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Tuberculosis: A Continuing Public Health Challenge
Tuberculosis: A Continuing Public Health Challenge
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 200-440 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 heavy…In 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 non-problem
– 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 Infection
(70-90%) (10-30%)
Latent TB Active TB
(90%) (10%)
Never develop
Active disease Untreated Treated
221
TB Case Rate per 100,000 VA and
US: 2007-2011
Year Virginia TB Virginia TB US TB Cases US,521TB
Cases Rate Rate
140
120 2008
100 2009
80
2010
60
2011
40
20
0
Northwest Southwest Central Eastern Northern
VA TB Cases by Age and Sex: 2011
60
50
Number of Cases
40
30 Male
Female
20
10
0
0-14 15-24 25-44 45-64 65+
Age Group
TB as a Worldwide
Public Health Issue
• Philippines Ethiopia
•
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)
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