Tuberculosis – Regulations and control in Norway- of relevance for approved doctors outside Norway Dept director Karin Rønning MD NIPH, Dept for infectious diseases epidemiology NMA/ NCMM Approved doctors meeting, Bergen 2014
Nov 28, 2014
Tuberculosis – Regulations and control in Norway- of relevance
for approved doctors outside Norway
Dept director Karin Rønning MD
NIPH, Dept for infectious diseases epidemiology
NMA/ NCMM Approved doctors meeting, Bergen 2014
Powerty
Crowded housing conditions
Coinfection with HIV
Other immunosuppresant
treatments and conditions
Small children (<2)
Risc factors for TB infection
Appr 30% of the world
popultaion are infected
with TB (latent TB)
• M. tuberculosis spreads from person to person by droplets inhaled
• 5-10 % of those infected get sick
– A few during the first weeks
– Most during the first 1-2 yrs
– Risk 5-10% during the lifetime
TB transmission
Droplets containing M.tuberculosis
bronchioleblood vessel
tubercle bacilli
alveoli
2
M.Tb multiplies in alveoli, with onset of infection
TB disease
shell breaks down and tuberclebacilli escape
multiply(in this example,TB disease develops in the lungs)
and
5
• If the immune system cannot keep the M.tb under
control, the bacteria starts to duplicate rapidly and
causes disease
• The process might start in different organs
Localizations of disease
Most commonly:
Brain
Lymph node
Pleura
Lung
SpineKidney
Bone
Larynx
Dr. Ulf Dahle, NIPH)
Top 10 countries with TB patients
• India
• China
• Indonesia
• Nigeria
• South Africa
• Bangladesh
• Ethiopia
• Pakistan
• Philippines
• Democratic Republic of the Congo
• The rest of Africa..
Law/Regulations
Guidelines
NIPH- how to…
Infection control measures
Screening- whom?
Contact tracing
Obligations and rights for patients
Treatment of latent TB-
whom?
From the Norwegian
TB control of
relevance for You
Who should be screened following Norwegian TB regulations
• §1.2 Jurisdiction • §3.1.a TB screening of all that will stay in Norway > 3 mths
coming from a country with TB insidence >40/100´/ year
• Regulations also covers employees/ seafarers going to work on mobile Norwegian oil installations at sea, on Norwegian ships and aircrafts wherever they are located
– the screening of seafarers should primarily be done do exclude contagious TB • Pulmonary TB (CXR)
TB screening of seafarers
• Regulation on TB with comments
• Regulation for health examination of seamen (2014)
– Not risk group aspect, but security aspects
– Contagious diseases are contra indication regarding work on a ship, and should be avoided
Good practice for TB control and treatment- Norwegian guidlines
Where is
given the
methods of
TB screening
and TB
treatment
FORM FOR MEDICAL EXAMINATION
Regulation on medical examinations of employees on Norwegian ships or moveable installations offshore -
2014
ICD10 codes
A00-B99
Certain infectious diseases
A15-16
Pulmonary TB Contagious, relapse
T- Pos screening or history- until examined If infectious- until treatment is stabilized and the patient is documented non- contagious (3 neg sputum microscopies) P- Relapse, or serious lung sequelae
NA Completed treatment following Norwegian guidelines and/or WHO Treatment TB guidelines
Test follows Norwegian regulations and guidelines
DOT? Direct observed treatment Treatment plan
What kind of methods for TB examinations?
How to exclude contagious lung TB
• CXR!
• Clinical history
– Cough > 3 weeks
– Weight loss
– Fever
– Chest pains
– Feeling of illness
• HIV+ may have no CRX changes
• Pulmonary TB is the only contagious form of TB
Methods for screening
• CXR
– Active TB or scars from former TB (latent TB?)
• TB infection- IGRA´s
– Mantoux (TST)
– IGRA (Quantiferon-QFT, T Spot TB)
Mantoux and IGRA tests
Measures immunilogical responce
to TB antigens in the kits or in the
TST solution
Mtx (TST) / IGRA- tests
• Cannot be used to diagnose active TB disease
– 20% of those with active disease have anergy
– Will not reverse to zero after treatment
• Can be used to diagnose TB infection- latent TB
– Of no use if no intention to treat latent TB
– TST difficult to interpret if BCG vaccinated or repeated tests with TST
Conclusions
• TB control of seafarers is not obligatory per se following the Norwegian TB regulation
– Follows a risk group aspect
– Seamen recruited from High incidence countries are often at risk of beeing infected in their childhood
• Contageous diseases are contraindication for working on ships and installations
• Main screening method should be CXR
• Mantoux/IGRA normally not indicated