Download TB Cases Tennessee, 2007-2011

Tuberculosis in Tennessee
“Goodbye Don’t Mean I ‘m Gone”
Jon Warkentin, MD, MPH
State TB Control Officer
Tennessee Department of Health
6th Annual Fall Symposium – Middle TN APIC
Baptist Hospital, Nashville, TN
September 13, 2012
1
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.
2
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”
3
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
4
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?
5
Objective
1. Describe the changing
epidemiology of TB in Tennessee
6
7
8
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
9
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
10
TB Case Rates
TN and United States, 1986-2011
Case Rate per
100,000 Population
14
12
10
Tennessee
US
8
6
4
2
0
86 88 90 92 94 96 98 00 02 04 06 08 10
Year
11
Reported TB Cases
Tennessee, 1998-2011
450
400
350
300
439
382
383
313
308
285 277
299
282
277
235
250
202
200
193
156
150
100
50
0
98 99 00 01 02 03 04 05 06 07 08 09 10 11
Year
12
TB Cases by Gender
Tennessee, 2007-2011
Percent of Cases
80
70
70.5
64.3
64.9
62.8
62.4
60
50
Male
40
Female
30
20
10
0
2007
2008
2009
Year
2010
2011
13
TB Cases by Age Group
Tennessee, 2007-2011
Percent of Cases
40
30
20
10
0
2007
2008
2009
2010
2011
Year
0-4
5-14
15-24
25-44
45-64
14
TB Cases by Race/Ethnicity
Tennessee, 2007-2011
60
50
Percent of Cases
40
30
20
10
0
2007
2008
2009
2010
2011
Year
White Non-Hispanic
American Indian/Alaskan Native
Hispanic
Multiple races
Black Non-Hispanic
Asian
Hawaiian or other PI
*Data do not include missing information; Race is Non-Hispanic and Hispanic is of all races.
15
Foreign-born TB Cases
Tennessee, 2007-2011
90
50
87
45
80
69
69
70
40
35
60
Percentage of Cases
Number of Cases
70
55
30
50
25
40
20
30
15
20
10
10
5
0
0
2007
2008
2009
Year
2010
Cases
2011
Percent
16
Countries of Birth for Foreign-born
TB Cases, Tennessee, 2011
5.5%
Mexico
16.4%
30.9%
Guatemala
India
21.8%
Other Asian Countries
Other African Countries
12.7%
Other Central American
Countries
12.7%
17
Site of TB Disease
Tennessee, 2007-2011
70
Percent of Cases
60
50
40
30
20
10
0
2007
2008
2009
2010
2011
Year
Pulmonary
Extra-pulmonary
Both
18
TB Cases with HIV Co-morbidity,
Tennessee, 2007-2011
20
40
30
15
28
23
20
20
20
10
18
5
10
0
0
2007
2008
2009
2010
Percent of Cases
Number of Cases
50
2011
Year
†
†
Number
Percent
Includes all cases
19
Multi-Drug Resistant (MDR) TB Cases
Tennessee, 2007-2011
Number of Cases
5
4
3
2
1
0
2007
2008
2009
Year
2010
2011^
Initial MDR *
Acquired MDR**
^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.
20
MDR-TB in Tennessee – 2007 case
21
Mortality of TB Cases
Tennessee, 2007-2011
80
Number of Cases
70
60
50
40
30
20
10
0
22
20
15
3
7
3
8
9
7
2007
2008
2009
2010
2011*
15
Year
Dead at diagnosis
Died during therapy
*data are preliminary
Note: Includes all causes of death.
22
Summary of TB Epidemiology
1. TB is a burgeoning global epidemic
2. Rate of decline in TB case rate in U.S. has
slowed, increasing in some states
3. Pediatric TB disease is sentinel for ongoing
TB transmission
4. Migration/immigration link every corner of
the globe with Tennessee
5. Substantial racial/ethnic disparities in TN
23
Objective
2. Explain the three-tiered
hierarchy of TB infection
controls
24
Three-tiered hierarchy of TB
infection control measures
1. Administrative controls
2. Environmental controls
3. Use of respiratory protective
equipment
25
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 infectioncontrol plan

Ensuring the timely availability of recommended
laboratory processing, testing, and reporting of
results to the ordering physician
26
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
27
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.
28
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.
29
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
30
Objective
3. Understand the key role of the
ICP in preventing TB
transmission
31
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
32
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!
33
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, AND
3. 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
34
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!
35
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
36
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
37
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
38
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 & CME
http://www.cdc.gov/tb/education/corecurr/index.htm
39
Pop Quiz - Answers
1.
Who wrote the song, “Goodbye Don’t Mean I’m Gone”?
Carole King
2.
Name of album?
Rhymes & Reasons
3.
Year of release
1972
4.
How old are you?
You gotta be kiddin’ me!
40
Rhymes & Reasons - Revisited
Old Lyrics - 1972
Missing you the way I do
You know I'd like to see more of you
But it's all I can do to be a mother
My baby is in one hand,
I've a pen in the other
You know my love is always there for the taking
And goodbye don't mean I'm gone
http://www.youtube.com/watch?v=njp0H2N3Y8w
41
Rhymes & Reasons - Revisited
New Lyrics - 2012
Missing you TB the way I do
You know I'd like to see more of you
But it's all I can do to be a mother doctor
My baby is X-ray’s in one hand,
I've a pen Sputum can in the other
You know my love INH is always there for the taking
And goodbye don't mean I'm gone
http://www.youtube.com/watch?v=njp0H2N3Y8w
42
The Impact of Tuberculosis
on Lives, Families, and Communities
43
44
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
45
Jon Warkentin, MD, MPH
State TB Control Officer
Tennessee Dept. of Health
Ph: 253-1364 Cell: 521-0315
E-mail: [email protected]
46