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 1: http://www.cdc.gov/tb/WorldTBDay/resources_global.htm

Global Perspective2

Global Perspective2 Global Tuberculosis Control 2009: Epidemiology, Strategy, Financing. WHO.

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. http://www.ctca.org/guidelines/IIA2targetedskintesting.pdf

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) 5 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

Riverside County7 2007 2006 cases reported 80 75 MDR cases 1 6 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

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, 249-253) 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