what are we doing about tb infection control? bess miller, m.d., m.sc. associate director, tb/hiv...

What are we doing about TB infection control?

Bess Miller, M.D., M.Sc.Associate Director, TB/HIV

Global AIDS ProgramCenters for Disease Control

and Prevention

PEPFAR Track 1.0 ART Program MeetingAtlanta, Georgia

September 24-25, 2007

CS113808

Acknowledgments

• Chris Dye, Abigail Wright – WHO• Allyn Nakashima• Anand Date• Monita Patel• Barbara Marston• Alyssa Finlay• Kevin Cain• Paul Jensen• Naomi Bock

Outline of Presentation

• Do we have a problem?• How does PEPFAR support TB infection control?• What can you do?• Where can you get help?

Do we have a problem?

Yes

1539 patients evaluated

542 with TB 997 without TB

221 MDRTB (39%) 321 Susceptible

53 (10%) XDRTB• 44 HIV+• 52/53 died

Extensively Drug Resistant (XDR) TBRecent Outbreak in Kwazulu Natal, SA

Gandhi NR, et al, Lancet 2006

From C Wells

Estimated TB incidence rate, 2005

No estimate

0–24

50–99

100–299

300 or more

25–49

Estimated new TB cases

(all forms) per 100 000 population

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.

Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2006. All rights reserved

Estimated HIV prevalence in newTB cases, 2005

No estimate

0–4

20–49

50 or more

5–19

HIV prevalence in TB cases, 15–49 years (%)

0.0

50.0

100.0

150.0

200.0

250.0

1987 1989 1991 1993 1995 1997 1999 2001 2003 2005

Чис

ло ж

ивущ

их с

ВИ

Ч н

а 10

0 ты

с. н

асел

ения

HIV Prevalence is the Driver of TB/HIVRussia - 1987- 2005

0.60.6

Russia Federal AIDS Centre2005

Estimated rates of MDR among new TB cases 2004

3 – 6 %

No estimate

> 6%

< 3%

3 – 6 %3 – 6 %

No estimateNo estimate

> 6%> 6%

< 3%< 3%

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2006. All rights reserved

Estimated rates of MDR among previously treated TB cases, 2004

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2006. All rights reserved

No estimate

< 6%

6 – 20 %

20 – 40%

> 40 %

No estimateNo estimate

< 6%< 6%

6 – 20 %6 – 20 %

20 – 40%20 – 40%

> 40 %> 40 %

Countries with XDR-TB Confirmed cases as of July 2007

Czech Republic

The b

oundarie

s and n

am

es sh

ow

n a

nd th

e d

esig

natio

ns u

sed o

n th

is map d

o n

ot im

ply

the e

xpre

ssion o

f any o

pin

ion

whatso

ever o

n th

e p

art o

f the W

HO

conce

rnin

g th

e le

gal sta

tus o

f any co

untry

, territo

ry, city

or a

rea o

r of its a

uth

oritie

s, or co

nce

rnin

g th

e d

elim

itatio

n o

f its frontie

rs or b

oundarie

s. Dotte

d lin

es o

n m

aps re

pre

sent a

ppro

xim

ate

bord

er lin

es fo

r w

hich

there

may n

ot y

et b

e fu

ll agre

em

ent.

WH

O 2

005. A

ll rights re

serv

ed

Ecuador

Georgia

Argentina

Bangladesh

Germany

Republic of Korea

Armenia

Russian Federation

South Africa

Portugal

Latvia

Mexico

Peru

USA

Brazil

UKSweden

Thailand

Chile

Spain

Islamic Republic of Iran

China, Hong Kong SAR

France

Japan

Norway

Canada

Italy

Netherlands

Estonia

Lithuania

Ireland

Romania

Israel

Azerbaijan

Poland

Slovenia

Based on information provided to WHO Stop TB Department - July 2007

Reasons for unsuccessfultreatment under DOTS

0 10 20 30

AFR

AMR

EMR

EUR

SEAR

WPR

Percent of cohort

Died

Failed

Defaulted

Transfered

Not evaluated

Higher risk of TB infection and disease are associated with work in health care settings

• Menzies D, Joshi R, Pai M; IJTLD 2007: 593-605• Corbett EL, Muzangwa J, Chaka K, et al; CID

2007: 317-323• Kassim S, Zuber P, Wiktor SZ, et al; IJTLD

2000: 321-326

How does PEPFAR support TB Infection Control?

TB infection control in the era of expanding HIV care and treatment

• Describes– Work practice and administrative controls– Environmental controls– Personal respiratory protection

• Sample infection control plan• Sample monitoring tools• Training material (powerpoint presentation)

Source: WHO addendum on Tb infection control

Screen

Educate

Separate

Provide HIV Services

Investigate for TB or Refer

PEPFAR funds support:

• Development of national TB infection control policies and guidelines for facility level

• Assessments and renovations of facilities (TB and HIV)• INTENSIFIED TB CASE FINDING and referrals with

tracking systems for diagnosis and treatment of TB• Evaluation of TB among health care workers

Source - ’07 Plus up funding activities, COP ’08 draft activities

PEPFAR funds support:

• Training of personnel• STRENGTHENING TB LABORATORY SERVICES• Technical assistance• Surveys of drug-resistant TB

Source - ’07 Plus up funding activities, COP ’08 draft activities

What can you do?

• Support and evaluate intensified TB case finding at all HIV service sites (aka TB screening)

• Assure that TB suspects receive diagnostic and treatment services. Evaluate referral systems.

• Find out where HIV-infected TB patients are receiving care. Do AIDS patients and TB patients share air space in corridors and waiting rooms?

• Put up cough etiquette posters and buy tissues.• Build an outdoor waiting area (Bring a hammer and nails.)• Assess hospital wards. Is there cohorting of TB patients? Is rapid

discharge of TB patients encouraged?

What can you do?

• Emphasize administrative and work practice controls.• In an inner city hospital in Atlanta, Georgia, tuberculosis

exposures and tuberculin skin test conversions declined substantially after mandatory isolation of TB patients, TB suspects, and persons with HIV infection who had an abnormal CXR.

• Blumberg HM, Watkins DL, Berschling, et al, Ann Intern Med 1995; 658-663

What can you do?

• Assist with program monitoring and evaluation

• Some measures commonly used include

– Tuberculin skin testing programs for HCW

– Evaluation of Screening and triage processes Separation of potential transmitters Turn-around time for sputum smear microscopy results Turn-around time for symptomatics to begin treatment Length of stay in hospital TB treatment completion rates

Where can you get help?

• National TB Control Programs• Technical consultation

– GAP TB/HIV Team– USAID TB/CAP-funded projects– DTBE consultant and trainer

• WHO TB Infection Control Sub-working Group• Other PEPFAR country programs

This helps too.