Investments in Preparedness Help Mitigate Sheboygan, WI Tuberculosis Outbreak

Submitted By

Dale Hippensteel
Sheboygan County Health and Human Services, Wisconsin
September 17, 2013

What happens when a scenic tourist destination faces a tuberculosis (TB) outbreak? Sheboygan, WI found out in the spring of 2013 when a case of TB arose in a family in this city of nearly 50,000 on the shores of Lake Michigan. Although Sheboygan County averages three active cases of TB per year, it became clear as this year’s outbreak unfolded that this would not be an average year for Sheboygan.

On April 11, Sheboygan County Health and Human Services was alerted to a case of TB in a woman who is part of a tightly-knit but economically challenged family. Upon confirmation of her case, county health officials investigated her extended family members, who were working and attending school in the community. Upon testing, many of these individuals were shown to have been infected with TB and several were found to also have active disease. Several of the younger family members were in the Sheboygan school system, requiring the county to test over 100 students in a local middle school and high school. The county activated its Incident Command Structure to respond to the enormous task of contact investigation, testing and monitoring suspected cases, implementing care for those found to be infected or ill with TB, establishing efforts to reduce further transmission, and sharing information with the community.

Further, in early May, lab reports indicated that the initial patient has multidrug-resistant TB (MDR-TB), which may require treatment with antibiotics for as many as two years to prevent the spread of this more severe strain of TB. County officials worked with a county purchasing agent to find housing for isolation, taking into consideration the family’s financial challenges. Early in the investigation, officials feared that if all the potential cases proved to have MDR-TB, the costs would escalate rapidly. The costs to isolate and treat these cases with antibiotics over two years could cost the county up to $14 million. Sheboygan County faced additional financial and legislative issues during the response. With only $200,000 budgeted for TB education and monitoring, the response to this outbreak required far more resources. Almost all of the county’s public health staff participated in the response, including overtime activities. Fifteen public health nurses’ usual work assignments and duties were shifted in an attempt to minimize TB spread, resulting in longer work days for weeks at a time. And while later tests showed that only one case was MDR-TB, nine other cases were identified as having isoniazid-resistant (INH) TB. Treatment for this strain is less costly than MDR-TB, but costs would still far exceed $200,000, given the substantial public health resource investment in providing directly observed therapy to many people for months.

Amidst the public health response, county officials worked with the state government to secure additional funding for Sheboygan County’s TB program. In addition to the public health concerns, county officials feared a drop in tourism revenue from extended media coverage of the outbreak. They worked closely with the County Administrator and Chamber of Commerce to share information about TB and to soothe fears about the outbreak. In spite of the many challenges, Sheboygan County is pleased to report that progress has been made. Only two individuals remain infectious and in isolation as of August 10, and health officials are initiating treatment of those cases found to have become infected with the TB germ. And in June, the state legislature approved an additional $4.6 million for the TB response in Sheboygan. Fortunately, the county’s training and expertise, coupled with strong partnerships, helped to prepare for the challenging response necessary to mitigate the outbreak. They were able to solicit help from local clinics and the fire department to administer tests to community members. Mutual aid agreements with neighboring public health agencies and the Centers for Disease Control and Prevention allowed other professionals to assist Sheboygan County with paperwork, tracking, and messaging.

Investments in preparedness helped Sheboygan County Health and Human Services to respond effectively to the outbreak. The partnerships already in place from years of emergency preparedness training at the state and local levels helped pull the community together quickly. Further, understanding the Incident Command System improved efficiency since officials followed their job roles and the structure, including several key people in the state capitol of Madison. Familiarity with the Wisconsin Emergency Management’s secure online E-sponder system allowed key personnel to see situation reports and track daily accomplishments. Dale Hippensteel, Division Manager and Health Officer at Sheboygan County Division of Public Health, emphasized the importance of preparedness. “Training for this type of incident helped us to be ready and coordinate,” he said.

Leave a Reply

Your email address will not be published. Required fields are marked *