1 “Goodbye Don’t Mean I ‘m Gone” Jon Warkentin, MD, MPH State TB Control Officer Tennessee Department of Health Tuberculosis in Tennessee 6 th Annual Fall Symposium – Middle TN APIC Baptist Hospital, Nashville, TN September 13, 2012
Feb 20, 2016
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“Goodbye Don’t Mean I ‘m Gone”
Jon Warkentin, MD, MPHState TB Control Officer
Tennessee Department of Health
Tuberculosis in Tennessee
6th Annual Fall Symposium – Middle TN APICBaptist Hospital, Nashville, TN
September 13, 2012
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Disclosure
In accordance with Accreditation Council for Continuing Medical Education (ACCME) guidelines, I, Jon Warkentin, have disclosed that I have no financial relationships with pharmaceutical or medical manufactory companies that would pose a conflict of interest in this presentation.
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Disclaimer
The presenter is a “TB evangelist,” not an infectious disease clinical specialist
Focus will not be on presenting data from the scientific literature
A call to “best practices” and enhanced public health capacity
“Blues-you-can-use”
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Objectives
1. Describe the changing epidemiology of TB in Tennessee
2. Explain the three-tiered hierarchy of TB infection controls
3. Understand the key role of the ICP in preventing TB transmission
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Pop Quiz
1. Who wrote the song, “Goodbye Don’t Mean I’m Gone”?
2. Name of album?3. Year of release?4. How old are you?
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Objective
1. Describe the changing epidemiology of TB in Tennessee
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TB as a critical public health issue
Worldwide Impact
8,000,000 people develop active TB every year
Each one can infect between 10-15 people in one year just by breathing
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TB as a critical public health issue
Worldwide Impact Someone dies of TB
every 15 seconds
Worldwide, over 2,000,000 people die annually from TB, mostly in less developed countries
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Tennessee US
TB Case RatesTN and United States, 1986-2011
Case
Rat
e pe
r 10
0,00
0 Po
pula
tion
Year
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Reported TB CasesTennessee, 1998-2011
98 99 00 01 02 03 04 05 06 07 08 09 10 110
50
100
150
200
250
300
350
400
450439
382 383
313 308285 277
299277
235
282
202 193
156
Year
Num
ber
of C
ases
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TB Cases by GenderTennessee, 2007-2011
2007 2008 2009 2010 20110
10
20
30
40
50
60
70
8064.3 64.9 62.4
70.562.8
MaleFemale
Perc
ent o
f Cas
es
Year
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2007 2008 2009 2010 20110
10
20
30
40
0-4 5-14 15-24 25-44 45-64
TB Cases by Age Group Tennessee, 2007-2011
Perc
ent o
f Ca
ses
Year
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TB Cases by Race/Ethnicity Tennessee, 2007-2011
2007 2008 2009 2010 20110
10
20
30
40
50
60
White Non-Hispanic Black Non-Hispanic American Indian/Alaskan Native Asian Hispanic
Hawaiian or other PI Multiple races
Perc
ent o
f Cas
es
Year
*Data do not include missing information; Race is Non-Hispanic and Hispanic is of all races.
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2007 2008 2009 2010 20110
10
20
30
40
50
60
70
80
90
0
5
10
15
20
25
30
35
40
45
50
69
87
69 70
55
Cases Percent
Foreign-born TB CasesTennessee, 2007-2011Nu
mbe
r of C
ases
Perc
enta
ge o
f Cas
es
Year
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Countries of Birth for Foreign-bornTB Cases, Tennessee, 2011
30.9%
12.7%
12.7%
21.8%
16.4%
5.5%
Mexico
Guatemala
India
Other Asian Countries
Other African Countries
Other Central American Countries
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2007 2008 2009 2010 20110
10203040506070
Pulmonary Extra-pulmonary Both
Site of TB DiseaseTennessee, 2007-2011Pe
rcen
t of C
ases
Year
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TB Cases with HIV Co-morbidity, Tennessee, 2007-2011
2007 2008 2009 2010 20110
10
20
30
40
50
0
5
10
15
20
2328
20 18
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Number Percent
Num
ber o
f Ca
ses
Perc
ent o
f Cas
es
Year†
† Includes all cases
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Multi-Drug Resistant (MDR) TB Cases
Tennessee, 2007-2011
2007 2008 2009 2010 2011^0
1
2
3
4
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Initial MDR * Acquired MDR**
Num
ber o
f Cas
es
Year^2011 Acquired MDR data are preliminary.* Initial MDR refers to those patients who were culture positive and that had initial drug susceptibility testing and who were found to have TB resistant to both INH and RIF.** Acquired MDR refers to those patients who were alive at diagnosis and not initially found to have MDR TB, but developed MDR-TB during therapy.
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MDR-TB in Tennessee – 2007 case
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Mortality of TB Cases Tennessee, 2007-2011
2007 2008 2009 2010 2011*0
1020304050607080
3 7 3 8 7
22 2015
159
Dead at diagnosis Died during therapy
Num
ber o
f Cas
es
Year
*data are preliminaryNote: Includes all causes of death.
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Summary of TB Epidemiology
1. TB is a burgeoning global epidemic2. Rate of decline in TB case rate in U.S.
has slowed, increasing in some states3. Pediatric TB disease is sentinel for
ongoing TB transmission4. Migration/immigration link every
corner of the globe with Tennessee5. Substantial racial/ethnic disparities in
TN
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Objective
2. Explain the three-tiered hierarchy of TB infection controls
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Three-tiered hierarchy of TB infection control measures
1. Administrative controls2. Environmental controls3. Use of respiratory
protective equipment
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1. Administrative controls (a)
First and most important! Assigning responsibility for TB infection
control in the setting Conducting a TB risk assessment of the
setting Developing and instituting a written TB
infection-control plan Ensuring the timely availability of
recommended laboratory processing, testing, and reporting of results to the ordering physician
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1. Administrative controls (b) Implementing effective work practices for
the management of patients with suspected or confirmed TB disease
Ensuring proper cleaning and sterilization or disinfection of potentially contaminated equipment
Training and educating health-care workers (HCWs) regarding TB, with specific focus on prevention, transmission, and symptoms
Screening and evaluating HCWs who are at risk for TB disease or who might be exposed to Mtb
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1. Administrative controls (c)
Applying epidemiologic-based prevention principles, including the use of setting-related infection-control data
Using appropriate signage advising respiratory hygiene and cough etiquette
Coordinating efforts with the local or state health department.
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2. Environmental controls
Primary environmental controls - control the source of infection by using local exhaust ventilation and dilute and remove contaminated air by using general ventilation
Secondary environmental controls control the airflow to prevent contamination of air in areas adjacent to the source (airborne infection isolation [AII] rooms) and clean the air by using high efficiency particulate air (HEPA) filtration, or ultraviolet germicidal irradiation.
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3. Use of respiratory protective equipment (PPE) Reduce risk for exposure of HCWs to
infectious droplet nuclei that have been expelled into the air from a patient with infectious TB disease
Implementing a respiratory protection program
Training HCWs on respiratory protection Training patients on respiratory hygiene and
cough etiquette procedures
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Objective
3. Understand the key role of the ICP in preventing TB transmission
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Conditions with Increased Risk for Progression to TB Disease
HIV infection / AIDS Substance abuse Recent infection Previous TB Diabetes Silicosis Corticosteroid tx
Imm. therapy CA of head/neck Hemato./RE
diseases ESRD Certain GI surgeries Malabsorption synd. Low body wt.
(10%)Must have a high index of suspicion for active TB disease
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The key role of the ICP
Respiratory isolation! • If TB is in the differential diagnosis, respiratory isolation is mandatory
• Recurrent “community-acquired pneumonia” (CAP) – THINK TB!
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The key role of the ICP
Release from respiratory isolation • Criteria for release from isolation*:
1. Clinical improvement on therapy, AND
2. Three AFB-negative smears, AND3. At least 14 days of anti-TB
therapy
• Stable AFB+ patients may be released to home – but only after appropriate home assessment by LHD
* For patients without a safe, stable living environment
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The key role of the ICP
Notify local health department! TN Statutes require medical providers,
hospitals and labs to call report of all TB suspects to LHD within 12 hrs.
• Contact investigation and case mgt. by LHD can start only after receiving report
• Early reporting protects children!
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The key role of the ICP
Discharge planning ! • Begins on hospitalization Day #1!• Involve ICN and Social Worker• Expect visit by LHD case manager• Share information and records• Coordinate release to ensure continuity
of care by LHD• NEVER release a homeless TB
case/suspect from the hospital without consulting LHD
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The key role of the ICP
Respiratory isolation! • AFB smear-negative patients may still
be infectious – protect patients, visitors,
staff, yourself• Stable AFB+ patients may be released
to home – but only after appropriate home assessment by LHD
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Pearls That Work
Rapid reporting of TB suspect to LHD• TN Statute requires provider phone report to
LHD within 12 hrs.• Contact investigation starts only after report
Discharge planning starts on Hosp. Day #1!• LHD case manager works with ICN and SW
NEVER release a homeless TB pt. from the hospital before consulting the LHD
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TB Resources for the Clinician
ATS website – http://www.thoracic.org/statements/• TB diagnosis and classification• TB treatment• Community Acquired Pneumonia (CAP)
CDC website – important guidelines http://www.cdc.gov/tb/publications/guidelines/default.htm• Infection control in healthcare facilities• Contact investigation• Patient education• “Core Curriculum” for provider education &
CMEhttp://www.cdc.gov/tb/education/corecurr/index.htm
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Pop Quiz - Answers1. Who wrote the song, “Goodbye Don’t Mean I’m
Gone”?
Carole King2. Name of album?
Rhymes & Reasons
3. Year of release
19724. How old are you?
You gotta be kiddin’ me!
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Rhymes & Reasons - Revisited
Old Lyrics - 1972Missing you the way I doYou know I'd like to see more of youBut it's all I can do to be a motherMy baby is in one hand,I've a pen in the otherYou know my love is always there for the takingAnd goodbye don't mean I'm gone
http://www.youtube.com/watch?v=njp0H2N3Y8w
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Rhymes & Reasons - Revisited
New Lyrics - 2012Missing you TB the way I doYou know I'd like to see more of youBut it's all I can do to be a mother doctorMy baby is X-ray’s in one hand,I've a pen Sputum can in the otherYou know my love INH is always there for the
takingAnd goodbye don't mean I'm gone
http://www.youtube.com/watch?v=njp0H2N3Y8w
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The Impact of Tuberculosison Lives, Families, and Communities
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Acknowledgements
Dr. Michael Iseman – NJRMC, Denver Jason Cummins – TTBEP Epidemiologist TTBEP Program Staff American Thoracic Society Centers for Disease Control &
Prevention World Health Organization Carole King
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Jon Warkentin, MD, MPHState TB Control OfficerTennessee Dept. of HealthPh: 253-1364 Cell: 521-0315E-mail: [email protected]