Tuberculosis Among Health Care Workers, Researchers, Trainees, and Travelers to Kenya in Association with AMPATH

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1 Tuberculosis Among Health Care Workers, Researchers, Trainees, and Travelers to Kenya in Association with AMPATH Adrian Gardner MD, MPH Clinical Research Fellow, Infectious Diseases Miriam Hospital/Alpert School of Medicine at Brown University 4/16/10

2 TB-infected resident doctor may have exposed hundreds of [Chicago] children! Apr 12, 2009 More than 3,700 face tests for TB! Boston Globe June, 2005 More than 3,700 hospital patients and workers started receiving notices yesterday that they should be tested for tuberculosis after possibly being exposed to a junior doctor who rotated through four Massachusetts hospitals while she had a contagious form of the disease for six months.

3 Background Tuberculosis continues to be one of the most common infectious diseases in the world (9.27 million new cases in 2007). Many regions of the world continue to report a rise in the number of cases of drug resistant tuberculosis. Kenya is #13 on the WHO list of 22 high-tb burden countries and has an incidence rate of approximately 350 new cases/100,000 population per year Latent TB infection: no symptoms, inactive bacteria, positive skin test TB disease: symptoms, usually culture positive, contagious (respiratory tract)

4 Background Growing number of students, faculty, physicians-in-training, researchers and other health professionals from the US traveling to work in areas of the world where tuberculosis (TB) and drug-resistant TB are endemic. Activities in these areas frequently involve exposure to infectious TB patients in settings that lack effective infection control policies and practices. Little is known about the risk of TB infection in this population and whether there is a need for specific, targeted education and counseling of program directors and participants.

5 Methods Survey program participants who traveled to Eldoret, Kenya in association with the AMPATH program between July, 2004 June, 2009 Administered questionnaire via an online survey tool and by hard copy upon request

6 Methods Survey designed to collect: Demographic characteristics of participants Experience with pre-travel TB counseling and testing In-country activities Post-travel TB testing

7 Results (Preliminary) 69% responded (N=418) Analysis in progress

8 Results: Demographics Age (years) >60 Gender Female N (%) 6 (1.4) 167 (40.3) 110 (26.6) 57 (13.8) 53 (12.8) 37 (8.9) 227 (54.8) Medical History No chronic medical illness 340 (93.4) TB History Negative test for LTBI History of LTBI Never tested for LTBI/Unknown 326 (80.5) 36 (8.9) 43 (10.6)

9 *Other- PCP, Health center, previous travelers, self

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11 Other includes safari trips, downtown restaurants/dance clubs, classrooms, weddings, operating room, pharmacy,tb clinic

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13 47% 41% 9%

14 Revealing Comments. I visited AMPATH, but was not involved in any of the TB work. Just wanted you to know that I will not be completing the survey. I don't think I should be on this list. I took a short mission trip to Kenya but I know nothing about the TB testing. I do not remember any council specific to TB before we left, just general information about immunizations but the discussions focused more on malaria. I work with SMILE providing laboratory support. The survey does not really apply to my experience in Eldoret. Therefore, I did not fill in the survey.

15 Results: Ideal care Definition of Ideal Care Pre-travel counseling on TB Pre-travel TST within one year of departure Post-travel TST related to travel Only 28% of adult participants received ideal care (i.e. met all three criteria)

16 Results: TST conversions 10 participants reported a negative or unknown pre-travel TST and + TST post-travel for a conversion rate of %. Of those who reported TST conversion or active TB, 8 (73%) reported participation in direct medical care vs. 3 (27%) reported no participation in direct medical care. One participant reported active TB 66 children under the age of 21 years accompanied survey respondents to Kenya. Of these, 26 (39%) had a TST upon return and 3 had a conversion for a conversion rate of 4.5% %.

17 Conclusions (Preliminary) HCW, researchers, trainees, and travelers to western Kenya with the AMPATH medical exchange program tend to be young and healthy. Their in-country activities place them at significant risk for TB infection Many do not receive adequate pre and post-travel counseling and testing Further study is needed to more accurately quantify the risk of TB infection and elucidate higher-risk in-country activities. Pre-travel consultation for travelers to TB-endemic countries should include specific TB education and counseling

18 Operational response AMPATH Designing an educational brochure which will be given to program participants upon arrival in Kenya Create a system for reminding participants to have a post-travel TST Ongoing efforts to develop and implement an infection control plan for the hospital in Eldoret At Brown, hoping to develop mechanism for educating all students, faculty, trainees who are working internationally in TB-endemic areas CDC working group: national guidelines for humanitarian and health care providers working in areas where drug-resistant TB is endemic

19 Asante Sana for your attention!