Transcript Assessment of Tuberculosis Risk in Family Care Clinic

Assessment of Tuberculosis
Risk in Family Care Clinic
Christopher Gordon, M.D.
Kris Lee, M.D.
RCRMC – Moreno Valley, CA
Tuberculosis
Infection caused by Mycobacterium
tuberculosis
Spread through air
Lungs usually affected
Can affect many areas of body including
brain, spine, kidneys
Fatal if not treated properly
Latent infection vs active disease
Global Perspective1
One third of world’s population infected
9 million people globally become sick
with TB annually
Leading killer of HIV-infected persons
Global Perspective2
Global Perspective2
United States5
Reported TB cases:
2008: 12,898
2007: 13,299
MDR TB (2007): 125
MDR TB: ~1% of all culture (+) cases
California, Florida, New York, and Texas
Each had >500 cases
The four states account for ~50% all cases
United States5
Selected Local Case Rates,
2007, per 100,0006
United States
California
S.J., Sunnyvale, Santa Clara
Honolulu, HI
S.F., Oakland, Fremont
McAllen, Edinburg, Mission, TX
S.D., Carlsbad, San Marcos
L.A., L.B., Santa Ana
Riverside, S.B., Ontario
4.4%
7.5%
13.4%
12%
10.8%
10%
9.4%
8.4%
3.4%
Active TB Disease
Bacteria attack body destroying tissue,
organs
Symptoms include cough, night sweats,
fatigue, weight loss, fever, chills,
hemoptysis, chest pain
+AFB sputum smear or culture, CXR
findings
Transmits bacteria to others
Latent TB Infection
Body fights bacteria, become inactive
Asymptomatic
No transmission of bacteria
Negative sputum smear, No CXR
findings
Consider treatment
Targeted TB Testing3
Indicated for individuals at increased
risk of developing TB disease
Persons recently infected at high risk
Those with clinical conditions which
increase rate of progression from latent
TB to active TB
Targeted TB Testing3
Close contacts of a person
with infectious TB
Persons who have
immigrated within the last 5
years from areas of the
world with high rates of TB
<18 yo who have one or
more positive responses to
the risk assessment
questionnaire.3,4 (See
Appendix 4.)
Mycobacteriology laboratory
workers
Groups with high rates of M.
tuberculosis transmission as
defined locally, such as
homeless persons, drug
users, and persons with HIV
infection
Work or reside with people
who are at high risk for TB in
facilities or institutions such
as hospitals, homeless
shelters, correctional
facilities, nursing homes, and
residential homes for those
with HIV/AIDS.
Targeted TB Testing4
Higher risk of LTBI ->
active TB
HIV infection
Pulmonary fibrotic lesions
seen on chest radiograph
consistent with prior healed
TB (TB4)
Diabetes mellitus (especially
insulin-dependent)
Silicosis
Chronic renal failure
/hemodialysis
Injection drug use
Chronic immunosuppression
Hematological and
reticuloendothelial diseases
(leukemia, lymphoma)
Malnutrition and clinical
situations associated with
rapid weight loss
– Cancer of the head and
neck or lung
– Intestinal bypass or
gastrectomy
– Chronic malabsorption
– Low body weight (15%
below ideal body weight)
Riverside County7
2007
2006
cases reported
80
75
MDR cases
1
6
8/2007 – discontinued mandatory TB
screening for school entry
No other specific procedure/ recommendation for
screening found on website
County clinics use standardized screening form for
all new Medi-Cal HMO patients
Riverside County8
Riverside County8
Riverside County Tuberculosis
Screening Form - 1
Do you (or does your child) have a family member or
close contact with a history of confirmed or
suspected TB?
Are you (or is your child) from Asia, Africa, Central or
South America? (These areas have a higher
prevalence of TB.)
Do you (or does your child) live in an “out of home”
placement facility or shelter?
Do you (or does your child) have a history of
confirmed or suspected HIV infection?
Riverside County Tuberculosis
Screening Form - 2
Do you (or does your child) live with any individual
who is HIV positive?
Have you (or has your child) been incarcerated in the
last 5 years? Do you (or does your child) live with
anyone who has been incarcerated in the last 5
years?
Do you (or does your child) live among, or are you
(or is your child) frequently exposed to individuals
who are homeless, migrant farm workers, users of
street drugs, or residents in a nursing home?
Objective
Evaluate current mechanism of risk
assessment for latent TB in FCC
Determine if our clinic population is at
increased risk for latent TB using risk
assessment tool
Determine need for universal risk
assessment in FCC for latent TB and
subsequent targeted testing
Methods
380 patients were randomly selected to complete the
County of Riverside TB Questionnaire.
Spanish language translation of questionnaire
validated by hospital interpreter.
Questionnaires handed out between 12/2008 and
3/2009 on days principal investigators were in clinic.
Questionnaires given to patients by investigators or
nursing staff.
Questionnaires given to patient according to their
language preference: English vs. Spanish.
1+“Yes” answer counted as positive screen.
Results
Total questionnaires (Q)
Total Q completed
English Q total
English Q completed
English Q positive
Spanish Q total
Spanish Q completed
Spanish Q positive
380
372
312
308
78
65
64
7
Tuberculosis Risk Screening
57
Spanish
7
Negative
11% positive
Positive
25% positive
78
230
English
23% positive
85
287
Total
0
100
200
300
400
Conclusions
Nearly one-quarter of patients at
RCRMC Family Care Clinic fit criteria for
targeted testing for LTBI
No mechanism exists for screening
patients for possible risk for LTBI at
RCRMC FCC
Recommendations
Establish a protocol for screening
patients for LTBI risk
Further Study
Follow up patients with positive risk
screening with testing for LTBI
Analyze data by which risk factor
correlates with higher risk for LTBI
Bibliography
1. http://www.cdc.gov/tb/WorldTBDay/resources_global.htm
2. Global Tuberculosis Control 2009: Epidemiology, Strategy, Financing. WHO.
3. http://www.ctca.org/guidelines/IIA2targetedskintesting.pdf
4. American Thoracic Society / Centers for Disease Control and Prevention.
Targeted skin testing and treatment of latent tuberculosis
infection. Am J Respir Crit Care Med. 2000; 161: S221-S247.
http://www.cdc.gov/mmwr/PDF/RR/RR4906.pdf
5. Trends in Tuberculosis - United States 2008. MMWR 2009; 58 (No. 10, 249253)
6. CDC. Reported Tuberculosis in the United States, 2007. Atlanta, GA: U.S.
Department of Health and Human Services, CDC, September 2008.
7. The Epidemiology of Tuberculosis in Riverside County - Public Health Update,
March 2008, http://www.rivco-diseasecontrol.org/PDF/033108tb.pdf
8. Riverside County Department of Public Health, Communicable Disease Report
2007. http://www.rivco-diseasecontrol.org/pdf/CDR_%202007.pdf