EPID 600 - Introduction to Public Health (On-Line 2012)

Communicable Diseases of Public Health Importance

Tuberculosis
An Old Disease New Twists
A Continuing Public Health
Challenge
Jane Moore, RN, MHSA
Director, TB Control & Prevention Program
2012
 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 heavyIn 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 in the US 1882-2010
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 1882-2010
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 1882-2011
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
2010
Lowest number of reported cases in US
Funding declining
 TB in the US
2011 Continuing needs
Continued support for TB prevention/control especially
with health care reform
New drugs and/or drug combinations to allow shorter
courses of treatment
Shorter, simpler, less expensive treatment regimens
Vaccine (beyond BCG)
Support for global TB prevention and control activities
Rapid diagnostic tests for limited resource settings
Better co-ordination of TB and HIV
prevention/treatment programs
Reliable access to TB drugs
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 Infection
(70-90%) (10-30%)

Latent TB Active TB
(90%) (10%)

Never develop
Active disease Untreated Treated
Die within 2 years Survive
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 in Virginia: 1990-2011
500
Number of Cases

400

300

200
221
100

0
1990 1993 1996 1999 2002 2005 2008 2011

Year
 TB Case Rate per 100,000 VA and
US: 2007-2011
Year Virginia TB Virginia TB US TB Cases US,521TB
Cases Rate Rate

2007 309 4.0 13,280 4.4

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

 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
 VA TB Cases by Region: 2007-2011
200
180
160
2007
Number of Cases

140
120 2008
100 2009
80 2010
60
2011
40
20
0
Northwest Southwest Central Eastern Northern
 VA TB Cases by Age and Sex: 2011
60

50
Number of Cases

40

30 Male
Female
20

10

0
0-14 15-24 25-44 45-64 65+

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/year
1.7 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
 Foreign-born TB Cases Top Five Countries of
Birth: US and Virginia

US (2010) Virginia (2011)

Mexico India
Philippines Ethiopia
India Viet Nam
Viet Nam Philippines
China (with 8 cases each China,
Mexico,Nepal,Peru)
 Addressing the Challenges TB
Control in the US - 2011
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
X-ray
Targeted testing/
LTBI treatment
Pharmacy
Inpatient care
Medical evaluation
Clinical
and follow-up Services Laboratory
Non-TB medical Social
services Interpreter/ HIV testing and
services counseling
translator Occupational health,
services Patient school, jail, shelter,
education Data collection LTCF screening
Coordination of Documentation
medical care Epidemiology
Home Contact
evaluation Case DOT investigation and Surveillance
Outbreak Data analysis
Housing Management Investigation Program
Isolation, Follow-up/treatment evaluation &
QA, QI for case
detention of contacts planning
management
Consultation on Data for local, state, national
difficult cases surveillance reports Training
Federal TB State TB Control Program
Guidelines
Control Program Funding
State statutes, Information
National surveillance Training regulations, for public
policies, guidelines
Technical assistance Funding VDH/DDP/TB
11/01/07 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

28
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 tests
TB medications for uninsured case patients
Incentives and enablers
Training for HDs, PHNs, ORW

29
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

30
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

31
Services provided by Central Office
Educational activities for public and private
sector HCPs, patients and the public
VDH conferences for public health workers
Invited speakers at private sector HCP meetings
Distribution of guidelines
Website
Telephone hot line

32
 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 Pharmokinetics 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
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 underway to determine if early testing can
prevent prolonged slow response to treatment
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
Thank you
Questions?

Jane Moore
Jane.moore@vdh.virginia.gov
804 864 7920