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State Lab Perspective

State Lab Perspective. Julie Tans-Kersten, MS, BS-MT (ASCP) Tuberculosis Laboratory Program Coordinator Wisconsin State Laboratory of Hygiene tanskejl@mail.slh.wisc.edu (608) 263-5364. Testing Timeline, Index Patient. 4/12/13 (Saturday): sputum specimens collected

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State Lab Perspective

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  1. State Lab Perspective Julie Tans-Kersten, MS, BS-MT (ASCP) Tuberculosis Laboratory Program Coordinator Wisconsin State Laboratory of Hygiene tanskejl@mail.slh.wisc.edu (608) 263-5364

  2. Testing Timeline, Index Patient • 4/12/13 (Saturday): sputum specimens collected • 4/15/13: smear result: 4+ positive • 4/15/13: TB PCR positive • 4/15/13: sent sediment for MDDR testing • California Public Health Laboratory: pyrosequencing for detection of mutations that confer INH and rifampin resistance • 4/23/13: Culture confirmation of MTBC

  3. Initial Molecular Results

  4. Testing Timeline • 4/12/13: WSLH received specimens from index case • ACL started receiving specimens from contacts about 1 week later • Specimens from index case collected by the public health department (to WSLH) • Specimens from contacts collected at community hospital (to ACL)

  5. Discordant Molecular Results: CA (pyrosequencing)

  6. Discordant Molecular Results: CDC (Sanger Sequencing)

  7. Testing Timeline • Learned of drug resistance and possible outbreak at about the same time • 4/29/13: started receiving bloody specimens from ACL for TB PCR • 5/7/13: 7 contacts with active TB, most specimens had been going to ACL • 5/8/13: ACL begins forwarding specimens to WSLH • 5/10/13: community hospital starts sending specimens directly to WSLH

  8. Significance of discordant Results • Sequencing of KatG locus gave “clean” results • Sequencing of rpoB locus gave “heterogenous” results • Genotyping for index patient was “heterogenous” • Genotype results between index case and contacts did not match.

  9. Discordant Results • Discovery that the index patient is infected with two strains of TB: • INH-resistant Beijing strain • INH and rifampin resistant Manila strain

  10. Significance of discordant Results • Sequencing of KatG locus gave “clean” results • Sequencing of rpoB locus gave “heterogenous” results • Genotyping for index patient was “heterogenous” • Genotype results between index case and contacts did not match.

  11. WSLH Testing Volume (Specimens per week), n=113

  12. Submitters and Health Care Providers Sheboygan Public Health Dept WSLH: smear, culture, TB PCR, conventional DST Local Public Health Departments Sheboygan Memorial Hospital State TB Program ACL: smear, culture, MTD CDC Marathon County Public Health Dept CDC: MDDR and Conventional second-line DST MI Public Health Lab: Genotyping CA Public Health Lab: MDDR and conventional DST

  13. Lessons Learned • It is difficult to keep track of TB suspects, test results and test volumes when specimens are submitted to multiple labs • Discordant results can cause confusion and delay appropriate patient management • Data management is critical (everyone has a spreadsheet). • Routine conference calls were invaluable • This outbreak highlights partnerships between local laboratories, WSLH, Local Public Health Departments, WI State Division of Public Health and CDC.

  14. Thank You • Wisconsin TB Program • Sheboygan public health Department • Marathon County Public Health Department • ACL Laboratories • St. Vincent Lab, Green Bay (800 QFTs)

  15. Contact Information Julie Tans-Kersten Tuberculosis Laboratory Program Coordinator Wisconsin State Lab of Hygiene (608) 263-5364 Fax: (608) 890-2548 julie.tanskersten@slh.wisc.edu TB (Mycobacteriology) Lab: (608) 262-1618

  16. WSLH Laboratory Team Nate Youngmi and Ana Dave Don Julie B. Julie TK

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