1. Tuberculosis in Virginia? Wendy Heirendt, MPA Public Health Advisor Division of TB Control Virginia Department of Health September 12, 2005

2. Areas to be Covered Tonight Epidemiology of TB in Virginia Diagnosis, Transmission, Treatment Role of the Health Department

3. Current TB Challenges in Virginia 329 cases in 2004, <1% decrease from 2002 Majority (39%) of the cases in 25-44 year olds 16.5% were in persons 0-24 years of age Large number of TB patients are born outside the US 43 nationalities 17 primary language, non-English Cases reported in 34 of 35 health districts

4. Number of Reported TB Cases in Virginia, 1986-2004 329

5. TB Case Rates in Virginia, 1996-2004 YearCasesVA RateUS Rate 19963495.38.0 19973495.37.4 19983395.26.8 19993344.96.4 20002924.15.8 20013064.35.6 20023154.55.2 20033324.55.1 20043294.44.9

6. Percent of Reported TB Cases by VA Region: 2003 and 2004 2003 2004

7. Number of Reported TB Cases by Age and Sex: VA, 2004

8. Chart 6 Percent of Reported TB Cases by Age: VA, 1996-2004

9. Number of Reported Foreign-Born vs.US-Born TB Cases, VA 1996-2004

10. *Culture confirmed cases with drug susceptibility tests performed MDR Cases & Percent of Resistance to Any First Line Drugs: VA, 1998-2004

11. Number of Reported TB/AIDS Cases: VA, 1993-2004

12. What is TB?? Disease caused by Mycobacterium tuberculosis Airborne disease passed from person to person Can be cured with medications Treatment for latent TB infection

13. Famous TB Patients Doc Holliday of Wild West fame Christy Mathewson of baseball lore Eleanor Roosevelt, First Lady Edgar Allan Poe and associates

14. How TB is Transmitted TB transmission occurs when a person with active, infectious TB disease coughs, sneezes, laughs, sings, etc. TB spreads through the air by inhaled droplet nuclei TB needs prolonged contact for transmission

15. Factors Affecting TB Transmission How infectious is the person with TB disease? Where does the exposure to TB infection occur? How much time does a person spend with another person who has infectious TB disease? source contact environment

16. Infection Can Result in… Limited disease Latent TB, no symptoms, not sick, positive skin test, cannot transmit to othters Active Disease progressive, M.tb replicating in any organ, only pulmonary is infectious

17. Active TB Disease May be infectious Has clinical symptoms Usually pulmonary involvement

18. Symptoms of Active TB Disease Prolonged cough (may produce sputum)* Chest pain* Hemoptysis* Fever Chills * Symptoms commonly seen in cases of pulmonary (lung) TB Night sweats Fatigue Loss of appetite Weight loss or failure to gain weight

19. Diagnostic Techniques Tuberculin Skin Test A decision to test is a decision to treat Sputum collection/testing Chest x-ray Medical evaluation

20. Medications for TB Disease Standard medication regimen Minimum of 6 months of therapy, sometimes longer Initial 4 drug therapy standard: Isoniazid (INH) Rifampin (RIF) Pyrazinamide (PZA) Ethambutol (EMB) Medications may need to be changed if the TB is drug resistant to any medication listed above

21. Directly Observed Therapy (DOT) A health care worker watches a TB patient swallow each dose of the prescribed drugs DOT is recommended for all persons who have TB disease The health care worker will conduct DOT at a time and place convenient for each patient who has TB disease

22. Latent TB Infection (LTBI) Occurs when TB bacteria are in the body, but are inactive or latent No clinical symptoms of active TB disease Not infectious to others Positive reaction to the TB Skin Test Normal chest X-ray

23. Treatment of Latent TB Infection (LTBI) Treating LTBI prevents the development of TB disease, especially for persons at high risk for developing TB disease if infected with TB Usual medication regimen for treating TB infection Isoniazid (INH) for 9 months Rifampin for 4 months is alternative in certain circumstances

24. Persons at Higher Risk for Becoming Infected with TB Close contacts of persons known or suspected to have active, infectious TB disease Foreign-born persons from areas in the world where TB is common Residents and employees of high-risk congregate settings (Continued on next slide)

25. Persons at Higher Risk for Becoming Infected with TB Health care workers who serve high-risk clients Children exposed to adults in high- risk categories

26. TB and HIV Coinfection: Reason for Concern For persons infected with TB, HIV positive status is the strongest risk factor for developing active TB disease In persons who are HIV positive and have TB infection, the chances of developing TB disease increases from 10% in a lifetime to 7% to 10% each year!

27. Public Health Implications Contagious, airborne disease Isolation of the infectious person must be instituted to prevent transmission Identification of exposed and infected contacts (by Regulation) Treatment for all

28. Case Study 34 y.o. male diagnosed with infectious TB Hx of negative TST, <12 months ago No known TB exposure Family, co-workers tested; no new cases Is this CI complete?

29. Another Case Study 30 yo male, infectious pulmonary TB Carpools to work at call center Risk to carpoolers? Workmates? Work from home? Other type of work for few weeks?

30. One More 20 y.o. college student Needs baseline TST for practicum at hospital Hx of BCG vaccination as a child Unsure of TST status TST= 12mm, cxr negative Start student on 9 mos of INH??

31. TB Issues in a Disaster Known TB cases are displaced [Focus on active; ignore LTBI] Treatment is interrupted Possible transmission – concern in shelters, buses, cars, homes

32. Things to Consider Plans- hope TB cases present to HD HD obtains history, treatment info May need cxr, labs Most will be non-infectious Isolate if coughing, not on meds Numbers are likely to be small

33. TB Prevention and Control: Short Term Shelters Same as acute illness screening on admission to shelters Look for symptoms Use form; administer by non-HCP Separate symptomatic from the crowd ASAP….med evaluation ASAP Obtain consent, recent and past medical hx, placement hx, We are not recommending TST Ignore LTBI…no symptoms, not infectious

34. TB Prevention and Control: Long Term Shelters Consider additional screening based on identified risk factors Likely exposure High risk medical conditions

35. Other Thoughts For HCPs: Communications (cell/satellite phones, internet, fax, copiers) Office supplies Confidential files, locked syringe box Past medical histories from home state Refrigeration for vaccines, etc

36. More Thoughts For the evacuees Handicap accessible, laundry facilities, bed linens, showers, food service, phone connections, internet, Recreational facilities, Playgrounds, other diversions Mental health resources, social workers Facility ID cards, Medicaid applicaitons

37. Resources http://www.bt.cdc.gov/disasters/hurricanes/ katrina/shelters.asp http://www.bt.cdc.gov/disasters/hurricanes/ katrina/shelters.asp http://www.nationaltbcenter.edu/catalogue/ downloads/tbhomelessshelters.pdf http://www.nationaltbcenter.edu/catalogue/ downloads/tbhomelessshelters.pdf http://www.umdnj.edu/ntbcweb/docs/Contac t%20Investigations.pdf http://www.umdnj.edu/ntbcweb/docs/Contac t%20Investigations.pdf http://www.umdnj.edu/ntbcweb/docs/congre gate/CongregateSetting.pdf http://www.umdnj.edu/ntbcweb/docs/congre gate/CongregateSetting.pdf

38. For More Information… Virginia Department of Health Division of TB Control 109 Governor Street, First Floor Richmond, VA 23219 804-864-7906 http://www.vdh.virginia.gov/epi/tb Local Health Departments http://www.vdh.virginia.gov/LHD/LocalHealthDistricts.asp Centers for Disease Control and Prevention Division of TB Elimination http://www.cdc.gov/nchstp/tb