Transcript Tuberculosis in the 21st Century

Tuberculosis in the 21st Century
Scott Lindquist MD MPH
Tuberculosis Medical Consultant
Washington State DOH
and
Kitsap County Health Officer
Feedback Poll
In my opinion, the recent media coverage of
the case of drug resistant tuberculosis
involving international travel was:
A. Balanced
B. Overblown
C. Confusing
D. None of the above
In the World
• One out of every three persons has
been infected with tuberculosis. . . .
• Our story begins . . . .
Person
Reported TB Cases by Race/Ethnicity*
United States, 2005
American Indian or
Alaska Native
(1%)
White
(18%)
Native Hawaiian or
Other Pacific Islander
(<1%)
Hispanic or Latino
(29%)
Asian
(23%)
Black or
African-American
(28%)
*All races are non-Hispanic. Persons reporting two or
more races accounted for less than 1% of all cases.
TB Case Rates* by Age Group
Cases per 100,000
United States, 1993–2005
20
15
10
5
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
<15
15–24
*Updated as of March 29, 2006.
25–44
45–64
>65
Estimated HIV Coinfection in Persons
Reported with TB: United States, 1993–2004*
% Coinfection
30
20
10
0
1993
1995
1997
All Ages
1999
2001
2003
Aged 25–44
*Updated as of March 29, 2006.
Note: Minimum estimates based on reported HIV-positive status
among all TB cases in the age group.
Reporting of HIV Test Results in Persons
with TB by Age Group: United States, 1993–
% with Test Results
2004*
80
60
40
20
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
All Ages
Aged 25–44
*Updated as of March 29, 2006.
Note: Includes TB patients with positive, negative, or indeterminate HIV
test results and persons from California reported with AIDS. (HIV test
results are not reported from California)
Adult TB Cases by Homeless Status*
1994-2001
10
8
6
4
2
0
%
1994

1995
1996
1997
1998
1999
Adult TB case = TB in person aged >18 years
* Homeless within year prior to TB diagnosis
2000
2001
Adult TB Cases by Correctional Facility
Status,* 1993-2001
10
8
6
4
2
0
1993 1994 1995 1996 1997 1998 1999 2000 2001

Adult TB case = TB in person aged >18 years old
* Resident of correctional facility at the time of TB diagnosis
Selected Risk Factors: Ten-Year Period, WA
1993-2005
% of Cases
50
40
Unemployed
Homeless
Alcohol
Previous Diagnosis
30
20
10
0
1994-1995 1996-1997 1998-1999 2000-2001 2002-2003 2004-2005
Place
TB Case Rates*: United States, 2005
D.C.
< 3.5 (year 2000 target)
3.6–4.8
*Cases per 100,000.
> 4.8 (national average)
Number of LowIncidence States
TB Low-Incidence States,* 1990–2000
25
20
15
10
5
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
* <3.5 TB cases per 100,00 population (Year 2000 target)
Countries of Birth of Foreign-born
Persons Reported with TB: US, 2005
Mexico
(25%)
Other
Countries
(38%)
Philippines
(11%)
Guatemala
(3%) Haiti
(3%)
China
(5%)
Vietnam
(8%)
India
(7%)
Trends in TB Cases in Foreign-born
Persons: US, 1986–2005*
No. of Cases
Percentage
10,000
60
50
40
30
20
10
0
8,000
6,000
4,000
2,000
0
86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05
No. of Cases
*Updated as of March 29, 2006.
Percentage of Total Cases
Proportion of Foreign-born Cases:
WA, 1996-2006
90%
75%
59%
63%
70%
61%
60%
72% 69%
66% 68%
67%
73%
60%
45%
30%
15%
0%
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Drug Resistance
Drug Resistance Definitions
• Primary drug resistance
 Applies to previously untreated patients who
are found to have drug- resistant organisms,
presumably because they have been infected
from an outside source of resistant
Mycobacterium tuberculosis.
• Acquired drug resistance
 Applies to patients who initially have drug-
susceptible bacteria that become drugresistant due to inadequate, inappropriate, or
irregular treatment or, more importantly,
because of non-adherence in drug taking.
Multidrug-Resistant Tuberculosis (MDR)
• Resistance to at least two of the best antiTB drugs, isoniazid and rifampicin.
• These drugs are considered first line
agents.
Extensively Drug Resistant TB (XDR TB)
• This is a rare type of multidrug-resistant
tuberculosis.
• It is resistant to almost all drugs used to treat
TB, including all first line agents and the best
second-line agents: fluoroquinolones and at
least one of three injectable agents (amikacin,
kanamycin, or capreomycin).
• There have been only 49 cases in the US
since 1993.
% Resistant
Primary Isoniazid Resistance in U.S.-Born vs.
Foreign-Born Persons: US, 1993–2005*
14
12
10
8
6
4
2
0
1993
1995
1997
U.S.-born
1999
2001
2003
2005
Foreign-born
*Updated as of March 29, 2006.
Note: Based on initial isolates from persons with no prior history of TB.
Primary Anti-TB Drug Resistance:
WA, 1996-2006
15%
INH
MDR TB
10%
5%
0%
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Note: Based on initial isolates from persons with no prior history of TB.
MDR TB defined as resistance to at least isoniazid and rifampin.
Primary MDR TB: US, 1993–2005*
No. of Cases
Percentage
500
400
300
200
100
0
3
2
1
0
93 94 95 96 97 98 99 00 01 02 03 04 05
No. of Cases
Percentage
*Updated as of March 29, 2006.
Note: Based on initial isolates from persons with no prior history of
TB. MDR TB defined as resistance to at least isoniazid and rifampin.
Primary MDR TB: WA,1996-2006
20
50%
No. of MDR cases
% of Total
No. of Cases
15
40%
30%
10
20%
5
10%
1.1% 2.0%
0.0% 1.0%
2.0%
2.0% 2.0% 0.4%
0.0% 0.4% 1.1%
0
0%
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Note: Based on initial isolates from persons with no prior history of TB.
MDR TB defined as resistance to at least isoniazid and rifampin.
Primary MDR TB in US-born vs. Foreignborn Persons with TB, 1993-2001
% Primary
MDR TB
3
2
1
0
1993
1994 1995
1996
US-born
1997 1998
1999 2000
2001
Foreign-born
Note: Based on initial isolates from persons with no prior history of TB.
MDR TB defined as resistance to at least isoniazid and rifampin.
New Diagnostics
• Quantiferon
• MTD testing
• Universal genotyping
Commonly Asked TST Questions (1 of 2)
• How do you know and ensure that the medical
community using the TST is properly trained?
• Can you place a TST on a Thursday and read
on a Monday?
• Who needs a two-step test and why?
• What is the boosted response?
Commonly Asked TST Questions (2 of 2)
•
What if the longitudinal reading of the TST is
12mm and the horizontal (official reading) is
8mm? Is that considered positive?
•
Can I accept a negative reading if the patient said
there was absolutely no reaction and there is no
reaction on day four after the test?
•
We switched products from tubersol to aplisol,
and I noticed more “positives.” We retested with
tubersol, and all were negative. Which test
do I believe?
The Answer
• Quantiferon

Blood-based testing method
MTD
• Mycobacterium Tuberculosis Direct Test (MTD)
• Nucleic acid amplification
• Sensitivity 85.7%–97.8%
• Criteria for use:
 Smear-positive cases
 Highly suspicious cases
 If it will change treatment
Universal Genotyping
• All TB cultures from WA state now sent
to CDC for genotyping “fingerprinting”
• Spoligotyping
• MIRU pattern
• Goal is to detect clusters
Homeless TB Cases in King County by
Treatment Start Date
No. Cases
8
Non-outbreak RFLP
No known epi link (RFLP pending)
Epi-link (RFLP pending)
Outbreak RFLP
Second RFLP cluster
Clinical case
7
6
5
4
3
2
1
0 Jan Mar May Jul Sep Nov Jan Mar May July Sept Nov Jan Mar May July Sept
2002
2003
Treatment Start Date
2004
Treatment
• DOT (consistency is key)
 Latent TB infection nine months
 Pulmonary six months
 Meningitis 12 months
 Adenopathy six months
 Bone/Joint 12 months
• Monthly weight check
Treatment Evaluation
• HIV screen
• Hep B and C (if risk factors)
• AST
• ALT
• Bilirubin
• A.Phos.
• Creatinine
• Platelets
• Vision testing (if Ethambutol used > 2 mo.)
Ongoing Diagnostic Monitoring
• Monthly sputum collection (until two
negative smears).
• Look for smear positive cases after initial
two months of therapy.
• Liver function tests if abnormalities on
screening or risk factors for hepatitis.
DOT or Not to DOT
• Strongly recommended.
• Patient centered approach is more
successful.

Social service support

Treatment incentives and enablers

Housing assistance

Substance abuse treatment
TB Case #1:“Doc, can he fly home?”
• 17-year-old male exchange student from
Azerbaijan.
• BCG at birth.
• One month of cough, hemoptysis, weight loss,
and acute chest pain.
• He presents to your office. . .now what do you
do?
Feedback Poll
What is your first step?
A. Place a PPD and order a chest radiograph
B. Place this patient in an N-95 mask
C. Start four drug therapy
D. All of the above
Results
• PPD 19 mm
• Cavitary right upper lobe on radiograph
• AFB smears all negative
The Rest of the Story
• Sputum MTD was positive
• Repeat of the AFB at state lab was positive
• INH, Rifampin, PZA and Ethambutol started
• Patient instructed not to fly home
• Held from last two days of high school
• Contact investigation begun
• Host family asks to have him removed from
home. . . .
Further Dilemmas
• Where can he go?
• When can he fly home?
• How certain are you that this is not XDR?
Feedback Poll
Can he fly home?
A. Yes
B. No
Contact Dr. Lindquist
You can call Dr. Lindquist with your TB-related
questions at:
360-337-5237
206-718-2664
Or contact him by e-mail at:
[email protected]