Block Grant Requirements and Tuberculosis in Substance Abusing Populations Christine Pickens RNBC,M.Ed. Operation Par, Inc. This product is supported by Florida Department of Children and Families Substance Abuse and Mental Health Program Office funding.
OVERVIEW Brief review of Block Grant Introduction to Linkage Tuberculosis (TB) Risk and Prevalence among Drug Abusers Treatment Adherence Targeted Testing Treatment Considerations Q&A
WHAT IS THE BLOCK GRANT?
TB and Substance Abuse a block grant is a large sum of money granted by the national government to a regional government with only general provisions as to the way it is to be spent. Substance Abuse Prevention and Treatment Grant
BLOCK GRANT SAPT WOMEN & DEP. CHILDREN COMMUNICABLE DISEASES CAPACITY MANAGM T INTERIM SERVICES SERVICE COORDINATION OTHER REQUIREMENTS HIV TB PEER REVIEW CONTINUING EDUCATION
WHAT IS THE BETWEEN SUBSTANCE ABUSE AND TB?
PREVALENCE 19% of reported TB cases also report abusing alcohol or using illicit & injectable drugs(idu) 1.8 times more likely to have a more contagious or virulent form of TB Female substance abusers were 2.5 times more likely to experience TB treatment failure than other females
PREVALENCE DEFINITIONS: LATENT TUBERCULOSIS INFECTION: TB bacteria can live in your body without making you sick. Immune system strong and able to stop bacteria from growing. Are not infectious and cannot spread the bacteria Can progress to Active TB ACTIVE TUBERCULOSIS DISEASE: Immune system can t stop bacteria from growing Infection can progress to disease People are sick able to spread
PREVALENCE ADDICTION Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.
Physiological factors Immunosuppression PREVALENCE IDU or alcohol abuse weakens immune system and cannot battle exposure Stay contagious longer Longer to achieve a negative culture Overall increase risk of mortality HIV infected IDUs are at greater risk Each disease speeds up the progress of the other
PREVALENCE Epidemiological Risk Factors: Tobacco use between 75 95% of persons in SA treatment smoke. Homelessness 35% of all sheltered adults had chronic SA issues Incarceration 75% of inmates meet DSM V criteria for substance use disorders
BARRIERS and CHALLENGES Unstable lifestyle Lack of primary care or health insurance Perceived stigma about SA and TB Lack of knowledge about TB and inability to recognize symptoms Wait to present to treatment until after symptom onset which can increase transmission rate as well as severity of disease
BARRIERS AND CHALLENGES Two hallmarks of TB control are: 1. Effective identification of TB cases 2. Effective treatment Where Are you
BARRIERS and CHALLENGES Drugs may suppress cough reflex and recognition and patient delay (morphine and opiates) Reluctance and low motivation to seek treatment Fail to return for reading of tuberculin skin test (tst) Fear of narcotic withdrawal if hospitalized Confusion of prevention (bleaching needles or condom use does not affect transmission. TB can be prevented using similar prevention methods used for HIV or hepatitis transmission.
TB MEDICATIONS AND SA TB treatment meds may increase drug induced hepatitis esp. if co infected with HIV and Viral Hepatitis Rifampin causes a decreased half life of many illicit drugs hence alters the high requiring more Directly affects methadone requiring increase dose amounts. This is the leading medication of choice for opiate addicted drug users.
STRATEGIES Collaboration and coordination of services across agencies and treatment providers Training for staff focused on Substance Abuse and TB for personnel across agencies Targeted testing for easier identification Continued efforts and education with this high risk population
QUESTIONS????
Part I: Public Health Laws for TB Control in Florida Karen Farrell, RN, BSN, RM, Executive Community Nursing Services Director Bureau of Communicable Diseases, TB Control Section, Florida Department of Health This product is supported by Florida Department of Children and Families Substance Abuse and Mental Health Program Office funding.
Communicable Disease Prevention & Control
Tuberculosis Control
Tuberculosis Control Program Strategies Treat to Cure Protect Close Contacts Prevent TB Disease Laboratories Health Care Providers FDOH Assure TB Outcome Federally Qualified Health Centers Ensure Infection Prevention Monitor & Evaluate Hospitals Academia Social Service Agencies
Community TB Program (s. 392.61, F.S.) Each community TB program will have: Community & professional education Community & individual screening Surveillance and contact investigation Reporting of all known cases Development of individualized treatment plan Provision of counseling, periodic retesting, and referral to appropriate agencies
Confidentiality (s. 392.65, F.S.) Exempt from s. 119.07(1), F.S. All records & information related to: known or suspected cases exposure to TB Specifics for release of information are provided
Surveillance Requirements 1. Reporting Required (s. 392.53, F.S.) a) Who: Person who makes a diagnosis or treats a person with TB Laboratory where specimen reveals tubercule baccilli b) When: Next Business Day (64D-3.029, F.A.C.) Physicians next business day Labs next business day c) Where: FDOH CHD d) How: DOH Disease Report Form (DH Form 2136, 3/06) Form supplied by provider
Surveillance Requirements (continued) 2. Contact Investigation (s. 392.54, F.S.) a) Who: FDOH may counsel and interview any person with active TB, suspected of having active TB or suspected of having been exposed to active TB b) Information gathered is confidential and exempt from s. 119.07(1), F.S.
Physical Exam & Treatment (s. 392.55, F.S.) WHO: Diagnosis has active TB or reasonably suspected of having TB Been exposed to active TB WHEN: Voluntary (consent) or court-ordered WHERE: Private physician or CHD facility (outpatient)
Treatment (continued) Diagnosed with active TB Treatment Plan (s. 392.64, F.S) a) Provider licensed under Chapter 458, 459, or 464, F.S. b) Implement using a case management approach c) Address non-compliance
Treatment (continued) Isolation in Home/Hospitalization (s. 392.56, F.S.) Voluntary Court-Ordered when: Active TB; Poses a public health threat Exhausted reasonable means to achieve compliance Note: court order expires in 180 days or when patient is no longer a public health threat If longer than 180 days, hearing must be held within 14 days of expiration Contracted Providers for Hospitalization
Enforcement of 392 & 64 D The State Health Officer or his or her designee can execute a Certificate of Involuntary Hold The department can petition the courts for: Petitions for Examination and Treatment Petitions for Directly Observed Therapy Residential Isolation Petitions for Hospitalization Petitions for Emergency Hold
Non-adherence Failure to adhere to the prescribed TX plan: May be due to a willful disregard by a fully competent individual May be related to addictions or chemical dependency Related to mental capacity Action required; may involve, Court ordered community supervision Hospitalization or residential treatment program, vs. incarceration
Addressing Non-adherence (continued) But I Don t Want A Test! I Feel Fine Educate the client & document the education 392.55, Florida Statutes requires physical examination and treatment, if appropriate If the client doesn t cooperate, an examination and treatment warrant may be issued!
Addressing Non-adherence If they still refuse (continued) The DOH will initiate court proceedings for a Petition for Examination and Treatment The court will issue a warrant And if they still refuse?
Certificate of Involuntary Hold for Tuberculosis F.S. 392.565 & Rule: 64D-3.045 Execution of Certificate for Involuntary Hold for Tuberculosis Appropriate when: Active or presumptively active TB Threat to the public Unlikely to appear at a scheduled hearing The treating physician has determined a need for involuntary hospitalization or commitment
Petitions for Court-Ordered DOT (1) 392.55 (2) - Appropriate for: Any client with DOT or DOPT prescribed as part of their treatment plan Typically used: Repeat No call/no show for DOT or clinic visits, despite counseling Step to avoid involuntary commitment High-risk contacts
Petitions for Hospitalization or Placement 392.56 - Appropriate for: Active or presumptive TB Threat to public Non-adherent despite counseling All other reasonable means of achieving compliance exhausted Hearing has been held
Petitions for Emergency Hold 392.57 - Appropriate if: Active or presumptive TB Poses a threat to public Not likely to show for a scheduled hearing Words or actions provide evidence of being likely to leave jurisdiction prior to hearing date Likely to continue exposing the public until hearing
Take Note!
TB MATH Active TB + 1. Not taking all meds 2. Missing clinic appointments 3. Missing DOT Appointments, or 4. Failing to adhere to MD orders: -drinking alcohol - illegal drug use -recreational prescription drug use = Non-adherence
Get the Ball Rolling Document all education, counseling and interventions in detail, from day ONE Address non-adherence with local DOH leadership and legal Notify the TBCS via email and phone call Conference call will be scheduled, case will be reviewed and appropriate guidance will be given, including action, if justified
Contact: Tuberculosis Control Section (850) 245-4350
PART II: Tuberculosis Overview: Karen Farrell, RN, BSN, RM Executive Community Nursing Services Director Bureau of Communicable Diseases, TB Control Section, Florida Department of Health
The Lord shall smite thee with a consumption and with a fever, and with an inflammation... and they shall pursue thee until thou perish. Deuteronomy 28:22
Expected and Observed TB Cases United States, 1980-1992
Factors Contributing to the Increase in TB Morbidity: 1985 1992 Emerging HIV/AIDS epidemic Immigration from countries where TB was common Transmission of TB in congregate settings Development of multidrug-resistant (MDR) TB Decades of funding cuts had impaired effectiveness of TB control programs
30,000 25,000 20,000 15,000 10,000 5,000 0 Reported TB Cases United States, 1982 2013
Tuberculosis Infected cases GLOBAL 1.7 billion (33% population) USA 10 million (4% population) Case incidence 8-9 million/year ~ 9,400/year Case prevalence 11-13 million ~14 thousand Deaths 1.3 million/year 1,000-2,000/year MDR Up to 15% (Dominican Republic and Ecuador) < 1%
Persons at Higher Risk for Exposure to or Infection with TB Close contacts of person known or suspected to have active TB Foreign-born persons from areas where TB is common Persons who visit TB-prevalent countries Residents and employees of high-risk congregate settings
Persons at Higher Risk for Exposure to or Infection with TB (cont.) Health care workers (HCWs) who serve high-risk clients Populations defined locally as having increased incidence of latent M. tuberculosis infection or TB disease, such as medically underserved, low-income persons who abuse drugs or alcohol Children and adolescents exposed to adults at increased risk for infection or disease
Everyone knows the air is terribly infected from the mortals who have died exhaling it. Moby Dick Herman Melville
Transmission of Tuberculosis
Pathogenesis of Tuberculosis
Probability TB Will Be Transmitted Susceptibility of the exposed person Infectiousness of person with TB (i.e., number of bacilli TB patient expels into the air) Environmental factors that affect the concentration of M. tb organisms Proximity, frequency, and duration of exposure (e.g., close contacts) Can be transmitted from children, though less likely
Sites of Disease Lungs (pulmonary): most common site; usually infectious Miliary: occurs when bacilli spread to all parts of the body; rare, but fatal if untreated Central nervous system: usually occurs as meningitis, but can occur in brain or spine
Sites of Disease (cont.) Outside the lungs (extrapulmonary): usually not infectious, unless person has: Concomitant pulmonary disease, Extrapulmonary disease in the oral cavity or larynx, or Extrapulmonary disease with open site, especially with aerosolized fluid.
Extra-pulmonary TB ~10% in HIV(-) HIV(+) 33% with extrapulmonary alone 33% with pulmonary alone 33% both pulmonary and extrapulmonary (many with negative CXRs) Any organ has been noted to be involved Pleural dx most common Lymph nodes GU Bone (Need to prolong therapy) Abdominal CNS (Need to prolong therapy)
LTBI vs. TB Disease Person with TB Disease Person with LTBI (Infected) (Infectious) Has a small amount of TB bacteria in his/her body that are alive, but inactive Cannot spread TB bacteria to others Does not feel sick, but may become sick if the bacteria become active in his/her body Usually has a TB skin test or TB blood test reaction indicating TB infection Radiograph is typically normal Sputum smears and cultures are negative Should consider treatment for LTBI to prevent TB disease Does not require respiratory isolation Not a TB case Has a large amount of active TB bacteria in his/her body May spread TB bacteria to others May feel sick and may have symptoms such as a cough, fever, and/or weight loss Usually has a TB skin test or TB blood test reaction indicating TB infection Radiograph may be abnormal Sputum smears and cultures may be positive Needs treatment for TB disease May require respiratory isolation A TB case
Progression from Infection to Disease is Increased by... HIV infection X-ray evidence of old, untreated TB Substance abuse, injecting drug use Silicosis, diabetes Certain therapies Certain cancers To protect, Underweight promote and improve the health of all by people in 10% Florida through or integrated more state, county, and community efforts.
Division Tuberculosis of Disease Control and Health Protection Overview: Disease Progression Progression from infection to disease caused by an inability to contain infection 5-10% of all HIV(-) will progress from infection to disease Up to 8% per year of TST(+), HIV(+) patients will progress from infection to disease The average patient with active TB infects 30 other individuals
Drug-Resistant TB Caused by organisms resistant to one or more TB drugs Transmitted same way as drugsusceptible TB, and no more infectious Delay in detecting drug resistance may prolong period of infectiousness because of delay in starting correct treatment
Clinical Significance of Resistance If pansensitive > 95% chance of cure If resistant to INH > 90% chance of cure If resistant to rifampin > 70% chance of cure If resistant to INH and RIF ~ 50% chance of cure Before chemotherapy ~ 50% chance of cure
Transmission and Pathogenesis of TB Tuberculosis is spread by airborne droplets ( droplet nuclei ) Most persons exposed to a person with tuberculosis do not become infected Close contacts are at high risk of acquiring infection Ten percent of infected persons will develop clinical tuberculosis Persons with tuberculosis infection but no disease are not contagious Cavitary or smear positive patients are more infectious than noncavitary or smear negative patients
Diagnosis of Active TB Disease Key: THINK TB
Infection Control Think TB, isolate, and start meds Six to eight air exchanges/hour Negative pressure Doors closed All entering room wear N95 mask Keep in isolation until three negative smears, on medications To protect, and promote responding and improve the health of all people in clinically Florida through integrated state, county, and community efforts.
Medical Evaluation for TB Medical history Physical examination Test for TB infection Chest radiograph Bacteriologic examination
Medical Evaluation for TB 1. Medical History Symptoms of disease; how long History of TB exposure, infection, or disease Past TB treatment Demographic risk factors for TB Medical conditions that increase risk for TB disease
Signs and Symptoms of TB Disease Often of long duration General Fatigue, malaise, weight loss, fever, night sweats Pulmonary Prolonged cough, coughing up blood Extrapulmonary Depends on site
Medical Evaluation for TB (cont.) 1. Medical History (cont.) Symptoms of possible extrapulmonary TB: Blood in the urine (TB of the kidney) Headache/confusion (TB meningitis) Back pain (TB of the spine) Hoarseness (TB of the larynx) Loss of appetite, unexplained weight loss Night sweats, fever Fatigue
Medical Evaluation for TB (cont.) 2. Physical Examination Provides information about the patient s overall condition Cannot be used to confirm or rule out TB disease
Methods for Detecting M. tb Infection in U.S. Mantoux tuberculin skin test (TST) IGRAs: QuantiFERON-TB Gold In-Tube (QFT-GIT), and T-Spot.TB These tests do not exclude LTBI or TB disease Decisions about medical/public health management should include other info/data, and not rely only on TST/IGRA results
Medical Evaluation for TB (cont.) 4. Chest Radiograph Chest abnormalities suggest, but do not confirm, TB disease Posterior-anterior view is standard Apical/posterior areas of upper lobe or superior areas of lower lobe often show abnormalities In immunosuppressed (e.g., HIV infected), lesions may have atypical appearance
Diagnosis of TB Disease Chest x-ray 95% of HIV(-) cases with upper lobe infiltrates and/or cavities
Diagnosis of TB Disease Up to 30% of HIV(+), active TB cases will have no infiltrates or cavities
Medical Evaluation for TB (cont.) 5. Bacteriologic Examination of Specimens (cont.) Specimen collection, processing, and review All persons suspected of TB disease should have sputum cultured Collect at least 3 sputum specimens at 8- to 24-hour intervals, at least 1 in the morning Follow infection control precautions during specimen collection Collection methods include coughing, sputum induction, bronchoscopy, gastric aspiration
TB Disease Diagnosis Smear Cheap & rapid Only 40-60% positive in cases of active TB The Standard for Diagnosis of TB in most of the world
TB Diagnosis Culture Takes 6-8 weeks by conventional Takes 1-3 weeks by liquid media Need ~100 organisms/ml to get 1 colony Sensitivity-Positive in 80% of CDC Verified Cases Specificity- 1-2% False Positive Susceptibility Takes 1-2 weeks after positive culture Molecular Techniques have the ability to give more rapid results Most of the world does not have access to these critical laboratory tests!!!
TB Diagnosis Nucleic Acid Amplification Results within eight hours 99% specificity on smear (+) cases Up to 80% sensitivity on three samples $30 to $50 per test Approved by the FDA for smearpositive and negative, untreated cases May have a rule in non-pulmonary samples
Major Goals of TB Treatment Cure patient, minimize risk of death/disability, prevent transmission to others Provide safest, most effective therapy in shortest time Prescribe multiple drugs to which the organisms are susceptible Never treat with a single drug or add single drug to failing regimen Ensure adherence and completion of therapy
Treatment of Active TB Disease Start with 4 drugs in all patients INH, RIF, PZA and EMB or SM until sensitivities return If pansensitive, D/C EMB or SM After 2 months of therapy, D/C PZA Continue INH & RIF for 4 more months for total of 6 months Must have culture conversion by 2 months 6 month regimen good for HIV(-) and (+) Can use BIW regimen (TIW? RIF Monoresistance in HIV pts after daily for first 2 months) Monitor adherence and toxicity DOT preferred, Combination pills for self administered
Directly Observed Therapy (DOT) Health-care worker watches patient swallow each dose DOT is preferred management strategy for all patients Can reduce acquired drug resistance, treatment failure, and relapse Nearly all regimens can be intermittent if given as DOT DOT reduces total number of doses and encounters For drug-resistant TB, use daily regimen and DOT
Current Anti-TB Drugs (cont.) Four first-line drugs considered standard treatment: Isoniazid (INH) Rifampin (RIF) Pyrazinamide (PZA) Ethambutol (EMB) Rifabutin and rifapentine also considered first-line drugs in some circumstances Streptomycin (SM) formerly first-line drug, but now less useful owing to increased SM resistance
TB Disease Treatment Regimens Four regimens recommended for treatment of drug-susceptible TB, with different options for number of doses and for length of continuation phase Initial phase: standard four drugs (INH, RIF, PZA, EMB) for 2 months (one excludes PZA) Continuation phase: additional 4 months; 7 months for some patients
Treatment Completion Defined as ingesting prescribed number of doses within specified time Duration depends on drugs used, isolate s susceptibility, and patient s response to drugs Most patients can be treated with 6-mo. or 9-mo. therapy; 6 mo. is used for most patients
Conditions Requiring Additional Considerations Renal insufficiency/end-stage renal disease Some TB drugs are cleared by the kidneys; thus the dosing must be altered with renal disease Rather than decrease dosage size, increase dosing interval Hepatic disease - consider regimens with fewer hepatotoxic agents Extrapulmonary TB - In most cases, treat with same regimens used for pulmonary TB
Conditions Requiring Additional Considerations (cont.) Multi-drug resistant TB (MDR TB) Presents high risk for treatment failure, relapse, further acquired resistance, and/or death Clinicians unfamiliar with its treatment should seek expert consultation Always use DOT to ensure adherence
All patients Division of Disease Control and Health Protection Baseline Monitoring Patient Recommended Test Measure aminotransferases (i.e., AST, ALT), bilirubin, alkaline phosphatase, and serum creatinine and a platelet count Patients at risk for hepatitis B or C (e.g., injection drug user, born in Asia or, or HIV infected) Patients who are taking EMB Conduct serologic tests Test visual acuity (Snellen chart) and color vision(ishihara) HIV-infected patients Obtain CD4+ lymphocyte count
Determinants of Response to Therapy Clinical signs Improved cough usually within two weeks Fever usually within two weeks However can last four to six weeks Weight gain and improved appetite Decreased organisms seen on smear Usually markedly decreased within three to four weeks However can last for months Decreased counts on cultures 90% convert in two months on INH/RIF/PZA
Evaluating Response to Treatment (cont.) Monitor for adverse reactions Common adverse reactions include Gastrointestinal problems Hepatitis Rash Fever
Likelihood of Infectiousness Probably infectious Positive sputum smears with viable AFB Presence or induction of coughing Not treated or recently started Poor clinical or bacteriologic response to prescription Not infectious Receiving effective therapy and responding Three daily negative sputums
Criteria to Be Considered Noninfectious Patients no longer considered infectious if: They have 3 consecutive negative sputum smears (2-3 consecutive negative cultures for MDR), Their symptoms have improved, and They are adhering to an adequate treatment regimen for at least 2 weeks The cultures are negative (despite positive smears)
Causes of Inadequate Response to Therapy Non adherence!!!!!!!!!!!!!!!!! DOT Involuntary detention Increased drug resistance/incorrect sensitivities Malabsorption/increased metabolism Inability of drugs to penetrate To effected protect, promote and improve tissues the health of all people in Florida through integrated state, county, and community efforts.
Responsibility for TB Control Health departments maintain primary responsibility for TB prevention and control Complexity of TB control requires public health sector to collaborate with others
Assure the treatment until cure of every tuberculosis patient!
Common Obstacles Adherence Resistance
Common Future Vaccine
What can you do to combat tuberculosis? Contact local health department to help arrange a plan of therapy for patient-health departments are responsible for the cure of tuberculosis patients Begin four medications on all patients until sensitivity of organisms returns Educate patient about tuberculosis and importance of adherence to medications Consider having patient sign Acknowledgement Form Monitor for effectiveness of therapy, adherence and side effects Consider DOT therapy If DOT therapy fails, consider court ordered DOT Involuntary commitment
TB Hotline 1-800- 4TB-INFO