States  MDR-TB cases are 1.3% of all cases in the U.S. between 2007- 2012 (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.

5. MDR-TB in the U.S. 2007-2012 States with no MDR-TB cases (10) States with 1-10 MDR-TB cases (27 including D.C.) D.C. States with >10 MDR-TB cases (14) 6 12 13 11 16 162 34 14 16 15 84 11 12 45 2 10 5 2 3 5 8 9 5 5 5 1 2 1 9 1 2 6 7 4 1 4 5 1 74 1 5

6. Protecting and promoting the health and safety of the people of Wisconsin 6 Douglas Bayfield Ashland Sawyer Washburn Burnett Polk BarronRusk Price Iron Vilas Oneida Lincoln Taylor Chippewa St. Croix Pierce Dunn Pepin Eau Claire Buffalo Trempealeau Jackson Monroe Clark Marathon Wood Portage Juneau Adams Sauk LaCrosse Vernon Crawford Richland Grant LaFayette Green Rock Dane Iowa Columbia Dodge JeffersonWaukesha Walworth Kenosha Racine Ozaukee Sheboygan Fond du Lac Green Lake Marquette Waushara Winnebago Calumet Manitowoc Kewaunee Brown Outagamie Waupaca Shawano Menom- inee Oconto Langlade Forest Marinette Florence Door Milwaukee Washington 62-Counties with no MDR-TB 4-Counties with 1 MDR-TB case 3-Counties with 2-3 MDR-TB 2-Counties with >3 MDR-TB MDR-TB in Wisconsin 2005-2013 4(5) 7 3 3 2

7. Where MDR-TB has occurred in Wisconsin Protecting and promoting the health and safety of the people of Wisconsin 7

8. 8 Who has MDR-TB in Wisconsin?

9. Average Age of MDR-TB patients in Wisconsin (Hmong and non-Hmong) Protecting and promoting the health and safety of the people of Wisconsin 9

10. MDR-TB Indicators (to date)  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 10

11. Protecting and promoting the health and safety of the people of Wisconsin 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 More MDR-TB Indicators (to date)