Tuberculosis by S4MCu46


									       EPID 600 - Introduction to Public Health (On-Line 2012)
       Communicable Diseases of Public Health Importance

               An Old Disease – New Twists
            A Continuing Public Health
Jane Moore, RN, MHSA
Director, TB Control & Prevention Program
      Tuberculosis – Old Disease
• May have evolved from M bovis; acquired by humans from
  domesticated animals ~15,000 years ago
• Endemic in humans when stable networks of 200-440 people
  established (villages) ~ 10,000 years ago; Epidemic in Europe
  after 1600 (cities)
• 354-322 BC - Aristotle – “When one comes near
  consumptives… one does contract their disease… The reason
  is that the breath is bad and heavy…In approaching the
  consumptive, one breathes this pernicious air. One takes the
  disease because in this air there is something disease
• 1882 – Robert Koch – “one seventh of all
  human beings die of tuberculosis and… if one
  considers only the productive middle-age
  groups, tuberculosis carries away one-third
  and often more of these…”
M tuberculosis as causative
  agent for tuberculosis

           Robert Koch
      TB in the US – 1882-2010
• 1900-1940 TB rates decreased in the US and
  Western Europe before TB drugs available
  – Better nutrition, less crowded housing
  – Public health efforts
     • Earlier diagnosis
     • Limit transmission to close contacts
  – TB sanatoria
  – Surgery
      TB in the US – 1882-2010
• 1940s-1960s TB specific antimicrobial agents
  – Single drugs – use produced resistance
  – Multiple drugs
• 1960s-1980s TB considered a non-problem
  – TB treatment moved to private sector
  – Loss of TB-specific public health infrastructure
         TB in the US – 1882-2011
• 1990s TB re-emerges as a threat
  – TB-HIV co-infection
  – Drug-resistant TB
  – Globalization allows TB to travel
• 1990s Increased support for TB prevention and
  – Funding for public health efforts (case management,
    contact investigation, directly observed therapy
  – Better diagnostic and patient management tools
• 2010
  – Lowest number of reported cases in US
  – Funding declining
                     TB in the US
• 2011 Continuing needs
   – Continued support for TB prevention/control especially
     with health care reform
   – New drugs and/or drug combinations to allow shorter
     courses of treatment
   – Shorter, simpler, less expensive treatment regimens
   – Vaccine (beyond BCG)
   – Support for global TB prevention and control activities
      • Rapid diagnostic tests for limited resource settings
      • Better co-ordination of TB and HIV
        prevention/treatment programs
      • Reliable access to TB drugs
TB: Airborne Transmission
TB Invades/Infects the Lung

                Effective immune

                      Infection limited
                      to small area of lung

                  Immune response
TB – A Multi-system Infection
     Natural History of TB Infection
            Exposure to TB

  No infection           Infection
  (70-90%)               (10-30%)

Latent TB                          Active TB
 (90%)                             (10%)

Never develop
Active disease                Untreated          Treated

         Die within 2 years      Survive
                                               Die   Cured
            Latent TB vs. Active TB
Latent TB (LTBI) (Goal = prevent future active disease)
   = TB Infection
   = No Disease

Active TB (Goal = treat to cure, prevent transmission)
  = TB Infection which has
        progressed to TB Disease
  = SICK (usually)
  = NOT INFECTIOUS if not PULMONARY (usually)
• Most TB is curable, but…
   – Four or more drugs required for the simplest regimen
   – 6-9 or more months of treatment required
   – Person must be isolated until non-infectious
   – Directly observed therapy to assure adherence/completion
   – Side effects and toxicity common
       • May prolong treatment
       • May prolong infectiousness
   – Other medical and psychosocial conditions complicate
       • TB may be more severe
       • Drug-drug interactions common
                         TB in Virginia: 1990-2011
Number of Cases




                        1990   1993   1996   1999   2002   2005   2008   2011

       TB Case Rate per 100,000 VA and
                US: 2007-2011
Year       Virginia TB   Virginia TB   US TB Cases   US,521TB
           Cases         Rate                        Rate

2007       309           4.0           13,280        4.4

2008       292           3.8           12,906        4.2

2009       273           3.5           11,545        3.8

2010       268           3.4           11,181        3.6

2011       221           2.7           10,521        3.4
  TB – continues as a public health issue in the
                 United States
• Old public health concepts (isolation of infectious individuals,
  closely monitored treatment, recognition and preventive
  treatment for infected contacts,) are still critical, but will not
  eradicate TB

• Care providers not familiar with signs/symptoms of TB
   – Diagnosis delayed
   – Inappropriate treatment
   – Drug resistance due to improper use of drugs

• Must address both US born and newcomer populations
   – Older, remote exposure
   – Incarcerated, homeless, history of drug , alcohol use
   – Newcomers from high TB prevalence areas
Challenges to Public Health System
• Public health workers must:
   – Educate, coordinate care with private sector
   – Identify support services (food, housing)
   – Treat TB in geriatric populations
   – Treat TB in children
   – Deal with alcohol, drug abusing, incarcerated and/or
     homeless patients
   – Manage TB in patients with underlying medical conditions
   – Provide culturally appropriate care for non-English
     speaking/non-literate populations
   – Treat TB cases with drug- resistant TB
                   VA TB Cases by Region: 2007-2011
Number of Cases

                  120                                                          2008
                  100                                                          2009
                   80                                                          2010
                        Northwest   Southwest   Central   Eastern   Northern
                  VA TB Cases by Age and Sex: 2011

Number of Cases


                  30                                            Male


                       0-14   15-24      25-44    45-64   65+

                                      Age Group
              TB as a Worldwide
              Public Health Issue

•   World population ~ 6 billion
•   ~ 1in 3 people in world infected
•   ~ 9.4 million new cases of active TB/year
•   1.7 million deaths/year

•   US population 280 million
•   ~ 3-5% infected
•   ~ 11,000 cases/year
•   ~ 5-7% mortality
  Percent Virginia TB Cases by
Race/Ethnicity and Place of Origin
    Foreign-born TB Cases Top Five Countries of
               Birth: US and Virginia

       US (2010)             Virginia (2011)
•   Mexico                   India
•   Philippines              Ethiopia
•   India                    Viet Nam
•   Viet Nam                 Philippines
•   China                      (with 8 cases each China,
   Addressing the Challenges – TB
      Control in the US - 2011
• Local, state and federal programs have separate but closely
  related activities
• Guidelines, Laws and Regulations
   – Guidelines – treatment, contact investigation, prevention –
      data driven/expert opinion
   – Laws – local or state – case reporting, isolation of
      infectious individuals
   – Regulations - local or state – implement laws
   – Federal laws/regulations – travel restrictions, entry into
      the US – no interstate restrictions
   – International travel regulations – WHO – limited
   Elements of a Tuberculosis Control Program
                                       Targeted testing/
                                       LTBI treatment
 Inpatient care
                             Medical evaluation
                             and follow-up             Services                        Laboratory
Non-TB medical                                 Social
services                     Interpreter/                  HIV testing and
                                               services    counseling
                             translator                                    Occupational health,
                             services      Patient                         school, jail, shelter,
                                           education      Data collection  LTCF screening
                  Coordination of         Documentation
                  medical care                              Epidemiology
  Home                                       Contact
  evaluation        Case          DOT        investigation and Surveillance
                                                           Outbreak Data analysis
Housing             Management                             Investigation Program
       Isolation,    Follow-up/treatment                                    evaluation &
                                                    QA, QI for case
       detention     of contacts                                            planning
                                           Consultation on Data for local, state, national
                                           difficult cases      surveillance reports       Training
                  Federal TB                      State TB Control Program
                  Control Program               Funding
                                                            State statutes,        Information
National surveillance       Training                        regulations,           for public
                                                            policies, guidelines
     Technical assistance       Funding                                                          VDH/DDP/TB
11/01/07                                                                                         Jan 2007
     VDH TB Prevention and Control
       Policies and Procedures
• Based on USPHS/CDC, ATS, IDSA and Pediatric “Red
  Book” guidelines
• Adapted to address uniquely Virginia issues

   DDP TB Prevention and Control
• Core activities
   – Identification and treatment of TB cases
   – Identification, evaluation and treatment of high risk close
     contacts of cases
   – Surveillance/case reporting
   – TB laboratory services
   – Targeted testing and LTBI treatment for high risk populations
   – Training/continuing education for health care providers
   – Program evaluation

TB Control provided funding for TB-
 related activities at Local Health
 – PHN/ORW/Epi Reps (VDH/DDP employees and
 – TB clinic physicians (contracts)
 – Chest x-rays and laboratory tests
 – TB medications for uninsured case patients
 – Incentives and enablers
 – Training for HDs, PHNs, ORW

Services directly provided by Central Office

     – Case reporting, surveillance activities
        •   Site visits to review case records, collect data
        •   Data entry/management/analysis/reports
        •   Feedback to local health departments
        •   Data for national TB surveillance system
        •   Information for local/state/federal government

Services directly provided by Central Office
     – Technical support/consultation
        • Case management
        • Contact investigations
        • Expert clinical consultation available through
          partnerships with EVMS and UVA
        • Case review conferences (QA, QI)
        • TB prevention/control in congregate living facilities,
          health care facilities

Services provided by Central Office
– Educational activities for public and private
  sector HCPs, patients and the public
   •   VDH conferences for public health workers
   •   Invited speakers at private sector HCP meetings
   •   Distribution of guidelines
   •   Website
   •   Telephone hot line

  Currently Available Laboratory
  – Standard TB Bacteriology
     • Smear, DNA Preliminary Culture, Standard Culture,
  – Molecular testing
     • MTD – Mycobacterium tuberculosis Direct
     • Cephid testing in validation process
   Currently Available Laboratory
• Other Laboratories
  – Florida State Laboratory
     • HAIN testing – molecular susceptibility for INH/RIF
  – Centers for Disease Control and Prevention
     • First and second-lined molecular drug susceptibility
     • Genotyping of isolates
  – University of Florida Pharmokinetics Laboratory
     • Serum drug level testing
 Current Programmatic Initiatives
• Statewide availability of Interferon Gamma
  Release Assay for testing for latent TB
  – Blood test
     • 2 commercial products
     • QuantiFeron Gold InTube
     • T-Spot-TB – Chosen for Virginia for logistical reasons
  Current Programmatic Initiatives
• New Treatment for latent TB infection (LTBI)
  – 12 week course of isoniazid and rifapentine
     • Virginia Guidelines document developed
  – Pros
     • Shortens treatment course from 9 months to 12 weeks
     • Weekly instead of daily or twice weekly treatment
  – Cons
     • Requires directly observed treatment – observe dose
     • Costly – but price is coming down
     • Number of pills – but new formulations under
  Current Programmatic Initiatives
• Routine serum level drug testing of all diabetic
  TB cases early in treatment
  – A study of slow to respond to treatment TB cases
    showed statistical significance for diabetes
  – Pilot underway to determine if early testing can
    prevent prolonged slow response to treatment
     • Goal
        – Shorten infectious period and potential for community
        – Shorter treatment duration with resulting lower cost
       Programmatic Initiatives
• Increased focus on contact investigation
  – Monitoring ongoing evaluation of contacts,
    especially children and immunocompromised
  – Monitoring treatment of infected contacts
       Programmatic Initiatives
• Focus on program evaluation activities
  – Ongoing case reviews of current cases
  – Cohort Review of prior year cases for 6 selected
    national indicators
     • Completion of treatment, HIV testing, Sputum
       collection, sputum conversion, susceptibility results,
       and initiation of treatment with 4 anti-TB drugs
  – District program review and record audit
Thank you

           Jane Moore
          804 864 7920

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