Tuberculosis In Texas Presentation by: Brian R. Smith, M.D., M.P.H., Regional Director

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Tuberculosis In TexasPresentation by Brian R.
Smith, M.D., M.P.H., Regional Director
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The captain of all these men of death that came
against him to take him away, was the
Consumption, for it was that that brought him
down to the grave.John Bunyan,
The Life and Death of Mr. Badman
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I have been sick as a dog the last two weeks. I
caught a cold in spite of 18 degrees C. of heat,
roses, oranges, palm, figs and the three most
famous doctors on the island. One sniffed at
what I spat up, the second tapped where I spat it
from, the third poked about and listened how I
spat it. One said I had died, the second that I
am dying, the third that I shall dieAll this has
affected the Preludes and God knows when you
will get them.
Frédéric Chopin
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Reported TB Cases United States, 1981-2001
No. of Cases
1981
1985
1989
1993
1997
2001
Year
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TB MorbidityUnited States, 1997-2001
Year Cases Rate
1997 19,851 7.4 1998 18,361
6.8 1999 17,531 6.4 2000 16,377
5.8 2001 15,989 5.6
Cases per 100,000
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TB Case Rates, United States, 2001
D.C.
lt 3.5 (year 2000 target)
3.6 - 5.6
gt 5.6 (national average)
Rate cases per 100,000
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Tuberculosis in Texas
Case Rate vs. D.O.T.
16
120
14
100
12
80
10
Cases per 100,000 population
8
60
Percent of patients on DOT
6
40
4
20
2
0
0
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
Rate
Directly Observed Therapy ( D.O.T. )
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Worldwide TB Concerns

• Increase in incidence of TB
• Increase in MDR-TB
• Increase in HIV infection
• Increase in immigration and travel
• Increase in demand for resources
• Interruptions in medicine supplies
• Improper drug prescription
• Non-adherence to treatment protocols

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Other regional challenges in 1992

• Poor reporting
• No infection control in clinics or hospitals
• No drug-resistant treatment
• No program for consultation
• Private patients not monitored 100 with major
  errors by physicians or patients not purchasing
  medications
• Drug resistance caused by physicians using
  various propietary regimens or by self-prescribing

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Pharmacist selling RifampinFarmacéutico que
vende Rifampin
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• A family of three generations residing along the
  Texas-Mexican border
• 1973 - Matriarch of the family was
  prescribed INH for a positive skin
  test
• 1974 - Diagnosed pulmonary TB
• 1994- Died of MDR TB with a final hospitalization
  cost of 1.5 million dollars
• 1996- 13 MDR cases, plus 54 PPD-positive family
  contacts monitored by X-ray

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D
D D D D D
X
3
X
X
X
2
X
Red - TB Case Green - Positive Reactor Blue
- Negative PPD Blue X - PPD Refused Black
- BCG D - Deceased -
Unknown
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MDR -TB medicationsMedicaciones del MDR-TB
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Cost for TB treatmentCosto para el tratamiento
del TB
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Plan focus on the key elements

• DOT and completion of treatment for all public
  and private patients with RIPE
• Thorough contact investigation and preventive
  treatment of contacts
• Attention to high risk areas such as jails, HIV
  patients, shelters
• Infection control in TB clinics, hospitals, and
  jails
• Prevention of MDR by active surveillance,
  monitoring patients of private doctors, and
  consultation in all resistant cases

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Directly Observed Therapy (DOT)

• Non-adherence is a major problem in TB control
• DOT mandatory for all Texas patients, including
  private pay because studies show that adherence
  is not related to income or education
• In DOT, a health care worker watches the patient
  swallow each does of medication
• WHO plan for TB control around the world
• DOT can lead to significant reductions in relapse
  and acquired drug resistance
• Use DOT with other measures to promote adherence

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Advantages of Successful DOT

• Reduces the period of infectivity
• Reduces treatment failure and acquired
  drug-resistance
• DOT is the best way to ensure that patients
  complete therapy
• Able to count number of TB drug doses ingested

DOT is the Standard of Care in Texas for all
TB cases/suspects TDH policy 9/95