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“Goodbye Don’t Mean I ‘m Gone”

Jon Warkentin, MD, MPHState TB Control Officer

Tennessee Department of Health

Tuberculosis in Tennessee

6th Annual Fall Symposium – Middle TN APICBaptist Hospital, Nashville, TN

September 13, 2012

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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.

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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”

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Objectives

1. Describe the changing epidemiology of TB in Tennessee

2. Explain the three-tiered hierarchy of TB infection controls

3. Understand the key role of the ICP in preventing TB transmission

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Pop Quiz

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

2. Name of album?3. Year of release?4. How old are you?

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Objective

1. Describe the changing epidemiology of TB in Tennessee

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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

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TB as a critical public health issue

Worldwide Impact Someone dies of TB

every 15 seconds

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

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Tennessee US

TB Case RatesTN and United States, 1986-2011

Case

Rat

e pe

r 10

0,00

0 Po

pula

tion

Year

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Reported TB CasesTennessee, 1998-2011

98 99 00 01 02 03 04 05 06 07 08 09 10 110

50

100

150

200

250

300

350

400

450439

382 383

313 308285 277

299277

235

282

202 193

156

Year

Num

ber

of C

ases

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TB Cases by GenderTennessee, 2007-2011

2007 2008 2009 2010 20110

10

20

30

40

50

60

70

8064.3 64.9 62.4

70.562.8

MaleFemale

Perc

ent o

f Cas

es

Year

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2007 2008 2009 2010 20110

10

20

30

40

0-4 5-14 15-24 25-44 45-64

TB Cases by Age Group Tennessee, 2007-2011

Perc

ent o

f Ca

ses

Year

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TB Cases by Race/Ethnicity Tennessee, 2007-2011

2007 2008 2009 2010 20110

10

20

30

40

50

60

White Non-Hispanic Black Non-Hispanic American Indian/Alaskan Native Asian Hispanic

Hawaiian or other PI Multiple races

Perc

ent o

f Cas

es

Year

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

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2007 2008 2009 2010 20110

10

20

30

40

50

60

70

80

90

0

5

10

15

20

25

30

35

40

45

50

69

87

69 70

55

Cases Percent

Foreign-born TB CasesTennessee, 2007-2011Nu

mbe

r of C

ases

Perc

enta

ge o

f Cas

es

Year

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

30.9%

12.7%

12.7%

21.8%

16.4%

5.5%

Mexico

Guatemala

India

Other Asian Countries

Other African Countries

Other Central American Countries

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2007 2008 2009 2010 20110

10203040506070

Pulmonary Extra-pulmonary Both

Site of TB DiseaseTennessee, 2007-2011Pe

rcen

t of C

ases

Year

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

2007 2008 2009 2010 20110

10

20

30

40

50

0

5

10

15

20

2328

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Number Percent

Num

ber o

f Ca

ses

Perc

ent o

f Cas

es

Year†

† Includes all cases

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Multi-Drug Resistant (MDR) TB Cases

Tennessee, 2007-2011

2007 2008 2009 2010 2011^0

1

2

3

4

5

Initial MDR * Acquired MDR**

Num

ber o

f Cas

es

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.

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MDR-TB in Tennessee – 2007 case

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Mortality of TB Cases Tennessee, 2007-2011

2007 2008 2009 2010 2011*0

1020304050607080

3 7 3 8 7

22 2015

159

Dead at diagnosis Died during therapy

Num

ber o

f Cas

es

Year

*data are preliminaryNote: Includes all causes of death.

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Summary of TB Epidemiology

1. TB is a burgeoning global epidemic2. Rate of decline in TB case rate in U.S.

has slowed, increasing in some states3. Pediatric TB disease is sentinel for

ongoing TB transmission4. Migration/immigration link every

corner of the globe with Tennessee5. Substantial racial/ethnic disparities in

TN

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Objective

2. Explain the three-tiered hierarchy of TB infection controls

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Three-tiered hierarchy of TB infection control measures

1. Administrative controls2. Environmental controls3. Use of respiratory

protective equipment

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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

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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

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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.

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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.

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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

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Objective

3. Understand the key role of the ICP in preventing TB transmission

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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%)Must have a high index of suspicion for active TB disease

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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!

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The key role of the ICP

Release from respiratory isolation • Criteria for release from isolation*:

1. Clinical improvement on therapy, AND

2. Three AFB-negative smears, AND3. 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

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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!

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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

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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

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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

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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 &

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

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Pop Quiz - Answers1. Who wrote the song, “Goodbye Don’t Mean I’m

Gone”?

Carole King2. Name of album?

Rhymes & Reasons

3. Year of release

19724. How old are you?

You gotta be kiddin’ me!

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Rhymes & Reasons - Revisited

Old Lyrics - 1972Missing you the way I doYou know I'd like to see more of youBut it's all I can do to be a motherMy baby is in one hand,I've a pen in the otherYou know my love is always there for the takingAnd goodbye don't mean I'm gone

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

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Rhymes & Reasons - Revisited

New Lyrics - 2012Missing you TB the way I doYou know I'd like to see more of youBut it's all I can do to be a mother doctorMy baby is X-ray’s in one hand,I've a pen Sputum can in the otherYou know my love INH is always there for the

takingAnd goodbye don't mean I'm gone

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

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The Impact of Tuberculosison Lives, Families, and Communities

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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

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Jon Warkentin, MD, MPHState TB Control OfficerTennessee Dept. of HealthPh: 253-1364 Cell: 521-0315E-mail: jon.warkentin@tn.us