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 200440 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 nonproblem

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
(70-90%)

Infection
(10-30%)

Latent TB
(90%)
Never develop
Active disease
Die within 2 years

Active TB
(10%)

Untreated
Survive

Treated
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

221

TB Case Rate per 100,000 VA

and US: 2007-2011
Year

Virginia
TB Cases

Virginia
TB Rate

US TB
Cases

US,521TB
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: 20072011

Number of Cases

VA TB Cases by Age and Sex:

2011

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)

Mexico
Philippines
India
Viet Nam
China

Virginia (2011)
India
Ethiopia
Viet

Nam
Philippines

(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

Targeted testing/
LTBI treatment

Inpatient care

Medical evaluation
and follow-up
Non-TB medical
services

Home
evaluation

Case
Management
Follow-up/treatment
of contacts

Pharmacy
Laboratory

Technical assistance

Training
Funding

Outbreak Data analysis

Investigation
Program

evaluation &
QA, QI for case
planning
management
Consultation on Data for local, state, national
Training
difficult cases
surveillance reports

Federal TB
Control Program

National surveillance
11/01/07

Clinical
Services

Social
HIV testing and
Interpreter/
services
counseling
Occupational health,
translator
school, jail, shelter,
services
Patient
LTCF screening
Data collection
education
Coordination of
Documentation
Epidemiology
medical care
Contact
DOT
investigation and Surveillance

Housing
Isolation,
detention

Guidelines

X-ray

State TB Control Program

Funding

State statutes,
regulations,
policies, guidelines

Information
for public
VDH/DDP/TB
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