Goodbye don t mean i m gone
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Tuberculosis in Tennessee. “Goodbye Don’t Mean I ‘m Gone”. Jon Warkentin, MD, MPH State TB Control Officer Tennessee Department of Health. 6 th Annual Fall Symposium – Middle TN APIC Baptist Hospital, Nashville, TN September 13, 2012. Disclosure.

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Goodbye don t mean i m gone

Tuberculosis in Tennessee

“Goodbye Don’t Mean I ‘m Gone”

Jon Warkentin, MD, MPH

State TB Control Officer

Tennessee Department of Health

6th Annual Fall Symposium – Middle TN APIC

Baptist Hospital, Nashville, TN

September 13, 2012


Disclosure

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.


Disclaimer

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”


Objectives

Objectives

  • Describe the changing epidemiology of TB in Tennessee

  • Explain the three-tiered hierarchy of TB infection controls

  • Understand the key role of the ICP in preventing TB transmission


Pop quiz

Pop Quiz

  • Who wrote the song, “Goodbye Don’t Mean I’m Gone”?

  • Name of album?

  • Year of release?

  • How old are you?


Objective

Objective

  • Describe the changing epidemiology of TB in Tennessee


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

TB as a critical public health issue


Tb as a critical public health issue1

Worldwide Impact

Someone dies of TB every 15 seconds

Worldwide, over 2,000,000 people die annually from TB, mostly in less developed countries

TB as a critical public health issue


Goodbye don t mean i m gone

TB Case RatesTN and United States, 1986-2011

Case Rate per

100,000Population

Year


Goodbye don t mean i m gone

Reported TB CasesTennessee, 1998-2011

Number of Cases

Year


Tb cases by gender tennessee 2007 2011

TB Cases by GenderTennessee, 2007-2011

Percent of Cases

Year


Goodbye don t mean i m gone

TB Cases by Age GroupTennessee, 2007-2011

Percent of Cases

Year


Tb cases by race ethnicity tennessee 2007 2011

TB Cases by Race/EthnicityTennessee, 2007-2011

Percent of Cases

Year

*Data do not include missing information; Race is Non-Hispanic and Hispanic is of all races.


Goodbye don t mean i m gone

Foreign-born TB CasesTennessee, 2007-2011

Number of Cases

Percentage of Cases

Year


Countries of birth for foreign born tb cases tennessee 2011

Countries of Birth for Foreign-bornTB Cases, Tennessee, 2011


Site of tb disease tennessee 2007 2011

Site of TB DiseaseTennessee, 2007-2011

Percent of Cases

Year


Goodbye don t mean i m gone

TB Cases with HIV Co-morbidity, Tennessee, 2007-2011

Percent of Cases

Number of Cases

Year

† Includes all cases


Multi drug resistant mdr tb cases tennessee 2007 2011

Multi-Drug Resistant (MDR) TB Cases Tennessee, 2007-2011

Number of Cases

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.


Mdr tb in tennessee 2007 case

MDR-TB in Tennessee – 2007 case


Mortality of tb cases tennessee 2007 2011

Mortality of TB CasesTennessee, 2007-2011

Number of Cases

Year

*data are preliminary

Note: Includes all causes of death.


Summary of tb epidemiology

Summary of TB Epidemiology

  • TB is a burgeoning global epidemic

  • Rate of decline in TB case rate in U.S. has slowed, increasing in some states

  • Pediatric TB disease is sentinel for ongoing TB transmission

  • Migration/immigration link every corner of the globe with Tennessee

  • Substantial racial/ethnic disparities in TN


Objective1

Objective

  • Explain the three-tiered hierarchy of TB infection controls


Three tiered hierarchy of tb infection control measures

Three-tiered hierarchy of TB infection control measures

  • Administrative controls

  • Environmental controls

  • Use of respiratory protective equipment


1 administrative controls a

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


1 administrative controls b

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


1 administrative controls c

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.


2 environmental controls

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.


3 use of respiratory protective equipment ppe

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


Objective2

Objective

  • Understand the key role of the ICP in preventing TB transmission


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%)

Conditions with Increased Risk for Progression to TB Disease

Must have a high index of suspicion for active TB disease


The key role of the icp

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!


The key role of the icp1

The key role of the ICP

Release from respiratory isolation

  • Criteria for release from isolation*:

    • Clinical improvement on therapy, AND

    • Three AFB-negative smears, AND

    • 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


The key role of the icp2

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!


The key role of the icp3

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


The key role of the icp4

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


Pearls that work

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


Tb resources for the clinician

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 & CME

      http://www.cdc.gov/tb/education/corecurr/index.htm


Pop quiz answers

Pop Quiz - Answers

  • Who wrote the song, “Goodbye Don’t Mean I’m Gone”?

    Carole King

  • Name of album?

    Rhymes & Reasons

  • Year of release

    1972

  • How old are you?

    You gotta be kiddin’ me!


Rhymes reasons revisited

Rhymes & Reasons - Revisited

Old Lyrics - 1972

Missing you the way I do

You know I'd like to see more of you

But it's all I can do to be a mother

My baby is in one hand,

I've a pen in the other

You know my love is always there for the taking

And goodbye don't mean I'm gone

http://www.youtube.com/watch?v=njp0H2N3Y8w


Rhymes reasons revisited1

Rhymes & Reasons - Revisited

New Lyrics - 2012

Missing youTB the way I do

You know I'd like to see more of you

But it's all I can do to be a motherdoctor

My baby isX-ray’s in one hand,

I've a penSputum canin the other

You know my loveINH is always there for the taking

And goodbye don't mean I'm gone

http://www.youtube.com/watch?v=njp0H2N3Y8w


The impact of tuberculosis on lives families and communities

The Impact of Tuberculosison Lives, Families, and Communities


Acknowledgements

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


Goodbye don t mean i m gone

Jon Warkentin, MD, MPH

State TB Control Officer

Tennessee Dept. of Health

Ph: 253-1364 Cell: 521-0315

E-mail: [email protected]


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