Beyond Sputum Cups and Four Drugs

The Responsibility of the Practicing Clinician in the Community Control of

Tuberculosis

V. R. Koppaka, MD, PhD

Division of TB Control

“...protection, improvement, and preservation of the public health and of the environment are essential to the general welfare of the citizens of the Commonwealth. For this reason, the State Board of Health and the State Health Commissioner, assisted by the State Department of Health, shall administer and provide a comprehensive program of preventive, curative, and restorative services...and abate hazards and nuisances to the health and...”

VAC §32.1-2

Priorities in Control of Tuberculosis

• Detection of all cases of tuberculosis disease

• Treat all cases of active tuberculosis disease

• Complete treatment of all cases of active disease and their infected contacts

TB Control: Physician Roles

• Efficient case detection• Appropriate and adequate treatment• Communication with health authorities• TB prevention• Advocacy

Active Tuberculosis Disease

Bacteriologically-DefinedBacteriologically-Defined

• M. tuberculosis present in any bodily fluid, or tissue.

• Confirmed by:– Culture– Nucleic acid detection– Acid Fast Smear

Clinically-DefinedClinically-Defined

• Clinical evidence– Symptoms– Radiography– TST result

• Response to therapy

VAC §32.1-49.1

Management of Tuberculosis

• Early diagnosis and treatment based on clinical features, radiography, bacteriology

• Baseline and monthly clinical assessment:– Treatment response – Adherence– Drug intolerance

• Maintain and update written treatment plan and record of adherence (VAC §32.1-50.1)

• Submission of initial and subsequent reports to LHD

Statement of Responsibility

“Because in the treatment of tuberculosis the benefits accrue to society as well as to the patient, any provider undertaking to treat a patient with tuberculosis is taking on a public health function in which she/he is assuming responsibility for successful completion of therapy.”

ATS/CDC/IDSA Guidelines for Treatment of Tuberculosis, 2002

Disease Reporting

Every physician practicing in this Commonwealth who shall diagnose or reasonably suspect that any patient of his has any disease required by the Board to be reported and every director of any laboratory doing business in this Commonwealth which performs any test whose results indicate the presence of any such disease shall make a report within such time and in such manner as may be prescribed by regulations of the Board.

VAC § 32.1-36

Reporting of Tuberculosis Disease

Who: PhysicianHealth Care FacilityLaboratory

What: Patient characteristicsDiagnostic information

Treatment/follow-up information

When: Within 24 hours (initial report) Within 1-2 weeks (secondary

report)

How: Telephone/fax/(internet)VAC § 32.1-50 B, C

TB Disease: Required Subsequent Reports

• Treatment ceases– Fails to keep treatment appointment– Relocates with transfer of care– Discontinues treatment on or against medical

advice

• Regimen changes• Clinical status changes • As updates become available

VAC §32.1-50 D

TB Treatment Plans

• Required for all patients receiving treatment for TB disease

• Local health director approval mandatory for– All inpatients prior to discharge– HIV co-infected– Confirmed or suspected rifampin resistance– History of prior TB treated or untreated– Demonstrated history of nonadherence

VAC §32.1-50.1

TB Treatment Plan Elements

• Tailored to patient’s medical and social needs• Updated at least monthly• Must include at minimum:

– Verified patient address– Name of MD responsible for care– Drug regimen and estimated completion date– Written record of adherence

VAC §32.1-50.1

Tuberculosis 2002: Global Emergency

• 1/3 of the world’s population infected• 8 million new cases of active disease per year• 2-3 million deaths per year• 80% of global morbidity found in just 22 countries • One person is newly infected every second and one

person dies every 10 seconds• Rising incidence of drug-resistant disease• Billions of dollars in lost productivity

“A fundamental human right”

“We are now at a critical juncture…”

“On the one hand, control of tuberculosis in the United States has been regained and we are at an all-time low in the number of new cases. On the other hand, we are particularly vulnerable again to the complacency and neglect that comes with declining numbers of cases. Now is the time to commit to the abolition of the recurrent cycles of neglect followed by resurgence that have been the history of tuberculosis. ... But to meet this goal, aggressive and decisive action beyond what is now in effect will be required."

p. viii

Institute of Medicine. Ending Neglect. 2000