Tuberculosis An Old Disease – New Twists A Continuing Public Health Challenge Jane Moore, RN, MHSA Director, TB Control & Prevention Program 2012 EPID.

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

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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

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10

20

30

40

50

60

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

MaleFemale

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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

•

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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

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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

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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

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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

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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 [email protected]

804 864 7920

Thank you