Marguerite A. Erme, DO, MPH Medical Director Summit County Public Health October 9, 2016

Transcription

1 Marguerite A. Erme, DO, MPH Medical Director Summit County Public Health October 9, 2016

2 Objectives By the end of this presentation, the participants will be able to Discuss the epidemiology of tuberculosis is the United States Compare the use of IGRA tests versus TSTs for tuberculosis screening Describe the treatment options for latent tuberculosis infection and who should receive treatment.

3 Photo courtesy of the CDC PHIL

4 Photo courtesy of the CDC PHIL

5 March 16, 1992 Photo courtesy of the CDC PHIL

6 Tuberculosis Microbiology Mycobacterium tuberculosis Humans only known reservoir Obligate aerobe Facultative intracellular bacillus Aid-fast staining Waxy wall does not allow Gram stain uptake Slow growing Can take 6-8 weeks before culture called negative Genetic testing can identify positive TB earlier Cannot distinguish viable from non-viable organisms Ziehl-Neelsen stain

7 History of TB (1) TB has affected humans for millennia Historically known by a variety of names, including: Consumption Phthisis Wasting disease White plague Scrofula No treatment; people tended to die quickly People who died of TB King Tutankhamen Cardinal Richelieu Simon Bolivar John Keats Elizabeth Barrett Browning Edgar Allan Poe Frederic Chopin Emily Bronte Robert Louis Stevenson Anton Chekhov Eleanor Roosevelt D.H. Lawrence George Orwell Vivien Leigh

8 History of TB (2) Until mid-1800s, many believed TB was hereditary 1865 Jean Antoine- Villemin proved TB was contagious 1882 Robert Koch discovered the bacterium, M. tuberculosis, that causes TB Photo credit: Janice Carr Accessed from CDC PHIL

9 TB Care Before Antibiotics Examination of immigrants Quarantine Respiratory hygiene coughs Laws against public spitting Herbs Blood-letting Travel to warmer, drier climates Spas/baths Public campaigns Sanatoriums NYC passed public spitting law in Many communities had their own TB association to work on TB prevention and awareness.

10 History of TB (3) Sanatoriums First public TB sanatorium was established in 1884 in Saranac Lake, NY Patients followed a regimen of bed rest, open air, and sunshine Other Tx: pneumothorax, thoracoplasty, lobectomy, segmentectomy, plombage TB patients who could not afford sanatoriums often died at home Pediatric patients in beds, Edwin Shaw Hospital Undated but between 1922 and 1947 Courtesy of Edwin Shaw Hospital Collection Akron Summit County Public Library

11 TB History Timeline 1993: TB cases decline due to increased funding and enhanced TB control efforts 1865: Jean-Antoine Villemin proved TB is contagious 1884: First TB sanatorium established in U.S. 1943: Streptomycin (SM) a drug used to treat TB is discovered Mid-1970s: Most TB sanatoriums in U.S. closed : Robert Koch discovers M. tuberculosis : Two more drugs are discovered to treat TB: INH and PAS Mid-1980s: Unexpected rise in TB cases 11

12 Global TB Epidemiology Estimated new cases (2014): 9.6 million people 5.4 million men, 3.2 million women and 1.0 million children. An estimated 1.2 million people living with HIV developed TB in TB deaths: 1.5 million people 1.1 million HIV-negative and 0.4 million HIV-positive 890,000 men, 480,000 women and 140,000 children One in 3 HIV deaths is due to TB Twenty-two countries account for about 85% of global TB burden

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14 Mortality has fallen 47% since 1990.

15 TB Rates in Selected Countries India 167/100,000 Democratic Republic of the Congo 69/100,000 Myanmar 53/100,000 Afghanistan 44/100,000 Mexico 21/100,000 Nepal 17/100,000 Bhutan 9.5/100,000 Iraq 2.2/100,000 Syria 0.1/100,000

16 Global Tuberculosis Report, 2015 WHO

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18 US Epidemiology In ,563 cases of TB were reported US rate 3.0/100,000 66% occurred in foreign-born persons. More than 85% of US TB cases believed to be reactivation of untreated LTBI Disparities in TB distribution Minority/ethnic Geographic

19 Source: CDC

20 Over half the TB cases were reported from California, New York, Texas, and Florida. Source: CDC

21 Rates of TB for different racial and ethnic categories-us, 2014 American Indians or Alaska Natives: 5.0 TB cases per 100,000 persons Asians: 17.8 TB cases per 100,000 persons Blacks or African Americans: 5.1 TB cases per 100,000 persons Native Hawaiians and other Pacific Islanders: 16.9 TB cases per 100,000 persons Hispanics or Latinos: 5.0 TB cases per 100,000 persons Whites: 0.6 TB cases per 100,000 persons

22 Ohio Epidemiology 2015 Ohio TB breakdown (n=143 cases) Overall rate was 1.2/100, % male; 39.2% female Most common age range was years (32.2); 24.5% of the cases were found in each of the age ranges and > 65 years 30.8% of the cases were in Whites; 34.3% of the cases were found in Blacks and also in Asians 89 of 143 cases (62.2%) were foreign-born cases There were only 2 INH resistant cases and no MDR

23 Regional TB Epidemiology Average number of cases from (rate/100,000) Summit: 5.6 (1.0) Portage: 0.6 (0.4) Stark: 1.0 (0.3) Cuyahoga: 31.4 (2.5) Medina: 1.4 (0.8) Ohio (1.3)

24 Summit County From 1/1/ /31/ cases of TB (pulmonary & extrapulmonary) 16 were US born 21 were foreign born 10 were immigrants (2 developed TB within 5 years of arrival) 11 were refugees (8 developed TB within 5 years of arrival Of the 10 cases that were diagnosed within 5 years of arrival, 9 were pulmonary and 1 was extrapulmonary

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27 Reasons for Continued Cases Increasing global travel Decreasing public health infrastructure in developing or undeveloped countries Increasing numbers of people with immunocompromised diseases or taking immunosuppressive medications Drug resistant tuberculosis Decreased awareness (in low incidence countries) of its continued threat

28 Risk Factors for Getting Active TB HIV infection Intravenous (IV) drug abuse Alcoholism Diabetes mellitus (3-fold risk increase) Silicosis Immunosuppressive therapy Tumor necrosis factor alpha (TNF-α) antagonists Cancer of the head and neck Hematologic malignancies End-stage renal disease Intestinal bypass surgery or gastrectomy Chronic malabsorption syndromes Low body weight - In contrast, obesity in elderly patients has been associated with a lower risk for active pulmonary TB Smoking - Smokers who develop TB should be encouraged to stop smoking to decrease the risk of relapse Age below 5 years

29 USPHS LTBI Recommendations New USPSTF recommendations came out in September Previous updated TB screening recommendations in 1996 Key CDC messages Eliminating TB in the US requires expanding testing and treatment of LTBI CDC and USPSTF recommend testing populations that are at increased risk for TB infection. Clinicians, health care agencies, and community organizations, especially those serving at-risk populations, have a critical role in TB elimination.

30 Who Should Get Screened? Based on Risk Assessment USPSTF recommendations People who were born in or frequently travel to countries with high TB prevalence People who have lived in large group settings, such as homeless shelters and correctional facilities CDC additional testing recommendations For healthcare workers* For contacts of people with confirmed or suspected TB disease As part of disease management for people with certain conditions such as HIV and diabetes As indicated before the use of certain medications

31 TB Testing TB testing is screening, not diagnostic. Active tuberculosis disease is not diagnosed by a positive test. A positive test indicates that someone may have been previously exposed and infected with TB bacilli. A positive TB test should prompt follow-up to rule out active tuberculosis disease. Each of the current TB testing modalities has limitations.

32 Tuberculin Skin Test AKA, Mantoux skin test Used purified protein derivative (PPD) to elicit reaction Must be read hours from placement Invalid if <48 or >72 hours; must be repeated Measure induration, not redness Always record size of induration Not positive or negative Source: CDC, Greg Knobloch

33 A TST reaction of 5 mm of induration is considered positive in: HIV-infected persons Recent contacts of a person with infectious TB disease Persons with fibrotic changes on chest radiograph consistent with prior TB Patients with organ transplants and other immunosuppressed patients (including patients taking the equivalent of 15 mg/day of prednisone for 1 month or more or those taking TNF-a antagonists) A TST reaction of 10 mm of induration is considered positive in the following individuals: Recent arrivals to the United States (within last 5 years) from high-prevalence areas Injection drug users Residents or employees of high-risk congregate settings (e.g., correctional facilities, long-term care facilities, hospitals and other health care facilities, residential facilities for patients with HIV infection/aids, and homeless shelters) Mycobacteriology laboratory personnel Persons with clinical conditions that increase the risk for progression to TB disease Children younger than 4 years of age Infants, children, and adolescents exposed to adults in high risk categories A TST reaction of 15 mm of induration is considered positive in the following individuals: Persons with no known risk factors for TB

34 Interferon-Gamma Release Assays (IGRAs) Interferon gamma release antibody test Two tests in US: Quantiferon -TB Gold-in-Tube Test and T-Spot TB Test Moderately sensitive but highly specific Must be processed 8-30 hours after collection Does not cause booster phenomenon Not biased by HCW interpretation Results not based on risk factors Read as positive, negative, or indeterminate

35 TST vs IGRA IGRAs are the preferred method of testing for: Groups of people who have poor rates of return for TST reading and interpretation (e.g., homeless persons) Persons who have received BCG vaccination TST is the preferred method for testing for: Children under the age of 5 years Either TST or IGRA may be used without preference for other groups that are tested for LTBI. Routine testing with both TST and IGRAs is not recommended There are certain situations where results from both tests may be useful

36 Latent Tuberculosis Infection Asymptomatic and not infectious Positive screening test, negative symptoms, negative CXR Must R/O active TB disease before starting LTBI Tx Exact prevalence of LTBI in the US is hard to determine Estimated prevalence from the 2012 NHANES data is 4.7% to 5.0% Approximately 30% of persons exposed to MTb will develop LTBI. If untreated 5-10% will progress to active TB disease

37 High Priority for LTBI Treatment (1) People with a positive IGRA result or a TST reaction of 5 or more millimeters HIV-infected persons Recent contacts of a TB case Persons with fibrotic changes on chest radiograph consistent with old TB Organ transplant recipients Persons who are immunosuppressed for other reasons (e.g., taking the equivalent of >15 mg/day of prednisone for 1 month or longer, taking TNF-α antagonists)

38 High Priority for LTBI Treatment (2) People with a positive IGRA result or a TST reaction of 10 or more millimeters Recent immigrants (< 5 years) from high-prevalence countries Injection drug users Residents and employees of high-risk congregate settings (e.g., correctional facilities, nursing homes, homeless shelters, hospitals, and other health care facilities) Mycobacteriology laboratory personnel Children under 4 years of age, or children and adolescents exposed to adults in high-risk categories

39 Lower Priority (but should be offered) Persons with no known risk factors for TB may be considered for treatment of LTBI if they have either a positive IGRA result or if their reaction to the TST is 15 mm or larger. Never know what conditions person may develop in the future

40 LTBI Treatment INH daily for 9 months Most common Preferred for children 2-11 years and people with HIV INH daily for 6 months RIF daily for 4 months INH and rifapentine once weekly for 12 weeks Must be given by DOT Rifapentine is not covered by Medicaid tbi/default.htm

41 LTBI Tx Monitoring: Clinical Clinical Monitoring done monthly Signs of hepatitis Adherence to medication regimen Symptoms of possible adverse drug reactions or interactions Advised to stop medication and contact health care provider immediately

42 LTBI Tx Monitoring: Patient Education Explain the disease process and rationale for medication in the absence of symptoms or radiographic abnormalities. Review the importance of completing treatment for LTBI. Discuss possible side effects of LTBI medications that may include: Fever Unexplained anorexia Dark urine (color of coffee or cola) Icterus Rash Persistent paresthesia of hands and feet Persistent fatigue or weakness lasting 3 or more days Abdominal tenderness, especially in right upper quadrant Easy bruising or bleeding Arthralgia Nausea Vomiting Discuss management of common side effects and the need to report to health care provider.

43 LTBI Tx Monitoring: Lab Testing Baseline laboratory testing (measurements of serum AST, ALT, and bilirubin) is not routinely necessary. Laboratory testing at the start of LTBI therapy is recommended for patients with any of the following factors: Liver disorders History of liver disease (e.g., hepatitis B or C, alcoholic hepatitis, or cirrhosis) Regular use of alcohol Risks for chronic liver disease HIV infection Pregnancy or the immediate postpartum period (i.e., within 3 months of delivery) Baseline testing can be considered on an individual basis, especially for patients taking other medications for chronic medical conditions. Periodic retesting is recommended for persons who had abnormal initial results and other persons at risk for hepatic disease Order tests if person develops any symptoms while on LTBI treatment

44 After LTBI treatment Persons treated for LTBI can still develop TB later Totally compliant LTBI Tx may reduce risk of future TB by 90% Persons may not have taken LTBI meds as prescribed LTBI Tx may not have eradicated every bacillus-may reactivate if person develops a high risk condition Person may be re-exposed and re-infected with TB All persons completing LTBI should receive their records that include TST or IGRA results, chest radiograph results, names and dosages of medication and duration of treatment. The patient should be instructed to present this document any time future TB testing is required. All persons completing LTBI Tx should get re-educated about the S/S of TB disease and to seek medical care if symptoms occur. Serial or repeat chest radiographs are not indicated unless the patient develops signs or symptoms suggestive of TB disease.

45 Final Words It is important to keep a high index of suspicion about TB and not just in foreign born individuals. Screen based on risks and clinical elements-universal testing would turn up more false positives leading to more evaluation, expense, time, and anxiety. Prescribing chemoprophylaxis for people with LTBI will decrease the number of future TB cases. LTBI treatment is within the realm of primary care. Use resources to become comfortable with LTBI Tx. Contact your local health department about TB Suspected cases of active TB disease are reportable; LTBI is not reportable.

46 References Esmail H, Barry CE, Young DB, Wilkinson RJ, 2014, The ongoing challenge of latent tuberculosis, Phil. Trans. R. Soc. B 369: Centers for Disease Control and Prevention, Updated Guidelines for Using Interferon Gamma Release Assays to Detect mycobacterium tuberculosis Infection-United States, 2010, MMWR 2010;59(No. RR-5 Centers for Disease Control and Prevention. Reported Tuberculosis in the United States, 2014, Atlanta, GA: US. Department of Health and Human Services, CDC, October 2015 Shepardson D, Marks SM, Chesson H, et al, Cost-effectiveness of a 12-dose regimen for treating latent tuberculous infection in the United States, December 2013, Int J Tuberc Lung Dis, 17(12) , Bliven-Sizemore, EE, Sterling TR, Shang N, et al, Three months of weekly rifapentine plus isoniazid is less hepatotoxic than nine months of daily isoniazid for LTBI, September 2015 Int J Tuberc Lung Dis, 19(9) , Screening for Latent Tuberculosis Infection in Adults, US Preventive Services Task Force Recommendation Statement, JAMA. 2016;316(9): doi: /jama Centers for Disease Control and Prevention, Latent Tuberculosis Infection; A Guide for Primary Care Providers,