Tuberculosis In Texas Presentation by: Brian R. Smith, M.D., M.P.H., Regional Director

The captain of all these men of death that came against him to take him away, was the Consumption, for it was that that brought him down to the grave. John Bunyan, The Life and Death of Mr. Badman

I have been sick as a dog the last two weeks. I caught a cold in spite of 18 degrees C. of heat, roses, oranges, palm, figs and the three most famous doctors on the island. One sniffed at what I spat up, the second tapped where I spat it from, the third poked about and listened how I spat it. One said I had died, the second that I am dying, the third that I shall die…All this has affected the “Preludes” and God knows when you will get them. Frédéric Chopin

Reported TB Cases United States, Year No. of Cases

TB Morbidity United States, Year Cases Rate* , , , , , *Cases per 100,000

TB Case Rates, United States, 2001 < 3.5 (year 2000 target) > 5.6 (national average) D.C. Rate: cases per 100,000

Tuberculosis in Texas Case Rate vs. D.O.T Cases per 100,000 population Percent of patients on DOT Rate Directly Observed Therapy ( D.O.T. )

Worldwide TB Concerns  Increase in incidence of TB  Increase in MDR-TB  Increase in HIV infection  Increase in immigration and travel  Increase in demand for resources  Interruptions in medicine supplies  Improper drug prescription  Non-adherence to treatment protocols

Other regional challenges in 1992  Poor reporting  No infection control in clinics or hospitals  No drug-resistant treatment  No program for consultation  Private patients not monitored; 100 % with major errors by physicians or patients not purchasing medications  Drug resistance caused by physicians using various propietary regimens or by self- prescribing

Pharmacist selling Rifampin “Farmacéutico que vende Rifampin”

A family of three generations residing along the Texas-Mexican border Matriarch of the family was prescribed INH for a positive skin test Diagnosed pulmonary TB Died of MDR TB with a final hospitalization cost of 1.5 million dollars MDR cases, plus 54 PPD-positive family contacts monitored by X-ray

X X X X Red - TB Case Green - Positive Reactor Blue - Negative PPD Blue X - PPD Refused Black - BCG D - Deceased - Unknown D D D D D D X

MDR -TB medications “Medicaciones del MDR-TB”

Cost for TB treatment “Costo para el tratamiento del TB” Cost for TB treatment “Costo para el tratamiento del TB”

Plan: focus on the key elements  DOT and completion of treatment for all public and private patients with RIPE  Thorough contact investigation and preventive treatment of contacts  Attention to high risk areas such as jails, HIV patients, shelters  Infection control in TB clinics, hospitals, and jails  Prevention of MDR by active surveillance, monitoring patients of private doctors, and consultation in all resistant cases

Directly Observed Therapy (DOT)  Non-adherence is a major problem in TB control  DOT mandatory for all Texas patients, including private pay because studies show that adherence is not related to income or education  In DOT, a health care worker watches the patient swallow each does of medication  WHO plan for TB control around the world  DOT can lead to significant reductions in relapse and acquired drug resistance  Use DOT with other measures to promote adherence

Advantages of Successful DOT  Reduces the period of infectivity  Reduces treatment failure and acquired drug-resistance  DOT is the best way to ensure that patients complete therapy  Able to count number of TB drug doses ingested DOT is the Standard of Care in Texas for all TB cases/suspects TDH policy 9/95