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New Approaches in Tuberculosis Management for the Primary Care Provider

New Approaches in Tuberculosis Management for the Primary Care Provider. Scott Lindquist, MD, MPH Tuberculosis Medical Consultant Washington State Department of Health and Kitsap County Health Officer. Reported TB Cases* United States, 1982–2007. No. of Cases. Year.

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New Approaches in Tuberculosis Management for the Primary Care Provider

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  1. New Approaches in Tuberculosis Management for the Primary Care Provider Scott Lindquist, MD, MPH Tuberculosis Medical Consultant Washington State Department of Health and Kitsap County Health Officer

  2. Reported TB Cases* United States, 1982–2007 No. of Cases Year *Updated as of April 23, 2008.

  3. Reported TB Cases by Race/Ethnicity* United States, 2007 American Indian or Alaska Native (1%) White (17%) Asian (26%) Native Hawaiian or Other Pacific Islander (<1%) Hispanic or Latino (29%) Black or African-American (26%) *All races are non-Hispanic. Persons reporting two or more races accounted for less than 1% of all cases.

  4. Asian/Pacific Islander American Indian/Alaska Native Black or African-American White Hispanic TB Case Rates by Race/Ethnicity* United States, 1993–2007** Cases per 100,000 *All races are non-Hispanic. In 2003, Asian/Pacific Islander category includes persons who reported race as Asian only and/or Native Hawaiian or Other Pacific Islander only.**Updated as of April 23, 2008.

  5. TB Case Rates by Race/Ethnicity* Washington State, 1996-2007 *All races are non-Hispanic. In 2003, Asian/Pacific Islander category includes people who reported race as Asian only and/or Native Hawaiian or Other Pacific Islander only

  6. TB Case Rates by Age Group Washington State, 1996-2007

  7. TB Case Rates by Age Group,WA 1993-2005

  8. Estimated HIV Coinfection in Persons Reported with TB, United States,1993–2006* % Coinfection 2006 *Updated as of April 23, 2008. Note: Minimum estimates based on reported HIV-positive status among all TB cases in the age group.

  9. Estimated HIV Coinfection in Persons Reported with TB, Washington State,1995-2007 Note: Minimum estimates based on reported HIV-positive status among all TB cases in the age group.

  10. Reporting of HIV Test Results in Persons with TB by Age GroupUnited States, 1993–2006* % with Test Results 2006 *Updated as of April 23, 2008. Note: Includes TB patients with positive, negative, or indeterminate HIV test results. Persons from California reported with AIDS only through 2004. (HIV test results are not reported from California)

  11. Homeless Adult TB Cases†by Homeless Status,* 1994-2001 †Adult TB case = TB in person aged >18 years * Homeless within year prior to TB diagnosis

  12. % Correctional Facility Adult TB Cases† by Correctional Facility Status,* 1993-2001 † Adult TB case = TB in person aged >18 years old * Resident of correctional facility at the time of TB diagnosis

  13. Selected Risk FactorsTen-Year Period, WA 1993-2005

  14. TB Case Rates,* United States, 2007 D.C. < 3.5 (year 2000 target) 3.6–4.4 > 4.4 (national average) *Cases per 100,000.

  15. Tuberculosis Incidence Rates, Washington State, 1988-2007 Healthy People 2010 Objective (<1 case per 100,000)

  16. Reported TB Cases by County, Washington State, 2007

  17. Number of TB Cases inU.S.-born vs. Foreign-born Persons United States, 1993–2007* No. of Cases *Updated as of April 23, 2008.

  18. Trends in TB Cases in Foreign-born Persons, United States, 1987–2007* No. of Cases Percentage *Updated as of April 23, 2008.

  19. DC Percentage of TB Cases Among Foreign-born Persons, United States* 1997 2007 DC >50% 25%–49% <25% *Updated as of April 23, 2008.

  20. Countries of Birth of Foreign-born Persons Reported with TB United States, 2007 Mexico (24%) Other Countries (39%) Philippines (12%) Rep. Korea (3%) Viet Nam (7%) Haiti (2%) India (8%) China (5%)

  21. Number of TB Cases in U.S.-born vs. Foreign-born Persons, WA State, 1995-2007

  22. Tuberculosis Cases by Country of Origin, Washington State, 2007

  23. Primary Anti-TB Drug Resistance United States, 1993–2007* % Resistant *Updated as of April 23, 2008. Note: Based on initial isolates from persons with no prior history of TB. Multidrug resistant TB (MDR TB) isdefined as resistance to at least isoniazid and rifampin.

  24. Primary MDR TBUnited States, 1993–2007* No. of Cases Percentage *Updated as of April 23, 2008. Note: Based on initial isolates from persons with no prior history of TB. MDR TB defined as resistance to at least isoniazid and rifampin.

  25. Primary Isoniazid Resistance in U.S.-born vs. Foreign-born Persons United States, 1993–2007* % Resistant *Updated as of April 23, 2008. Note: Based on initial isolates from persons with no prior history of TB.

  26. XDR TB Case Count Defined on Initial DST† by Year, 1993–2007* Case Count Year of Diagnosis †Drug susceptibility test. *Reported incident cases as of April 23, 2008. Extensively drug-resistant TB (XDR TB) is defined as resistance to isoniazid and rifampin, plus resistance to any fluoroquinolone and at least one of three injectable second-line anti-TB drugs.

  27. Primary Anti-TB Drug Resistance Washington State, 1995-2007 % Resistant Note: Based on initial isolates from persons with no prior history of TB. MDR TB defined as resistance to at least isoniazid and rifampin.

  28. New Diagnostics • Interferon Gamma Release Assays (IGRA’s) • Quantiferon • Elispot • MTD testing • Universal Genotyping • Rapid Molecular Amplification (NAAT)

  29. Commonly Asked TST Questions (1) • How do you know and ensure that the medical community using the TST is properly trained? • Can you place a TST on a Thursday and read on a Monday? • Who needs a 2-step test and why? • What is the boosted response?

  30. Commonly Asked TST Questions (2) • What if the longitudinal reading of the TST is 12mm and the horizontal (official reading) is 8mm? Is that considered positive? • Can I accept a negative reading if the patient said there was absolutely no reaction and there is no reaction on day 4 after the test? • We switched products from tubersol to aplisol and I noticed more “positives.” We retested with tubersol and all were negative. Which test do I believe?

  31. The Answer • Quantiferon or Elispot • Blood based testing method

  32. MTD • Mycobacterium tuberculosis direct test • Nucleic acid amplification • Sensitivity 85.7%-97.8% • Criteria for use: • Smear positive cases • Highly suspicious cases • Will it change your treatment?

  33. Universal Genotyping • All TB cultures are now sent to CDC for genotyping “fingerprinting” from WA state • Spoligotyping • MIRU pattern • Goal is to detect clusters

  34. Homeless TB Cases in King County by Treatment Start Date No. Cases 2004 2002 2003 Treatment Start Date

  35. How long does it take to find out if a strain is resistant? • 2 days? • 2 weeks? • 4 weeks? • 6 weeks? • 8 weeks?

  36. Turnaround Time for M. tb Drug Susceptibility Testing • From receipt of specimen to 1st drug susceptibility by culture method ~4 weeks • 2nd line drugs 2 additional weeks by MGIT (6 weeks) or an additional month by agar proportion (8weeks) • Molecular methods (nucleic acid amplification & detection of mutations) can be done within a day or two

  37. NAAT to Detect Drug Resistance As Well As Presence of M. tb • Line probe assays • Commercially available in Europe, but not cleared yet by U.S. FDA • Molecular beacons assay • Not a commercial product • Available as a “home brew” test at CA Microbial Diseases Laboratory

  38. Beyond Epidemiology and Labs:Physical Exam

  39. Signs of Pulmonary TB (1) SignInfantsChildrenAdolescents Rales Common Uncommon Rare Wheezing Common Uncommon Uncommon Fremitus Rare Rare Uncommon Dullness to Rare Rare Uncommon percussion Decreased Common Rare Uncommon breath sounds

  40. SymptomInfantsChildrenAdolescents FeverCommon Uncommon Common Night sweatsRare Rare Uncommon CoughCommon Uncommon Common ProductiveRare Rare Common Hemoptysis Never Rare Rare Dyspnea Common Rare Rare Signs of Pulmonary TB (2)

  41. Chest Radiographs Characteristic: Adults Children Location Apical Anywhere (25% multilobar) Adenopathy Rare Usual (30-90%) (except HIV) Cavitation Common Rare (except adolescents) Signs & symptoms Consistent Relative paucity

  42. Treatment • DOT (consistency is key) • Latent TB infection 9 months • Pulmonary 6 months • Meningitis 12 months • Adenopathy 6 months • Bone/joint 12 months • Monthly weight check

  43. Treatment Evaluation • HIV screen • Hep B and C (if risk factors) • AST • ALT • Bilirubin • A.Phos. • Creatinine • Platelets • Vision testing (if ethambutol used > 2 mo.)

  44. Ongoing Diagnostic Monitoring • Monthly sputum collection (until 2 negative smears) • Looking for smear positive cases after initial 2 months of therapy • Liver function tests if abnormalities on screening or risk factors for hepatitis

  45. DOT or Not To DOT • Strongly recommended • Patient centered approach is more successful: • Social service support • Treatment incentives and enablers • Housing assistance • Substance abuse treatment

  46. Mode of Treatment Administration, Washington State, 1994-2007

  47. Case #1The Start of It All • 10 y/o Filipino female moves to the U.S. with an extended family in 1999 • History of 6 months of INH in 1995 for LTBI • Positive TST 15 mm • Normal CXR • Now has a 1 year history of cough • Worse cough over last month • Multiple rounds of antibiotics for pneumonia • Weight loss

  48. Case #1

  49. Case #1 • Sputum AFB negative • Gastric aspirate AFB negative • Bronchoscopy wash AFB + • Started on INH, Rif, PZA, EMB • Sputum cultures positive…….

  50. Case #1 • Contact investigation: • Mom TST+/CXR normal, received INH in Guam • Sister TST+/CXR normal • Brother in law TST+/CXR normal • Sister TST x 2 • Nieces x 2 negative TST • Bottom line: large mobile family with movement back and forth to Guam and US

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