TB Free Marshall Islands Ebeye and Majuro, Republic of Marshall Islands,

Transcription

1 TB Free Marshall Islands Ebeye and Majuro, Republic of Marshall Islands, Janice Louie, MD, MPH Medical Consultant Meeting San Antonio, TX November 29-30, EXCELLENCE EXPERTISE INNOVATION Disclosures Janice Louie, MD, MPH has the following disclosures to make: No conflicts of interest No relevant financial relationships 2 1

2 3 TB-Free Marshall Islands Ebeye and Majuro, Republic of the Marshall Islands, Janice Louie, MD, MPH Medical Director San Francisco Department of Public Health Tuberculosis Clinic 3 Where are the Marshall Islands? Comprised of 1156 islands, 29 coral atolls surrounding a 655 sq mi lagoon Population 53,376 (2016) Main inhabited islands are Majuro or Ebeye atolls 4 2

3 Why do we care about the Marshall Islands? Discovered by Spanish in 1500s, occupied by Japan in WW2, became a US territory In 1986 under the Compact of Free Association Republic of Marshall Islands (RMI) became a sovereign state o US provides direct assistance (renewed in 2003, 3.5 billion until 2023) o US provides infrastructure: health, education, and defense until 2023 o Marshallese have unique legal status: maintain their citizenship, but may travel and work in the US ~18-20,000 Marshallese live in the US- the majority (~12,000) have settled in Springdale, Arkansas Net emigration of ~952 Marshallese to US annually (1.7%), mostly for jobs 5 Majuro Capital of RMI Population ~27,797 Land mass 10 square miles Per capita income $2700 Main exports are frozen fish (tuna), coconuts, ornamental clams and shells, and handicrafts 6 3

4 Kwajalein Atoll and Ebeye Island Ebeye Population ~10, square miles Slum of the Pacific Kwajalein Atoll Population ~1000 military and families 1.2 square miles Leased by US army until 2066 Main income generator for all of RMI ($15 million annually) 7 Ronald Reagan Ballistic Missile Defense Test Site 8 4

5 Bikini Atoll 1954, Castle Bravo Between the US dropped (tested) 67 nuclear bombs on Bikini and Enewetak atolls. The explosive yield was equivalent to 1.6 Hiroshima bombs detonated every day over the course of 12 years 9 The US Legacy of Nuclear Testing Communities downwind were exposed to deadly radioactive ash; nearby island residents describe how it snowed for the first time in the islands Nuclear fallout prompted a mass exodus to other islands and the US A 2004 U.S. National Cancer Institute study found the entire island nation remains affected. Radiation levels remain double the safe standard. The Compact allowed for settlement of claims against the US, as the fund is depleted current allocation is $98 quarterly per evacuated resident Bikini Town Hall 10 5

6 : As part of the clean-up of 3 of 40 islands, 111,000 cubic yards of radioactive waste was placed under a concrete dome, including plutonium (half-life 24,000 years). Due to rising sea levels, cracks are now appearing in the dome and trace plutonium has been detected in Chinese rivers. 11 Island currently 6 feet above sea level Over the past 30 years sea level has risen 1 foot Periodic extreme high tides destroy and flood homes Ten rows of this cemetery are now underwater Global warming and a rising sea 12 6

7 Demographics Median age: 20.6 years o 40% under age 14 o 53% under age 24 Average 6.8 persons/household 13 Average 4.1 children born/female Infant mortality rate 22/1000 (#83; US ~5.8/1000) Female mean age at birth of first child: 20.7 years Adolescent birth rate (age years): 85/

8 Life expectancy: 73.4 years 15 Overweight or obese: 62% (4 th in world) Diabetes prevalence: 40% (compare to 9.3% in US) Hypertension: 60% HIV prevalence: <0.1 % The Compact supplemental food program supplies processed foods such as Spam, flour and canned goods 16 8

9 Unemployment rate 36% o High rates of alcoholism (20%, 65% endorse binge drinking) and suicide in males (teens and young adults) 17 Marshallese Diet Fish, chicken, coconut, breadfruit, pandana, white rice, spam 18 9

10 Fresh fruits and vegetables are imported 19 Electricity spotty, frequent blackouts No reliable supply of potable water leads to high rate of gastrointestinal illnesses 20 10

11 Most households rely on collected rainwater or must purchase filtered water to carry home 21 RMI is highly dependent on foreign aid ($40 million annual revenue, 64% comes from grants from US, Taiwan, and Japan) Periodic donations not contributing to infrastructure or sustainable change

12 Poor standard of living, crowding, lack of sanitation, clean water, and healthy diet, and high rates of obesity and diabetes leads to TB program rates reported to CDC under the CDC cooperative agreement 23 RMI ranks 3 rd in tuberculosis deaths per capita 24 12

13 25 WHO Publication WF220 (2013) WHO recommendation Method 7, Option 3b 1. Systematic screening for active TB may be considered for geographically defined subpopulations with extremely high levels of undetected TB (>1% prevalence*) 2. Systematic screening for active TB may be considered for subpopulations that have very poor access to healthcare, such as people living in slums, homeless people, people living in remote areas with poor access to healthcare, and other vulnerable groups including some indigenous populations, migrants and refugees *The risk of false positive diagnosis increases as prevalence declines, therefore special attention should be paid to diagnostic accuracy particularly when prevalence is <1% 26 13

14 4X method: sx+ cxr + genexpert+ expertise = more accurate and specific diagnosis, resulting in more efficient use of resources and labor 27 Not only screen, but move toward elimination? Community intervention of INH prophylaxis in Native Alaskans N= ~7300 Remote areas Poor access to healthcare All treated with INH for 12 months regardless of TST status Marked decrease in number of active cases over ensuring 5 years Almost no cases observed in children <5 years 28 Comstock et al, A Controlled Trial of Community-Wide Isoniazid Prophylaxis in Alaska. Am Rev Resp Dis un;95(6):

15 Ideal Objectives of Mass Screening for Active TB Detect active TB cases early Reduce poor treatment outcomes, long term health problems, and adverse social and economic consequences of TB for the individual Reduce TB transmission by shortening the duration of infectiousness Prevent active TB in household contacts Active case finding in high risk persons (diabetes) Work shoulder-to-shoulder with experts Introduce new technology (genexpert) Launchpad for an enhanced TB control program Capacity building 29 Caveats with Mass Screening for Active TB Expensive for a few TB cases found; important to limit to high risk populations Chest X-ray screening can over-diagnose and over-treat non-tb Depends on local resources (equipment, personnel) Can overwhelm existing program with new cases Short-benefits only if not accompanied by program expansion (especially for latent TB) and repeat screening events 30 15

16 Feb-April 2017: TB-Free Ebeye Project Population ~10,000 3 month screening Age 18 years Identification and treatment of active TB cases LTBI treatment of contacts 31 TB-Free Ebeye 2017 Adults only Active 22.3% 25.9% National Tuberculosis Controllers Association Conference, Palm Springs, CA. May

17 Model: Sustainable Change in Ebeye March 2018: TB incidence on track to be less than half of prior 3 years Despite tripling the number of TB cases managed by the program, TB death rate was reduced by ~80% (compared to ) Current focus is on prevention >200 persons placed on LTBI treatment in past year Staffing increases put in place by mass screening have remained in place under the local budget (6 staff in Jan 2017 to 20 staff currently) Slide courtesy of R Brostom 33 TB-Free Majuro May-November 2018 Focus on active AND LTBI in all ages Rotating screening sites throughout the island 34 17

18 Management of Logistics Critical Two teams screening people/day 3 mobile X-ray machines (2 donated by Japan) Hire 7 new local permanent staff (2 nurses, 5 DOT) and many temporary staff 8 volunteer rotations 93 volunteers from US, Canada, Australia, Phillipines, Taiwan, Fiji, Palau, Federated States of Micronesia Expect to diagnose and treat 200+ active TB cases and LTBI cases Anticipate ,000 tablets of rifapentine needed (purchased at discount rate from Sanofi) 35 Majuro elementary school screening site 36 18

19 1. Registration (fingerprint) Mask if you have a cough TST placement 38 * placed daily **BCG vaccination is routine in the Republic of Marshall Islands 19

20 3. TST read 48 hours later 4. If TST positive, also check for diabetes, HTN and hyperlipidemia, ask about ETOH and tobacco use Pediatric exam Regardless of TST result, if age <10 years, child sent to pediatric exam station for lymph node and Hansen s disease check 40 20

21 6. X-ray and skin exam for Hansen s Disease (Leprosy) anyone over 10 years or <10 years with symptoms or exposure CXR interpretation by MD to determine if latent vs possible active TB Average CXR daily per reader 21

22 8. If CXR normal and TST positive, counsel and treat for LTBI

23 9. If CXR is abnormal, sputum collected Algorithm for Suspect Active Cases: First sputa collected on-site sent for genexp testing at Majuro Hospital (sometime induced) CHOW collects second and third sputa at patient s home (ideally in AM) to be sent to Hawaii for smear and culture Case conference: all abnormal CXRs and genexp results reviewed, treatment decisions made 46 23

24 The assignment: Identify chest X-rays with lesions suggestive of active TB disease OR compatible with TB (active or inactive) Marshall Islands normal 47 Suggestive of active TB 48 24

25 Suggestive of active TB 49 Suggestive of active TB 50 25

26 Suggestive of active TB 51 Compatible with TB (active or inactive)? 52 26

27 Compatible with TB (active or inactive)? 53 Compatible with TB (active or inactive)? 54 27

28 Compatible with TB (active or inactive)? 55 Compatible with TB (active or inactive)? 56 28

29 Compatible with TB (active or inactive)? 57 Typical Case Presentation Asymptomatic Never treated for TB but thinks a nephew who lived in the same house 3 years ago may have taken TB pills Seems to be lot of people coughing in the neighborhood No prior chest X rays or record of TB treatment Long term smoker GeneXpert negative 58 29

30 59 LTBI Treatment Checklist 60 30

31 11. Directly Observed Therapy 61 Managing and packing medications: a laborious but critical task: 3HP (once weekly) or INH/RIF (daily) 62 31

32 October 26, 2018 Preliminary Results: 81% screened (n=22,104) 285 active cases 5286 LTBI cases (24%); 4564 started on treatment (3HP) 54 new leprosy cases (incidence 24/10,000) 63 Preliminary Results: Active Case Finding Screening is currently ongoing As of September 2, 56% of the population had completed TB screening 64 32

33 Caveats Data still coming in, but based on Ebeye results. Opportunity for a young TB control program to identify possible gaps in laboratory testing by performing QA on specimen collection, transport, and local genexp methods May be difficult to improve culture yield based on flights from RMI to Honolulu only go three times weekly 65 Possible causes of low culture yield: In India, positive cultures after storage at room temp: 3 days: 83% 5 days: 71% 7 days: 63% 66 33

34 Transport time of RMI specimens longer than recommended (especially Ebeye, which may explain low yield) Temperature control during specimen storage is important USAPI Transport times to Honolulu Pacific Island TB Controllers Association (PITCA) Meeting Honolulu, Hawaii September submissions to Hawaii commercial laboratory: contamination rates Possible proxy: Contamination rates increase with time of transport: 3 days-7% 5 days- 12% 7 days- 18% Paramasivan et al, Tubercle 1983 Pacific Island TB Controllers Association (PITCA) Meeting Honolulu, Hawaii September

35 TB-Free Majuro Summary: Lessons and Challenges Drew international attention to TB in the Marshall Islands and Marshallese in the US Built TB infrastructure for screening, diagnosis, laboratory testing and contact investigation Hands-on training by experts in the field Identified opportunities for program improvement Results of mass screening: >80% of population screened (goal 85%) o > 285 diagnosed with active TB and started on treatment (~1.3%) o Extraordinarily high incidences in young children o ~5200 (28%) diagnosed with LTBI (TST+), >85% started on 3-HP o 54 newly diagnosed with leprosy ( rate 24.4/10,000) 69 TB-Free Majuro Summary: Lessons and Challenges Overdiagnosis? most active cases initially diagnosed clinically/radiographically o May need to adjust case numbers once all data available, but still identified a high TB prevalence Overdiagnosis? all LTBI cases diagnosed by +TST in setting of BCG vaccination o Although numbers are similar to those seen in Marshallese in Arkansas Jury still out: o Incidence of adverse events in a population with?hep B prevalence and likely high prevalence of ETOH o Possible under-dosing in an obese population -?Efficacy down the line of treatment and prophylaxis o Will the same decrease in TB incidence and TB-related mortality observed in Ebeye be seen in Majuro? o Long-term impact and sustainability 70 35

36 Group C Volunteers, TB-Free Majuro Thank you: Barbara Seaworth, Richard Brostrom, Pennan Barry, Ed Desmond, John Bernardo and Jon Warkentin 72 36

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38 Sensitivity and Specificity of Testing Diagnostic Test Sensitivity (%, CI) Specificity (%, CI) Liquid culture (GOLD standard) Sputum AFB 61 (31-89) 98 (93-100) Xpert MTB 92 (70-100) 99 (91-100) Clinical Diagnosis* 24 (10-51) 94 (79-97) * Clinical evaluation plus chest radiography after negative sputum smear microscopy or Xpert REF: WHO Systematic Screening for Active Tuberculosis: Principles and Recommendations. WF 220,