TuberculosisAn Old Disease New TwistsA Continuing Public Health Challenge

Jane Moore, RN, MHSADirector, TB Control & Prevention Program2012EPID 600 - Introduction to Public Health (On-Line 2012)Communicable Diseases of Public Health Importance

Tuberculosis Old DiseaseMay have evolved from M bovis; acquired by humans from domesticated animals ~15,000 years agoEndemic 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 heavyIn approaching the consumptive, one breathes this pernicious air. One takes the disease because in this air there is something disease producing.

Tuberculosis1882 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 tuberculosis1886Robert Koch

TB in the US 1882-20101900-1940 TB rates decreased in the US and Western Europe before TB drugs availableBetter nutrition, less crowded housingPublic health effortsEarlier diagnosis Limit transmission to close contactsTB sanatoriaSurgery

TB in the US 1882-20101940s-1960s TB specific antimicrobial agentsSingle drugs use produced resistanceMultiple drugs1960s-1980s TB considered a non-problemTB treatment moved to private sectorLoss of TB-specific public health infrastructure

TB in the US 1882-20111990s TB re-emerges as a threatTB-HIV co-infectionDrug-resistant TBGlobalization allows TB to travel1990s Increased support for TB prevention and controlFunding for public health efforts (case management, contact investigation, directly observed therapyBetter diagnostic and patient management tools2010Lowest number of reported cases in USFunding declining

TB in the US 2011 Continuing needsContinued support for TB prevention/control especially with health care reformNew drugs and/or drug combinations to allow shorter courses of treatmentShorter, simpler, less expensive treatment regimensVaccine (beyond BCG)Support for global TB prevention and control activitiesRapid diagnostic tests for limited resource settingsBetter co-ordination of TB and HIV prevention/treatment programs Reliable access to TB drugs

TB: Airborne Transmission

TB Invades/Infects the LungEffective immuneresponseInfection limited to small area of lungImmune responseinsufficient

TB A Multi-system Infection

Natural History of TB InfectionExposure to TBNo infection (70-90%)Infection(10-30%)Latent TB (90%) Active TB(10%)

UntreatedDie within 2 yearsSurviveTreatedDieCuredNever develop Active disease

Latent TB vs. Active TBLatent 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)

TreatmentMost TB is curable, butFour or more drugs required for the simplest regimen6-9 or more months of treatment requiredPerson must be isolated until non-infectiousDirectly observed therapy to assure adherence/completion recommendedSide effects and toxicity commonMay prolong treatmentMay prolong infectiousnessOther medical and psychosocial conditions complicate therapyTB may be more severeDrug-drug interactions common

TB in Virginia: 1990-2011221

TB Case Rate per 100,000 VA and US: 2007-2011

YearVirginia TB CasesVirginia TB RateUS TB CasesUS,521TB Rate20073094.013,2804.420082923.812,9064.220092733.511,5453.820102683.411,1813.620112212.710,5213.4

TB continues as a public health issue in the United StatesOld 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 TBDiagnosis delayedInappropriate treatmentDrug resistance due to improper use of drugs

Must address both US born and newcomer populationsOlder, remote exposureIncarcerated, homeless, history of drug , alcohol useNewcomers from high TB prevalence areas

Challenges to Public Health SystemPublic health workers must:Educate, coordinate care with private sectorIdentify support services (food, housing)Treat TB in geriatric populationsTreat TB in childrenDeal with alcohol, drug abusing, incarcerated and/or homeless patientsManage TB in patients with underlying medical conditionsProvide culturally appropriate care for non-English speaking/non-literate populationsTreat TB cases with drug- resistant TB

VA TB Cases by Region: 2007-2011

VA TB Cases by Age and Sex: 2011Number of Cases Age Group

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/year1.7 million deaths/year

US population 280 million~ 3-5% infected~ 11,000 cases/year~ 5-7% mortality

Percent Virginia TB Cases by Race/Ethnicity and Place of Origin

Chart1

3

2

25

31

US Born

Hispanic3%

Sheet1

US Born

Asian3

Hispanic2

Black25

White31

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Chart1

83

40

22

15

Foreign Born

Hispanic 25%

Sheet1

Foreign Born

Asian83

Hispanic40

Black22

White15

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Foreign-born TB Cases Top Five Countries of Birth: US and Virginia MexicoPhilippinesIndiaViet NamChina

US (2010)Virginia (2011)IndiaEthiopiaViet NamPhilippines(with 8 cases each China, Mexico,Nepal,Peru)

Addressing the Challenges TB Control in the US - 2011Local, state and federal programs have separate but closely related activitiesGuidelines, Laws and RegulationsGuidelines treatment, contact investigation, prevention data driven/expert opinionLaws local or state case reporting, isolation of infectious individualsRegulations - local or state implement lawsFederal laws/regulations travel restrictions, entry into the US no interstate restrictionsInternational travel regulations WHO limited

11/01/07

VDH TB Prevention and Control Policies and ProceduresBased on USPHS/CDC, ATS, IDSA and Pediatric Red Book guidelinesAdapted to address uniquely Virginia issues

*DDP TB Prevention and Control ActivitiesCore activitiesIdentification and treatment of TB casesIdentification, evaluation and treatment of high risk close contacts of casesSurveillance/case reportingTB laboratory servicesTargeted testing and LTBI treatment for high risk populations Training/continuing education for health care providersProgram evaluation

*TB Control provided funding for TB-related activities at Local Health Departments

PHN/ORW/Epi Reps (VDH/DDP employees and contracts)TB clinic physicians (contracts)Chest x-rays and laboratory testsTB medications for uninsured case patientsIncentives and enablersTraining for HDs, PHNs, ORW

*Services directly provided by Central Office (Richmond)

Case reporting, surveillance activitiesSite visits to review case records, collect dataData entry/management/analysis/reportsFeedback to local health departmentsData for national TB surveillance systemInformation for local/state/federal government officials

*Services directly provided by Central OfficeTechnical support/consultation Case managementContact investigationsExpert clinical consultation available through partnerships with EVMS and UVA Case review conferences (QA, QI)TB prevention/control in congregate living facilities, health care facilities

*Services provided by Central OfficeEducational activities for public and private sector HCPs, patients and the publicVDH conferences for public health workersInvited speakers at private sector HCP meetingsDistribution of guidelinesWebsiteTelephone hot line

Currently Available Laboratory ServicesDCLSStandard TB BacteriologySmear, DNA Preliminary Culture, Standard Culture, SusceptibilityMolecular testingMTD Mycobacterium tuberculosis DirectCephid testing in validation process

Currently Available Laboratory ServicesOther LaboratoriesFlorida State LaboratoryHAIN testing molecular susceptibility for INH/RIFCenters for Disease Control and PreventionFirst and second-lined molecular drug susceptibility testingGenotyping of isolatesUniversity of Florida Pharmokinetics LaboratorySerum drug level testing

Current Programmatic InitiativesStatewide availability of Interferon Gamma Release Assay for testing for latent TB infectionBlood test2 commercial productsQuantiFeron Gold InTubeT-Spot-TB Chosen for Virginia for logistical reasons

Current Programmatic InitiativesNew Treatment for latent TB infection (LTBI)12 week course of isoniazid and rifapentineVirginia Guidelines document developedProsShortens treatment course from 9 months to 12 weeksWeekly instead of daily or twice weekly treatmentConsRequires directly observed treatment observe dose ingestionCostly but price is coming downNumber of pills but new formulations under development

Current Programmatic InitiativesRoutine serum level drug testing of all diabetic TB cases early in treatmentA study of slow to respond to treatment TB cases showed statistical significance for diabetesPilot underway to determine if early testing can prevent prolonged slow response to treatmentGoalShorten infectious period and potential for community transmissionShorter treatment duration with resulting lower cost

Programmatic InitiativesIncreased focus on contact investigation activitiesMonitoring ongoing evaluation of contacts, especially children and immunocompromised contactsMonitoring treatment of infected contacts

Programmatic InitiativesFocus on program evaluation activitiesOngoing case reviews of current casesCohort Review of prior year cases for 6 selected national indicatorsCompletion of treatment, HIV testing, Sputum collection, sputum conversion, susceptibility results, and initiation of treatment with 4 anti-TB drugsDistrict program review and record audit

Questions?Jane MooreJane.moore@vdh.virginia.gov804 864 7920Thank you

TuberculosisJane L. Moore, RN, MHSA, Virginia Department of Health

Review the slide show presentation on Tuberculosis: Part 1,Slides,. Then look at the example ofgoal setting to reduce TB incidenceand be prepared to discuss the epidemiological basis for such goal setting. Even though this slide is more than 30 years old there are still lessons to be learned today. Although increasing, there are still few only a few instances of community analysis and results oriented programming and evaluation on the web. Also, review at the CDC web pages devoted toTB, HIV & STDsand click on Dr Fenton's blog.Finally look at a discussion of a recentTB outbreak in New York compared to one in London, UK(Second item under Perspective). Where was the information published? Why do you think I selected this topic? Consider why TB persists today with all our antibiotics. Take a look at the Global Issues defined by theWHO(look at some of the publications on the right side of the screen). Scan at the WHO global plan toSTOP TBand the reprint from the NEJM ofglobal TB. You may wish to visit the PBSDeadly Diseases - TBsite All of you should watch the 4 minute video (part III). Also students from outside the US who have seen the effectiveness of BCG in TB prevention, look atthis articlefrom the Lancet (April 2006) and try to determine why BCG is not used in the US. A recent article on the planneduse of BCG in Londonis worth reviewing,as is thisreport in the Guardian. Also look at this editorial onBCG use in Developing Countries(thesecond editorial). The latest informationon anew test for TB The [WHO] has endorsed a new rapid test for tuberculosis use worldwide. Review the articles on the [WHO] website. How will this new test be a game changer for TB diagnosis and morbidity? Blood testing for TB infection -http://www.medscape.com/viewarticle/738519 Pros and cons of available blood tests over tuberculin skin test Do you agree with the current CDC recommendations if you were making policy what would you change? Program evaluation for TB Control are we evaluating the right indicators? Review the 15 national TB Program indicators. How will improvement on these indicators improve TB Control in the United States?http://www.cdc.gov/tb/publications/factsheets/statistics/NTIP.htm. Look at this shorteditorialfrom the Lancet. Finally a recent report onTB Trends in the USAfrom the MMWR.References: The BCG Quandary(pdf) BCG Effectiveness(pdf) Stopping BCG in the UK TB & AIDS, Recent JAMA Article TB among Foreign Bornin US, JAMA, July 08 What isThwarting Tb Prevention- Editorial NEJM, July 2011

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