Download Tuberculosis – Old Disease, New Disease

Introduction to Public Health/Communicable Diseases/Tuberculosis
Tuberculosis
An Old Disease – New Twists
A Continuing Public Health
Challenge
Jane Moore, RN, MHSA
Director, TB Control & Prevention Program - VHD,
2013
Tuberculosis – Old Disease
• May have evolved from M bovis; acquired by humans from
domesticated animals ~15,000 years ago
• Endemic in humans when stable networks of 200-440 people
established (villages) ~ 10,000 years ago; Epidemic in Europe
after 1600 (cities)
• 354-322 BC - Aristotle – “When one comes near
consumptives… one does contract their disease… The reason
is that the breath is bad and heavy…In approaching the
consumptive, one breathes this pernicious air. One takes the
disease because in this air there is something disease
producing.”
Tuberculosis
• 1882 – Robert Koch – “one seventh of all
human beings die of tuberculosis and… if one
considers only the productive middle-age
groups, tuberculosis carries away one-third
and often more of these…”
M tuberculosis as causative
agent for tuberculosis
Robert Koch
1886
TB as a Worldwide
Public Health Issue
•
•
•
•
World population ~ 6 billion
~ 1in 3 people in world infected
~ 9.4 million new cases of active TB/year
1.7 million deaths/year
•
•
•
•
US population 280 million
~ 3-5% infected
Now < 10,000 cases/year
~ 5-7% mortality
TB in the US – 1882-2012
• 1900-1940 TB rates decreased in the US and
Western Europe before TB drugs available
– Better nutrition, less crowded housing
– Public health efforts
• Earlier diagnosis
• Limit transmission to close contacts
– TB sanatoria
– Surgery
TB in the US – 1882-2012
• 1940s-1960s TB specific antimicrobial agents
– Single drugs – use produced resistance
– Multiple drugs
• 1960s-1980s TB considered a non-problem
– TB treatment moved to private sector
– Loss of TB-specific public health infrastructure
TB in the US – 1882-2012
• 1990s TB re-emerges as a threat
– TB-HIV co-infection
– Drug-resistant TB
– Globalization allows TB to travel
• 1990s Increased support for TB prevention and
control
– Funding for public health efforts (case management,
contact investigation, directly observed therapy
– Better diagnostic and patient management tools
• 2012
– Lowest number of reported cases in US - <10,000
•
One-third of the world is infected with TB, an average of one
new infection per second
•
Two million people died from tuberculosis in 2010, 1 every 20
seconds
•
TB is the leading killer of those with HIV
•
TB is the 2nd leading killer from an infectious disease
*Estimated
TB in Virginia: 1990-2012
Number of Cases
500
400
300
200
235
100
0
1990
1993
1996
1999
2002
Year
2005
2008
2011
Virginia TB Cases - 2012
Place of Origin
Race and Ethnicity
Other (1%)
Mexico
White
7%
(22%)
Asian (51%)
Other Countries
(39%)
Philippines
Black (15%)
(11%)
Hispanic
(26%)
Vietnam
Haiti
(3%)
Guatemala
(3%)
China
(6%)
India
(8%)
(8%)
TB Case Rate per 100,000 VA and
US: 2007-2012
Year
Virginia TB
Cases
Virginia TB
Rate
US TB Cases
US,521TB
Rate
2008
292
3.8
12,906
4.2
2009
273
3.5
11,545
3.8
2010
268
3.4
11,181
3.6
2011
221
2.7
10,521
3.4
2012
235
2.9
9,951
3.2
Number of Cases
VA TB Cases by Region: 2007-2012
200
180
160
140
120
100
80
60
40
20
0
2007
2008
2009
2010
2011
2012
Northwest
Southwest
Central
Eastern
Northern
TB: Airborne Transmission
TB Invades/Infects the Lung
Effective immune
response
Infection limited
to small area of lung
Immune response
insufficient
TB – A Multi-system Infection
Natural History of TB Infection
Exposure to TB
No infection
(70-90%)
Infection
(10-30%)
Latent TB
(90%)
Never develop
Active disease
Die within 2 years
Active TB
(10%)
Untreated
Survive
Treated
Die
Cured
Latent TB vs. Active TB
Latent TB (LTBI) (Goal = prevent future active disease)
= TB Infection
= No Disease
= NOT SICK
= NOT INFECTIOUS
Active TB (Goal = treat to cure, prevent transmission)
= TB Infection which has
progressed to TB Disease
= SICK (usually)
= INFECTIOUS if PULMONARY (usually)
= NOT INFECTIOUS if not PULMONARY (usually)
Treatment
• Most TB is curable, but…
–
–
–
–
Four or more drugs required for the simplest regimen
6-9 or more months of treatment required
Person must be isolated until non-infectious
Directly observed therapy to assure adherence/completion
recommended
– Side effects and toxicity common
• May prolong treatment
• May prolong infectiousness
– Other medical and psychosocial conditions complicate
therapy
• TB may be more severe
• Drug-drug interactions common
TB – continues as a public health issue in the
United States
• Old public health concepts (isolation of infectious individuals,
closely monitored treatment, recognition and preventive
treatment for infected contacts,) are still critical, but will not
eradicate TB
• Care providers not familiar with signs/symptoms of TB
– Diagnosis delayed
– Inappropriate treatment
– Drug resistance due to improper use of drugs
• Must address both US born and newcomer populations
– Older, remote exposure
– Incarcerated, homeless, history of drug , alcohol use
– Newcomers from high TB prevalence areas
Challenges to Public Health System
• Public health workers must:
– Educate, coordinate care with private sector
– Identify support services (food, housing)
– Treat TB in geriatric populations
– Treat TB in children
– Deal with alcohol, drug abusing, incarcerated and/or
homeless patients
– Manage TB in patients with underlying medical conditions
– Provide culturally appropriate care for non-English
speaking/non-literate populations
– Treat TB cases with drug- resistant TB
Addressing the Challenges – TB
Control in the US - 2012
• Local, state and federal programs have separate but closely
related activities
• Guidelines, Laws and Regulations
– Guidelines – treatment, contact investigation, prevention –
data driven/expert opinion
– Laws – local or state – case reporting, isolation of
infectious individuals
– Regulations - local or state – implement laws
– Federal laws/regulations – travel restrictions, entry into
the US – no interstate restrictions
– International travel regulations – WHO – limited
Elements of a Tuberculosis Control Program
Targeted testing/
LTBI treatment
Inpatient care
Medical evaluation
and follow-up
Non-TB medical
services
Home
evaluation
Case
Management
Follow-up/treatment
of contacts
Pharmacy
Laboratory
Technical assistance
Training
Funding
Outbreak Data analysis
Investigation
Program
evaluation &
QA, QI for case
planning
management
Consultation on Data for local, state, national
Training
difficult cases
surveillance reports
Federal TB
Control Program
National surveillance
11/01/07
Clinical
Services
Social
HIV testing and
Interpreter/
services
counseling
Occupational health,
translator
school, jail, shelter,
services
Patient
LTCF screening
Data collection
education
Coordination of
Documentation
Epidemiology
medical care
Contact
DOT
investigation and Surveillance
Housing
Isolation,
detention
Guidelines
X-ray
State TB Control Program
Funding
State statutes,
regulations,
policies, guidelines
Information
for public
VDH/DDP/TB
Jan 2007
VDH TB Prevention and Control
Policies and Procedures
• Based on USPHS/CDC, ATS, IDSA and Pediatric “Red
Book” guidelines
• Adapted to address uniquely Virginia issues
•
DDP TB Prevention and Control
Activities
• Core activities
– Identification and treatment of TB cases
– Identification, evaluation and treatment of high
risk close contacts of cases
– Surveillance/case reporting
– TB laboratory services
– Targeted testing and LTBI treatment for high
risk populations
– Training/continuing education for health care
providers
– Program evaluation
26
TB Control provided funding for TBrelated activities at Local Health
Departments
– PHN/ORW/Epi Reps (VDH/DDP employees and
contracts)
– TB clinic physicians (contracts)
– Chest x-rays and laboratory tests
– TB medications for uninsured case patients
– Incentives and enablers
– Training for HDs, PHNs, ORW
27
Services directly provided by Central Office
(Richmond)
– Case reporting, surveillance activities
• Site visits to review case records, collect
data
• Data entry/management/analysis/reports
• Feedback to local health departments
• Data for national TB surveillance system
• Information for local/state/federal
government officials
28
Services directly provided by Central Office
– Technical support/consultation
• Case management
• Contact investigations
• Expert clinical consultation available through
partnerships with EVMS and UVA
• Case review conferences (QA, QI)
• TB prevention/control in congregate living
facilities, health care facilities
29
Services provided by Central Office
– Educational activities for public and private
sector HCPs, patients and the public
• VDH conferences for public health workers
• Speakers at private sector HCP meetings
• Distribution of guidelines
• Website
30
Currently Available Laboratory
Services
• DCLS
– Standard TB Bacteriology
• Smear, DNA Preliminary Culture, Standard Culture,
Susceptibility
– Molecular testing
• MTD – Mycobacterium tuberculosis Direct
• Cephid testing in validation process
Currently Available Laboratory
Services
• Other Laboratories
– Florida State Laboratory
• HAIN testing – molecular susceptibility for INH/RIF
– Centers for Disease Control and Prevention
• First and second-lined molecular drug susceptibility
testing
• Genotyping of isolates
– University of Florida Pharmacokinetics Laboratory
• Serum drug level testing
Current Programmatic Initiatives
• Statewide availability of Interferon Gamma
Release Assay for testing for latent TB
infection
– Blood test
• 2 commercial products
• QuantiFeron Gold InTube
• T-Spot-TB – Chosen for Virginia for logistical
reasons
Current Programmatic Initiatives
• New Treatment for latent TB infection (LTBI)
– 12 week course of isoniazid and rifapentine (3HP)
• Virginia Guidelines document developed
– Pros
• Shortens treatment course from 9 months to 12 weeks
• Weekly instead of daily or twice weekly treatment
– Cons
• Requires directly observed treatment – observe dose
ingestion
• Costly – but price is coming down
• Number of pills – but new formulations under
development
Current Programmatic Initiatives
• Routine serum level drug testing of all diabetic
TB cases early in treatment
– A study of slow to respond to treatment TB cases
showed statistical significance for diabetes
– Pilot demonstrated high percentage of diabetics
had low serum levels for TB drugs
• Next phase – impact on sputum conversion
– Goal
– Shorten infectious period and potential for community
transmission
– Shorter treatment duration with resulting lower cost
Programmatic Initiatives
• Increased focus on contact investigation
activities
– Monitoring ongoing evaluation of contacts,
especially children and immunocompromised
contacts
– Monitoring treatment of infected contacts
Programmatic Initiatives
• Focus on program evaluation activities
– Ongoing case reviews of current cases
– Cohort Review of prior year cases for 6 selected
national indicators
• Completion of treatment, HIV testing, Sputum
collection, sputum conversion, susceptibility results,
and initiation of treatment with 4 anti-TB drugs
– District program review and record audit
Current Needs for TB in the US
• General
– Continued support for TB prevention/control
especially with health care reform
• Sequestration and future federal budget reductions will
have impact
– New drugs and/or drug combinations to allow
shorter courses of treatment
• New drug bedaquiline approved by FDA
• Use limited to multi-drug resistant pulmonary cases
who cannot be treated with other drugs
Current Needs for TB in the US
– Shorter, simpler, less expensive treatment
regimens
– Vaccine (beyond BCG)
• Still waiting
– Support for global TB prevention and control
activities
• Federal funding reductions for global TB activities
Current Needs for TB in the US
• Reliable access to anti-tuberculosis drugs
– Isoniazid – ongoing national shortage since Fall
2012
• Use in Virginia now limited to certain persons
– PPD Solution – not a diagnostic – classified as a
Schedule VI drug in Virginia
• Started as national shortage of Tubersol, now spread to
alternative product , Aplisol
– Multiple injectible agents used for drug resistant
TB in short supply
• National shortage for several years
Assessing the Impact
• TB currently at lowest number and rate for
both US and Virginia since records kept
– Current drug shortages have the potential to
hamper further progress in TB control and
elimination
– Priority on identifying and treating contacts to
known cases
• Using T-Spot.TB for testing contacts > age 12, skin test
for younger children
• Using isoniazid and rifapentine to treat contacts
– Isoniazid sparing regimen
• Others at high risk – testing & treatment deferred
Thank you
Questions?
Jane Moore
[email protected]
804 864 7920