1. Community-Driven Tuberculosis Interventions for Aboriginal Communities
The TBSAC Program is funded and delivered in partnership with the FNHA
Jessica Harper & Nash Dhalla
February 19, 2015
Hyatt Regency Vancouver

2. Conflict of Interest:
Neither presenter (Nash Dhalla, RN, BScN or Jessica Harper, RN, BScN) have any affiliation financial or otherwise, with a commercial or other industry interest that may bias our presentation.

3. Outline TBSAC: Who we are What is TB? TST vs IGRA
Feasibility of Portable Incubator in LTBI testing
Challenges
Next Steps

4. TB Services in BC
Centralized: pharmacy, labs, database, physician consultant, and nurse consultant services provided by TB Services, BC Centre for Disease Control
TB Services for Aboriginal Communities (TBSAC): provides TB services to Health Centers located on-reserve, funded and delivered in partnership with First Nations Health Authority (FNHA). 4

5. TB Services First Nations Communities
TB Services for Aboriginal Communities
First Nations Health Authority
Community Health Nurse
Community Health Worker
DOT Workers
Health Directors
Community Members
CDC Coordinator-TB, Funding, Education, Resources
Physician Consultation
Nurse Consultation
Case Management
Pharmacy, Lab, Diagnostics, X-Ray, Surveillance, Training and Education

6. TB Team BCCDC (TBSAC) FNHA, Health Protection
Dr. Victoria Cook, TBSAC Physician
Shawna Buchholz, Clinical Nurse Educator
Nash Dhalla, Nurse Consultant
Karen Beinhaker, Nurse Consultant
FNHA, Health Protection
Jessica Harper, CDC Coordinator, TB
TEAM AWESOME:

7. Background: What is TB? Curable and Preventable!
Mycobacterium tuberculosis
Airborne disease
Generally infects the lungs
In BC: incidence rate of ~7 per
Symptoms: coughing, fever, weight loss, night sweats
Curable and Preventable!
BC: Foreign Born – rate is 18.9 per , Aboriginal on-reserve and on –reserve is 40.3

8. Background: What is LTBI?
“Sleeping” Latent TB infection (LTBI):
Infected with bacteria? YES
Symptoms present? NO
Infectious? NO
A healthy individual infected with LTBI has a 5-10% risk of developing active TB over their lifetime
(BCCDC TB Control Manual, 2012)

9. Background: Diagnosing & Treating LTBI
Tuberculin Skin Test (TST) is an intradermal injection of 0.1ml of purified protein derived from M.Tuberculosis bacteria
Follow up Chest X-ray to check for active TB

10. Background: Diagnosing & Treating LTBI
Recommended for preventative therapy:
Isoniazid for 9 months –270 doses OR
Rifampin for 4 months –120 doses
Decision to start treatment is based on:
Context of TST – likelihood of false positive
Reason client was being tested
Risk of progression to active disease
Ability to adhere to medication
Possible intolerance to medication
Alcohol use, desire for pregnancy, etc.
(BCCDC TB Control Manual, 2012)

11. The IGRA Test Interferon Gamma Release Assay (IGRA)
Detects interferon gamma released from WBC
Two tests: Quantiferon Gold and T-Spot
BC: offered in Vancouver, New Westminster, Victoria, Prince George and Kelowna

12. IGRA vs. TST
(TB Manual: Interferon Gamma Release Assay Testing Guideline for Diagnosis of Latent Tuberculosis Infection by Physicians, 2013, pg. 2)

13. TST vs. IGRA TST IGRA Good for serial testing
Not as good for serial testing
Inexpensive
More expensive
Universally accessible
Skill, equipment and timeframe needed limit accessibility
Low specificity in certain populations (BCG-60%)
High specificity in all populations
Two visits
One visit
Variability in test interpretation by reader *****
Low variability in test interpretation by reader

14. WHY IGRA?
To identify the proportion of patients in whom treatment for LTBI could be avoided because an IGRA test was negative yet a TST test was positive.
To determine if there is a statistically significant difference in treatment adherence between BC residents who have had LTBI confirmed with an IGRA test and those whose diagnoses was made using a TST only.

15. IGRA Feasibility In First Nations Communities
Currently IGRA is offered at the BCCDC, in New Westminster, Victoria, Kelowna and Prince George
Increase access to testing for patients who are less likely/able to travel for testing:
Remote communities
Outbreak investigation
Enhanced communities
Identify and treat true LTBI
Are communities interested in the IGRA test?

16. IGRA testing: Feasibility
TBSAC Team & Community Leaders discussed IGRA
Based on enhanced community survey
Strong links with HCP
Geographic location
IGRA available in Canada 2007 with strong evidence base
BCG Factor
Community engagement

17. Results: Feasibility Test
Community approval
Meet with BCCDC lab to agree on expectations of how samples are delivered
Develop detailed protocol on sample collection, processing and transportation to lab
Confirm site visit date(s)
Conduct site visit & feasibility test
Determine results
Summarizing results
Lessons learned

18. Vision of the FNHA
In partnership with BC First Nations Communities the FNHA TBSAC program is working towards the Vision of: “Healthy, Self-determining and Vibrant BC First Nations Children, Families and Communities.”
Directives:
1-Community Driven, Nation Based
2 increase FN Decision making and control
3Improve services
4Foster meaningful collaboration and partnership

19. Thank You! Acknowledgements First Nations Communities
BCCDC- Zoonotic Lab
Yvonne Simpson
Muhammad Morshed
Quantine Wong
FNHA and TBSAC team
April MacNaugton
Dr. Isaac Sobol
Dr. Victoria Cook
Jane Lopez
Maggie Wong
Shawna Buchholz
Karen Beinhaker
First Nations Communities
Healthcare Professionals
Community members
Community leaders
Thank You!

20. Contact Information
TBSAC Nurses:
Nash Dhalla: (604)
Karen Beinhaker: (604)
Shawna Buchholz: (250)
FNHA Nurse:
Jessica Harper: (604)
TBSAC Fax: (604) TBSAC Toll Free: FNHA Health Protection Toll Free: 20

21. Thank You!