Tuberculosis in Virginia?

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Tuberculosis in Virginia?

• Wendy Heirendt, MPA Public Health
  AdvisorDivision of TB ControlVirginia
  Department of HealthSeptember 12, 2005

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Areas to be Covered Tonight

• Epidemiology of TB in Virginia
• Diagnosis, Transmission, Treatment
• Role of the Health Department

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Current TB Challenges in Virginia

• 329 cases in 2004, lt1 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

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Number of Reported TB Cases inVirginia, 1986-2004
329
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TB Case Rates in Virginia, 1996-2004

• Year Cases VA Rate US Rate
• 1996 349 5.3 8.0
• 1997 349 5.3 7.4
• 1998 339 5.2 6.8
• 1999 334 4.9 6.4
• 2000 292 4.1 5.8
• 2001 306 4.3 5.6
• 2002 315 4.5 5.2
• 2003 332 4.5 5.1
• 2004 329 4.4 4.9

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Percent of Reported TB Casesby VA Region 2003
and 2004
2003
2004
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Number of Reported TB Cases by Age and Sex VA,
2004
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Percent of Reported TB Casesby Age VA,
1996-2004
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Number of Reported Foreign-Born vs.US-Born TB
Cases, VA 1996-2004
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MDR Cases Percent of Resistance toAny First
Line Drugs VA, 1998-2004
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Number of Reported TB/AIDS Cases VA, 1993-2004
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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

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Famous TB Patients

• Doc Holliday of Wild West fame
• Christy Mathewson of baseball lore
• Eleanor Roosevelt, First Lady
• Edgar Allan Poe and associates

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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

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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?

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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

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Active TB Disease

• May be infectious
• Has clinical symptoms
• Usually pulmonary involvement

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Symptoms of Active TB Disease

• Prolonged cough(may produce sputum)
• Chest pain
• Hemoptysis
• Fever
• Chills

• Night sweats
• Fatigue
• Loss of appetite
• Weight loss orfailure to gain weight

Symptoms commonly seen in cases of pulmonary
(lung) TB
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Diagnostic Techniques

• Tuberculin Skin Test
• A decision to test is a decision to treat
• Sputum collection/testing
• Chest x-ray
• Medical evaluation

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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

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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

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Latent TB Infection (LTBI)

• 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

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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

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Persons at Higher Risk forBecoming 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)

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Persons at Higher Risk for Becoming Infected with
TB

• Health care workers who serve high-risk clients
• Children exposed to adults in high-risk
  categories

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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!

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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

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Case Study

• 34 y.o. male diagnosed with infectious TB
• Hx of negative TST, lt12 months ago
• No known TB exposure
• Family, co-workers tested no new cases
• Is this CI complete?

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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?

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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??

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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

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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

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TB Prevention and Control Short Term Shelters

• 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 LTBIno symptoms, not infectious

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TB Prevention and Control Long Term Shelters

• Consider additional screening based on identified
  risk factors
• Likely exposure
• High risk medical conditions

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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

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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

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Resources

• http//www.bt.cdc.gov/disasters/hurricanes/katrina
  /shelters.asp
• http//www.nationaltbcenter.edu/catalogue/download
  s/tbhomelessshelters.pdf
• http//www.umdnj.edu/ntbcweb/docs/Contact20Invest
  igations.pdf
• http//www.umdnj.edu/ntbcweb/docs/congregate/Congr
  egateSetting.pdf

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For More Information

• Virginia Department of Health Division of TB
  Control109 Governor Street, First Floor
  Richmond, VA 23219804-864-7906
  http//www.vdh.virginia.gov/epi/tb
• Local Health Departmentshttp//www.vdh.virginia.g
  ov/LHD/LocalHealthDistricts.asp
• Centers for Disease Control and
  PreventionDivision of TB Eliminationhttp//www.c
  dc.gov/nchstp/tb