Successes and Challenges Vaccines for Infectious Diseases small pox, polio, and beyond'''

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Its the Air you Breathe Diagnosis, Treatment
and Prevention of TB in Correctional
Settings Course Material developed for
Correctional Medical Providers
Anne S. De Groot M.D. / IDCR Brown University
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Goal of this session
New Stuff Review Epidemiology of TB in Prisons
and Jails Understand Rationale for Testing and
Treatment Real Life Lessons - cases of
opportunity missed
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Whats New (1)

• New Medications
• New Risk Groups
• Expanded definitions of affected HCWs
• TST instead of PPD

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Whats New (2)

• QuantiFERON-TB Gold test (QFT-G)
• QFT-G is a type of blood assay for M.
  tuberculosis (BAMT)
• Measures the patients immune system reaction to
  M. tuberculosis
• Blood samples must be processed within 12 hours
• Interpretation of QFT-G results is influenced by
  the patients risk for infection with M.
  tuberculosis
• An alternative to TST

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Real Life Lessons
MMWR reported Outbreak of TB in prison in SC One
medical student gravely ill. Correctional
Professionals are also at risk. (more on this in
a moment)
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Real Life Lessons
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Real Life Lessons
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Outline EpidemiologyInfectionDiseaseTreatmen
tReal Life Lesson
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The Epidemic 29,000 excess cases
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who?
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Tuberculosis
TB HIV Double Trouble

• HIV is accelerating the TB epidemic
• TB is the leading cause of death from AIDS

HIV
TB
1/3
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HIV Seroprevalence Observed among the Prison
Population
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HIV Seroprevalence Observed among Patients with
Active TB
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Tuberculosis
Regional Epi

• USA
• 1980 Elimination of TB scheduled for 2010
• 1985 HIV epidemic begins
• 1990-1992 Outbreak of TB in NY, FLA, NJ
  (prisons)
• 1994 Renewed control efforts bring NY under
  control
• 1996 Strain w spreads beyond NY state borders
• 1999 New concerns about TB immigration
• 2000 . . . yet another prison outbreak (South
  Carolina) . . .
• 2000 Revised estimates of eradication to 2040
  or beyond

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Tuberculosis in the United States
National Surveillance System Highlights from 2005
Division of Tuberculosis Elimination Centers for
Disease Control and Prevention
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Reported TB Cases United States, 19822005
No. of Cases
Year
Updated as of March 29, 2006
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TB Case Rates, United States, 2005
D.C.
lt 3.5 (year 2000 target)
3.64.8
gt 4.8 (national average)
Cases per 100,000.
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TB Case Rates by Age Group and Sex, United
States, 2005
Cases per 100,000


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Reported TB Cases by Race/Ethnicity United
States, 2005
American Indian or Alaska Native (1)
White (18)
Asian (23)
Native Hawaiian or Other Pacific Islander (lt1)
Hispanic or Latino (29)
Black or African-American (28)
All races are non-Hispanic. Persons reporting
two or more races accounted for less than 1 of
all cases.
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Prisons TB is a Risk
lt 1 of US population is incarcerated gt 3 of
US TB cases are in prisons
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Prompt TriageThink TB!

• Primary TB risk to HCWs is patient with
  undiagnosed or unrecognized infectious TB
• Promptly initiate AII precautions and manage or
  transfer patients with suspected or confirmed TB
• Ask about and evaluate for TB
• Check for signs and symptoms
• Mask symptomatic patients
• Separate immunocompromised patients

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Public Health Can Help TB
TB case rate in NY State dropped from 225 per
100,000 to 26 per 100,000 over the past
decade Involvement of public health was key.
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Tuberculosis
Regional Epi

• USA
• 1980 Elimination of TB scheduled for 2010
• 1985 HIV epidemic begins
• 1990-1992 Outbreak of TB in NY, FLA, NJ
  (prisons)
• 1994 Renewed control efforts bring NY under
  control
• 1996 Strain w spreads beyond NY state borders
• 1999 New concerns about TB immigration
• 2000 Revised estimates of eradication to 2040
  or beyond

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TB epidemiology now
Western Europe
Eastern Europe
Sub Saharan Africa
1995
1990
1997
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Tuberculosis
Epidemiology / HIV

• HIV is accelerating the TB epidemic
• TB is the leading cause of death from AIDS
• (30 of AIDS deaths world wide)
• Of 37 million people world wide who were HIV
  positive in 2002, 1/3 were infected with TB.

HIV
TB
1/3
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(No Transcript)
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Number of TB Cases inU.S.-born vs. Foreign-born
Persons United States, 19932005
No. of Cases
Updated as of March 29, 2006.
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Primary MDR TBUnited States, 19932005
No. of Cases
Percentage
Updated as of March 29, 2006. Note Based on
initial isolates from persons with no prior
history of TB. MDR TB defined as resistance to
at least isoniazid and rifampin.
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Primary MDR TB inUS-born vs. Foreign-born
Persons United States, 1993-2000
Resistant
Note Based on initial isolates from persons with
no prior history of TB. MDR TB defined as
resistance to at least isoniazid and rifampin.
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Primary MDR TB inU.S.-born vs. Foreign-born
Persons, United States, 19932005
Resistant
Updated as of March 29, 2006. Note Based on
initial isolates from persons with no prior
history of TB. MDR TB defined as resistance to at
least isoniazid and rifampin.
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Outline EpidemiologyInfectionDiseaseTreatmen
tReal Life Lessons
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Tuberculosis
Transmission

• Transmission is by aerosol Coughing, sneezing,
  talking, singing
• An individual with active tuberculosis infects,
  on average,
• 10-15 new people each year that they remain
  infectious and untreated
• Transmission is increased in a closed environment
  
• (classroom, airline, bus, or train)

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Transmission of M. tuberculosis

• Spread by airborne route droplet nuclei
• Transmission affected by
• Infectiousness of patient
• Environmental conditions
• Duration of exposure
• Most exposed persons do not become infected

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TB Patient Characteristics That Increase Risk for
Infectiousness (1)

• Coughing
• Undergoing cough-inducing or aerosol-generating
  procedure
• Failing to cover cough
• Having cavitation on chest radiograph

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TB Patient Characteristics That Increase Risk for
Infectiousness (2)

• Positive acid-fast bacilli (AFB) sputum smear
  result
• Disease of respiratory tract and larynx
• Disease of respiratory tract and lung or pleura
• Inadequate TB treatment

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Environmental Factors That Increase Risk for
Transmission

• Exposure in small, enclosed spaces
• Inadequate ventilation
• Recirculating air containing infectious droplets
• Inadequate cleaning and disinfection of equipment
• Improper specimen-handling procedures

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Risk for Health-careAssociated Transmission of
M. tuberculosis (1)

• Risk varies by
• TB prevalence in health-care setting
• TB prevalence in community
• Patient population served
• Health-care worker occupational group
• Effectiveness of infection control measures

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Risk for Health-careAssociated Transmission of
M. tuberculosis (2)

• Linked to close contact with infectious TB
  patients during procedures generating aerosols

• Bronchoscopy
• Endotracheal intubation or suctioning
• Open abscess irrigation
• Autopsy
• Sputum induction
• Aerosol treatments

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Previous Health-careAssociated Transmission of
M. tuberculosis (1)

• In hospital TB outbreaks, 1980s1990s
• MDR TB spread to patients and HCWs
• Many patients, some HIV-infected HCWs
• Rapid progression from new infection to disease
• Factors
• Delayed diagnosis
• Lapses in AII precautions
• Lapses in respiratory protection

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Outline EpidemiologyInfectionDiseaseTreatmen
tReal Life Lessons
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Some Definitions

TB Disease The Tip of the Iceberg
Sick with TB
TB Disease
Could get sick
TB INFECTION
Source HEPP www.HIVcorrections.org
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Testing for TB Disease and Infection
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Reading the Tuberculin Skin Test

• Read reaction 48-72 hours after
• injection
• Measure only induration
• Record reaction in millimeters

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TB Pathogenesis (1)Latent TB Infection

• Once inhaled, bacteria travel to lung alveoli and
  establish infection
• 212 wks after infection, immune response limits
  activity infection is detectable
• Some bacteria survive and remain dormant but
  viable for years (latent TB infection, or LTBI)

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TB Pathogenesis (2)Latent TB Infection

• Persons with LTBI are
• Asymptomatic
• Not infectious
• LTBI formerly diagnosed only with TST
• Now QFT-G can be used

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Groups That Should Be Tested for LTBI

• Persons at higher risk for exposure to
  or infection with TB
• Close contacts of a person known or suspected
• to have TB
• Foreign-born persons from areas where TB is
• common
• Residents and employees of high-risk
• congregate settings
• Health care workers (HCWs) who serve high-
• risk clients

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Groups That Should Be Tested for LTBI (cont.)

• Persons at higher risk for exposure to or
  infection with TB
• Medically underserved, low-income populations
• High-risk racial or ethnic minority populations
• Children exposed to adults in high-risk
  categories
• Persons who inject illicit drugs

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Two-Step Testing

• Use two-step testing for initial skin testing of
  adults
• who will be retested periodically
• If first test positive, consider the person
  infected
• If first test negative, give second test 1-3
  weeks
• later
• If second test positive, consider person infected
• If second test negative, consider person
• uninfected

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Persons at High Risk for LTBI Progressing to TB
Disease

• Persons coinfected with HIV and M. tuberculosis
  (highest risk)
• Those with recent M. tuberculosis infection
  (within 2 years)
• Children under 4 years of age
• Persons with certain clinical conditions or other
  conditions of compromised immunity
• Those with a history of untreated or poorly
  treated TB

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Candidates for Treatment for LTBI
The frequency of TB testing for HCWs will be
determined by the risk classification for the
setting.
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Tuberculosis
Treatment of Infection
Based on PPD and no disease CDC
recommendations (MMWR June 9, 2000 Vol 49 no.
RR-6) INH prophylaxis x 9 months Or PZA and
rifampin x 2 months MMWR Alert, 21 cases of
Fatal and Severe Liver Injury in some patients
taking this regimen MMwr (including one inmate)
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Treatment Regimens for LTBI
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Diagnosis of TB
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TB Pathogenesis Active TB Disease

• LTBI progresses to TB disease in
• Small number of persons soon after infection
• 510 of persons with untreated LTBI sometime
  during lifetime
• About 10 of persons with HIV and untreated LTBI
  per year

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Tuberculosis
Disease pathogenesis

• inhalation (or ingestion) of Mtb
• colonization of macrophages (lung)
• bacteria grow slowly, resist WBC killing
• granuloma formation
• Bacteria in the nodules can remain viable for
  decades.
• Reactivation event (aging, cancer chemotherapy,
  HIV, stress, malnutrition) impairs defenses,
• bacteria spread.
• Symptomscoughs, severe weight loss, fever,
  "night sweats" and fatigue.
• 80 chance of death if not treated.

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Chest Radiograph

• Abnormalities often seen in apical
• or posterior segments of upper
• lobe or superior segments of
• lower lobe
• May have unusual appearance in
• HIV-positive persons
• Cannot confirm diagnosis of TB

Arrow points to cavity in patient's right upper
lobe.
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Cultures

• Use to confirm diagnosis of TB
• Culture all specimens, even if smear negative
• Results in 4 to 14 days when liquid medium
• systems used

Colonies of M. tuberculosis growing on media
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TREATMENT OF TUBERCULOSIS, 2003
American Thoracic Society
Centers for Disease Control and Prevention
Infectious Diseases Society of America

• Division of Tuberculosis Elimination
• Centers for Disease Control and Prevention

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Why a New TB Treatment Statement?

• Last TB treatment statement published in 1994
• Several new drugs available e.g., rifapentine,
  newer fluoroquinolones
• New research information on treatment regimens

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Treatment for TB Disease (1)

• TB treatment regimens must contain multiple drugs
  to which M. tuberculosis is susceptible
• Treating TB disease with a single drug can lead
  to resistance
• Also, adding a single drug to a failing regimen
  can lead to drug resistance

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Treatment for TB Disease (2)

• Preferred regimen
• Initial phase 2 months isoniazid (INH), rifampin
  (RIF), pyrazinamide (PZA), and ethambutol
• Continuation phase 4 months INH and RIF
• In patients with cavitary pulmonary TB and
  positive culture results at end of initiation
  phase, continuation phase should be 7 months
• TB patients with HIV who are taking
  anti-retrovirals (ARVs) should be managed by
  TB/HIV disease experts
• TB treatment regimens might need to be altered

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Whats New? (1)

• Provider/program responsibility for successful
  treatment, not the patient
• Patient-centered case management with emphasis on
  directly observed therapy (DOT)
• Evidence-based ratings of treatment options
• Role of two-month sputum cultures to identify
  patients at increased relapse risk

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Whats New? (2)

• Extend treatment for patients with
  drug-susceptible pulmonary TB at increased risk
  for relapse
• Role of new drugs (rifabutin, rifapentine, and
  fluoroquinolones)
• Practical aspects of therapy drug
  administration, fixed-dose combinations, adverse
  effects monitoring and management, and drug
  interactions

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Antituberculosis Drugs

• First-Line Drugs

• Second-Line Drugs

• Streptomycin
• Cycloserine
• p-Aminosalicylic acid
• Ethionamide
• Amikacin or kanamycin
• Capreomycin
• Levofloxacin
• Moxifloxacin
• Gatifloxacin

• Isoniazid
• Rifampin
• Pyrazinamide
• Ethambutol
• Rifabutin
• Rifapentine

• Not approved by the U.S. Food and Drug
  Administration for use in the treatment of TB

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Drug Abbreviations

• Ethambutol EMB
• Isoniazid INH
• Pyrazinamide PZA
• Rifampin RIF
• Rifapentine RPT
• Streptomycin SM

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Role of New Drugs (1)

• Rifabutin For patients receiving medications
  having unacceptable interactions with rifampin
  (e.g., persons with HIV/AIDS)
• Rifapentine Used in once-weekly continuation
  phase for HIV-negative adults with
  drug-susceptible noncavitary TB and negative AFB
  smears at completion of initial phase of treatment

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Role of New Drugs (2)

• Fluoroquinolones (Levofloxacin, Moxifloxacin,
  Gatifloxacin) Used when
• -first-line drugs not tolerated
• -strains resistant to RIF, INH, or EMB or
• -evidence of other resistance patterns with
  fluoroquinolone susceptibility

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Special Treatment SituationsHIV/AIDS

• Treatment for HIV-positive patients same as for
  HIV-negative patients, except
• Once-weekly INH-rifapentine in continuation phase
  is contraindicated in HIV-positive patients
• Twice-weekly INH-RIF or INH-rifabutin should not
  be used in patients with CD4 T-lymphocyte
  counts less than 100/?l
• Every effort should be made to use a
  rifamycin-based regimen for the entire course of
  therapy

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Treatment of TB for HIV-Positive Persons

• Management of HIV-related TB is complex
• Care for HIV-related TB should be provided
• by or in consultation with experts in management
• of both HIV and TB

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Mode of Treatment Administration in Persons
Reported with TB United States, 19932003
Updated as of March 29, 2006. Directly
observed therapy (DOT) Self-administered therapy
(SA)
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Outline EpidemiologyInfectionDiseaseTreatmen
t Real Life Lesson
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Real Life Lessons
1980-1990 Outbreak of MDR TB in NY City
Hospitals and NYS Correctional Facilities
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Real Life Lessons
CDC. Tuberculosis outbreaks in prison housing
units for HIV-infected inmates California,
19951996. MMWR 1999487982.
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Real Life Lessons
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Real Life Lessons
As of November 2000, 31 current or former
inmates had TB diagnosed. All case-patients were
non-Hispanic black men born in the United States
and HIV infected.
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Real Life Lessons
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Training and Educating HCWs

• Initial TB training and education
• Provide initial TB training to all HCWs,
  including physicians, and document training
• Follow-up TB training and education
• Annually evaluate the need for follow-up training
  for HCWs
• Provide retraining if exposure occurs
• Provide annual respiratory protection training
  for HCWs who use respirators

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TB Infection Control Surveillance
TB screening programs provide critical info and
consist of

• Baseline testing for M. tuberculosis infection
  (new hires)
• Serial testing for M. tuberculosis infection
• Serial screening for symptoms or signs
• Clinical evaluation
• Chest radiograph
• TB training and education

And other persons who will be tested
periodically (i.e., residents and staff of long
termcare facilities and correctional settings).
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Resources are Available
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References

• Centers for Disease Control and Prevention.
  Guidelines for preventing the transmission of
  Mycobacterium tuberculosis in health-care
  settings, 2005. MMWR 2005 54 (No. RR-17) 1141.
  
• http//www.cdc.gov/nchstp/tb/pubs/mmwrhtml/
  Maj_guide/infectioncontrol.htm
• Errata (August 2006) available onlinehttp//www.c
  dc.gov/nchstp/tb/pubs/mmwrhtml/ Errata_table.pdf

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Its the Air you Breathe Get your PPD
Checked! Thank You!
http//www.IDCRonline.com