Download Management of Tuberculosis in Emergency Department Settings

Text of Slides from Management of Tuberculosis in Emergency Department
Settings Web-based Seminar
Presented on November 19, 2009
Housekeeping Slides
Dr. Lee Reichman
Slide 1: Management of Tuberculosis in Emergency Department Settings
o Sponsored by New Jersey Medical School Global TB Institute
Slide 2: Objectives
o Upon completion of this seminar, participants will be able to:
 Describe how suspected TB patients present in the emergency
department in order to more rapidly recognize infectious patients
and provide appropriate management
 Identify appropriate diagnostic and treatment methods for TB in
emergency department settings in order to provide effective cure of
TB disease
 Describe personal respiratory protection and administrative
infection control procedures in emergency departments in order to
prevent transmission of M. tuberculosis
 Apply programmatic strategies to develop collaborative
relationships between TB control programs and hospital emergency
departments to reduce missed opportunities for appropriate
treatment of TB patients
Slide 3: Faculty
o Elissa Schechter-Perkins MD, MPH, DTMH
Boston University School of Medicine
o Juanette Reece, MHS
Baltimore City Health Department
Tuberculosis Control Program
Slide 4: Agenda
o Overview & Opening Remarks – Dr. Lee Reichman
o Overview of TB in Emergency Departments -- Dr. Elissa SchechterPerkins
o Infection Control in the ED: Triage, Airborne Isolation, and Personal
Respiratory Controls for Patients & Providers -- Dr. Elissa SchechterPerkins
o Case Study: Program and Emergency Department Collaboration in
Baltimore City – Juanette Reece, MHS
o Discussion
o Concluding Remarks – Dr. Lee Reichman
Slide 5: Tuberculosis: Emergency Department Diagnosis, Treatment, and
Infection Control
 By Elissa Schechter-Perkins MD, MPH, DTMH
 Assistant Professor of Emergency Medicine
 Boston University School of Medicine
Slide 6: Topics of Discussion
•
•
•
First topic: Suspicion of TB
Initial management
Infection control
Slide 7: Who Might have Tuberculosis
 EVERYBODY
Slide 8: Who Might have Tuberculosis
 Worldwide:
o Leading infectious cause of death
o Affects over 1/3 of the world’s population
o 1,700,000 people die from it every year
 United States:
o Increased from 1980s to 1993
o In 2008, 4.2 cases per 100,000 people
o 12,898 cases in the USA in 2008
 Massachusetts
o In 2008, 4.11 cases per 100,000 people
o 261 cases in Massachusetts in 2008
Slide 9: Who Might have Tuberculosis
 EVERYBODY
Slide 10: Why the ED
•
•
•
We see it
We miss it
We spread it
Slide 11: Why the ED
 Picture of the Emergency Department at Boston Medical Center.
Slide 12: Why the ED
 We see it
 We miss it
 We spread it
Slides 12: Why the ED: We see it
 Everybody
Slide 13: Why the ED: We see it
 Diagram with three circles. On the left are two circles: one representing the
population at high risk for TB, and the other at low risk for TB. On the right is a
circle representing Emergency Department patients. This shows that the
patients at high risk for TB are in large part the same patients seen in the
Emergency Department
Slide 14: Why the ED: We see it
 Table showing number of reported cases of TB in the USA with various risk
factors. In racial/ethnic minorities, 29% were Hispanic/Latino, 26% were
Asian/Pacific Islander, and 25% were Black/African American. 59% of reported
TB cases in the USA were in foreign-born persons, and 15% of reported cases
also reported HIV infection. Note that information about HIV infection is limited by
incomplete HIV reporting
Slide 15: Why the ED: We see it
•
Table showing number of reported cases of TB in Massachusetts with certain risk
factors. 9% of TB cases reported in Massachusetts had substance abuse issues,
3% were homeless (case rate of 29.4 per 100,000 people), 2% were connected
with correctional facilities (case rate of 20 per 100,000 people), and 2% of TB
cases were in nursing homes
Slide 16: Why the ED: We see it
•
•
•
Most likely to have tuberculosis: ethnic minorities, foreign born, those with HIV,
drug users, nursing home patients, homeless patients, prisoners
Most Likely to have
• No “usual source of care”
• Acute illnesses requiring urgent medical attention
Most Likely to show up to an ED near you
Slide 17: Why the ED: We see it
 Diagram showing that people from the following groups are at higher risk of TB:
o Ethnic minorities
o Foreign born
o HIV
o Drug users
o Nursing home
o Homeless
o Prisoners
Slide 18: Why the ED: We miss it
Slide 19: Why the ED: We miss it
•
In a 30 month time period, 44 contagious TB patients made 66 visits to the ED
prior to diagnosis
Slide 20: Why the ED: We miss it
•
Nearly 50% of newly diagnosed TB cases had antecedent ED visit in previous
6 months
• An average of 2.2 visits
• As approached diagnosis, more likely to have an ED visit
• Those seen in the ED are the most sick of all TB patients
Slide 21: Why the ED: We miss it
•
•
In hospitalized patients, the median interval from admission to initiation of
medications was 6 days
75% of patients had a delay of at least 24 hours
Slide 22: Why Oh Why
 Picture of man at the beach with his swimwear sagging
Slide 23: Why the ED: We miss it
•
Clinical presentation of TB can be variable and non-specific
• Cough present in only 64%
• Cough was chief complaint in only 20%
• Only 36% had respiratory complaint at triage
Slide 24: Why the ED: We miss it
 Clinical presentation of contagious TB patient may not even be related to TB
Slide 25: Why the ED: We miss it
•
Definitive diagnosis is frequently not possible in the ED
• Culturing the organism can take days to weeks
• Ziehl-Neelson staining, which identifies Acid Fast Bacilli, is only 50-80%
sensitive
Slide 26: Why the ED: We spread it
•
Picture from the Rothman article illustrating that emergency departments are a
high risk place propagation of infection and can serve as a potential bridge for
aerosolized infection
Slide 27: Why the ED: We spread it
•
•
•
Between patients
From patients to health care workers
From patients to family members
Slide 28: Why the ED: We spread it between patients
 Emergency department infrastructure
Slide 29
 Picture of a large crowd of people
Slide 30: Why the ED: We spread it between patients
• Emergency department infrastructure
• Overcrowding in the waiting room
• Boarding in ED hallway or room without sufficient ventilation precautions
Slide 31: Why the ED: We spread it from patients to staff
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•
Emergency department acuity
• Intubation
• Induced sputum
Atypical presentations
Slide 32: Why the ED: We spread it from patients to staff
•
Emergency department staff at risk
• TST conversion from 1-12%
• Higher than other hospital workers
Slide 33: Why the ED: We spread it from patients to family
•
•
Patients go upstairs
Patients go home
Slide 34: Topics of Discussion
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•
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Covered suspicion of TB
Next topic: initial management
Infection control
Slide 35: Let’s Get Clinical
Slide 36: Case #1
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CC: Cough, fever
HPI: 35 y/o male with 4 days of cough productive of yellow sputum
PMH: None
Meds: None
Exam: Febrile, well appearing, coughing. Rales at Right Lung Base
Slide 37: Case #1
 Chest x-ray showing possible pneumonia
Slide 38: Community-Acquired Pneumonia
• Patient NOT:
• Ethnic minority
• Foreign born
• HIV
• Drug user
• Nursing home
• Homeless
• Prisoner
•
Organisms:
S pneumoniae
• H flu
• Atypicals
•
Slide 39: Community-Acquired Pneumonia
•
High level drug resistant strep pneumoniae
Slide 40: Community-Acquired Pneumonia
 Graphic of IDSA guidelines recommending use of a macrolide for communityacquired pneumonia
Slide 41: Case #2
•
Picture of nebulizer
Slide 42: Community-Acquired Pneumonia

Graphic of IDSA guidelines recommending that patients with co-morbidities or
who were diagnosed with streptococcus pneumoniae in an area with a high rate
of macrolide resistance should be prescribed a fluoroquinolone
Slide 43: Community-Acquired Pneumonia
•
•
Don’t we use respiratory fluoroquinolones to treat resistant TB??
Can this be a problem??
Slide 44: Community-Acquired Pneumonia: Fluoroquinolone Risk
•
Partially treated tuberculosis
• Delay in diagnosis
• Development of resistant tuberculosis
Slide 45: Community-Acquired Pneumonia: Fluoroquinolone Risk
•
Appears to be more theoretical
Slide 46: Community-Acquired Pneumonia: Fluoroquinolone Risk
•
•
Of 428 Pts diagnosed with pulmonary tuberculosis:
• 17% of patients had been prescribed a fluoroquinolone in previous 6 Months
• Most within 90 days of diagnosis
Only 3/74 who had been treated had resistant TB
• All had received more than one course of fluoroquinolones
Slide 47: Community-Acquired Pneumonia: Fluoroquinolone Risk
•
Among fluoroquinolone resistant tuberculosis, majority appear to be in MDR-TB
• Likely secondary to multi-drug regimen
• Not due to isolated fluoroquinolone use in the community
Slide 48: Community-Acquired Pneumonia: Fluoroquinolone Risk
•
•
Might be a bigger problem if
• Prevalence of TB increases
• Use of fluoroquinolones increases
Consider trying alternative regimens
Slide 49: Community-Acquired Pneumonia: Fluoroquinolone Risk
•
Consider missed TB if patient returns after failing course of fluoroquinolones
Slide 50: Case #3
•
46 year old homeless male, born in Peru, complains of cough, fever, night
sweats, and weakness for 1 month
Slide 51: Clinical Suspicion
•
•
We Learned:
• Cough >2 weeks duration
• Dyspnea
• Fevers/chills
• Night sweats
• Weight loss
• Hemoptysis
We See:
• Variable clinical presentation
Slide 52: High Suspicion of TB
•
Decision to initiate treatment
• Epidemiologic information
• Clinical, pathologic, and radiologic findings
• Microscopic findings of acid fast bacilli
• Cultures for mycobacteria
Slide 53: High Suspicion of TB in the Emergency Department
•
Chest X-Ray
• Looking primarily for active tuberculosis
Slide 54: Chest X-Ray
 Chest x-ray of a patient seen in Peru with active pulmonary TB. This is a fairly
classic x-ray. Has a right upper lobe cavitary infiltrate
Slide 55: Chest X-Ray
 X-ray showing milliary TB, with small 1-3 millimeter nodules throughout the lung
field
Slide 56: High Suspicion of TB in the Emergency Department
•
Sputum sample
• Looking for AFB on smear (Ziehl-Neelson stain)
• Rapid
• Sensitivity of 60% in culture positive patients
• Depends on skill of lab technician
• Depends on bacillary load
Slide 57: High Suspicion of TB in the Emergency Department
• Sputum sample
• Looking for AFB on smear (Ziehl-Neelson stain)
• Rapid
• Sensitivity of 60% in culture positive patients
• Depends on skill of lab technician
• Depends on disease level
• Culture
• Slower results
• Gold standard
Slide 58: High Suspicion of TB in the Emergency Department
•
Other Methods
• PPD
• QuantiFERON® Gold
Slide 59: High Suspicion of TB in the Emergency Department
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Disposition?
• Can be treated as outpatient
• NOT SO EASY!!
• Not ill appearing
• Appropriate social situation
• Contact with local health department
•
MOST WILL BE ADMITTED
Slide 60: Case #4
•
46 year old female, noncompliant with HIV meds, complains of cough for 1
month
Slide 61: Case #4
 Chest x-ray. A non-typical presentation of TB, but this is what the patient has.
Slide 62: Tuberculosis AND HIV
•
•
Occurs at ANY CD4 count (only 11.4%of TB patients have HIV)
Degree of immunosuppression influences clinical, radiographic, and
histopathologic presentation of TB
• CD4>350: Appears as typical TB (RUL, +/- cavitations)
• CD4<200: Extrapulmonary manifestations, sepsis syndrome with (-) CXR, no
granulomas or cavitations, miliary TB
Slide 63: Tuberculosis AND HIV
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1/3 of co-infected AIDS patients have primary TB
2/3 have reactivation TB
• 7-10% annual risk in HIV-infected patients with positive TST
• In HIV uninfected, 5-10% lifetime risk
Faster progression of HIV
More severe TB in HIV
Slide 64: Tuberculosis and HIV
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Sputum smear AND culture
Need 3 (decreased sensitivity when immunocompromised)
Slide 65: Case #5
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CC: Back pain
HPI: 19 y/o male from Vietnam with gradually worsening back pain
PMH: None
Meds: None
Exam: uncomfortable, significant tenderness over back
Slide 66: Potts Disease
 CAT scan showing a problem with patient's vertebral body. Potts disease
showing destruction of the vertebral body due to tuberculosis
Slide 67: Potts Disease
 A picture of Potts Disease showing destruction of the vertebral body due to
Tuberculosis in another patient.
Slide 68: More Tuberculosis
•
•
Can be anywhere
Do NOT require isolation unless it is pulmonary or laryngeal
Slide 69: Tuberculous Pericarditis
 X-ray showing tuberculosis pericarditis
Slide 70: Tuberculosis Iritis
 Picture showing tuberculosis iritis
Slide 71: Topics of Discussion
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Covered: suspicion of TB
Covered: initial management
Next: infection control
Slide 72: Why Bother?
 IT WORKS!!!
Slide 73: Why Bother

6 fold decrease in development of LTBI after beginning TB infection control
program
Slide 74: Back to Basics
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Spread by droplet nuclei (airborne particles)
From patients with pulmonary or laryngeal TB
• Cough, sneeze, shout
1-5 µm
Normal air currents keep particles airborne for prolonged periods
Slide 75: High Risk Transmission
• Exposure to TB in small, enclosed spaces
• Inadequate local or general ventilation that results in insufficient dilution or
removal of infectious droplet nuclei
• Recirculation of air containing infectious droplet nuclei
• Inadequate cleaning and disinfection of medical equipment
• Improper procedures for handling specimens
Slide 76: Sound Familiar?
 Picture of Emergency Department at Boston Medical Center
Slide 77: Hierarchy of Infection Control
 Picture depicting the hierarchy of infection control. The picture has three bars in
the shape of an inverse pyramid. At the top of the pyramid with the largest bar is
administrative controls. In the middle of the pyramid, with a medium bar, is
environmental controls. At the bottom of the pyramid, with the smallest bar, is
respiratory protection
Slide 78: Infection Control
•
•
•
Administrative controls:
• reduce risk of exposure via effective IC program
Environmental controls:
• prevent spread and reduce concentration of droplet nuclei
Respiratory protection controls:
• further reduce risk of exposure in special areas and circumstances
Slide 79: Administrative Controls
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•
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Test and evaluate HCWs at risk for TB or for exposure to M. tuberculosis
Train HCWs about TB infection control
Ensure proper cleaning of equipment
Use appropriate signage advising cough etiquette and respiratory hygiene
Slide 80: Awareness
 Picture of a poster with a chest x-ray on the right with THINK TB superimposed
over it. On the left is checklist that begins "Does your patient have...." any of the
following risk factors: cough, fever, weight loss; positive TB test; history of TB;
high risk factors, including international travel, HIV, homelessness, or healthcare
worker. At the bottom is the contact information for the Massachusetts TB
Division.
Slide 81: Awareness
 Picture of a magnet with a clipboard on it. The top says Think TB, and the
clipboard says cough of greater than 3 weeks, time in a high TB prevalence area,
history of TB, and positive TB test. At the bottom of the magnet is contact
information for the Massachusetts TB Division.
Slide 82: Respiratory Protection (RP) Controls
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•
Implement RP program
• Protocols
• Training
• Mask fitting
Minimum respiratory protection is a filtering facepiece respirator
• Nonpowered, air-purifying, half-facepiece
• N-95 disposable
Slide 83: Environmental Controls
• Control source of infection
• Dilute and remove contaminated air
• Prevent spread of infectious droplet nuclei
• Reduce concentration of infectious droplet nuclei
•
Control airflow (clean air to less-clean air)
Slide 84: Environmental Controls
• High Air Flow (At Least 6 Air Changes/Hour)
• Air Cleaning Methods
• High Energy Particulate Air Filtration (HEPA)
• Ultraviolet Germicidal Irradiation (UVGI)
• Negative Pressure
• Air Exhausted to the outside
Slide 85: Environmental Controls
•
Airborne Infection Isolation (AII) rooms (“TB room”)
Slide 86: Environmental Controls
•
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1995 Most ED’s did not have adequate engineering measures
• 19.6% of EDs
• 1.7% of triage/waiting areas
Have things changed since then??
Slide 87: Resource utilization
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If the ED has isolation rooms
The trick is getting the appropriate patients into these rooms
In the magic hat are protocols for identifying, evaluating, and managing infectious
TB patients
Slide 88: Triage
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Important and vulnerable point of entry into the ED and the hospital
Effective strategy here will minimize nosocomial infections throughout ED and
entire hospital
Slide 89: Triage
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Initial patient encounter
Consider infection control measures on arrival
• Masking
• ED isolation room
• Notification of staff members
Slide 90: Difficulties
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Triage procedures have met with limited success
• In sensitivity
• In specificity
Problem is that talking to the patient is just not sufficient
Slide 91: Plan
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Mask everybody with a cough
• Droplet precautions sufficient for most bacteria/viruses
• Large droplets
• Don’t remain suspended in the air
“TB Rooms” for those with epidemiologic high risk factors
High-risk procedures done only in rooms with non-recirculated air
Slide 92: Admission to Hospital
•
If ED does not have isolation room:
• Rapid identification of possible cases and rapid admission to
hospital bed
Slide 93: Admission to Hospital
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If ED does have isolation room:
• Screen high-risk patients in ED to determine who needs an isolation
bed
Slide 94: Decision Instrument
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History of tuberculosis
Immigrant
Homeless
History of incarceration
Recent weight loss
Chest radiograph with apical infiltrate
Chest radiograph with cavitary lesion
Slide 95: Decision Instrument
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Sensitivity: 96.4%
Specificity: 48.7%
Slide 96: What Have We Learned
Slide 97: What Have We Learned
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Emergency Departments are Dangerous Places!!
Slide 98: What Have We Learned
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Suspicion of TB
Initial management
Infection control
Slide 99: Apologies for any...
 Picture of presenter holding a sloth
Slide 100: References
 CDC. Reported Tuberculosis in the United States, 2008. Atlanta, GA: U.S.
Department of Health and Human Services, CDC, September 2009
 http://www.cdc.gov/tb/statistics/reports/2008/pdf/2008report.pdf
 2008 Annual Statistical Report, Division of Tuberculosis Prevention and Control,
Bureau of Infectious Disease Prevention, Response and Services, MA
Department of Public Health
 Rao VK, Iademarco EP, Fraser VJ, et al. Delays in the suspicion and treatment
of tuberculosis among hospitalized patients Ann Intern Med. 1999;130:404-411.
 Sokolove, PE et al. “The Emergency Department Presentation of Patients with
Active Pulmonary Tuberculosis.” Academic Emergency Medicine Volume 7
Issue 9, September 2000.
 Long, R et al. “The emergency department is a determinant point of contact of
tuberculosis patients prior to diagnosis.” The International Journal of
Tuberculosis and Lung Disease. 6(4):332–339. April 2002.
 Rothman, RE et al. “Communicable Respiratory Threats in the ED: Tuberculosis,
Influenza, SARS, and Other Aerosolized Infections.” Emergency Medicine
Clinics of North America. 24(4) 2006.
 Mandell, Lionel Et Al. “Infectious Diseases Society of America/American
Thoracic Society Consensus Guidelines on the Management of
Community‐Acquired Pneumonia in Adults” Clinical infectious Disease. 44(5).
2007.
 Long, Richard Et Al. “Empirical Treatment of Community Acquired Pneumonia
and the Development of Fluoroquinolone-Resistant Tuberculosis.” Clinical
infectious Disease. 48:1354-1360. 2009.
 Low, Donald E. “Fluoroquinolones for Treatment of Community Acquired
Pneumonia And Tuberculosis: Putting the Risk of Resistance into Perspective.”
Clinical infectious Disease. 48:1361-3. 2009.
 Huang TS, et al. “Trends in fluoroquinolone resistance of Mycobacterium
tuberculosis complex in a Taiwanese medical centre: 1995–2003.” Journal of
Antimicrobial Chemotherapy. 56:1058–62. 2005
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De Cock, Kevin M Et Al. “Tuberculosis and HIV Infection in Sub-Saharan Africa.”
Journal of the American Medical Association. 268(12). 1992.
Behrman A, Et Al. “Tuberculosis exposure and control in an urban emergency
department.” Annals Emergency Medicine. 3(3):370–5. 1998.
Centers for Disease Control and Prevention. Guidelines for Preventing the
Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.
MMWR 2005;54(No. RR-17)
Moran, GJ et al. “Tuberculosis infection-control practices in United States
emergency departments.” Annals of Emergency Medicine. 26(3) 283-289. 1995;
Moran, Gregory G et al. “Decision Instrument for the Isolation of Pneumonia
patients with Suspected Tuberculosis Admitted Through US Emergency
Departments.” Annals of Emergency Medicine. 53(5) 2009.
Slide 101: The End
Slide 102: Think TB in EDs: Response to the TB Outbreak in Baltimore City
Homeless Persons
 Juanette Reece, MHS
 Baltimore City Health Department -TB Control Program
Slide 103: TB Outbreak in the Homeless Population
 In 2004, smear-positive pulmonary TB was diagnosed in a homeless man
o While contagious, the homeless TB patient made numerous visits to
homeless service providers and health care providers
 The initial homeless TB case had 12+ clinical encounters
 From ’04-’08 Baltimore City had 39 outbreak linked TB cases
o Several cases visited local emergency departments (EDs) (TB was not
considered in the diagnosis)
Slide 104: TB Cases in Baltimore City Homeless, 1999-2008
 Graph showing TB Cases in Baltimore City Homeless, 1999-2008. In 1999, there
were 2 non-outbreak linked cases. In 2000, there were 3 non-outbreak linked
cases. In 2001, there was 1 non-outbreak linked case. In 2002, there were 4 nonoutbreak linked cases. In 2003, there were 2 non-outbreak linked cases. In 2004,
there were 3 non-outbreak linked cases and 9 outbreak-linked cases. In 2005,
there were 2 non-outbreak linked cases and 10 outbreak-linked cases. In 2006,
there was 1 non-outbreak linked case and 1 outbreak-linked case. In 2007, there
was 1 non-outbreak linked case and 14 outbreak-linked cases. In 2008, there
were zero non-outbreak linked cases and one outbreak-linked case.
Slide 105: Program Activities in Response to TB Outbreak
 Enhanced case findings among homeless persons
 Contact tracing
 Education of health care providers
o Education of homeless service providers and clients
o Environmental controls
Slide 106: Education of Health Care Providers: Action Steps
 Identification of facilities to target
 Notification of outbreak
 Development of a 30 min. presentation for TB in-service trainings
 Coordinate and conduct annual in-service TB training
Slide 107: Identification of Facilities
 Activities focused on “high priority” locations
o High priority locations were defined as locations/settings at which
transmission may have occurred based on epidemiological trends and
data
 Homeless persons were frequently admitted and seen in the EDs of local
hospitals
 Program activities were targeted to emergency department and infection control
staff of these high priority locations then expanded overtime to include additional
facilities
Slide 108: Notification of Outbreak
 Initial communication of outbreak to EDs and infection control nurses (ICNs)
o Bulletins
o Emailed alerts
o Newsletters
o Phone calls
 Follow-up communication of outbreak
o “Think TB” reminders to infection control and ED staff
Slide 109: TB Alert
 Picture of the TB Alert sent to facilities with the following text:
o The average homeless patient sees a physician several times a year
o Often times a homeless person may identify emergency department
physicians as their primary source of care
o Most people with active TB are diagnosed in hospitals and emergency
departments
o Most people with active TB have a cough for several months before a
diagnosis is made
o During the winter months homeless individuals sometimes stay in crowded
shelters
o Due to the factors listed above homeless individuals are at a higher risk of
becoming infected with and spreading TB disease.
o WHAT CAN YOU DO?:
 Remain alert for signs and symptoms of TB:
 Cough >2 weeks, Fever and/or sweats, weight loss, fatigue
 Consider sending sputum for AFB smear and culture on all
individuals with these signs/symptoms
 Call the Baltimore City Eastern Chest Clinic for questions or to refer
a patient: 410-396-9413
Slide 110: Example of Reminder Message
 Since November, 2006, the city has had 6 confirmed cases of TB among homeless
men. These men used only 2 homeless shelters, and we have been able to link
their TB by DNA genotyping. We'd like to remind health care providers to THINK
TB, and ask that you post the attached handout in your Emergency Department
and Community Health Clinics, to remind the staff if they have a patient who is
homeless and is coughing to think TB and get a sputum in addition to the Chest XRay.
 One of the staff members at the Eastern Chest Clinic would like to make
arrangements to talk to the staff in the ED and clinics to expand on this handout
and answer any questions. Please let us know of someone we could contact to
arrange this.
 Thank you for your attention to this and your help.
 Baltimore City Health Department
Eastern Chest Clinic
Phone: 410-396-9413
Fax: 410-396-9403
Slide 111: Coordinating with Health Care Providers
 Established a point of contact for each facility (usually ICN)
 We requested to conduct TB in-service trainings with ED staff either by email or
phone contact
 TB in-service training was delivered at least on an annual basis
Slide 112: TB In-service Trainings
 Objectives:
o Increase knowledge of TB
o Increase awareness of outbreak
o Reduce delay in diagnosis
o Ensure appropriate referrals to the TB Control Program
Slide 113: Key messages
 “Think TB” – consider TB in any homeless person with a cough > 2 weeks, night
sweats, fever, and weight loss
 Prompt respiratory isolation and the use of masks
 Prompt diagnostic evaluation including the collection of 1 or more sputum
samples
Slide 114: TB In-service Trainings (continued)
 Trainings were delivered by either our medical director, nurse practitioner, nurse
case manager, community health educator, or a combination
 Trainings included a TB refresher, information on homelessness in Baltimore
City, and updates on the outbreak
o Review and update of homeless TB outbreak
o Barriers to effective prevention in the homeless population
o Latent TB infection & TB disease
o
o
o
o
Pathogenesis & transmission
TB/HIV co-infection
Diagnosis & treatment
Recommended protocol & prevention
Slide 115: Picture of CDC Think TB Poster
 The middle of the poster says “Think TB!”
 Scattered around the poster are signs and symptoms of tuberculosis:
coughing up blood, weakness, loss of appetite, chest pains, anorexia,
exposure to tuberculosis, significant skin test, weight loss, chills, failure to
thrive, positive skin test, malaise, fatigue, abnormal x-ray, night sweats,
fever, hemoptysis, difficult breathing, cough, and shortness of breath.
 The bottom of the poster says “Recognize positive signs and symptoms of
Tuberculosis. Early diagnosis and treatment reduces spread. Contact your
Health Department or Physician for more information.”
Slide 116: What We Learned
 There were gaps in TB case detection in EDs
 Homeless individuals with TB were usually in the hospital at the time of diagnosis
 Program activities resulted in increased communication between health
department and health care providers
 ED staff were very receptive to training and recommendations
Slide 117: Thank you!
 Baltimore City Health Department
TB Control Program
Eastern Chest Clinic
620 N. Caroline St.
410-396-9413
Slide 118: Questions and Discussion
Slide 119: Medical Consultation
 New Jersey Medical School Global TB Institute Information Line: 1-800-482-3627
Slide 120: Thank you for your participation!