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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
TB TEACHING POINTS
Dominic Gaziano, M.D., F.C.C.P.,
Medical Director
West Virginia
Division of TB Elimination
November 15-16, 2012
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
TB TEACHING POINTS
• “I went to South Africa and spent 5 months in a shanty community---22 bed TB & HIV hospital.”
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
Community Health Workers, Cape Town, SA
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
TB Teaching Points (cont.)
• “Shortly after I returned to America on December 2007, I started having G.I. symptoms. Ulcerative colitis/Crohn’s Disease was diagnosed.”
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
TB Teaching Points (cont.)
• 30,000 inflammatory colon disease/yr in USA
• <500 cases estimated of bowel TB
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
TB Teaching Points (cont.)
• “They began treating me with prednisone.”
? In this specific case, was it appropriate?
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
Medical Conditions Which Increase the Risk of Developing Clinical TB once TB Infection has
Occurred:
• HIV infection 10-170 • Silicosis 2-30 • Abnormal chest radiograph showing fibrotic lesions • Diabetes mellitus 3 • Prolonged corticosteroid therapy 3 • Immunosuppressive therapy • Hematologic and reticuloendothelial diseases 10 • End-stage renal disease 2-16 • Intestinal bypass 30 • Post-gastrectomy 6 • Chronic malabsorption syndromes • Carcinomas of the oropharynx and upper gastrointestinal tract • Being 10 % or more below ideal body weight 2 • TNF antagonist 20-30 • Alcoholic intake 3-10
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
TB Teaching Points (cont.)
• “I was considered for a colectomy, but first treatment with Remicade and prednisone was recommended.”
*Surgery for ulcerative colitis – My Experience*
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
TB Teaching Points (cont.) TNF Antagonists*
• Remicade
• Embrel
• Humera
• Simponi
• Others
*Used for:
Rheumatoid Arthritis, Rheumatoid Spondylitis, Inflammatory Bowel Disease, and Psoriasis
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
TB Teaching Points (cont.)
• “Prior to treating me with Remicade, a TB skin test and a chest x-ray were done.”
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
Medical Conditions Which Increase the Risk of Developing Clinical TB once TB Infection has
Occurred:
• HIV infection 10-170 • Silicosis 2-30 • Abnormal chest radiograph showing fibrotic lesions • Diabetes mellitus 3 • Prolonged corticosteroid therapy 3 • Immunosuppressive therapy • Hematologic and reticuloendothelial diseases 10 • End-stage renal disease 2-16 • Intestinal bypass 30 • Post-gastrectomy 6 • Chronic malabsorption syndromes • Carcinomas of the oropharynx and upper gastrointestinal tract • Being 10 % or more below ideal body weight 2 • TNF antagonist 20-30 • Alcoholic intake 3-10
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
TB Teaching Points (cont.)
• “Then the doctors decided treat me with INH and B6 for Latent TB Infection.”
? Knowing course of this case, was this appropriate?
?What are 2 reasons this was not appropriate in this specific case?
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
TB Teaching Points (cont.)
• “I had chest congestion and treatment with a fluroquinalone for pneumonia was started. I became much improved.”
? Knowing course of this case, was this drug appropriate?
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
Antituberculosis Drugs Currently in Use in the United States
First-line Drugs Second-line Drugs
Isoniazid Cycloserine
Rifampin Ethionomide
Rifapentine Levofloxacin*
Rifabutin* Moxifloxacin*
Ethambutol Gatifloxacin*
Pyrazinamide ρ-Aminosalicylic acid
Streptomycin
Amikacin/kanamycin*
Capreomycin
*Not approved by the United States Food and Drug Administration for use in the
treatment of tuberculosis.
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
TB Teaching Points (cont.)
• “A lung biopsy confirmed TB!”
*A CXR is positive in 40-70% of Extrapulmonary TB cases.*
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
TB Teaching Points (cont.)
• “One month later MDR-TB was diagnosed.”
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
TB Teaching Points (cont.)
• “I was started on multiple toxic drugs which had potential CNS toxicity.”
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
Antituberculosis Drugs Currently in Use in the United States
First-line Drugs Second-line Drugs
Isoniazid Cycloserine
Rifampin Ethionomide
Rifapentine Levofloxacin*
Rifabutin* Moxifloxacin*
Ethambutol Gatifloxacin*
Pyrazinamide ρ-Aminosalicylic acid
Streptomycin
Amikacin/kanamycin*
Capreomycin
*Not approved by the United States Food and Drug Administration for use in the
treatment of tuberculosis.
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
TB Teaching Points (cont.)
• “I wouldn’t be here without the comprehensive care that I received. I wish that the people in Africa could receive care like I received.”
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
Components for Controlling and Preventing MDR-TB
• Prioritization of TB by policy makers; political will
• Resources for TB control activities
• Effective, well-organized TB control programs
• Accurate reporting systems
• Adequate and accessible laboratory services for TB diagnosis and susceptibility testing
• Supervision of therapy---directly observed therapy (DOT) in context of patient-centered management
• Adherence to published protocols and standards
• Adequate supply of anti-tuberculosis first-and second-line drugs
• Access to specialized centers with expertise in use of second-line drugs and alternate therapies
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Office of Epidemiology and Prevention Services
DIVISION OF TUBERCULOSIS ELIMINATION www.tb.wv.gov
TB Teaching Points (cont.)
APPROXIMATE COST OF XDR-TB
• Meds - $100,000
• Domiciliary (Hosp. & Home) - $200,000
• Labs, DOT, Nurse - $100,000
• TOTAL $400,000