Transcript The Affects of Tuberculosis Internationally

The Effects of Tuberculosis
Internationally
Tuberculosis Control In Vulnerable
Groups
• Bulletin of the World Health Organization
• TB is an in important public health problem in
industrialized countries
• Most cases occur in minority groups
• Immigrants who arrive from high endemicity
WHO Bulletin
• Association between TB and poverty is
mediated by ;
• Overcrowding
• Poorly ventilated housing
• Malnutrition
• Smoking
• Stress
• Social deprivation
Displaced populations
• Large groups of refugees affects TB control in
receiving country.
• Poor living conditions and overcrowding in
refugee settlements increase the risk of TB
MMWR March 20, 2014
Morbidity and Mortality Weekly Report
• Cases and rates of TB continue to fall in the US
• Foreign – Born and racial/ethnic minorities
are keeping TB elimination out of reach
• TB rate for foreign born individuals is 13 times
higher than among individuals born in the US.
• The proportion of TB cases in foreign-born
group continues to increase.
New TB Screening
• CDC recommendations for overseas
tuberculosis screening of immigrants and
refugees has improved diagnosis prior to
arrival
• Sputum more sensitive screening
• Chest x-ray
• $15 million decrease in US Health Care costs
TB screening overseas
• Guidelines require testing of children ages 2 –
14 who are arriving from countries with high
rates of TB
• The 2007 guidelines are require the use of
DOT Direct Observed Therapy. This is
considered the gold standard
Incidence
• The four greatest immigrant magnet states
have over half the TB cases in the U.S.
• 1992 27 % TB cases in the U.S. are foreign
born: Hawaii
83% of cases
Washington State 48% of cases
California
61% of cases
• The Queens, New York, Health Dept. 81% of
new TB cases in 2001 to immigrants
Impact on the Unites States
• Immigrants/refugees, these groups intend to
reside in the U.S.
• Nonimmigrant visitors students, exchange
visitors temporary workers, tourists,
business travelers.
• Only immigrants and refugees are screened.
Positive Patient
• Recently a visiting student from Singapore
tested positive for active TB
• Required hospitalization
• Collection of Sputum
• Medication
• Contact investigation work, church, family
Basic principles of TB Control
• Early and accurate detection, diagnosis and
reporting of TB cases leading to initiation and
completion of treatment
• Identification of contacts of patients with
infectious TB
• Identification of those patients with LTBI and
at risk for progression to TB disease
Delays in Obtaining Health Care
• Homeless patients
• Fear of Immigration authorities
• Those who speak language other than English
• Cultural factors, social stigma of TB
Importance of Tb Training and
Education
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Deficiencies in clinical knowledge and practice
Staffing and workforce concerns
New guidelines and recommendations
Education of new contributors to TB control
Diminished teaching about TB in medical and
nursing schools
Civil Surgeon
• Licensed physicians conduct health screening
including LTBI and active TB on foreign born
persons living in the US for permanent
residency
• Civil surgeons receive immigration-focused
training
Drug –resistant TB
• Refers to an isolate of M. Tuberculosis that is
resistant to one of the first-line antiTB drugs:
• Isonaizid
• Rifampin
• Pyrazinsmide
• Ethambutol
• Streptomycin
Multidrug-resistant TB
• MDR-TB
• Multidrug resistant TB refers to an isolate of
M.Tuberculosis that is resistant to at least
isoniazid and rifampin and possibly additional
agents
Extensive Drug Resistant
• XDR-TB
• This refers to an isolate of M.Tuberculosis that
is resistant to at least Isoniazid, rifampin and
fluroquinolones as well as either
aminoglycosides (amikacin, kanamycin or
capreomycin or both
Totally drug-resistant TB
• TDR-TB refers to an isolate of M.tuberculosis
resistant to all locally tested medications
Primary Drug Resistance
• Primary drug resistance is said to occur in a
patient who has never received ant-TB
therapy
Secondary drug Resistance
• Secondary drug resistance refers to the
development of resistance during or following
chemotherapy in patients who had previously
had drug-susceptible TB
CDC’s Do Not Board and/or Lookout
Lists Explained
U.S. Federally Quarantinable Communicable Diseases
• Cholera
• Viral hemorrhagic fevers
• Diphtheria
• Sever acute respiratory (SARS)
• Infectious TB Plague
• Influenza novel or reemerging influenza causing or with
potential to cause a pandemic
• Smallpox
• Yellow fever
Definitions
Do Not Board (DNB) List
• Travel restriction tool: Prevents people who
meet specific criteria from obtaining a
boarding pass for any flight inbound to,
outbound from, or within the United States
• Implented by the TSA
• Does NOT prevent passengers from boarding ships,
trains, or buses
DNB/LO at a Glance
DNB
Boarding pass denied
For any flight inbound to,
Outbound from, or within
US
Implemented by TSA
LO
Traveler evaluated
evaluated when
entering US at
a border
Enforced by Customs
and Border Protection
NOTE
• People on the Do Not Board list are not part of
the No Fly List
• The Do Not Board list is designed to protect
the public’s health
• The No Fly list is intended for law enforcement
purposes, such as terrorist threats.
Criteria for DNB/LO Removal
• Removal is facilitated when person is
determined to be NONINFECTIOUS
Wall Street Journal
October 29, 2014
• Few diseases need new medicines as much as
tuberculosis.
• Some medications are 40 years old
• Funding for R&D rose annually 2005-2012
• Most cuts came from private sector donors
• Bedaquiline, Johnson & Johnson
• Awaiting regulatory approval outside US
where 450,000 annual drug resistant TB occur
Delamanid
• Otsuka Pharmaceutical failed to get approval
from European Union committee in July
• Pfizer
• Astra-Zeneca
• Bill & Melinda Gates
• President Obama in 2014 budget proposed a
19% cut to $191 Million
Goal
Currently, most cases are diagnosed via the
longtime sputum smear microscopy method.
Doctors need a test that can be used to
diagnose patients in the examination room and
begin treatment right away.