wisconsin state laboratory of hygiene 1 state lab perspective julie tans-kersten, ms, bs-mt (ascp)...

WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE 1

State Lab Perspective

Julie Tans-Kersten, MS, BS-MT (ASCP)Tuberculosis Laboratory Program CoordinatorWisconsin State Laboratory of Hygienetanskejl@mail.slh.wisc.edu(608) 263-5364

WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

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

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WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

Initial Molecular Results

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WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

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)

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WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

Discordant Molecular Results: CA (pyrosequencing)

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WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

Discordant Molecular Results: CDC (Sanger Sequencing)

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WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

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

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WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

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.

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WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

Discordant Results

• Discovery that the index patient is infected with two strains of TB:–INH-resistant Beijing strain

–INH and rifampin resistant Manila strain

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WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

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.

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WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

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WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

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

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WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

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Sheboygan Public Health Dept

Sheboygan Memorial Hospital

Marathon County Public Health Dept

ACL: smear, culture, MTD

WSLH: smear, culture, TB PCR, conventional DST

CDC:MDDR andConventional second-line DST

MI Public Health Lab: Genotyping

CA Public Health Lab:MDDR and conventional DST

Submitters and Health Care Providers

Local Public Health Departments

State TB Program

CDC

WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

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.

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WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

Thank You

• Wisconsin TB Program• Sheboygan public health

Department• Marathon County Public Health

Department• ACL Laboratories• St. Vincent Lab, Green Bay (800

QFTs)

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WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

Contact Information

Julie Tans-KerstenTuberculosis Laboratory Program

CoordinatorWisconsin State Lab of Hygiene(608) 263-5364Fax: (608) 890-2548julie.tanskersten@slh.wisc.edu

TB (Mycobacteriology) Lab: (608) 262-1618

WISCONSIN STATE LABORATORY OF HYGIENEWISCONSIN STATE LABORATORY OF HYGIENE

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Dave

Julie TKJulie B.

Nate

Youngmi and Ana

WSLH Laboratory Team

Don