Tuberculosis An Old Disease – New Twists A Continuing Public Health Challenge Jane Moore, RN, MHSA Director, TB Control & Prevention Program 2012 EPID.
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Tuberculosis
An Old Disease – New Twists
A Continuing Public Health Challenge
Jane Moore, RN, MHSA
Director, TB Control & Prevention Program
2012
EPID 600 - Introduction to Public Health (On-Line 2012)Communicable Diseases of Public Health Importance
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 producing.”
Tuberculosis• 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
1886Robert 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 control– 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 immuneresponse
Infection limited to small area of lung
Immune responseinsufficient
TB – A Multi-system Infection
Natural History of TB InfectionExposure to TB
No infection (70-90%)
Infection(10-30%)
Latent TB (90%)
Active TB(10%)
Untreated
Die within 2 years Survive
Treated
Die Cured
Never develop Active disease
Latent TB vs. Active TB
Latent TB (LTBI) (Goal = prevent future active disease)= TB Infection = No Disease = NOT SICK = NOT INFECTIOUS
Active TB (Goal = treat to cure, prevent transmission)= TB Infection which has
progressed to TB Disease= SICK (usually)= INFECTIOUS if PULMONARY (usually)= NOT INFECTIOUS if not PULMONARY (usually)
Treatment• 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 recommended– Side effects and toxicity common
• May prolong treatment• May prolong infectiousness
– Other medical and psychosocial conditions complicate therapy
• TB may be more severe• Drug-drug interactions common
TB in Virginia: 1990-2011
221
TB Case Rate per 100,000 VA and US: 2007-2011
Year Virginia TB Cases
Virginia TB Rate
US TB Cases US,521TB 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
0
20
40
60
80
100
120
140
160
180
200
Nu
mb
er o
f C
ases
Northwest Southwest Central Eastern Northern
2007
2008
2009
2010
2011
VA TB Cases by Age and Sex: 2011
0
10
20
30
40
50
60
0-14 15-24 25-44 45-64 65+
MaleFemale
Nu
mb
er o
f C
ases
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
• Mexico• Philippines• India• Viet Nam• China
US (2010) Virginia (2011)
India Ethiopia Viet Nam Philippines (with 8 cases each China,
Mexico,Nepal,Peru)
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
11/01/07
Elements of a Tuberculosis Control Program
Clinical Services
CaseManagement Data analysis
Inpatient careMedical evaluation and follow-up
X-ray
Laboratory
Pharmacy
Social services
Interpreter/translatorservices
Home evaluation
HousingIsolation,detention
Contact investigation
Coordination of medical care
DOT
Programevaluation &planning
VDH/DDP/TBJan 2007
Epidemiology and Surveillance
HIV testing andcounseling
State TB Control ProgramFederal TB Control ProgramGuidelines
Training
Funding
National surveillance
Non-TB medicalservices
Data collection
State statutes,regulations,policies, guidelines
Consultation on difficult cases
Outbreak Investigation
Training
FundingInformation for public
Technical assistance
QA, QI for case management
Data for local, state, national surveillance reports
Follow-up/treatment of contacts
Patienteducation
Targeted testing/LTBI treatment
Documentation
Occupational health, school, jail, shelter, LTCF screening
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
•
28
DDP TB Prevention and Control Activities
• 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
29
TB Control provided funding for TB-related activities at Local Health
Departments– PHN/ORW/Epi Reps (VDH/DDP employees and
contracts)– TB clinic physicians (contracts)– Chest x-rays and laboratory tests– TB medications for uninsured case patients– Incentives and enablers– Training for HDs, PHNs, ORW
30
Services directly provided by Central Office (Richmond)
– 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
officials
31
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
32
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 Services
• DCLS– Standard TB Bacteriology
• Smear, DNA Preliminary Culture, Standard Culture, Susceptibility
– Molecular testing• MTD – Mycobacterium tuberculosis Direct• Cephid testing in validation process
Currently Available Laboratory Services
• 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
testing• 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 infection– 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
ingestion• Costly – but price is coming down• Number of pills – but new formulations under development
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 transmission
– Shorter treatment duration with resulting lower cost
Programmatic Initiatives
• Increased focus on contact investigation activities– Monitoring ongoing evaluation of contacts,
especially children and immunocompromised contacts
– 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
Questions?
Jane MooreJane.moore@vdh.virginia.gov
804 864 7920
Thank you
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