TB in Foreign Born and High Risk Populations

TB Nurse Case Management San Antonio, Texas December 8-10, 2009 TB in Foreign Born and High Risk Populations John J. Nava, M.D. December 9, 2009 Tuberculosis in High Risk Populations and the Foreign Born Nurse Case Management Course Heartland Center December 9, 2009 John J. Nava, M.D. Medical Chief City Chest Clinic San Antonio Metropolitan Health District http://www.sanantonio.gov/health/ 1

Objectives (1) High risk populations due to recent exposure to active contagious TB case Social conditions that promote transmission Conditions that predispose persons to progress from latent infection to active disease preexisting medical condition acquired states 3 Objectives (2) Newly diagnosed TB cases in the US foreign born vs. US born Historical perspective Compare previous and revised Tuberculosis Component of Technical Instructions for Civil Surgeons Become familiar with countries of origin of newly diagnosed cases in foreign born Challenges of caring for refugees, recent immigrants, legal residents, visitors, students Case studies 4 2

Tuberculosis: Not Just a Disease From the Past! Social Conditions That Increase the Risk of TB Disease (1) Overcrowding in high risk congregate settingse.g. correctional facilities, ICE facilities, shelters for the homeless, schools, health care facilities, all for both residents and employees Poor sanitation Poor ventilation Impoverished populations with limited access to health services and limited health literacy 6 3

Social Conditions That Increase the Risk of TB Disease (2) Travel to or from areas of the world where TB is prevalent Close contacts to cases of active contagious TB 7 Risk of Developing TB Disease if Infected 5-10% of infected adults with normal immune systems develop TB disease at some point in life HIV strongest risk factor for development of TB disease if infected Risk of developing TB disease 7% to 10% each year Certain medical conditions increase risk that TB infection will progress to TB disease 8 4

Medical Conditions That Increase the Risk of Progression to TB Disease (1) HIV infection Substance abuse Co-existing infections Diabetes mellitus Silicosis Prolonged corticosteroid therapy Other immunosuppressive therapy, e.g. TNF-α blockers, anti-rejection meds for transplant recipients, antimetabolites 9 Medical Conditions That Increase the Risk of Progression to TB Disease (2) Cancer of the head and neck Hematological and reticuloendothelial diseases End-stage renal disease Intestinal bypass or gastrectomy Chronic malabsorption syndromes Low body weight (10% or more below the ideal) 10 5

Children with Exposure to TB Infants from birth to 1 year of age have the highest risk of developing TB disease upon exposure. Children < 5 years of age require an early and thorough medical evaluation, including a CXR, when exposure is suspected. A child that has TB requires a family and community intervention! 11 Children with TB Infection Most infants and children who develop TB disease Progress within 3-12 months of TB infection. Are prone to rapid progression and more severe forms of TB disease. Contact investigation of adult pulmonary TB cases is crucial to the detection, control and prevention of pediatric TB and its complications. (MMWR Controlling TB in the US, 2005, pg. 43) 12 6

Number of TB Cases in U.S.-born vs. Foreign-born Persons United States, 1993 2008* No. of Cases 20000 15000 10000 5000 0 1993 1996 1999 2002 2005 2008 U.S.-born Foreign-born *Updated as of May 20, 2009. Trends in TB Cases in Foreign-born Persons, United States, 1988 2008* No. of Cases Percentage 10,000000 70 8,000 60 50 6,000 40 4,000 30 2,000 20 10 0 1988 1990 1992 1994 1996 1998 2000 2002 0 2004 2006 2008 No. of Cases Percentage of Total Cases *Updated as of May 20, 2009. 7

Reported TB Cases by Origin and Race/Ethnicity,* United States, 2008 U.S.-born Foreign-born** Asian (3%) American Indian or Alaska Native (3%) Black or African American (42%) White (5%) Asian (43%) White (33%) Native Hawaiian/Other Pacific Islander (<1%) Hispanic or Latino (17%) Hispanic or Black or African Latino (38%) American (14%) *All races are non-hispanic. Persons reporting two or more races accounted for less than 1% of all cases. **American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander accounted for less than 1% of foreign-born cases and are not shown. Reported Tuberculosis in the United States, 2008, Executive Commentary Age as risk factor Highest burden of disease 65 years and older with case rate 6.4 per 100,000 contrasting to children < 14 years with case rate 1.3 per 100,000 Case rates for all age groups either declined or remained constant. Race and ethnicity Hispanics (8.1 from 19.9), African Americans or blacks (8.8 from 28.5), and Asians (highest at 25.6, 3X AA or HA) 16 8

TB Case Rates in U.S.-born vs. Foreign-born Persons United States, 1993 2008* Cases per 100,000 0 40 30 20 10 0 1993 1996 1999 2002 2005 2008 U.S. Overall U.S.-born Foreign-born *Updated as of May 20, 2009. TB Case Rates in U.S.-born vs. Foreign-born Persons United States,* 1993 2008** Ca ases per 100,000 100 10 1 1993 1996 1999 2002 2005 2008 U.S. Overall U.S.-born Foreign-born *Includes the same data as slide 15, but rates presented on a logarithmic scale. **Updated as of May 20, 2009. 9

Countries of Birth of Foreign-born Persons Reported with TB United States, 2008 Other Countries (38%) Mexico (23%) Philippines (11%) Haiti (3%) Guatemala (3%) China (5%) Vietnam (8%) India (8%) Reported Tuberculosis in the United States, 2008, Executive Commentary From 2004 to 2008, top five countries of origin of foreign-born persons with TB were Mexico, Philippines, Vietnam, India, and China Of the 7,563 TB cases reported among foreign-born persons in 2008, 43% among persons born in the Americas region, and 30% among persons born in the Western Pacific region From 1993 to 2008, proportions of cases increased among persons born in the Eastern Mediterranean region (3% to 4.5%), the Southeast Asia region (6% to 13%), and the African region (2% to 8%) These trends reflect the changing resettlement patterns of new arrivals to the US by immigrants and refugees. 20 10

Percent of Foreign-born with TB by Time of Residence in U.S. Prior to Diagnosis, 2008 100% 80% 60% 40% 20% 0% All Mexico Philippines India Missing* <1 yr 1 4 yrs >5 yrs * Foreign-born TB patients for whom information on length of residence in the U.S. prior to diagnosis is unknown or missing. % Resistant Primary Isoniazid Resistance in U.S.-born vs. Foreign-born Persons United States, 1993 2008* 14 12 10 8 6 4 2 0 1993 1996 1999 2002 2005 2008 U.S.-born Foreign-born *Updated as of May 20, 2009. Note: Based on initial isolates from persons with no prior history of TB. 11

Tuberculosis Case Studies 23 Case 1: CDC Request for evaluation of recent immigrant family (1) 7 year old male from Philippines, urgent B1 TB evaluation, arrived DFW 11/23/09 TBST 11 mm on 11/19/08, no history of TB Rx. 07/15/09 abnormal CXR noted in Manila, asymptomatic Nodular infiltrate RUL with R hilar adenopathy, partial clearing since 11/19/08 Sputum smear and culture negative X 3 on July 22, 23, 24 in 2009 24 12

Case 1: CDC Request for evaluation of recent immigrant family (2) 12/02/09 presents to City Chest Clinic, with mother and sister TBST replaced, result 10 mm 48 hours later CXR repeated on 12/02/09, parahilar markings increased with fullness of hilar regions, but no focal infiltrate, still asymptomatic CT considered, but no resources, waiting period for Medicaid or CHIP 25 Case 1: CDC Request for evaluation of recent immigrant family (3) 42 year old female from Philippines, urgent B1 TB evaluation, arrived DFW 11/23/09, mother of 7 year old 07/15/09 abnormal CXR noted in Manila, asymptomatic Right apical pleural thickening with infiltrates, but stable since 11/17/08 Sputum smear and culture negative X 3 on July 22, 23, 24 in 2009, and patient reports similar evaluation in November 2008 26 13

Case 1: CDC Request for evaluation of recent immigrant family (4) Mother had TBST placed and induced sputum collected at City Chest Clinic i on 12/02/09, despite denial of any symptoms of TB (associate investigation for son) TBST result 00 mm at 48 hours Sputum smear few 2+ AFB (1-9 per 10 HPF) RIPE begun on both patients 12/04/09 27 Old versus Revised Technical Instructions for Tuberculosis 1991 Algorithm Sputum smear X 3 required if CXR abnormal and suspicious for active disease No sputum smear required if CXR abnormal but appeared inactive Treat PTB until smear negative, then cleared for travel 28 14

1991 Tuberculosis Technical Instructions: for applicants 15 years of age Inactive TB Chest radiograph No TB Class B2 Active TB No Class Valid for travel within 6 months Valid for travel within 12 months Valid for travel within 6 months AFB sputum smears (3) Noninfectious Class B1 All (-) (at least one +) Infectious Class A Treat until smear negative Rationale for Overseas Screening and Domestic Follow-up Overseas Panel Physicians screen TB suspects using DGMQ TIs Restrict entry of infectious TB cases Facilitate entry of the rest to allow U.S.entry, evaluation and treatment per ATS/CDC standards per ATS/CDC standards US Health Department follow-up evaluation and treatment of noninfectious cases is cost-effective 15

2007 Technical Instructions: Classifications Class 1991 Technical 2007 Technical Instructions Instructions No Classification Normal evaluation Normal evaluation Class A Tuberculosis disease Tuberculosis disease Class B1- Pulmonary Abnormal CXR, sputum smears negative Abnormal CXR, sputum smears and cultures negative Extrapulmonary tuberculosis Class B1 Et Extrapulmonary Et l Extrapulmonary tuberculosis Class B2 Inactive tuberculosis on LTBI Evaluation CXR Class B3 Old or healed tuberculosis Contact Evaluation Old versus Revised TI s New for May 2008 If CXR abnormal, do sputum smear and add culture and DST CXR for age > 15 years TST for ages 2 to 15 years If PTB, must complete treatment per ATS/CDC guidelines and by DOT, prior to travel to US LTBI treatment recommended for highest risk contacts, such as child < 5, HIV+ 32 16

TI Appendix B - Radiographic Findings Suggestive of Active TB Disease Infiltrate or consolidation Any cavitary lesion Nodule with poorly defined margins Pleural effusion Hilar or mediastinal adenopathy Any other finding suggestive of active TB - miliary 33 TI Appendix B - Radiographic Findings Suggestive of Inactive TB Disease Discrete fibrotic scar or linear opacity Discrete nodule(s) without calcification Discrete fibrotic scar with volume loss or retraction Other any other finding suggestive of prior TB, such as upper lobe bronchiectasis (bronchial dilation with bronchial wall thickening) CAUTION : Assessments of the activity of TB disease cannot be made accurately on the basis of a single radiograph. CAUTION : Blunting of the costophrenic angle may be a nonspecific finding in adults. In contrast, a larger pleural effusion suggests active TB disease. CAUTION : In children, even minor blunting of the costophrenic angle suggests active TB disease. 34 17

Reported Tuberculosis in the United States, 2008, Executive Commentary Improve overseas screening of immigrants and refugees by systematically monitoring and evaluating the screening process Strengthen the current notification system that alerts local health departments about the arrival of immigrants or refugees who have suspected TB to enhance the evaluation and treatment of such persons Improve coordination of TB control activities between the United States and Mexico to ensure completion of treatment among TB patients who cross the border Test recent arrivals from high-incidence incidence countries for latent TB infection and monitor treatment completion Survey foreign-born TB patients in the United States to determine opportunities for improving prevention and control interventions 35 Common Barriers to Timely Evaluation Moves after arrival to U S Moves after arrival to U.S. No legal authority to get patients in for screening and evaluation Language/cultural barriers 18

Tuberculosis Case Studies 37 Case 2: Delayed B1 TB evaluation with evolving CXR (1) 17 year old recent immigrant from Vietnam, entered US 08/11/09, referred to City Chest Clinic by ICE for B1 TB evaluation. PMH of TB treatment with two drugs for 4 months, starting in April 2009, but no documentation. Also with H/O stomach ulcer in 2007. Had recently been seen by grandfather s PCP for stomach pain, resolved with OTC Pepcid and Maalox for two weeks. Patient denied any other symptoms and was looking forward to taking placement test to enter high school, as he had already finished the 12 th grade in Vietnam. CXR showed RUL nodular opacity noted in Ho Chi Minh City on 03/03/09 Collected sputum X 3 on 03/4, 3/5, and 3/16/09, all smear negative and culture negative in Vietnam, cleared to travel 38 19

Case 2: Delayed B1 TB evaluation with evolving CXR (2) Reported to City Chest Clinic on 09/28/09, and had TBST placed and repeat CXR ordered, due to the long interval (6 months) since prior film, and no old film to examine. The patient denied all symptoms of TB. CXR showed patchy and interstitial opacities in LUL that may be acute, and suggestion of a 2 cm. cavitary lesion, again suggesting acute disease. Right lung had small oval calcified granuloma. Collected induced sputum on 09/29/09 and ordered two more natural sputum collections at home, and started RIPE by daily DOT for Class 5, TB suspect Smear results subsequently came back <1 AFB on 09/29/09, >10 on 09/30/09, and 1-10 on 10/01/09 39 Case 2: Delayed B1 TB evaluation with evolving CXR (3) Cultures subsequently grew out MTBC, sensitivity ypending Clinical improvement noted, with 3 ½ pound weight gain after one month of RIPE Sputum smear improving with negative on 10/7 (natural), <1 AFB on 10/20 (natural), negative on 10/22 (natural), and <1 on 10/27 (induced) 11/2 through 11/5 received notification Resistant to INH, rifampin, rifabutin, ethambutol, PZA, and ofloxacin 40 20

Case 2: Delayed B1 TB evaluation with evolving CXR (4) Sensitive to ethionamide, capreomycin, and dkanamycin 2 nd line drug susceptibility requested for cycloserine, linezolid, moxifloxacin, PAS Initiated process for admission to TCID Now on amikacin, ethionamide, moxifloxacin, cycloserine, PAS, and B6 41 42 21

The more we Think TB the more likely that cases are diagnosed without delays that lead to increased morbidity and mortality, especially in our children. 43 For Reporting and Consultation San Antonio Metropolitan Health District Chest Clinic 44 22

Resources on TB San Antonio Metropolitan Health District - www.sanantonio.gov/health/ CDC Division of Tuberculosis Elimination - www.cdc.gov/tb Guidelines Available Online at: CDC s - Morbidity and Mortality Weekly Report - www.cdc.gov/mmwr Heartland National TB Center TB Educate TBresources.com 45 23