Assessment of Assessment of Tuberculosis Risk in Family Tuberculosis Risk in Family

Care ClinicCare Clinic

Christopher Gordon, M.D.Kris Lee, M.D.

RCRMC – Moreno Valley, CA

TuberculosisTuberculosis

Infection caused by Mycobacterium tuberculosisSpread through airLungs usually affectedCan affect many areas of body including brain, spine, kidneysFatal if not treated properlyLatent infection vs active disease

Global PerspectiveGlobal Perspective11

One third of world’s population infected9 million people globally become sick with TB annuallyLeading killer of HIV-infected persons

Global PerspectiveGlobal Perspective22

Global PerspectiveGlobal Perspective22

United StatesUnited States55

Reported TB cases:2008: 12,8982007: 13,299MDR TB (2007): 125MDR TB: ~1% of all culture (+) cases

California, Florida, New York, and Texas Each had >500 casesThe four states account for ~50% all cases

United StatesUnited States55

Selected Local Case Rates, Selected Local Case Rates, 2007, per 100,0002007, per 100,00066

United StatesCalifornia

S.J., Sunnyvale, Santa ClaraHonolulu, HI

S.F., Oakland, FremontMcAllen, Edinburg, Mission,

TXS.D., Carlsbad, San Marcos

L.A., L.B., Santa AnaRiverside, S.B., Ontario

4.4%7.5%13.4%12%10.8%10%9.4%8.4%3.4%

Active TB DiseaseActive TB Disease

Bacteria attack body destroying tissue, organsSymptoms include cough, night sweats, fatigue, weight loss, fever, chills, hemoptysis, chest pain+AFB sputum smear or culture, CXR findingsTransmits bacteria to others

Latent TB InfectionLatent TB Infection

Body fights bacteria, become inactiveAsymptomaticNo transmission of bacteriaNegative sputum smear, No CXR findingsConsider treatment

Targeted TB TestingTargeted TB Testing33

Indicated for individuals at increased risk of developing TB diseasePersons recently infected at high riskThose with clinical conditions which increase rate of progression from latent TB to active TB

Targeted TB TestingTargeted TB Testing33

Close contacts of a person with infectious TBPersons 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 infectionWork 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.

Targeted TB TestingTargeted TB Testing44

Higher risk of LTBI -> active TBHIV infectionPulmonary fibrotic lesions seen on chest radiograph consistent with prior healed TB (TB4)Diabetes mellitus (especially insulin-dependent)SilicosisChronic renal failure /hemodialysisInjection drug use

Chronic immunosuppressionHematological 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)

Riverside CountyRiverside County77

2007 2006cases reported 80 75MDR cases 1 68/2007 – discontinued mandatory TB screening for school entry

No other specific procedure/ recommendation for screening found on websiteCounty clinics use standardized screening form for all new Medi-Cal HMO patients

Riverside CountyRiverside County88

Riverside CountyRiverside County88

Riverside County Riverside County Tuberculosis Screening Tuberculosis Screening

Form - 1Form - 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 Riverside County Tuberculosis Screening Tuberculosis Screening

Form - 2Form - 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?

ObjectiveObjective

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 toolDetermine need for universal risk assessment in FCC for latent TB and subsequent targeted testing

MethodsMethods380 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.

ResultsResults

Total questionnaires (Q)Total Q completedEnglish Q totalEnglish Q completedEnglish Q positiveSpanish Q totalSpanish Q completedSpanish Q positive

3803723123087865647

Tuberculosis Risk Tuberculosis Risk ScreeningScreening

287

230

57

85

78

7

0 100 200 300 400

Total

English

SpanishNegative

Positive11% positive

25% positive

23% positive

ConclusionsConclusions

Nearly one-quarter of patients at RCRMC Family Care Clinic fit criteria for targeted testing for LTBINo mechanism exists for screening patients for possible risk for LTBI at RCRMC FCC

RecommendationsRecommendations

Establish a protocol for screening patients for LTBI risk

Further StudyFurther Study

Follow up patients with positive risk screening with testing for LTBIAnalyze data by which risk factor correlates with higher risk for LTBI

BibliographyBibliography1. http://www.cdc.gov/tb/WorldTBDay/resources_global.htm2. Global Tuberculosis Control 2009: Epidemiology, Strategy, Financing. WHO.3. http://www.ctca.org/guidelines/IIA2targetedskintesting.pdf4. American Thoracic Society / Centers for Disease Control and Prevention. Targeted skin testing and treatment of latent tuberculosisinfection. Am J Respir Crit Care Med. 2000; 161: S221-S247. http://www.cdc.gov/mmwr/PDF/RR/RR4906.pdf5. 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.pdf8. Riverside County Department of Public Health, Communicable Disease Report 2007. http://www.rivco-diseasecontrol.org/pdf/CDR_%202007.pdf