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The Challenges of Multi-Drug Resistant (MDR) Tuberculosis Investigation and Follow-up

The Challenges of Multi-Drug Resistant (MDR) Tuberculosis Investigation and Follow-up. Aaron Aitchsion, PHN Middlesex-London Health Unit. What’s Involved in a TB investigation?. 1. Isolate the case 2. Establish a treatment regime 3. Establish compliance with treatment regime

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The Challenges of Multi-Drug Resistant (MDR) Tuberculosis Investigation and Follow-up

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  1. The Challenges of Multi-Drug Resistant (MDR) Tuberculosis Investigation and Follow-up Aaron Aitchsion, PHN Middlesex-London Health Unit

  2. What’s Involved in a TB investigation? 1. Isolate the case 2. Establish a treatment regime 3. Establish compliance with treatment regime 4. Establish period of infectivity 5. Determine degree of infectiousness 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts”

  3. What’s challenging in a TB investigation? • Communication • language barriers • risk • Cross Jurisdictional referrals • Stigma • iPHIS

  4. What’s challenging in a MDR-TB investigation? MDR-TB is a result of a breakdown in: 1. Isolate the case 2. Establish a treatment regime 3. Establish compliance with treatment regime 4. Establish period of infectivity 5. Determine degree of infectiousness 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts” • Treatment of the case • Prophylaxis of those exposed to the case • Stigma The Media

  5. Settlement House for new immigrants Family of 14 ESL School Family Home

  6. Identifying the case • Father flagged for Immigration Medical Surveillance for Inactive TB • Interview: smoker’s cough + previous treatment for lung infection (denied TB diagnosis) • Administered TB skin test  Sent for Chest x-ray

  7. Cavitating lesion + lived in top 23 high-burden countries Clinical Case 1. Isolate the case 2. Establish a treatment regime 3. Establish compliance with treatment regime 4. Establish period of infectivity 5. Determine degree of infectiousness 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts”

  8. Isolating the case • Language barrier (interpreter exposures) • Strain on family • son’s interpretation = shoot the messenger • new to country and lose head of household • Admitted to negative pressure • Obtain sputum for laboratory analysis • Wait for results

  9. Treatment 1. Isolate the case 2. Establish a treatment regime - standard four drug therapy 3. Establish compliance with treatment regime 4. Establish period of infectivity 5. Determine degree of infectiousness 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts” 1. Isolate the case 2. Establish a treatment regime - standard four drug therapy 3. Establish compliance with treatment regime - acute care 4. Establish period of infectivity 5. Determine degree of infectiousness 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts”

  10. Infectivity 1. Isolate the case 2. Establish a treatment regime - standard four drug therapy 3. Establish compliance with treatment regime - acute care 4. Establish period of infectivity - cough present since arrival to Canada 5. Determine degree of infectiousness 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts” 1. Isolate the case 2. Establish a treatment regime - standard four drug therapy 3. Establish compliance with treatment regime - acute care 4. Establish period of infectivity - cough present since arrival to Canada 5. Determine degree of infectiousness - smear = numerous (highly infectious) 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts”

  11. Resistant to INH and Rifampin Infectivity 1. Isolate the case 2. Establish a treatment regime - standard four drug therapy 3. Establish compliance with treatment regime - acute care 4. Establish period of infectivity - cough present since arrival to Canada 5. Determine degree of infectiousness - smear = numerous (highly infectious) 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts” 2nd line drugs West Park Treatment facility

  12. Challenges in determining contacts? • Transmission factors related the case • Transmission factors related to shared air space • Transmission risk factors related to exposed person Case was smear (numerous) Previous treatment failure Huge cavity on CXR Denial of diagnosis Symptomatic (cough) Over 6 years old Transmission factors = high

  13. Family Home Less shared space High risk for previous infection Common volume of air Re-circulated air Ultraviolet radiation? Small classrooms Contact 5 days a week High risk for previous infection

  14. Issues with Contact Tracing 1. Isolate the case 2. Establish a treatment regime - 2nd line drugs 3. Establish compliance with treatment regime - West Park 4. Establish period of infectivity - cough present since arrival to Canada 5. Determine degree of infectiousness - highly infectious 6. Establish “contacts” - family / airplane / settlement house / ESL School 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts” 1. Isolate the case 2. Establish a treatment regime - 2nd line drugs 3. Establish compliance with treatment regime - West Park 4. Establish period of infectivity - cough present since arrival to Canada 5. Determine degree of infectiousness - highly infectious 6. Establish “contacts” - family / airplane / settlement house / ESL School 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts”

  15. Our Plan of Action • Multiple teleconferences with experts from around the world • Greater than 1 hour of face-to-face contact Rx PZA and ETBI for 6 months • Moxifloxacin substituted for PZA or ETBI if side effects developed • CXR’s at 0, 3, 6, 12, 18, 24 months

  16. The research says… • Fraser et al Int Jouranl of TB (2006). • Systemic review of comparative studies of people treated and not treated of LTBI following MDR-TB exposure • Presented combinations of PZA/ETBI, PZA and a quinolone, ETBI and a quinolone, Quinolone alone • Serious adverse effects can affect adherence causing prolonged treatment, further development of resistance and relapse. The balance of benefits and detriments is far from clear and should be addressed in a randomized controlled trial.

  17. Our Plan of Action • Baseline and monthly blood tests (CBC, BUN, creatinine, uric acid, HIV, Hepatitis screening and LFT’s) • Opthalmologic assessment with dilation at 0, 3, and 6 months with Ishihara color tests performed monthly • Twice monthly symptom and side effect review

  18. TBST Offer INH Referred flight manifest to PHAC TBST PZA + ETBI TBST PZA + ETBI

  19. Many TBST+ Majority complete INH Unknown Multiple TB Clinics 33 TBST+ 19 of 33 complete PZA/ETBI Entire family TBST+ 1 secondary case 3 of 12 complete PZA/ETBI

  20. The Clinic Challenges • At least 7 different languages • Minimal literacy in mother tongue • Cultural taboos of TB and gender • Index family persecution (moved) • New immigrant population mobility • Risk factors for TB already • Healthcare issues unrelated to TB

  21. The Family results… • Index case + 1 secondary case (not MDR) • 12/12 TBST (+) (further evidence of infectiousness) • 3/12 completed prophylaxis • Family re-located due to stigma (media) • Index case remains defiant of TB diagnosis

  22. The “other” results… • Many interpreters TBSTed with 3 positive and several previously positive • Only one offered MDR prophylaxis and did not complete (INH for others) • Only one settlement house contact offered MDR prophylaxis – completed (INH for others)

  23. The Side Effects • Elevated liver enzymes (abdominal pain) • Headache • Fatigue • Alterations in mood • Yeast infections • Joint aches

  24. In Conclusion... 1. Isolate the case 2. Establish a treatment regime - 2nd line drugs 3. Establish compliance with treatment regime - West Park 4. Establish period of infectivity - cough present since arrival to Canada 5. Determine degree of infectiousness - highly infectious 6. Establish “contacts” - family / airplane / settlement house / ESL School 7. Co-ordinate follow-up of “contacts” - clinics 8. Offer prophylaxis to “contacts” - INH and PZA/ETBI (Moxi)

  25. All TB Investigations are challenging... 1. Isolate the case 2. Establish a treatment regime 3. Establish compliance with treatment regime 4. Establish period of infectivity 5. Determine degree of infectiousness 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts” • Communication • Cross Jurisdictional referrals • Stigma • iPHIS

  26. Questions?

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