“Goodbye Don’t Mean I ‘m Gone”

1. Tuberculosis in Tennessee “Goodbye Don’t Mean I ‘m Gone” Jon Warkentin, MD, MPH State TB Control Officer Tennessee Department of Health 6th Annual Fall Symposium – Middle TN APIC Baptist Hospital, Nashville, TN September 13, 2012

2. Disclosure • In accordance with Accreditation Council for Continuing Medical Education (ACCME) guidelines, I, Jon Warkentin, have disclosed that I have no financial relationships with pharmaceutical or medical manufactory companies that would pose a conflict of interest in this presentation.

3. Disclaimer • The presenter is a “TB evangelist,” not an infectious disease clinical specialist • Focus will not be on presenting data from the scientific literature • A call to “best practices” and enhanced public health capacity • “Blues-you-can-use”

4. Objectives • Describe the changing epidemiology of TB in Tennessee • Explain the three-tiered hierarchy of TB infection controls • Understand the key role of the ICP in preventing TB transmission

5. Pop Quiz • Who wrote the song, “Goodbye Don’t Mean I’m Gone”? • Name of album? • Year of release? • How old are you?

6. Objective • Describe the changing epidemiology of TB in Tennessee

9. Worldwide Impact 8,000,000 people develop active TB every year Each one can infect between 10-15 people in one year just by breathing TB as a critical public health issue

10. Worldwide Impact Someone dies of TB every 15 seconds Worldwide, over 2,000,000 people die annually from TB, mostly in less developed countries TB as a critical public health issue

11. TB Case RatesTN and United States, 1986-2011 Case Rate per 100,000Population Year

12. Reported TB CasesTennessee, 1998-2011 Number of Cases Year

13. TB Cases by GenderTennessee, 2007-2011 Percent of Cases Year

14. TB Cases by Age GroupTennessee, 2007-2011 Percent of Cases Year

15. TB Cases by Race/EthnicityTennessee, 2007-2011 Percent of Cases Year *Data do not include missing information; Race is Non-Hispanic and Hispanic is of all races.

16. Foreign-born TB CasesTennessee, 2007-2011 Number of Cases Percentage of Cases Year

17. Countries of Birth for Foreign-bornTB Cases, Tennessee, 2011

18. Site of TB DiseaseTennessee, 2007-2011 Percent of Cases Year

19. TB Cases with HIV Co-morbidity, Tennessee, 2007-2011 Percent of Cases Number of Cases Year † Includes all cases †

20. Multi-Drug Resistant (MDR) TB Cases Tennessee, 2007-2011 Number of Cases Year ^2011 Acquired MDR data are preliminary. * Initial MDR refers to those patients who were culture positive and that had initial drug susceptibility testing and who were found to have TB resistant to both INH and RIF. ** Acquired MDR refers to those patients who were alive at diagnosis and not initially found to have MDR TB, but developed MDR-TB during therapy.

21. MDR-TB in Tennessee – 2007 case

22. Mortality of TB CasesTennessee, 2007-2011 Number of Cases Year *data are preliminary Note: Includes all causes of death.

23. Summary of TB Epidemiology • TB is a burgeoning global epidemic • Rate of decline in TB case rate in U.S. has slowed, increasing in some states • Pediatric TB disease is sentinel for ongoing TB transmission • Migration/immigration link every corner of the globe with Tennessee • Substantial racial/ethnic disparities in TN

24. Objective • Explain the three-tiered hierarchy of TB infection controls

25. Three-tiered hierarchy of TB infection control measures • Administrative controls • Environmental controls • Use of respiratory protective equipment

26. 1. Administrative controls (a) • First and most important! • Assigning responsibility for TB infection control in the setting • Conducting a TB risk assessment of the setting • Developing and instituting a written TB infection-control plan • Ensuring the timely availability of recommended laboratory processing, testing, and reporting of results to the ordering physician

27. 1. Administrative controls (b) • Implementing effective work practices for the management of patients with suspected or confirmed TB disease • Ensuring proper cleaning and sterilization or disinfection of potentially contaminated equipment • Training and educating health-care workers (HCWs) regarding TB, with specific focus on prevention, transmission, and symptoms • Screening and evaluating HCWs who are at risk for TB disease or who might be exposed to Mtb

28. 1. Administrative controls (c) • Applying epidemiologic-based prevention principles, including the use of setting-related infection-control data • Using appropriate signage advising respiratory hygiene and cough etiquette • Coordinating efforts with the local or state health department.

29. 2. Environmental controls • Primary environmental controls - control the source of infection by using local exhaust ventilation and dilute and remove contaminated air by using general ventilation • Secondary environmental controls control the airflow to prevent contamination of air in areas adjacent to the source (airborne infection isolation [AII] rooms) and clean the air by using high efficiency particulate air (HEPA) filtration, or ultraviolet germicidal irradiation.

30. 3. Use of respiratory protective equipment (PPE) • Reduce risk for exposure of HCWs to infectious droplet nuclei that have been expelled into the air from a patient with infectious TB disease • Implementing a respiratory protection program • Training HCWs on respiratory protection • Training patients on respiratory hygiene and cough etiquette procedures

31. Objective • Understand the key role of the ICP in preventing TB transmission

32. HIV infection / AIDS Substance abuse Recent infection Previous TB Diabetes Silicosis Corticosteroid tx Imm. therapy CA of head/neck Hemato./RE diseases ESRD Certain GI surgeries Malabsorption synd. Low body wt. (10%) Conditions with Increased Risk for Progression to TB Disease Must have a high index of suspicion for active TB disease

33. The key role of the ICP Respiratory isolation! • If TB is in the differential diagnosis, respiratory isolation is mandatory • Recurrent “community-acquired pneumonia” (CAP) – THINK TB!

34. The key role of the ICP Release from respiratory isolation • Criteria for release from isolation*: • Clinical improvement on therapy, AND • Three AFB-negative smears, AND • At least 14 days of anti-TB therapy • Stable AFB+ patients may be released to home – but only after appropriate home assessment by LHD * For patients without a safe, stable living environment

35. The key role of the ICP Notify local health department! TN Statutes require medical providers, hospitals and labs to call report of all TB suspects to LHD within 12 hrs. • Contact investigation and case mgt. by LHD can start only after receiving report • Early reporting protects children!

36. The key role of the ICP Discharge planning ! • Begins on hospitalization Day #1! • Involve ICN and Social Worker • Expect visit by LHD case manager • Share information and records • Coordinate release to ensure continuity of care by LHD • NEVER release a homeless TB case/suspect from the hospital without consulting LHD

37. The key role of the ICP Respiratory isolation! • AFB smear-negative patients may still be infectious – protect patients, visitors, staff, yourself • Stable AFB+ patients may be released to home – but only after appropriate home assessment by LHD

38. Pearls That Work • Rapid reporting of TB suspect to LHD • TN Statute requires provider phone report to LHD within 12 hrs. • Contact investigation starts only after report • Discharge planning starts on Hosp. Day #1! • LHD case manager works with ICN and SW • NEVER release a homeless TB pt. from the hospital before consulting the LHD

39. TB Resources for the Clinician • ATS website – http://www.thoracic.org/statements/ • TB diagnosis and classification • TB treatment • Community Acquired Pneumonia (CAP) • CDC website – important guidelines http://www.cdc.gov/tb/publications/guidelines/default.htm • Infection control in healthcare facilities • Contact investigation • Patient education • “Core Curriculum” for provider education & CME http://www.cdc.gov/tb/education/corecurr/index.htm

40. Pop Quiz - Answers • Who wrote the song, “Goodbye Don’t Mean I’m Gone”? Carole King • Name of album? Rhymes & Reasons • Year of release 1972 • How old are you? You gotta be kiddin’ me!

41. Rhymes & Reasons - Revisited Old Lyrics - 1972 Missing you the way I do You know I'd like to see more of you But it's all I can do to be a mother My baby is in one hand, I've a pen in the other You know my love is always there for the taking And goodbye don't mean I'm gone http://www.youtube.com/watch?v=njp0H2N3Y8w

42. Rhymes & Reasons - Revisited New Lyrics - 2012 Missing youTB the way I do You know I'd like to see more of you But it's all I can do to be a motherdoctor My baby isX-ray’s in one hand, I've a penSputum canin the other You know my loveINH is always there for the taking And goodbye don't mean I'm gone http://www.youtube.com/watch?v=njp0H2N3Y8w

43. The Impact of Tuberculosison Lives, Families, and Communities

45. Acknowledgements • Dr. Michael Iseman – NJRMC, Denver • Jason Cummins – TTBEP Epidemiologist • TTBEP Program Staff • American Thoracic Society • Centers for Disease Control & Prevention • World Health Organization • Carole King

46. Jon Warkentin, MD, MPH State TB Control Officer Tennessee Dept. of Health Ph: 253-1364 Cell: 521-0315 E-mail: jon.warkentin@tn.us