TB Issues in LTC: Challenges and Best Practices

Transcription

1 TB Issues in LTC: Challenges and Best Practices HA NGUYEN PEEL PUBLIC HEALTH, RN, MN DR. NICOLA MERCER WELLINGTON-DUFFERIN-GUELPH PUBLIC HEALTH DR. ELIZABETH REA TORONTO PUBLIC HEALTH

2 Financial Interest Disclosure (over the past 24 months) Speaker Name: Ha Nguyen, RN, MN Peel Public Health I have no conflict of interest. Speaker Name: Dr. Nicola Mercer, MD, MBA, MPH, FRCPC Medical Officer of Health & CEO Wellington-Dufferin-Guelph Public Health Speaker Name: Dr. Elizabeth Rea, MD, MSc, FRCPC Associate Medical Officer of Health Toronto Public Health I have no conflict of interest. I have no conflict of interest.

3 Outline Why worry? The worst case scenario Dr. Nicola Mercer The context Ha Nguyen The options Dr. Elizabeth Rea Discussion Everyone

4 TB Outbreak in Long-Term Care Home 2010

5 Background Privately owned Long-Term Care and Retirement Home in a rural community in SW Ontario Population = 2,599 (Stats Canada 2011) 16.3% > 65 years No identified ethnic minorities LTC and RH are joined and share entrance, staff, kitchen and dining area 64 Long-term Care (LTC) Beds 42 Retirement Home (RH) Beds

6 Index Case: May y.o. healthy female HCW Immigrated to Canada in 2004 Several visits to family MD for shoulder/chest pain and night sweats in April Initial Rx antibiotic for possible pneumonia May 10 ER visit sputums ordered and AFB Negative on smear Culture positive on May 28 for MTB Genetic typing SIT #167 T1-lineage European-American

7 Results of Initial Investigation TST on LTC residents (53), staff (76), volunteers (5) 7 previous positive staff 2 previous positive residents 10 new positive staff 4 new positive LTC residents

8 Case #2: August y.o. female in LTC side Comorbidities of CHF, OA and?pancreatic ca step TST 0 mm 2010 July 10, TST 17mm CXR July 2010 nil acute Symptoms - low grade fever, cough, wt. loss August 4 sputum culture positive (smear neg.) Spoligotyping match to index case Type #167, T1 Lineage

9 Second Round of Testing TSTs on LTC residents (55), staff (76) and volunteers (7) 4 new positive LTC residents 1 new positive staff and 1 new positive volunteer 32 staff and volunteers did not show for test

10 TB in the elderly: It can look like.. Recurrent/non-resolving pneumonia Decreased level of function Chronic low-grade fever Chronic fatigue Cognitive impairment Disseminated, skeletal, genitourinary TB more common

11 Case #3: October y.o. female in LTC side Comorbidities of DM, HPT, Parkinson s, dementia 2006 TST 0mm 2010 July, 0 mm 2010 Oct. 4 0 mm after 48 hrs but day 5 induration TST repeated, positive = 30 mm CXR showed a LUL cavitating lesion Bronchoscopy Oct. 21 smear negative but culture positive Genetically linked to other cases

12 Case #4: October y.o. male in LTC side Comorbidities of renal ca, prostatic ca 2007 TST 0 mm 2010 July, 0 mm 2010 Oct. 18 mm CXR WNL Asymptomatic Sputums x3 were smear negative culture positive Spoligotyping match to both previous cases

13 October 25: Declared Outbreak During and because of a contact investigation, two or more of the identified contacts are diagnosed as secondary cases of active TB Canadian TB Standards, 7th Edition, 2013 p. 312

14 Case #5: May y. o. female on LTC side born in Canada Significant underlying co-morbidities step TST 0 mm 2010 July 0 mm 2012 Jan. -TST positive 10 mm No cough no sputum CXR LLL infiltrate, CT multiple small nodules LUL, LL nodule Gastric Lavage x 3, AMTD negative on smear positive result but culture positive Genetically linked to other cases

15 Outbreak Summary to Date 5 confirmed active cases All sensitive to first line therapy All 5 are genetically linked Spoligo-international type (SIT) #167 belonging to the T1-lineage of TB strains. This strain has been identified as being European-American. 4 of 5 active cases have died 28 new latent infections 11 LTC residents, 6 RH residents, 11 staff

16 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Jan Feb Mar Apr May Jun Number of Cases TB Epidemic Curve by Case Definition: May 2010 June Year and Month of Diagnosis New Latent Infection Confirmed Active TB

17 Treatment Summary of 5 Cases 1 staff member completed treatment uneventfully 4 residents - ages ranged from 83 to 97 None of the resident cases completed treatment All 4 cases died while on treatment 1 case INH hepatitis TB contributing factor on Death Certificate

18 Challenges for Public Health Identifying those with active disease in this population was very difficult Coughs, fevers, wt. loss common Comorbidities including dementia Accuracy of baseline TST False Negative TST Differentiating between TST boosting and conversion to identify new LTBI Poor quality of CXR s especially portable

19 Summary No active TB identified in visitors, family contacts or residents of the residential home Source case never confirmed but suspected WDG completed over 980 TSTs at this facility in managing this outbreak

20 Review of TB epidemiology in LTC

21 TB From the World to Ontario

22 Born in a TB Endemic Country TB rate in Canada before 1950 = same rate as Burundi, Azerbaijan, Guyana in / 100,000 per year

23 TB Risk Goes Way Up in Elderly

24 Why are TB Rates Higher in Old Age? Lots more TB around when elderly were growing up high LTBI prevalence Decreased immune function with age Medical treatment Diabetes Dialysis Oncology Rheumatology, GI (TNF alpha inhibitors) HIV (4% of Toronto cases) Congregate settings: increased risk of transmission

25 Volume of TB screening: Number of admissions and residents in a LTCF in Ontario, Year # of residents # of admissions Data source: Continuing Care Reporting System (CCRS), MOHLTC.

26 Proportion of total Ontario TB cases # of pulmonary TB cases among LTC residents Total number of TB cases = 39 / 6,363 = 0.61% Average annual ratio TB cases/ltc beds # of pulmonary TB cases among LTCF residents # of residents in Ontario LTCF = 5/100, : 4 / 105,988 = 4/100,000 TB diagnosis at entry screening vs after admission Unknown, but no Toronto cases diagnosed on admission screening (N=17), No Guelph outbreak cases (N=4)

27 Current Ontario LTC TB Screening Policy

28 Ontario Legislation In Ontario, screening of LTC residents for active TB on admission is legislated under the Long Term Care Homes Act of 2007 (i.e., O. reg. 79/10 section 229 (10)), which states that: Each resident admitted to the home must be screened for tuberculosis within 14 days of admission unless the resident has already been screened at some time in the 90 days prior to admission and the documented results of this screening are available to the licensee. Important: Long Term Care Homes Act does not specify the method(s) to be used to screen

29 2011 MOHLTC Tuberculosis Prevention & Control Guidance Document For screening purposes, residents should undergo a baseline posterior-anterior and lateral chest radiography within 14 days of admission to the institutions. Any documented TST results should be transcribed into their record. If the population of residents is at increased risk of active TB, then a baseline TST is warranted. Serial TSTs are not required for residents.

30 CTBS, 7th edition (2013) Due to the decreasing utility of TST to diagnose LTBI after age 65 and the increasing risk of adverse effects from LTBI treatment in this age group, screening with a posterior-anterior and lateral chest x-ray for active TB is preferred upon admission for those over 65 years old. A baseline 2-step TST is still recommended upon admission for those 65 years old and under who also belong to an identified at-risk group. Annual TST not necessary. p. 312 Public Health Agency of Canada and the Canadian Lung Association/Canadian Thoracic Society. Canadian Tuberculosis Standards, 7th Edition. Canada; No evidence cited for the above recommendation

31 CTBS, 7th edition (2013) TST is no longer recommended as a primary assessment tool in the contact follow-up of elderly residents in long-term care, in whom it is less reliable and for many of whom the risks of treatment of LTBI in old age will outweigh any benefit. The focus for these individuals should be on early detection of secondary cases. p. 297 Public Health Agency of Canada and the Canadian Lung Association/Canadian Thoracic Society. Canadian Tuberculosis Standards, 7th Edition. Canada; 2013.

32 Jurisdictional Scan of LTC TB Screening Policy across Canada

33 Province/ Territory TB Incidence (2013 per 100,000) Risk Factor Inquiry Symptom Inquiry CXR TST Note Alberta 4.6 X X British Columbia 5.6 X X under 65yr Manitoba 13.4 X New Brunswick 0.4 Newfoundland 2.5 X X NWT 9.2 X under 65 Nova Scotia 0.9 X under 65 X over 65 X under 65 LTC Screening Recommendation Summary Nunavut X X X X Ontario 4.7 X PEI 0.0 Screening for general diseases Quebec 2.9 LTC residents for TB as contacts of an active TB case Saskatchewan 7.7 X X Yukon 5.4 X X X- risk factor X- immunecompromise

34 CDC/MMWR Symptom Screening for incoming staff and residents Screening Based on local epidemiology consider adding TST to the intake screening if 3+ cases per year If 0 cases in the past 5 years & no known staff TST conversion: no screening beyond symptoms indicated

35 Literature on the effectiveness of TB screening at entry to LTC

36 What are we trying to accomplish? Not screening for latent TB (LTBI) Very limited opportunity to give preventive treatment Hepatotoxocity on INH preventive treatment up to 5% for those >65yrs Not for baseline in case of contact-follow-up in future TST increasingly unreliable with age/co-morbidities TST extremely unreliable in active TB disease (25% neg) Staff/visitor TST much more reliable indicator of transmission See Guelph outbreak experience

37 What are we trying to accomplish #2? To prevent someone with infectious TB entering LTC Single point-in-time screening Early detection of active disease, to minimize transmission tests for diagnosis = symptoms, CXR, sputum (not TST) Effectiveness of this strategy depends on when LTC residents develop active TB: mainly prevalent at entry, or after admission? Efficiency depends on how much TB among LTC residents

38 TST reactivity declines with age findings in this report suggest considerable limitations in utilizing tuberculin testing in control of TB in institutions for the elderly Dorken et al Chest 1987 N=933 LTC residents, British Columbia

39 CXR sensitivity for TB dx Sensitivity 75% (59-80%) for classic TB findings, specificity 60% (52-99%) *usually in the context of symptoms, all adults Interpretation notoriously variable Complicated in elderly by concurrent chronic disease (eg COPD), image/positioning quality Atypical findings more common with diabetes, dialysis, other immunocompromised Can be logistically difficult; expensive; radiation exposure

40 Sputum smear and culture Gold standard for diagnosis of TB 3 specimens = sensitivity>90%, specificity 97% for pulmonary TB Not recommended for case finding expensive, inefficient Can be difficult to collect in elderly, especially if cognitive impairment

41 Symptom screening cough lasting more than 2 3 weeks haemoptysis, fever weight loss night sweats low specificity for PTB as individual questions However, observational studies from high-burden settings suggest that where these symptoms are combined, for example by enquiring about any symptom, they show moderate to high sensitivity (65 90%), albeit with low to moderate specificity (30 68%) to detect microbiologically confirmed TB. Int J Tuberc Lung Dis 17(5): Low cost, can be incorporated easily into existing LTC placement physician assessment, no harms to patient

42 In practice: not a lot of evidence Alberta LTC cost-effectiveness modelling study Verma et al, 2013 Incremental cost/1000 Cases/1000 NNS Cost per case averted* No screen 5.3 TST 78, ,913 CXR 531, ,298 Conclusion: TST more cost-effective than CXR as initial screening test, but neither accomplished much. Screening all entrants to long term care for TB may not be costeffective in a low burden setting. In practice: Alberta LTC TB cases occur/diagnosed not at admission but months/years later

43 Considerations Effectiveness: can the screening test(s) detect cases early, to minimize transmission and avert severe disease Epidemiology: burden of disease? prevalent vs incident disease - is point-intime screening appropriate? Targetted high-risk screening vs universal? Efficiency: Number Needed to Screen (NNS) and harm/benefit ratio for population Programmatic: opportunity costs, alternative intervention strategies, harm re missed cases

44 Bottom line Key issue in elderly is active TB, not LTBI Active TB is not very common in Ontario LTC facilities There is no perfect screening test, especially in elderly TB risk in LTC is mainly post-admission: high level of TB awareness even more important than intake screening At least as important : staff screening (AND good LTBI counselling!)

45 What next? PIDAC-TBWG currently reviewing guidelines for LTC admission screening stay posted! Questions? Comments?