Effect of TB in a Prison Population

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1 Effect of TB in a Prison Population LCDR Tara Ross, BSN, RN US Public Health Service Infectious Disease Coordinator Federal Bureau of Prisons FDC Houston

2 TB 101 Quiz True or False 1. TB is a virus. 2. TB is spread through the air. 3. TB is not treatable. 4. TB infection is not contagious. 5. TB can spread to other parts of the body. 6. If you are coughing you have TB. 7. I will definitely have TB if I share air space with someone who has TB disease.

3 History Of Tuberculosis (TB) Tuberculosis- known as consumption, wasting disease, and the White plague Up until mid-1800 s people believed TB was hereditary (not realizing it could be spread person to person through the air) Until the 1940 s-1950 s there was no antibiotic treatment for TB

4 History Of Tuberculosis (TB) prove TB was contagious discovered the bacterium that caused TB Still took a half a century to develop drugs to treat TB

5 People were sent to sanitorium (if they could afford it) and followed a prescribed routine daily

6 History Of Tuberculosis (TB) discovered a drug that could kill TB bacteria (Streptomycin) Para aminosalicylic Acid was also discovered 1952-discovered Isoniazid (INH) TB death rates drop significantly with treatment By mid-1970 s most of the TB sanitoriums had closed

7 History Of TB Mid 1980 s - US experienced an unexpected rise in TB Federal and State funding is increased TB cases in US start to steadily decline TB continues to be reported in almost every state in the country

8 Epidemiology TB infection- one of the most common infections in world. Estimated 1/3 of the world s population is infected. Yearly- 9 million people develop TB disease and 2 million die. Leading cause of death from infectious disease in the world.

9 Epidemiology The 50 states, District of Columbia, New York City, Puerto Rico and seven other areas in the Pacific and Caribbean report TB cases to the CDC more than 84,000 cases decrease by average of 6% each yr all time low first significant rise ,582 cases

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12 Why the increase? Between there was a 20% increase. 5 factors contributing to the increase: 1. Inadequate funding for TB control 2. HIV epidemic 3. Increased immigration from TB common countries 4. Spread of TB in congregate settings 5. Spread of multidrug-resistant TB

13 Upward trend reverses number of cases steadily decline new low since Federal and State Programs were able to Promptly identify people with TB Start appropriate initial treatment for TB cases Ensure patients completed their treatment.

14 Concerns TB rates decline, but continue to be reported in almost every state. Foreign born individuals. Racial/ethnic minorities disproportionately affected. Drug resistant TB.

15

16 Transmission TB is caused by organism called Mycobacterium tuberculosis. Other mycobacterium can cause tuberculous. Nontuberculous mycobacteria do NOT cause TB, common type is M. avium complex

17 Transmission TB is spread from PERSON to PERSON through the AIR. TB is NOT spread by contact of inanimate objects. When a person with infectious TB disease coughs, sneezes, speaks, or sings tiny particles containing M. tuberculosis may be expelled into the air.

18 Droplet Nuclei Droplet nuclei- 1 to 5microns in diameter. Can remain suspended in the air for several hours. Transmission- spread of M. Tuberculosis from one person to another.

19 Probability of Transmission Probability of transmission depends on four factors: 1. How infectious or contagious is the inmate? 2. In what kind of environment did the exposure occur? 3. How long did the exposure last? 4. How strong are the tubercle bacilli? Best way to stop transmission is to isolate the infectious inmate and start treatment. Not everyone who is exposed will become infected.

20 Transmission The infectiousness of a inmate with TB disease is directly related to the number of tubercle bacilli that he or she expels into the air. Inmates who expel many tubercle bacilli are more infectious than inmates who expel few or no bacilli.

21 Infectiousness The number of tubercle bacilli expelled by depends on: Presence of a cough Cavity in the lung Positive sputum smear or culture Site of TB Covering of mouth Lack of treatment Cough-inducing procedures Very important to collect sputums in airborne infection isolation room.

22 BOP criteria for release from isolation Isolation is ordinarily maintained until all three of the following parameters are achieved: Treatment with a 4-drug regimen has been administered for at least 2 weeks by DOT; and The inmate shows clinical evidence of improvement; and Three consecutive sputum smears are negative (which have been obtained at least 8 hours apart, including one early morning specimen).

23 Drug-resistant TB Caused by M. Tuberculosis organisms that are resistant to at least one first line drugs. Mono-resistant Poly-resistant Multidrug-resistant (MDR TB) Extensively drug resistant (XDR TB)

24 Drug-resistant TB Harder to treat Can survive even after RIPE treatment is started More expensive Takes longer to diagnose May result in more inmates/staff becoming infected

25 Drug-resistant TB Can be caused two different ways Primary resistance Secondary (acquired) resistance

26 Pathogenesis

27 Pathogenesis How does TB develop in the body? Inhale air with M. tuberculosis in it Droplet nuclei may reach alveoli In alveoli, some TB killed, some enter the bloodstream and spread throughout the body.

28 Pathogenesis Bacilli can reach any part of the body. Immune system will usually intervene. Inmate now has latent TB infection (LTBI).

29 Latent TB Infection (LTBI) Tubercle bacilli are in your body Your immune system produces special cells (macrophages) They keep the bacilli contained and inactive.

30 LTBI Detected by Mantoux tuberculin skin test (TST) or Interferon-gamma release assay (IGRA) Inmates with LTBI are NOT infectious Usually have normal CXR Not a case of TB

31 LTBI vs TB Disease LTBI TB Disease Inactive tubercle bacilli in the body TST or QuantiFERON TB Gold test usually positive CXR usually normal Sputum smears and cultures negative No symptoms Not infectious Not a case of TB Active tubercle bacilli in the body TST or QuantiFERON TB Gold test usually positive CXR usually abnormal Sputum smears and cultures may be positive Symptoms such as cough, fever, weight loss, night sweats Often infectious before treatment A case of TB

32 TB Disease Immune system fails to keep the tubercle bacilli under control. Immunocompromised inmates- higher risk. May develop soon after infection or years later. In US about 10% of untreated persons will develop TB.

33 TB disease First 2 years after infection= highest risk for TB disease. Recognize TB infection and treat to prevent TB disease. Certain conditions can increase risk of developing TB. 3X higher for diabetes 100X higher for HIV infection 7%-10% each year LTBI then infected with HIV = TB Disease HIV then infected with LTBI=rapid development of TB Disease

34 Pulmonary TB- occurs in the lungs -Most cases of TB -Usually cough and abnormal CXR -Consider infectious

35 Extrapulmonary TBoccurs in other places than the lungs -Larynx -Lymph nodes -Pleura (membrane around lungs) -Brain -Kidneys -Bones -Joints

36 Miliary TB-occurs when tubercle bacilli enter bloodstream and cause disease in multiple sites -Rare but serious -Can be carried to all parts of the body -CXR has appearance of millet seeds scattered throughout your lungs

37 Classification System for TB Class Type Description 0 No TB Exposure Not infected 1 TB exposure No evidence of infection No history of TB exposure Negative TST or QFT-G History of TB exposure Negative TST (10 weeks after exposure) or negative QFT-G 2 TB infection No TB disease Positive TST or QFT-G Negative smears and cultures (if done) No clinical or x-ray evidence of active TB 3 TB, clinically active Positive culture for M. tuberculosis Positive TST or QFT-G, and clinical, bacteriological, or x-ray evidence of TB 4 Previous TB disease (not clinically active) Medical history of TB disease Abnormal but stable CXR Positive TST or QFT-G Negative smears and cultures No clinical or X-ray evidence of TB 5 TB suspected Signs and symptoms of TB, but evaluation not complete

38 High Risk Groups Close contacts Foreign born/immigrants Low income groups Homeless Congregate Settings People who inject illegal drugs Health Care Workers Race and Ethnicity

39 TB in children Decreasing since 1993 and remain the lowest in case numbers. When a child has TB infection or disease Transmitted recently Source may still be infectious Others probably been exposed to TB.

40 Infection Control Ensure you have an infection control program at your facility. Main goals of a TB infection control program are. 1. Detection of TB disease 2. Isolation of inmates with TB or suspected TB 3. Treatment of inmates with TB or suspected TB

41 Detection of TB disease Symptoms to suspect TB disease Persistent cough (3 weeks or longer) Bloody sputum Weight loss or loss of appetite Fever Night sweats

42 Airborne Precautions Preferably placed in Airborne Infection Isolation (AII) room. Isolate if no AII room. Inmate = surgical mask Staff = N95 respirator at all times. Travel with windows open. Air out vehicle for 2 hours. Limit movement as much as possible.

43 Treatment of TB disease Treatment should start treatment immediately BOP guidelines- baseline lab work completed prior to initiation. At least 6 months of treatment Start RIPE treatment -initial phase INH and Rifampin daily or twice a week continuation phase

44 Treatment of LTBI 9 months of Isoniazid & B6 daily(270 doses) or twice weekly (76 doses). 6 months of INH & B6 daily (180 doses) or twice weekly (52 doses). 4 months of Rifampin daily (120 doses). 3 months of Alternate therapy of Rifapentin and INH once a week recently approved in BOP.

45 TB Infection Control Program Should include 3 levels of control measures. 1. Administrative Controls 2. Environmental Controls 3. Respiratory protection Controls

46 Administrative Controls Assign a staff member for infection control. Conduct a TB risk assessment. Develop a written TB infection control plan. Ensure availability of laboratory testing. Implement effective practices. Education and training of health care staff. Annual testing of staff members for TB. Posters or signs in high risk areas of facility. Coordinate with local health departments.

47 Environmental Controls Ventilation Systems Airborne Infection Isolation Rooms (AII) negative pressure Routine maintenance of systems by Facilities Dept. Annual inspections by certified personnel.

48 Respiratory Protection Control Train health care workers on respiratory protection. Educate inmates on respiratory hygiene. Personal respirator protection should be used by staff in : TB AII rooms When transporting inmates When cough inducing procedures are done

49 Summary TB is a major health concern in correctional facilities. All correctional facilities should have a written TB infection control plan for staff and inmates. Be vigilant in screening inmates entering your facility and consider TB as a diagnosis when symptoms present during sick call or chronic care appointments. Keep up to date on current treatments and standards for TB. Educate and keep staff informed about possible TB cases in your facility. Remember knowledge is power, the more your staff knows, the safer they feel.

50 QUESTIONS? Contact information: LCDR Tara Ross, BSN, RN USPHS

51 References CDC. Self-Study Modules on Tuberculosis. Atlanta, GA: Department of Health and Human Services, CDC; Tuberculosis. Nobleprize.org. Noble Media AB Web. 8 May sis/readmore.html

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