TUBERCULOSIS: The Elephant in The Room

There are no disclosures

Disclosures

The purpose of this presentation is to awaken an awareness and continued existence of tuberculosis in our world and community.

Purpose

WORKING TOGETHER TO ELIMINATE

TUBERCULOSIS IN OUR LIFETIME

Human remains unearthed contain markers for TB as far back as 9000 BC!

An Ancient Disease

In 2013 9 million developed TB disease!! - 56% in South-East Asia,

Western Pacific - 25% were in African Region - 1.5 million died from this

disease - 360,000 were HIV positive - 480,000– MDR (multi drug

resistant) 3.5% were new cases and

20.5% previously treated cases Death is preventable if diagnosed,

treated quickly and appropriately

TB: One of the World’s Deadliest Communicable Diseases

World Health Organization (WHO) MILLENNIUM DEVELOPMENT

GOAL (relative to 2015) By 2025: reduce case

incidence by 50% & death rate by 75%

By 2035: achieve 90% reduction in case incidence & 95% reduction in death rates

No catastrophic costs to families due to TB treatment

US BORN/FOREIGN BORN2014

TOTAL CASES - 9,412(2.2% decrease)

(MS CASE RATE –74)(13% increase)

US BORN CASES - 3,114 (33%) (MS –49 (75%)FOREIGN BORN CASES – 6,181 ( 65%) (MS –16 (25%)

2003 2014

DC

*Updated as of June 11, 2014.

CDC

Percentage of TB Cases Among Foreign-born Persons, United States*

DC

>50%25%–49%<25%

Countries of Birth of Foreign-born Persons Reported with TB, United States, 2014

Mexico(1268)

Philippines(745)

India(472)

Vietnam(498)

China(420)

Guatemala)

Haiti

Other Countries40%

MISSISSIPPI, 2014

Mississippi Population: 2,984,926*

TB cases 2014: 74 (a 13% increase) Case Rate 2.2 %/ 100,000 596 persons suspected of tuberculosis 378 atypical mycobacterial disease 1790 TBI

*2010 Census

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

020406080

100120140160180200

173154

134128119

103115

137117121116

9181

6574

MS Reported TB Cases2000 - 2014

I

II

III

IV

V

VI

VII

VIII

IX

0 5 10 15 20 25 30

8

8

7

4

27

3

7

6

9

2014 Cases By District

Factors Contributing to the Increase in TB Morbidity HIV epidemic (1.4 million co-infected) (27%)* Increased immigration Complacency about TB; departure from

policy Lack of resources; “orphan disease” (CDC) Deterioration of the health care infrastructure Homeless increase (12% TB cases)* LTC facilities (5.0%) Substance abuse * % in MS

MycobacteriumTuberculosis

Member ofAcid Fast Bacilli (AFB)

Family ofDiseases

TB is Airborne and Contagious!

PATHOGENESIS Follows air currents.

Droplets containing

TB bacilli are inhaled, enter the lungs, and travel to the alveoli.

Infection occurs.

Host Immune Response Immune system contains/limits bacilli growth

ORThere is an ineffective immune response and the patient progresses to primary disease

Risk Factors for Exposure Close contacts of person with TB

disease Foreign born persons from areas where TB is common

Residents, employees of high risk congregate settings

HCW who serve high risk patients

Risk Factors (continued)

Certain racial/ ethnic minority populations

Children exposed to adultsPersons who inject illicit drugsPersons who travel outside US

TB Infection vs. TB Disease

TB Infection (TBI)* Positive TB skin test

or blood assay test (IGRA)

Normal Chest x-ray Alive, inactive

bacteria present No S/S Not contagious;

not sick

*Recommend treatment to prevent active disease

TB Disease ** Positive TB skin

test/blood assay test (IGRA)

Abnormal Chest x-ray Active TB bacteria in

body S/S of TB Positive AFB Smear Positive MTB Culture Contagious; sick

**Must take multiple drug treatment

Mantoux (old)

Administered intradermally using .1 ml PPD resulting in > 6 mm tense, blanched wheal

Read at 48-72 hrs later by feeling at site of injection for induration

Report induration in MM

Subjective results

IGRA (new)

Interferon Gamma Release Assay (blood test):

QuantiFeron TB Gold In Tube (QFT) and Tspot

- Draw blood - Send to lab for testing - Identifies presence/absence of infection - More specific for TB infection - One patient visit - No interpretation problems - No adverse reaction

Testing For Tuberculosis Infection

TREATMENT FOR TB INFECTION(TBI)

If chest xray negative for active TB disease, then evaluate for treatment for TBI:

New Treatment

Rifapentine\Isoniazid: 3HP

Directly observed only

One dose every 7 days for 12 weeks

Must be complete in 16 weeks

Not appropriate for some individuals

Weekly/monthly nurse assessment is critical

Proven effective as daily INH X 9 months

Decrease in hepatotoxicity

Increased completion rate 85-87%

Conditions That Increase the Risk of Progression to TB Disease: HIV infection (100 -800X greater risk) (29% cases) X-ray evidence of old, untreated TB Substance abuse (esp. drug injection) Recent infection with M. TB Diabetes (3X greater risk) (9% cases/11.8% TBI) Silicosis End-stage renal disease Tobacco use and alcohol abuse (1/12/11) (Includes exposure to second hand smoke!)

more conditions… Immunosuppressive therapies

- Prolonged corticosteroid therapy(> 15 mg qd > 3 wks)

- Anti TNF agents ( ie:Remicaide, Enbrel, Humira)- Any immunosuppressive therapy

Certain cancers- head and neck- Leukemia- Hodgkin’s

10% or more underweight- intestinal bypass or gastrectomy- chronic malabsorption syndromes

Productive, prolonged cough >3 weeks

Hemoptysis Chest pain

Fever Chills Night sweats Easy fatigability Loss of appetite Weight loss

Symptoms of TB Disease

Medical history; s/s of pulmonary disease Physical examination of overall condition Test for M. tuberculosis infection Chest radiograph (suggestive of TB; never

diagnostic) Bacteriologic exam of sputum specimens - Smear classification and results - Culturing and identification; Gold

standard - Drug-susceptibility testing

Diagnosisof Active TB Disease

MAJOR GOALS OF TB DISEASE TREATMENT

Cure individual patient

Minimize risk of death/disability

Reduce transmission to other persons

Standard treatment is 4 drugs. Responsibility for successful completion of

therapy is assigned to health-care provider! (Not the patient).

Vital component that ensures patients adhere to therapy.

Watch patient swallow each dose of anti-TB drugs Can reduce development of drug resistance, treatment failure or relapse

Drectly Observed Therapy (DOT)

Increase in HIV (+) and diabetes Rapid spread of antibiotic-resistant TB germs MDR – resistant in INH and RIF (3.5%) XDR - MDR + fluoroquinolones, injectables Immigration from TB high burden countries Lack of adequate funding for TB control

programs resulting in loss of experienced staff

Need for new treatments, drugs, a vaccine

Barriers to Eliminating Tuberculosis in Our Lifetime

Failure to report possibility of TB disease: - when patient exhibits s/s with questionable chest xrays

Declining awareness of possible TB disease

Adequate access to health care

Complacency

Not Enough?

Decreased funding: _

60% of States have been forced to cut TB Control Budgets since 2009 which results in decreased staffing which leads to

- Less ability to provide DOT medication

- Less ability to deliver optimal therapy in drug resistant TB

- Less ability to do contact investigation

- Less ability to investigate TB outbreaks

America’s Eroding TB Programs

“Orphan Disease” Questions?

Global Tuberculosis Report, 2014; World Health Organization

Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report (MMWR), Trends in Tuberculosis, 2013 and 2014

Stop TB USA, The U.S. Partner in the Global Stop TB Partnership, August 18, 2015

MS State Department of Health, Office of Tuberculosis Control and Refugee Health, TB Manual of Policy and Procedure

Resources