TUBERCULOSIS AND HIV SCREENING IN HEALTHCARE WORKERS AT MAPUTO CENTRAL HOSPITAL, MOZAMBIQUE

Susannah Graves and Kristen LeePresented by Francesca Torriani

Internal Medicine Residency ProgramUniversity of California, San Diego

Sept 18, 2012

Background

Source: UNAIDS and WHO Source: WHO

HIV prevalence: 11.5 in Mozambique

TB incidence

Site: Maputo Central Hospital

1500 beds totalMedicine Wards: 112+ beds >65% patients HIV+ Pulm TB:

25-30 cases/mo cases in HCW?MDR-TB in HCW3 cases in 20101 case in 2012

Patients waiting waiting to be seen in the Emergency Room

Background & Significance

Infection control committee chartered Sept 2011 National TB reference laboratory recently acquired

capacity for mycobacterial culture and DST Currently no TB control program Unknown prevalence, incidence of HIV and TB in HCW Recent study of HCW from Northern Mozambique:

43% HIV prevalence 9 new TB cases (2.1% of enrollees).

Casas et al. Tropical Med and International Health. Aug 18, 2011.

Methods

Population: Internal Medicine Department

Study Period: 1 week in February 2012

Recruitment: Flyers and an assembly advocating screening

Eligibility Criteria – working in MCH Medicine Department

Enrollment and consent for HIV testing

Questionnaire: Contact/ID, demographic data, symptoms and history of HIV and TB, contacts.

Methods

HIV testing (2 rapid tests) and CD4 count (flow cytometry)

Chest Xray – read by a radiologist and a pulmonologist

Sputum sample for those with productive cough AFB smear and mycobacterial culture

Further standard of care workup (LN biopsy, CT scan)

Treatment referrals as appropriate for HIV and TB

Diagnostic Algorithm for TB

Questionnaire Chest Xray Sputum x2 ordered if productive cough Pulmonary TB suspect definition

Symptoms or radiographic evidence of pulm disease

TB Case Definitions – WHO Definite: culture positive or 2+ AFB sputum smears Smear Negative: 2 NEG smears, abnormal CXR, no response

to a course of broad-spectrum ABX (unless HIV infected)

Demographics

No. %Total 156 100.0%

SexMale 35 22.4%Female 121 77.6%

Age (years)16–29 39 25.0%30–39 56 35.9%40–49 34 21.8%49–59 23 14.7%>60 4 2.6%

Time working in Hospital<5 years 52 33.8%5-9 years 34 22.1%10-14 years 17 11.0%15-19 years 6 3.9%>20 years 45 29.2%

HIV prevalence

No. %HIV testing 148 95.0%

Resultspositive 25 16.9%negative 122 82.4%indeterminate 1 0.7%"pending" 4 2.6%

Of HIV positive:

new diagnoses 10 40.0%CD4 count avail 22 88.0%

TB symptoms

Tuberculosis Symptoms No. %

Cough >3 weeks 24 15.4%Productive cough 19 12.2%Hemoptysis 0 0.0%Chest pain 9 5.8%Weight loss 14 9.0%Fatigue 10 6.4%Sweats 6 3.8%Fever 3 1.9%Asymptomatic 129 82.7%

Radiographic Findings

Abnormal Xray in12 HCW Lymphadenopathy Diffuse opacities Nodular opacities “Bronchiectasis” Cavitary lesion

2/12 had prior Hx of TB 42% were HIV+ 25% had symptoms

Microbiologic Data

19 HCW reported productive cough

Only 9 sputum samples obtained: AFB smear – negative in all 9 Mycobacterial culture – 8 negative, 1 contaminated

TB diagnosis during screening

A single case of TB was diagnosed

Generalized lymphadenopathy No cough Initial CXR – mediastinal lymphadenopathy LN biopsy – positive AFB smear Clinical decompensation hospitalized, treated CT chest – miliary TB + adenopathy

CT findings

Cases found after initial screening

Among participants 2 more participants re-presented to the screening clinic Both were symptomatic Found to have AFB smear positive pulmonary TB

HCW’s who were not enrolled in our study 3 HCWs presented to the occupational TB screening service Symptoms: productive cough Diagnosed with active pulmonary TB One of them was MDR-TB

Discussion

Strong points: Ease of recruitment HIV testing and CD4 countsDifficulties: Obtaining sputum samples Tracking and quality of sputum cultures Diagnostic work up of TB suspects Maintaining confidentiality

Discussion

Strategies for improvement: Concrete diagnostic algorithm & case definition Documentation of follow-up and treatment Supervised sputum collection Better communication with TB lab Secure storage space for Xrays and other records Defined office space and hours for follow-up

Current Progress

Occupational Health/TB Screening Office was created with defined office space and secure storage for CXR and other records

Needs assessment for TB infection control in Emergency Room was done F-A-S-T: FINDING TB cases ACTIVELY by cough

surveillance and rapid diagnosis, SEPARATION and exposure reduction until effective TREATMENT starts

TB infection control plans with support from the hospital director

TB infection control plan

By Anna Levitt

By Anna Levitt

Future Directions

The Study (CFAR Grant, pending approval from NIH IRB): Tuberculosis screening in all HCW at MCH Active and latent TB High-risk latent TB (HIV, high-reactors)

The Ultimate Goal: Incorporation of routine TB screening into occupational

health at MCH Comprehensive TB control program at MCH

TB Control Team, MCH

Acknowledgements

Elizabete Nunes, MD, PhD Francesca Torriani, MD Philip Lederer, MD Sophia Viegas Koen Hulshof, MD Anna Levitt, PE Joaquim Aracua, MD Anilsa Daniel, MD Catarina David, MD Anila Hassane, MD

Questions and Suggestions