Download CDC Update on the 2007 TB Technical Instructions

CDC Update on the 2007 TB
Technical Instructions
Sharmila Shetty, MD
Immigrant, Refugee & Migrant Health Branch
Division of Global Migration and Quarantine
Centers for Disease Control and Prevention
Summary
• Overview of Immigrant, Refugee, Migrant
Health Branch
• Epidemiology and trends of TB in the US
• Changes in 2007 TB Technical Instructions (TI)
Annual Estimate of Migrants Entering the U.S.
Total: ~60 million
Source: U.S. Department of Homeland Security
Refugee admissions: 61,498 (2008)
Immigrant, Refugee, and Migrant
Health Branch (IRMH) Role
• Track and report diseases in these populations
• Respond to disease outbreaks in the US and
overseas
• Advise U.S. partners on health care for refugee
groups
• Educate and communicate with immigrant and
refugee groups and partners.
• Provide medical screening and treatment
guidelines (technical instructions)
Technical Instructions (TIs)
 Consist of medical screening guidelines
 Used by overseas panel physicians who conduct
medical examinations for U.S.-bound refugees and
immigrants
 Identify applicants with medical conditions of
public health concern
Inadmissible communicable diseases of
public health significance







Tuberculosis, active
Syphilis, untreated
Chancroid, untreated
Gonorrhea, untreated
Granuloma Inguinale, untreated
Lymphogranuloma Venereum, untreated
Hansen’s disease (Leprosy)
Panel Physician Program: Basics
• Statistics
 670 panel sites (1 or more panel physicians)
 > 1,000 laboratory and radiology facilities
• Contracted through Dept. of State
 TB=disease of greatest public health concern
Estimated TB Incidence Rate, 2007
Estimated new TB cases
(all forms) per 100 000
population
No estimate
0-24
25-49
50-99
100-299
300 or more
1/3 of world infected
9.3 million cases of active TB
1.8 million deaths
TB Cases, United States, 19932008
TB rate:
FB 20.6/100K
US 2.1/100K
MDR TB Cases, United States
1993-2007
XDR TB (’00-’06): 76%
XDR TB (’00-’06): 76%
Simplified TB Screening Algorithm
CDC required
TB screening 
overseas medical exam:
panel physicians
Abnormal CXR
Normal CXR
Sputum work-up to
identify active TB
TB follow-up exam
requested
+
Post-arrival medical exam
1991 Tuberculosis Technical Instructions
• CXR if ≥ 15 years old; no screening for <15 yr
• If chest x-ray abnormal
• Serial AFB smears
• If AFB+
• treat until smear negative
• complete therapy in US
• No cultures, no DST
Study of 1991 TB TI
Culture versus Smears*
• 1,179 with CXR suggestive of active TB
• TB culture and AFB smears for all
• 183 culture positive
--Only 63 (34%) smear-positive
=
+
34% Sensitivity
AFB Smear
Conclusion: 1991 protocol missed 66% of culture-positive active
TB cases
*Maloney SM, et al. Arch Int Med 2006;166:234-40
Hmong Refugee Resettlement,
2004—2005
• 16,000 Laotian Hmong in Wat Tham Krabok, Thailand
• Five states
identified 48 TB
Cases (7 MDR) in
newly arrived Hmong
refugees
•TB culture added
to screening
TB in US-bound Hmong Refugees
TB Cases
# of Refugees
Location Cases Identified
N
Rate/100,000
9482
Wat Tham Krabok
24
126
US
48
506
*Screened with 1991 TB TI
TB in US-bound Hmong Refugees
TB Cases
# of Refugees
Location Cases Identified
N
Rate/100,000
9482
Wat Tham Krabok
24
126
US
48
506
•TB culture added to screening algorithm
5801
Wat Tham Krabok
24
420
US
5
86
Recommendations
• Overseas: Expand screening, treatment,
and overall TB control
• Focus on high-prevalence countries
• Improve TB screening
• To include culture
• To screen persons <15 years esp. highprevalence countries
• Domestic: Support timely and complete
post-arrival follow-up of immigrants and
refugees with overseas TB classifications
2007 TB TI
• CDC process to revise Technical Instructions
began in 2005
• Scientific literature reviewed
• Input from U.S. Tuberculosis Community :
• Advisory Council for the Elimination of Tuberculosis
(ACET)
• National Tuberculosis Controllers Association (NTCA)
• National Coalition for the Elimination of Tuberculosis
(NCET)
2007—TB TI
• Chest x-ray for persons ≥15 years of age
 and for persons 2-14 years with a TST>10 mm* or
positive IGRA
• If chest x-ray abnormal, serial AFB smears
 and cultures
 Drug susceptibility testing (DST) for all TB isolates
 Treatment to completion of therapy according to
ATS/CDC/IDSA guidelines, delivered as DOT
+
+
*countries with WHO-estimated incidence rate ≥20 per 100,000
Saint Luke’s Extension Clinic, Philippines
FY 2007 (52,530 applicants, 1991 TB TI) vs.
FY 2008 (41,793 applicants, 2007 TB TI)
505
Number of Applicants
with Pulmonary TB
291
102
95
Smear + / Culture +
93
Smear + / Culture –
75
306
Smear – / Culture +
4
Smear – / Culture –
2007 Technical Instruction
Smear – / No Culture
Done
1991 Technical Instruction
121
0
50
100
150
200
250
300
350
400
TB case detection rate 1991 vs 2007 TB TI: 554 vs. 1,208 (per 100,000)
450
500
550
Implementation
• TB culture facilities built -liquid culture w/ Bactec MGIT 960
• Training of panel physicians
• Rollout in countries according to:
• #s of applicants
• TB rates
• In-country resources
As of January, 2010
• Populations from 27 countries on three continents are being
screening according to the 2007 TB TI
• 53% immigrants
• >50% refugees
Implementation of the 2007 TB TI
-Current Status
Current status
27 countries
53% of immigrants
>50% of refugees
Implementation of the 2007 TB TI
-2010 Implementation
South Korea
Ghana
Panel physician training
India: January 13-15
Ghana: March 16-18
Dominican Republic: May 3-5
Summer/Fall
Spring
Nepal
Spring
ACET/NTCA
Vietnam
India
Summer/Fall
Guatemala
Summer/Fall
Thailand
Nigeria
Summer/Fall
Spring
Malaysia
Indonesia
Summer/Fall
Spring
2007 Technical Instructions:
Impact on Prevention of Disease
• Improve detection of tuberculosis overseas
• More refugees that need treatment will receive it
• Improve stateside follow-up
• Decrease importation of tuberculosis
• Assist in global tuberculosis control efforts
• Improve tuberculosis expertise and infrastructure
overseas
2007 TB Technical Instructions
Available at:
http://www.cdc.gov/immigrantrefugeehealth/exams/ti/pane
l/tuberculosis-panel-technical-instructions.html
Acknowledgments
International Organization for Migration (IOM)
•Tom O’Rourke
•Warren Jones
•Raz Wali
•Dr. Yen
Dept. of State
•Bureau of Population, Refugees, and Migration
CDC
•Drew Posey
•Marty Cetron
•John Painter
•Greg Armstrong
•Luis Ortega
•Susan Maloney
Thank you!!
1991 Tuberculosis Technical Instructions:
for applicants ≥15 years of age
or
Valid for travel
within 6 months
Signs and
symptoms
Sputum smears x 3
All (-)
(at least one +)
Treat until smear
negative
Noninfectious
Class B1
Infectious
Class A
Class A
waiver
2007 TB TI
If TB rate ≥20/100,000
2-14 years of age:
TST ≥10 mm or
Positive IGRA
Valid for travel
within 6 months
HIV
or
Signs and
symptoms
Sputum smears x 3
All (-)
+ cultures
(at least one +)
DOT
Treat until smear
negative
3
Noninfectious
Class B1
Infectious
Class A
cured
Class A
waiver
2007 Technical Instructions:
Classifications
Class
1991 Technical
Instructions
2007 Technical
Instructions
No classification
Normal evaluation
Normal evaluation
Class A
Tuberculosis disease
Tuberculosis disease
Class B1Pulmonary
Abnormal CXR, sputum
smears negative
Abnormal CXR, sputum
smears and cultures
negative
Class B1 –
Extrapulmonary
Extrapulmonary
tuberculosis
Extrapulmonary
tuberculosis
Class B2
Inactive tuberculosis on
CXR
LTBI evaluation
Class B3
Old or healed
tuberculosis
Contact evaluation
Waivers for Medical Conditions
Basic Points
• IRMH/CDC is involved in the waiver process for
immigrants based on the following medical
conditions:
HIV Infection
Mental/Physical Disorders with associated harmful
behavior
Tuberculosis
Class A Medical Conditions
Inadmissible
Treatment or waiver required for admission
Examples
•
•
•
•
TB (laboratory positive)
HIV
STIs (untreated)
Mental Disorders with Harmful Behavior (including
Alcohol Abuse)
• Substance Abuse (no waiver for immigrants)
Class B Medical Conditions
Admissible
Substantial departure from normal health
Examples:
•
•
•
•
TB (laboratory negative)
STIs (treated),
Mental Disorders without Harmful Behavior
Substance Abuse (in remission)
Stateside notifications for TB