cdc update on the 2007 tb technical instructions
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CDC Update on the 2007 TB Technical Instructions. Sharmila Shetty, MD Immigrant, Refugee & Migrant Health Branch Division of Global Migration and Quarantine Centers for Disease Control and Prevention. Summary. Overview of Immigrant, Refugee, Migrant Health Branch - PowerPoint PPT PresentationTRANSCRIPT
CDC Update on the 2007 TB Technical Instructions
Sharmila Shetty, MDImmigrant, Refugee & Migrant Health BranchDivision of Global Migration and QuarantineCenters for Disease Control and Prevention
Summary
• Overview of Immigrant, Refugee, Migrant Health Branch
• Epidemiology and trends of TB in the US• Changes in 2007 TB Technical Instructions (TI)
Source: U.S. Department of Homeland Security Refugee admissions: 61,498 (2008)
Annual Estimate of Migrants Entering the U.S.
Total: ~60 million
Immigrant, Refugee, and Migrant Health Branch (IRMH) Role
• Track and report diseases in these populations • Respond to disease outbreaks in the US and
overseas • Advise U.S. partners on health care for refugee
groups • Educate and communicate with immigrant and
refugee groups and partners. • Provide medical screening and treatment
guidelines (technical instructions)
Technical Instructions (TIs)
Consist of medical screening guidelines Used by overseas panel physicians who conduct
medical examinations for U.S.-bound refugees and immigrants
Identify applicants with medical conditions of public health concern
Inadmissible communicable diseases of public health significance
Tuberculosis, active Syphilis, untreated Chancroid, untreated Gonorrhea, untreated Granuloma Inguinale, untreated Lymphogranuloma Venereum, untreated Hansen’s disease (Leprosy)
Panel Physician Program: Basics
• Statistics 670 panel sites (1 or more panel physicians) > 1,000 laboratory and radiology facilities
• Contracted through Dept. of State TB=disease of greatest public health concern
Estimated TB Incidence Rate, 2007
No estimate
0-24
50-99
100-299
300 or more
25-49
Estimated new TB cases (all forms) per 100 000 population
1/3 of world infected9.3 million cases of active TB1.8 million deaths
TB Cases, United States, 1993-2008
TB rate:FB 20.6/100KUS 2.1/100K
MDR TB Cases, United States 1993-2007
XDR TB (’00-’06): 76%XDR TB (’00-’06): 76%
Simplified TB Screening AlgorithmCDC required TB screening
overseas medical exam:
panel physicians
TB follow-up exam requested
Sputum work-up to identify active
TB
Abnormal CXR Normal CXR
Post-arrival medical exam+
1991 Tuberculosis Technical Instructions
• CXR if ≥ 15 years old; no screening for <15 yr• If chest x-ray abnormal• Serial AFB smears
• If AFB+ • treat until smear negative• complete therapy in US
• No cultures, no DST
Study of 1991 TB TI Culture versus Smears*
• 1,179 with CXR suggestive of active TB• TB culture and AFB smears for all
• 183 culture positive --Only 63 (34%) smear-positive
*Maloney SM, et al. Arch Int Med 2006;166:234-40
+ 34% Sensitivity=
AFB Smear
Conclusion: 1991 protocol missed 66% of culture-positive active TB cases
Hmong Refugee Resettlement, 2004—2005
• 16,000 Laotian Hmong in Wat Tham Krabok, Thailand
• Five states identified 48 TB Cases (7 MDR) in newly arrived Hmong refugees
•TB culture added to screening
TB in US-bound Hmong Refugees
# of Refugees Location Cases Identified N Rate/100,000
9482 Wat Tham Krabok
US
24
48
126
506
*Screened with 1991 TB TI
TB Cases
TB in US-bound Hmong Refugees
# of Refugees Location Cases Identified N Rate/100,000
9482 Wat Tham Krabok
US
24
48
126
506
•TB culture added to screening algorithm5801 Wat Tham Krabok
US
24
5
420
86
TB Cases
Recommendations• Overseas: Expand screening,
treatment, and overall TB control• Focus on high-prevalence countries• Improve TB screening• To include culture• To screen persons <15 years esp.
high-prevalence countries
• Domestic: Support timely and complete post-arrival follow-up of immigrants and refugees with overseas TB classifications
2007 TB TI
• CDC process to revise Technical Instructions began in 2005
• Scientific literature reviewed• Input from U.S. Tuberculosis Community :• Advisory Council for the Elimination of Tuberculosis
(ACET)• National Tuberculosis Controllers Association (NTCA)• National Coalition for the Elimination of Tuberculosis
(NCET)
• Chest x-ray for persons ≥15 years of age and for persons 2-14 years with a TST>10
mm* or positive IGRA• If chest x-ray abnormal, serial AFB smears
and cultures Drug susceptibility testing (DST) for all TB
isolates Treatment to completion of therapy
according to ATS/CDC/IDSA guidelines, delivered as DOT
2007—TB TI
+ +
*countries with WHO-estimated incidence rate ≥20 per 100,000
Saint Luke’s Extension Clinic, PhilippinesFY 2007 (52,530 applicants, 1991 TB TI) vs.
FY 2008 (41,793 applicants, 2007 TB TI)
TB case detection rate 1991 vs 2007 TB TI: 554 vs. 1,208 (per 100,000)
121
75
95
291
306
93
102
505
4
0 50 100 150 200 250 300 350 400 450 500 550
Smear – / No CultureDone
Smear – / Culture –
Smear – / Culture +
Smear + / Culture –
Smear + / Culture +
Number of Applicantswith Pulmonary TB
2007 Technical Instruction
1991 Technical Instruction
Implementation• TB culture facilities built -liquid culture w/ Bactec MGIT 960
• Training of panel physicians
• Rollout in countries according to:• #s of applicants• TB rates• In-country resources
As of January, 2010• Populations from 27 countries on three continents are being screening
according to the 2007 TB TI• 53% immigrants• >50% refugees
Implementation of the 2007 TB TI-Current Status
Current status27 countries53% of immigrants>50% of refugees
Implementation of the 2007 TB TI-2010 Implementation
GuatemalaSummer/Fall
IndiaSummer/Fall
GhanaSummer/Fall Nepal
Spring
ThailandSpring
South KoreaSpring
MalaysiaSpring
NigeriaSummer/Fall
IndonesiaSummer/Fall
Panel physician trainingIndia: January 13-15Ghana: March 16-18Dominican Republic: May 3-5
ACET/NTCAVietnam
2007 Technical Instructions:Impact on Prevention of Disease
• Improve detection of tuberculosis overseas• More refugees that need treatment will receive it• Improve stateside follow-up • Decrease importation of tuberculosis
• Assist in global tuberculosis control efforts
• Improve tuberculosis expertise and infrastructure overseas
2007 TB Technical Instructions
Available at:
http://www.cdc.gov/immigrantrefugeehealth/exams/ti/panel/tuberculosis-panel-technical-instructions.html
Acknowledgments
International Organization for Migration (IOM)• Tom O’Rourke• Warren Jones• Raz Wali• Dr. Yen
Dept. of State• Bureau of Population, Refugees, and Migration
CDC• Drew Posey• Marty Cetron• John Painter• Greg Armstrong• Luis Ortega• Susan Maloney
Thank you!!
Sputum smears x 3
InfectiousClass A
NoninfectiousClass B1
All (-) (at least one +)
1991 Tuberculosis Technical Instructions: for applicants ≥15 years of age
Valid for travel
within 6 months
Treat until smear negative
Class A waiver
Signs and symptomsor
Sputum smears x 3
InfectiousClass A
NoninfectiousClass B1
All (-) (at least one +)
2007 TB TI
Valid for travel
within 6 months
Treat until smear negative
Class A waiver
+ cultures
If TB rate ≥20/100,0002-14 years of age:TST ≥10 mm or Positive IGRA
3 cured
DOT
or
HIVSigns and symptoms
2007 Technical Instructions:Classifications
Class 1991 Technical Instructions
2007 Technical Instructions
No classification Normal evaluation Normal evaluation
Class A Tuberculosis disease Tuberculosis disease
Class B1- Pulmonary
Abnormal CXR, sputum smears negative
Abnormal CXR, sputum smears and cultures negative
Class B1 – Extrapulmonary
Extrapulmonary tuberculosis
Extrapulmonary tuberculosis
Class B2 Inactive tuberculosis on CXR
LTBI evaluation
Class B3 Old or healed tuberculosis
Contact evaluation
Waivers for Medical ConditionsBasic Points
• IRMH/CDC is involved in the waiver process for immigrants based on the following medical conditions:
– HIV Infection
– Mental/Physical Disorders with associated harmful behavior
– Tuberculosis
Class A Medical Conditions– Inadmissible– Treatment or waiver required for admission– Examples• TB (laboratory positive) • HIV • STIs (untreated) • Mental Disorders with Harmful Behavior (including
Alcohol Abuse) • Substance Abuse (no waiver for immigrants)
Class B Medical Conditions
– Admissible– Substantial departure from normal health– Examples:• TB (laboratory negative) • STIs (treated),• Mental Disorders without Harmful Behavior • Substance Abuse (in remission)
– Stateside notifications for TB