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