Focusing on Treatment of LTBI in High Risk Populations

1. Focusing on Treatment of LTBI inHigh Risk Populations Alejandro Conference, Sept 2007 Jerry Carlile, Epidemiologist UT TB Control Program

2. Courtesy of Francis J Curry National TB Center 10-15 million persons with Latent TB infection Only the “tip of the iceberg” → 14,511 active TB cases ~ 294 million people U.S. population Tuberculosis in the United States - 2004

3. Nomenclature changes: “Latent TB Infection” • “Latent TB Infection” emphasizes concept of true infection • Choosing our terms carefully can clarify the take-home message we send to both practitioners and patients…… ….repeat that message over and over and over…… Courtesy of Francis J Curry National TB Center

4. Nomenclature changes: Latent TB Infection • Rather than saying: • “You have been exposed to TB…” • “We would like to give you preventative/prophylactic treatment for TB…” • Say this: • “You are infected with TB, but it is in a dormant state now (what we call latent TB infection). We would like to treat the infection now before it has a chance to ‘wake-up’ and become active…” Courtesy of Francis J Curry National TB Center

5. High Risk Population:Contacts “Every case was once a contact… there is no immaculate infection”

6. Contacts - Recent Infection • 4-5% risk of developing ATBD in first 1-2 years • Risk may double if <4 years old • 40% progression to disease in infants <12 months old

7. Between 1/06 & 6/07, 25% of cases (14 of 56) had known sources

8. 1 was not fully evaluated during CI • 2 were not offered TLTBI • 1 chose not start TLTBI • 2 stopped TLTBI • 1 chose to stop • 1 had side effects to meds TLTBI Status During Source CI • 5 diagnosed w/ATBD during source CI • 3 had already completed TLTBI

9. Case #1 - Contacts <5 yrs • Source #1: • 9/8/04: 24 mm TST @ RH screening; no TLTBI • 1/2/06: ER w/TB symptoms; cavitary CXR • Numerous AFB sp smear; Resistant to INH & EMB • Started tx ATBD 1/9/06 • 3 yr old HH contact • 1/7/06: 20 mm TST (vs 2/6/04: 0 mm) • 1/19/06: CT scan shows enlarged lymph nodes • Sputa not collected; called clinical case • Started tx ATBD 1/23/06

10. Case #1 - Contacts <5 yrs (2) • 3 yr old former HH contact • 1/26/06: 0 mm TST • Window prophylaxis not started • 7/28/06: 20 mm TST • 8/10/06: CXR showslymphadenopathy • Patient not symptomatic • Sputa not collected; clinical case • Started tx ATBD 8/31/06

11. Time Between Source* & <5 Yrs Case *Source cases were sputum AFB-smear positive.

12. Initial Eval Timelines – HP Contacts • Contacts < 5 yrs are high-priority contacts for • AFB sputum smear positive/negative or • Cavitary TB cases • Conduct initial encounter w/in 7 busi days of naming of contact • Face to face meeting; administer TST; schedule further eval, including physical exam & CXR • Medical evaluation* should be complete • AFB sp smear+ or cavitary cases 5 busi days • AFB sp smear- cases 10 busi days • * Excludes final mycobacteriologic results

13. Additional Guidelines Contacts < 5 yrs • Start window prophylaxis if • Initial TST is <5 mm and • Last exposure to index case was <8 wks • UT Objective: Use DOPT • Administer 2nd TST 8-10 wks after exposure • If this TST is <5 mm, stop window prophylaxis • If TST is >= 5 mm, finish TLTBI

14. Case #2 – IC Case • 19 yr old male; arrived from MX 12/03 • “Very ill” since 2/06; life-flight to UUMC in 6/06 for cardiomegaly • Heart transplant in 11/06 • Living in post-transplant communal setting • Diagnosed w/ P & EP TB in 3/07 • Claims no known TB exposure upon admission • “He has no TB in the family.”

15. Case #2 – Was an IC Contact! • 5/07 – GT match with a TB 5/06 ATBD case in a neighboring state • This case is our patient’s aunt! • UT case was part of CI: 5/12/06 – 0 mm TST • No further evaluation for CI • TST prior to transplant: 8/3/06 – 0 mm • Lessons: • Fully evaluate contacts • Ask contacts about immune status

16. Contact Investigation Record Obtain CXRs to exclude ATBD before starting TLTBI

17. High Priority Contacts - IC • Should receive full diagnostic medical eval, including physical exam, TST, CXR • Start window prophylaxis if 1st TST <5 mm • Even if 2nd TST is <5 mm, a full course of TLTBI is recommended

18. Prophylactic TLTBI for IC Contacts • Two factors to consider before starting tx: • Freq, duration, and intensity of exposure • Evidence of transmission from index case • Groups likely to benefit from full course include: • with HIV infection • taking immunosuppressive tx for organ transplants • taking TNF- antagonists • chronically taking >15 mg/d prednisone

19. What if an IC or <5 yr contact was previously treated? • Obtain documentation • if not available, use standard algorithm • Contacts who are IC or otherwise susceptible (<5 yrs) are recommended for: • physical exam, CXR, etc to exclude TB disease • full course of TLTBI regardless of previous TB history and documentation

20. High Risk Population:Recent Arrivals to the US • Newcomers to the US (<5 years) have TB incidence rates similar to their country of origin. • Over the past 5 years in UT, 20% (34 of 169) of our ATBD cases were in persons arriving to the US as refugees • In 2006, 47% (269 of 578) of refugees had a positive TST at RH screening

21. Refugee Length of US Residence Prior to TB Dx, 2004-2006

22. Problems Identified w/TLTBI • Discovered that an ATBD refugee case had “completed” TLTBI • Patient admitted to not taking medication • Some refugees were picking up their TLTBI medication but not taking them • Group formed to  refugees that start and finish TLTBI • State & local HD • Resettlement agencies

23. Somali Bantu Arrivals, 04-05 • 69 persons w/LTBI • 65 candidates for tx • 51% start tx • 73% of those that started tx finished tx • 37% of candidates finished tx

24. Solution Sought • A variety of methods to improve TLTBI compliance were discussed • Conclusion: • need to better understand cultural beliefs and barriers specific to the different groups • provide individual education sessions that address these issues

25. Resources • Ethnomed • Info about cultural beliefs & medical issues • www.ethnomed.org • Healthy Roads Media • Health info in various languages & formats • www.healthyroadsmedia.org

26. Action Plan • IRC – developed questionnaires to better understand barriers • Interview Burmese & Burundian arrivals • Train peer support workers using national curriculum • SLVHD/Asian Assoc – modify questionnaires for use with Somali Bantu population • UDOH – start gathering TLTBI data • Use “layered approach”

27. The End