2/9/2012. A case of TB from the 1950s. Tuberculosis Local and Global Perspectives. II Treatment. III Discharge. A State Sanatorium Hospitalization

Transcription

1 Tuberculosis Local and Global Perspectives MUSC February 7, 2012 Eric Brenner, MD Bureau of Disease Control SC DHEC Dept of Epidemiology and Biostatistics USC School of Public Health Columbia, SC A case of TB from the 1950s I A State Sanatorium Hospitalization Young woman ~30 y.o. from Coastal SC Pulmonary TB, Far Advanced, Bilateral Admitted: July 1953 Discharged: November 1959 Length of stay: 6 years + 4 months Discharged for disciplinary reasons! A case of TB from the 1950s II Treatment Bed Rest ( ) Chemotherapy (various courses ) Surgery Pneumoperitoneum November 1953 August 1955 Thoracoplasty, 1st stage right: January 1956 Thoracoplasty, 2nd stage right, February 1956 Pulmonary lobectomy, RLL, October 1958 A case of TB from the 1950s III Discharge Discharge Diagnoses: Pulmonary TB, far advanced, bilateral Pregnancy (two occasions) delivered September 1956 and March 1958 Discharge Medications: INH 300 mg qd and PAS 12 gm qd indefinitely (!) Other instructions: X ray and sputum q 3 4 months Do no work Schema of a typical modern case of TB January March: progressive cough, night sweats, weight loss, fatigue. Several MD visits => considered bronchitis, walking pneumonia, pertussis etc. Various antibiotics have no effect. April 1: Referred to Infectious Disease specialist who finally thinks TB => presumptive Dx with 3 AFB positive smears (Dx later confirmed by +cultures)=> treatment begins April 4 Treatment: daily for 2 weeks (3 days in hospital + 11 days) at home; then twice weekly for 24 weeks directly supervised at home, work, or in pool hall by a public health nurse (PHN); sucessful treatment (62 doses) ends October 4. PHN also completed contact investigation (home, work, and social contacts); identified infected but asymptomatic persons who were treated for latent TB infection (LTBI). 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Outcomes of TB According to TB Program Setting? No Program Poor Program Good Program Chronic Cure Die 1

2 Robert Koch ( ) Discover of the tubercle bacillus in 1882 Some Landmarks in the History of Tuberculosis 1882 Koch discovers the tubercle bacillus 1890 Koch develops tuberculin (initially as Rx for TB?) 1895 Roengten discovers x rays s Sanatoria as TB hospitals (bed rest + some surgery!) 1921 BCG vaccine (Bacillus of Calmette & Guerin = attenuted M. bovis) 1944 Streptomycin first used to treat a patient 1949 PAS (para aminosalycylic acid) 1952 Isoniazid (Rx often lasts months) 1954 Pyrazinamide 1962 Ethambutol 1963 Rifampin 1970s Rx shortened to 9 months for most pts 1980s Rx shortened to 6 months for most pts 1990s Challenges => MDRTB, TB+HIV=double trouble; Full magnitude of Global TB epidemic finally appreciated Some Mycobacterial Species of Medical Importance M. TB complex M. tuberculosis M. bovis (including BCG) M. africanum Non tuberculous mycobacteria (NTM) M. avium intracellular (M. intracelluare, MAI, MAC) M. kansassi M. fortuitum M. chelonei (and several dozen other species) M. leprae [agent of Leprosy or Hansen s Disease] A normal PA x ray of the chest 2

3 Mycobacteriology Laboratory III AFB Smears Detects presence of mycobacteria (and occasionally other uncommon pathogens as well e.g. Nocardia) Cannot distinguish M. TB from NTM. Clue to possible diagnosis AND to potential infectiousness of patient. Always interpret in context of all other findings. Mycobacteriology Laboratory IV More Positive AFB Smears (*) Mycobacteriology Laboratory V Fluorochrome Method for Mycobacterial Smears (*) Again with traditional Ziehl Neelsen staining which most hospitals can do More sensitive than traditional ZN staining Uses auraminerhodamine stain Requires special equipment which smaller hospitals will not have M. Tuberculosis colonies growing on agar in the laboratory Schema of the Pathogenesis of Tuberculosis Lymphatics => systemic circulation via the thoracic duct Dissemination via circulation to distant sites including (i) apex of lungs; (ii) kidneys, (iii) bone, (iv) brain, (v) multiple other sites. Potential for disease to occur in 5 10% of infected persons; months, years, decades later. Site of initial infection often peripheral (sub pleural) Typical apical cavitary disease seen in many patients who have TB from late reactivation of Latent TB Infection (LTBI) Spread via pulmonary lymphatics Hilar lymph nodes (hilar adenopathy) 3

4 Natural History of Tuberculosis (Schema) Not Infected Infected + No disease, but LTBI 95% Still no disease, but possible lifelong LTBI 90% Back to a bit of TB History! 100% Disease soon [within 1 2 yrs] Disease anytime later in life [reactivation of LTBI) 5% 5% Caution!! Co infection with HIV totally upsets this schema! Instead of having a 10% lifetime risk of developing TB disease persons coinfected with HIV may have a risk as high as 10% per year!!!! In 1914, $10,000 was set aside by the legislature to establish the South Carolina State Sanatorium. The State Sanatorium opened in 1915 as a tent facility and over time, progressed to wooden buildings or cottages. TB Camps were established all over SC Hopewell in Greenville, Camp Alice in Sumter, Pinehaven in Charleston, Marion County Camp A Cottage at the Ridgewood Sanatorium Note the windows all around the building and the swings & chairs in the yard for the fresh air cure Reminder of the not so distant past An imposing Sanatorium TB hosptial Note extensive sun porches = Solariums Mont Joli (Quebec; 1939) Pavilion at the TB San 4

5 Sun treatment for TB early in the early XXth. century State Park Health Center opened in 1938 This picture shows mass screening in the United States. These projects started in the 1930s. Mass screening with conventional equipment was impractical, so special devices were developed. Mobile vans equipped with photofluorographic X ray units allowed countries around the world to mass screen their populations... Visting patients in the TB sanatorium. (is that why they call him Santa?) Patients taking the air at the Ninette Tuberculosis Sanitorium, Manitoba [ A TB patient at the sanatorium getting an X ray completed. South Carolina Board of Health 5

6 Cut out drawing of a mobile X ray Van X rays were less expensive, easier to complete and used more & more both in and outside the Sanatorium setting. South Carolina Board of Health State Board of Health hired 7 public health nurses; Ruth Dodd and Helen Fenton were the first TB public health nurses in South Carolina. They were to teach the TB patients how to take care of themselves and prevent others from getting TB Modern TB Chemotherapy 6

7 In concert with ALASC, DHEC developed and started the Enablers and Incentives Program. The funding was provided by the ALASC through a trust fund and still functions today. 7

8 Immigration Routes for the First Americans Columbus Four Voyages to the New World: 1492, 1493, 1498 & 1502 First (2003) US Cow with Bovine Spongioform Encephalopathy (BSE) [ Mad Cow Disease ] had been imported from Canada in Swine flu (H1N1 of 2009) imported from Mexico Another old Question about disease importation: Was there Tuberculosis in the New World before the arrival of Columbus and other Europeans? 8

9 NYT March 15, 1994 But. On a more immediate and practical note, how about importations of TB into the USA right now in the 21 st Century? Case of TB Imported from India 1 29 yo woman arrives SC Aug 2004 part of group of teachers from India with contracts to teach science in underserved rural SC high schools Contracting agency did not know of her two previous episodes of pulmonary TB (had selfadministered therapy!?) TB relapses Summer 2005 => smear+ & culture+ At first just one of ~ 200 SC TB cases for the year. but Case of TB Imported from India 2 Case of TB Imported from India 3 Contact Investigation Drug susceptibilities: => R to INH, Rif & PZA Rx then proceeds with Emb, Cys, Cap, Lev, Mox, Rfb Complex course (e.g. drug intolerance, other systemic diseases) requires several regimen modifications Eventual good treatment outcome: completed teaching contract. Now studying nursing in Georgia Spouse and sister have +TSTs PEP with Rx with Rifabutin All co teachers in the HS now tested. Only one student patient had taught had a positive skin test. Felt had likely been infected before. PEP with Isoniazid Complex, this case only one of over 5,000 foreign born TB cases seen in the USA each year 9

10 What overview then of Tuberculosis in the USA and its Relation to Importation No. of Cases 30,000 25,000 20,000 15,000 10,000 5,000 0 Reported TB Cases United States, * *Updated as of July 21, 2011 Year 20.0 TB Case Rates* by Age Group United States, TB Case Rates by Age Group and Sex, United States, 2010 Cases per 100, Cases per 100, > Under Male Female * Updated as of July 21, 2011 Number of TB Cases in U.S.-born vs. Foreign-born Persons United States, * Percentage of TB Cases Among Foreign born Persons, United States* No. of Cases 20,000 15,000 10,000 5, DC DC 0 *Updated as of July 21, 2011 U.S. born Foreign born *Updated as of July 21, 2011 >50% 25% 49% <25% 10

11 14 Primary Isoniazid Resistance in U.S. born vs. Foreign born Persons United States, * 12 XDR TB Case Count Defined on Initial DST* by Year, ** % Resistant Case Count U.S. born Foreign born Year of Diagnosis *Updated as of July 21, 2011 Note: Based on initial isolates from persons with no prior history of TB. * Drug susceptibility test ** Updated as of July 21, 2011 Note: Extensively drug resistant TB (XDR TB) is defined as resistance to isoniazid and rifampin, plus resistance to any fluoroquinolone and at least one of three injectable second line anti TB drugs Estimated HIV Coinfection in Persons Reported with TB, United States, * Mode of Treatment Administration in Persons Reported with TB United States, * % Coinfection Percentage** Aged All Ages *Updated as of July 21, 2011 Note: Minimum estimates based on reported HIV positive status among all TB cases in the age group DOT only DOT + SA SA only *Updated as of July 21, Data available through 2008 only. **Percentage of total cases in persons alive at diagnosis, with an initial regimen of one or more drugs prescribed, and excluding cases with unknown mode of treatment administration. Directly observed therapy (DOT); Self administered therapy (SA) Percentage Completion of TB Therapy United States, * Completed Completed in 1 year or less And how is it that we (or CDC) even know all this about TB in the foreign born? * Updated as of July 21, Data available through 2008 only. Note: Includes persons alive at diagnosis, with initial drug regimen of one or more drugs prescribed, who did not die during therapy. Excludes persons with initial isolate rifampin resistant, or patient with meningeal disease, or pediatric patient (aged <15) with miliary disease or positive blood culture. 11

12 Global Perspectives! Geneva, Switzerland The Pont du Mont Blanc where the Lake of Geneva empties into the Rhone River The old League of Nations Building (now part of UN) HQ of the World Health Organization 12

13 The Six WHO Regions Flashback. to the eradication of smallpox. 13

14 Images of Smallpox Smallpox Day 8 14

15 Stages in the disease control wars Control Elimination Eradication Destruction Reduction of disease incidence, prevalence, morbidity, mortality, and disability to a locally acceptable level. Reduction of infection and disease to zero in a defined area. Surveillance crucial. Continued efforts required. Permanent reduction of worldwide incidence to zero as a result of deliberate interventions. Surveillance crucial. Continued efforts may not be required. Destruction of all isolates of microbial agent. 15

16 Elimination of TB in the USA!? What would the term elimination mean? Is elimination an appropriate goal or not. and, if so: For what date and for what subpopulations should elimination be targetted? Should DTBE have its named changed back to the DTBC? Thank you! Discussion.? 16