The Challenges of MultiDrug Resistant MDR Tuberculosis Investigation and Followup

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The Challenges of Multi-Drug Resistant (MDR)
Tuberculosis Investigation and Follow-up

• Aaron Aitchsion, PHN
• Middlesex-London Health Unit

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Whats Involved in a TB investigation?

• 1. Isolate the case
• 2. Establish a treatment regime
• 3. Establish compliance with treatment regime
• 4. Establish period of infectivity
• 5. Determine degree of infectiousness
• 6. Establish contacts
• 7. Co-ordinate follow-up of contacts
• 8. Offer prophylaxis to contacts

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Whats challenging in a TB investigation?

• Communication
• language barriers
• risk
• Cross Jurisdictional referrals
• Stigma
• iPHIS

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Whats challenging in a MDR-TB investigation?
MDR-TB is a result of a breakdown in 1. Isolate
the case 2. Establish a treatment regime 3.
Establish compliance with treatment regime 4.
Establish period of infectivity 5. Determine
degree of infectiousness 6. Establish contacts
7. Co-ordinate follow-up of contacts 8. Offer
prophylaxis to contacts

• Treatment of the case
• Prophylaxis of those exposed to the case
• Stigma

The Media
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Identifying the case

• Father flagged for Immigration Medical
  Surveillance for Inactive TB
• Interview smokers cough previous treatment
  for lung infection (denied TB diagnosis)
• Administered TB skin test ? Sent for Chest x-ray

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Cavitating lesion lived in top 23 high-burden
countries
Clinical Case
1. Isolate the case 2. Establish a treatment
regime 3. Establish compliance with treatment
regime 4. Establish period of infectivity 5.
Determine degree of infectiousness 6. Establish
contacts 7. Co-ordinate follow-up of
contacts 8. Offer prophylaxis to contacts
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Isolating the case

• Language barrier (interpreter exposures)
• Strain on family
• sons interpretation shoot the messenger
• new to country and lose head of household
• Admitted to negative pressure
• Obtain sputum for laboratory analysis
• Wait for results

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Treatment
1. Isolate the case 2. Establish a treatment
regime - standard four drug therapy 3. Establish
compliance with treatment regime 4. Establish
period of infectivity 5. Determine degree of
infectiousness 6. Establish contacts 7.
Co-ordinate follow-up of contacts 8. Offer
prophylaxis to contacts
1. Isolate the case 2. Establish a treatment
regime - standard four drug therapy 3. Establish
compliance with treatment regime - acute care 4.
Establish period of infectivity 5. Determine
degree of infectiousness 6. Establish contacts
7. Co-ordinate follow-up of contacts 8. Offer
prophylaxis to contacts
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Infectivity
1. Isolate the case 2. Establish a treatment
regime - standard four drug therapy 3. Establish
compliance with treatment regime - acute care 4.
Establish period of infectivity - cough present
since arrival to Canada 5. Determine degree of
infectiousness 6. Establish contacts 7.
Co-ordinate follow-up of contacts 8. Offer
prophylaxis to contacts
1. Isolate the case 2. Establish a treatment
regime - standard four drug therapy 3. Establish
compliance with treatment regime - acute care 4.
Establish period of infectivity - cough present
since arrival to Canada 5. Determine degree of
infectiousness - smear numerous (highly
infectious) 6. Establish contacts 7.
Co-ordinate follow-up of contacts 8. Offer
prophylaxis to contacts
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Infectivity
Resistant to INH and Rifampin
1. Isolate the case 2. Establish a treatment
regime - standard four drug therapy 3. Establish
compliance with treatment regime - acute care 4.
Establish period of infectivity - cough present
since arrival to Canada 5. Determine degree of
infectiousness - smear numerous (highly
infectious) 6. Establish contacts 7.
Co-ordinate follow-up of contacts 8. Offer
prophylaxis to contacts
2nd line drugs
West Park Treatment facility
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Challenges in determining contacts?

• Transmission factors related the case
• Transmission factors related to shared air space
• Transmission risk factors related to exposed
  person

Case was smear (numerous) Previous treatment
failure Huge cavity on CXR Denial
of diagnosis Symptomatic (cough)
Over 6 years old
Transmission factors high
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Less shared space High risk for previous infection
Common volume of air Re-circulated
air Ultraviolet radiation?
Small classrooms Contact 5 days a week High risk
for previous infection
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Issues with Contact Tracing
1. Isolate the case 2. Establish a treatment
regime - 2nd line drugs 3. Establish compliance
with treatment regime - West Park 4. Establish
period of infectivity - cough present since
arrival to Canada 5. Determine degree of
infectiousness - highly infectious 6. Establish
contacts - family / airplane / settlement house
/ ESL School 7. Co-ordinate follow-up of
contacts 8. Offer prophylaxis to contacts
1. Isolate the case 2. Establish a treatment
regime - 2nd line drugs 3. Establish compliance
with treatment regime - West Park 4. Establish
period of infectivity - cough present since
arrival to Canada 5. Determine degree of
infectiousness - highly infectious 6. Establish
contacts - family / airplane / settlement house
/ ESL School 7. Co-ordinate follow-up of
contacts 8. Offer prophylaxis to contacts
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Our Plan of Action

• Multiple teleconferences with experts from around
  the world
• Greater than 1 hour of face-to-face contact Rx
  PZA and ETBI for 6 months
• Moxifloxacin substituted for PZA or ETBI if side
  effects developed
• CXRs at 0, 3, 6, 12, 18, 24 months

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The research says

• Fraser et al Int Jouranl of TB (2006).
• Systemic review of comparative studies of people
  treated and not treated of LTBI following MDR-TB
  exposure
• Presented combinations of PZA/ETBI, PZA and a
  quinolone, ETBI and a quinolone, Quinolone alone
• Serious adverse effects can affect adherence
  causing prolonged treatment, further development
  of resistance and relapse. The balance of
  benefits and detriments is far from clear and
  should be addressed in a randomized controlled
  trial.

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Our Plan of Action

• Baseline and monthly blood tests (CBC, BUN,
  creatinine, uric acid, HIV, Hepatitis screening
  and LFTs)
• Opthalmologic assessment with dilation at 0, 3,
  and 6 months with Ishihara color tests performed
  monthly
• Twice monthly symptom and side effect review

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TBST Offer INH
Referred flight manifest to PHAC
TBST PZA ETBI
TBST PZA ETBI
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Many TBST Majority complete INH
Unknown
Multiple TB Clinics
33 TBST 19 of 33 complete PZA/ETBI
Entire family TBST 1 secondary case 3 of 12
complete PZA/ETBI
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The Clinic Challenges

• At least 7 different languages
• Minimal literacy in mother tongue
• Cultural taboos of TB and gender
• Index family persecution (moved)
• New immigrant population mobility
• Risk factors for TB already
• Healthcare issues unrelated to TB

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The Family results

• Index case 1 secondary case (not MDR)
• 12/12 TBST () (further evidence of
  infectiousness)
• 3/12 completed prophylaxis
• Family re-located due to stigma (media)
• Index case remains defiant of TB diagnosis

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The other results

• Many interpreters TBSTed with 3 positive and
  several previously positive
• Only one offered MDR prophylaxis and did not
  complete (INH for others)
• Only one settlement house contact offered MDR
  prophylaxis completed (INH for others)

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The Side Effects

• Elevated liver enzymes (abdominal pain)
• Headache
• Fatigue
• Alterations in mood
• Yeast infections
• Joint aches

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In Conclusion...
1. Isolate the case 2. Establish a treatment
regime - 2nd line drugs 3. Establish compliance
with treatment regime - West Park 4. Establish
period of infectivity - cough present since
arrival to Canada 5. Determine degree of
infectiousness - highly infectious 6. Establish
contacts - family / airplane / settlement house
/ ESL School 7. Co-ordinate follow-up of
contacts - clinics 8. Offer prophylaxis to
contacts - INH and PZA/ETBI (Moxi)
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All TB Investigations are challenging...
1. Isolate the case 2. Establish a treatment
regime 3. Establish compliance with treatment
regime 4. Establish period of infectivity 5.
Determine degree of infectiousness 6. Establish
contacts 7. Co-ordinate follow-up of
contacts 8. Offer prophylaxis to contacts

• Communication
• Cross Jurisdictional referrals
• Stigma
• iPHIS

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Questions?