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Tuberculosis in Virginia?

Wendy Heirendt, MPA
Public Health Advisor
Division of TB Control
Virginia Department of
Health
September 12, 2005
Areas to be Covered Tonight
Epidemiology of TB in Virginia
 Diagnosis, Transmission, Treatment
 Role of the Health Department

Current TB Challenges in Virginia

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329 cases in 2004, <1% decrease from 2002
 Majority (39%) of the cases in 25-44 year olds
 16.5% were in persons 0-24 years of age
Large number of TB patients are born outside the
US
 43 nationalities
 17 primary language, non-English
Cases reported in 34 of 35 health districts
Number of Reported TB Cases in
Virginia, 1986-2004
500
Number
400
329
300
200
100
0
1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Year
TB Case Rates in Virginia,
1996-2004
Year
1996
1997
1998
1999
2000
2001
2002
2003
2004
Cases
349
349
339
334
292
306
315
332
329
VA Rate
5.3
5.3
5.2
4.9
4.1
4.3
4.5
4.5
4.4
US Rate
8.0
7.4
6.8
6.4
5.8
5.6
5.2
5.1
4.9
Percent of Reported TB Cases
by VA Region: 2003 and 2004
Southwest
Southwest
7%
Northwest
9%
Central
20%
7%
Northwest
7%
Central
15%
Eastern
20%
Eastern
18%
Northern
46%
2003
Northern
51%
2004
Number of Reported TB Cases
by Age and Sex: VA, 2004
70
Male
Number of Cases
60
50
40
30
20
10
0
0-14
15-24
25-44
45-64
Age Group in Years
65+
Female
Percent of Reported TB Cases
by Age: VA, 1996-2004
Percent of Cases
50
40
30
20
10
0
1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
0-14
Chart 6
15-24
25-44
45-64
65+
Number of Reported Foreign-Born
vs.US-Born TB Cases, VA 1996-2004
US Born
Foreign Born
Number of cases
250
200
150
100
50
0
1996 1997 1998
1999 2000 2001
Year
2002 2003 2004
12
16.3
10
10
Number
14.1
8
11
7
9.5
6
4
4
2
0
1
18
16
14
13.4
12
12.2
10
8
4
6
2
4
3.3
1
2
0
1998 1999 2000 2001 2002 2003 2004
*Culture confirmed cases with
drug susceptibility tests
performed
Percent
MDR Cases & Percent of Resistance to
Any First Line Drugs: VA, 1998-2004
Number of Reported TB/AIDS
Cases: VA, 1993-2004
30
25
20
15
10
5
0
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
Number of Cases
35
Year
What is TB??
Disease caused by Mycobacterium
tuberculosis
 Airborne disease passed from person
to person
 Can be cured with medications
 Treatment for latent TB infection

Famous TB Patients
Doc Holliday of Wild West fame
 Christy Mathewson of baseball lore
 Eleanor Roosevelt, First Lady
 Edgar Allan Poe and associates

How TB is Transmitted
TB transmission occurs when a
person with active, infectious TB
disease coughs, sneezes, laughs,
sings, etc.
 TB spreads through the air by
inhaled droplet nuclei
 TB needs prolonged contact for
transmission

Factors Affecting TB Transmission



How infectious is the
person with TB disease?
Where does the exposure
to TB infection occur?
How much time does a
person spend with another
person who has infectious
TB disease?
contact
source
environment
Infection Can Result in…
Limited disease Latent TB, no
symptoms, not sick, positive skin
test, cannot transmit to othters
 Active Disease progressive, M.tb
replicating in any organ, only
pulmonary is infectious

Active TB Disease

May be infectious

Has clinical symptoms

Usually pulmonary involvement
Symptoms of Active TB Disease

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Prolonged cough
(may produce
sputum)*
Chest pain*
Hemoptysis*
Fever
Chills

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Night sweats
Fatigue
Loss of appetite
Weight loss or
failure to gain weight
*Symptoms commonly seen in cases of pulmonary (lung) TB
Diagnostic Techniques
Tuberculin Skin Test
A decision to test is a decision to
treat
 Sputum collection/testing
 Chest x-ray
 Medical evaluation

Medications for TB Disease


Standard medication regimen
 Minimum of 6 months of therapy,
sometimes longer
 Initial 4 drug therapy standard:
• Isoniazid (INH)
• Rifampin (RIF)
• Pyrazinamide (PZA)
• Ethambutol (EMB)
Medications may need to be changed if the TB
is drug resistant to any medication listed
above
Directly Observed Therapy
(DOT)

A health care worker watches a TB
patient swallow each dose of the
prescribed drugs

DOT is recommended for all
persons who have TB disease

The health care worker will conduct
DOT at a time and place convenient
for each patient who has TB disease
Latent TB Infection (LTBI)




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Occurs when TB bacteria are in the body,
but are inactive or latent
No clinical symptoms of active TB
disease
Not infectious to others
Positive reaction to the TB Skin Test
Normal chest X-ray
Treatment of Latent TB
Infection (LTBI)

Treating LTBI prevents the development
of TB disease, especially for persons at
high risk for developing TB disease if
infected with TB

Usual medication regimen for treating TB
infection
 Isoniazid (INH) for 9 months
 Rifampin for 4 months is alternative in
certain circumstances
Persons at Higher Risk for
Becoming Infected with TB

Close contacts of persons known or
suspected to have active, infectious
TB disease

Foreign-born persons from areas in the
world where TB is common

Residents and employees of high-risk
congregate settings
(Continued on next slide)
Persons at Higher Risk for
Becoming Infected with TB

Health care workers who serve
high-risk clients

Children exposed to adults in highrisk categories
TB and HIV Coinfection: Reason
for Concern

For persons infected with TB, HIV
positive status is the strongest risk
factor for developing active TB disease

In persons who are HIV positive and
have TB infection, the chances of
developing TB disease increases from
10% in a lifetime to 7% to 10% each
year!
Public Health Implications
Contagious, airborne disease
 Isolation of the infectious person
must be instituted to prevent
transmission
 Identification of exposed and
infected contacts (by Regulation)
 Treatment for all

Case Study

34 y.o. male diagnosed with infectious TB
Hx of negative TST, <12 months ago
No known TB exposure
Family, co-workers tested; no new cases

Is this CI complete?



Another Case Study
30 yo male, infectious pulmonary TB
 Carpools to work at call center
 Risk to carpoolers? Workmates?
 Work from home? Other type of
work for few weeks?

One More
20 y.o. college student
 Needs baseline TST for practicum at
hospital
 Hx of BCG vaccination as a child
 Unsure of TST status
 TST= 12mm, cxr negative
 Start student on 9 mos of INH??

TB Issues in a Disaster
Known TB cases are displaced
[Focus on active; ignore LTBI]
 Treatment is interrupted
 Possible transmission – concern in
shelters, buses, cars, homes

Things to Consider
Plans- hope TB cases present to HD
 HD obtains history, treatment info
 May need cxr, labs
 Most will be non-infectious
 Isolate if coughing, not on meds
 Numbers are likely to be small

TB Prevention and Control:
Short Term Shelters

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Same as acute illness screening on
admission to shelters
Look for symptoms
Use form; administer by non-HCP
Separate symptomatic from the crowd
ASAP….med evaluation ASAP
Obtain consent, recent and past medical
hx, placement hx,
We are not recommending TST
Ignore LTBI…no symptoms, not infectious
TB Prevention and Control:
Long Term Shelters

Consider additional screening based
on identified risk factors
Likely exposure
 High risk medical conditions

Other Thoughts
For HCPs:
Communications (cell/satellite phones,
internet, fax, copiers)
 Office supplies
 Confidential files, locked syringe box
 Past medical histories from home state
 Refrigeration for vaccines, etc

More Thoughts
For the evacuees
Handicap accessible, laundry facilities,
bed linens, showers, food service,
phone connections, internet,
 Recreational facilities, Playgrounds,
other diversions
 Mental health resources, social workers
 Facility ID cards, Medicaid applicaitons

Resources
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http://www.bt.cdc.gov/disasters/hurricanes/
katrina/shelters.asp
http://www.nationaltbcenter.edu/catalogue/d
ownloads/tbhomelessshelters.pdf
http://www.umdnj.edu/ntbcweb/docs/Contac
t%20Investigations.pdf
http://www.umdnj.edu/ntbcweb/docs/congre
gate/CongregateSetting.pdf
For More Information…

Virginia Department of Health Division of TB Control
109 Governor Street, First Floor Richmond, VA 23219
804-864-7906
http://www.vdh.virginia.gov/epi/tb

Local Health Departments
http://www.vdh.virginia.gov/LHD/LocalHealthDistricts.asp

Centers for Disease Control and Prevention
Division of TB Elimination
http://www.cdc.gov/nchstp/tb