Tuberculosis
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Introduction to Public Health/Communicable Diseases/Tuberculosis. Tuberculosis. An Old Disease – New Twists A Continuing Public Health Challenge. Jane Moore, RN, MHSA Director, TB Control & Prevention Program - VHD, 2013. Tuberculosis – Old Disease.

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Tuberculosis

Introduction to Public Health/Communicable Diseases/Tuberculosis

Tuberculosis

An Old Disease – New Twists

A Continuing Public Health Challenge

Jane Moore, RN, MHSA

Director, TB Control & Prevention Program - VHD, 2013


Tuberculosis old disease

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.”


Tuberculosis1

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

M tuberculosis as causative agent for tuberculosis

Robert Koch

1886


Tb as a worldwide public health issue

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

  • Now < 10,000 cases/year

  • ~ 5-7% mortality


Tb in the us 1882 2012

TB in the US – 1882-2012

  • 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 20121

TB in the US – 1882-2012

  • 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 20122

TB in the US – 1882-2012

  • 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

  • 2012

    • Lowest number of reported cases in US - <10,000


Tuberculosis

TB Around the World

  • One-third of the world is infected with TB, an average of one new infection per second

  • Two million people died from tuberculosis in 2010, 1 every 20 seconds

  • TB is the leading killer of those with HIV

  • TB is the 2nd leading killer from an infectious disease


Tuberculosis

Global TB Incidence Rates *2011

*Estimated


Tb in virginia 1990 2012

TB in Virginia: 1990-2012

235


Virginia tb cases 2012

Virginia TB Cases - 2012

Race and Ethnicity

Place of Origin


Tb case rate per 100 000 va and us 2007 2012

TB Case Rate per 100,000 VA and US: 2007-2012


Va tb cases by region 2007 2012

VA TB Cases by Region: 2007-2012


Tb airborne transmission

TB: Airborne Transmission


Tb invades infects the lung

TB Invades/Infects the Lung

Effective immune

response

Infection limited

to small area of lung

Immune response

insufficient


Tb a multi system infection

TB – A Multi-system Infection


Natural history of tb infection

Natural History of TB Infection

Exposure to TB

No infection

(70-90%)

Infection

(10-30%)

Latent TB

(90%)

Active TB

(10%)

Never develop

Active disease

Untreated

Treated

Die within 2 years

Survive

Die

Cured


Latent tb vs active tb

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

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 continues as a public health issue in the united states

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

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


Addressing the challenges tb control in the us 2012

Addressing the Challenges – TB Control in the US - 2012

  • 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


Tuberculosis

Elements of a Tuberculosis Control Program

X-ray

Targeted testing/

LTBI treatment

Clinical

Services

Pharmacy

Inpatient care

Medical evaluation

and follow-up

Laboratory

Non-TB medical

services

Social

services

HIV testing and

counseling

Interpreter/

translator

services

Occupational health,

school, jail, shelter,

LTCF screening

Patient

education

Data collection

Coordination of

medical care

Documentation

Epidemiology

and Surveillance

Home

evaluation

Contact

investigation

Case

Management

DOT

Outbreak

Investigation

Data analysis

Housing

Program

evaluation &

planning

Isolation,

detention

Follow-up/treatment

of contacts

QA, QI for case

management

Consultation on

difficult cases

Data for local, state, national

surveillance reports

Training

Federal TB

Control Program

State TB Control Program

Guidelines

State statutes,

regulations,

policies, guidelines

Information for public

Funding

National surveillance

Training

Technical assistance

Funding

VDH/DDP/TB

Jan 2007


Vdh tb prevention and control policies and procedures

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


Ddp tb prevention and control activities

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


Tb control provided funding for tb related activities at local health departments

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


Services directly provided by central office richmond

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


Services directly provided by central office

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


Services provided by central office

Services provided by Central Office

  • Educational activities for public and private sector HCPs, patients and the public

    • VDH conferences for public health workers

    • Speakers at private sector HCP meetings

    • Distribution of guidelines

    • Website


Currently available laboratory services

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 services1

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 Pharmacokinetics Laboratory

      • Serum drug level testing


Current programmatic initiatives

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 initiatives1

Current Programmatic Initiatives

  • New Treatment for latent TB infection (LTBI)

    • 12 week course of isoniazid and rifapentine (3HP)

      • 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 initiatives2

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 demonstrated high percentage of diabetics had low serum levels for TB drugs

      • Next phase – impact on sputum conversion

    • Goal

      • Shorten infectious period and potential for community transmission

      • Shorter treatment duration with resulting lower cost


Programmatic initiatives

Programmatic Initiatives

  • Increased focus on contact investigation activities

    • Monitoring ongoing evaluation of contacts, especially children and immunocompromised contacts

    • Monitoring treatment of infected contacts


Programmatic initiatives1

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


Current needs for tb in the us

Current Needs for TB in the US

  • General

    • Continued support for TB prevention/control especially with health care reform

      • Sequestration and future federal budget reductions will have impact

    • New drugs and/or drug combinations to allow shorter courses of treatment

      • New drug bedaquiline approved by FDA

      • Use limited to multi-drug resistant pulmonary cases who cannot be treated with other drugs


Current needs for tb in the us1

Current Needs for TB in the US

  • Shorter, simpler, less expensive treatment regimens

  • Vaccine (beyond BCG)

    • Still waiting

  • Support for global TB prevention and control activities

    • Federal funding reductions for global TB activities


Current needs for tb in the us2

Current Needs for TB in the US

  • Reliable access to anti-tuberculosis drugs

    • Isoniazid – ongoing national shortage since Fall 2012

      • Use in Virginia now limited to certain persons

    • PPD Solution – not a diagnostic – classified as a Schedule VI drug in Virginia

      • Started as national shortage of Tubersol, now spread to alternative product , Aplisol

    • Multiple injectible agents used for drug resistant TB in short supply

      • National shortage for several years


Assessing the impact

Assessing the Impact

  • TB currently at lowest number and rate for both US and Virginia since records kept

    • Current drug shortages have the potential to hamper further progress in TB control and elimination

    • Priority on identifying and treating contacts to known cases

      • Using T-Spot.TB for testing contacts > age 12, skin test for younger children

      • Using isoniazid and rifapentine to treat contacts

        • Isoniazid sparing regimen

      • Others at high risk – testing & treatment deferred


Questions

Thank you

Questions?

Jane Moore

[email protected]

804 864 7920


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