Tuberculosis: What you need to know! Gini Orthner RN, BScN TB Nurse Clinician TB Control Saskatchewan – Regina Office History of TB Control Provincial program run through the Saskatoon Health Region. Staff include 6 RN’s 5 physicians 6 office staff 1 health records 3 stationary clinincs – Saskatoon, P.A., and Regina Mobile clinics through out the northern part of the province Partner with GP’s, specialists, FNIH, FN bands and staff, immigration, correctional institutions, general public

History of TB in Saskatchewan Saskatchewan Anti-TB League was founded in 1911 (TB was out of control with nearly 1000 new cases every year and 1-2 deaths each day).

First TB Sanitorium was built in 1917 at Fort Qu Appelle (Fort San).

Saskatoon Sanitorium was built in 1925.

Prince Albert Sanitorium was built in 1930.

In 1929 Saskatchewan became the first jurisdiction in North America to provide TB treatment at no cost to the patient – it remains this way! In 1948 Dr. John Orr introduced prophylactic use of antibiotics in the treatment of children under 5 with positive Mantoux tests.

1957 a centralized patient record system was introduced 1957 a centralized patient record system was introduced. This database attracted international attention. We continue to use a form of this database – now a computerized version.

Prince Albert Sanitorium closed in 1961. Fort San closed in 1972. Saskatoon Sanitorium closed in 1978.

Directly observed therapy (DOT) was started in 1990. In 1987 the responsibility for TB was transferred from the Anti-TB League to the provincial government. Directly observed therapy (DOT) was started in 1990. In 2007 responsibility for TB was transferred to the Saskatoon Health Region. The Encyclopedia of Saskatchewan

Current TB Control 3 stationary clinics (Saskatoon, Regina, Prince Albert) Mobile clinics in northern Sask. Staff consists of 4 physicians 6 nurses 6 administrative support staff 4 TB medication workers

Our Partners General Practitioners/Specialists First Nations and Inuit Health First Nations Bands and Staff Immigration Canada Correctional Institutions Communicable Disease Programs General Public

What is Tuberculosis (TB) an Acid Fast Bacilli (AFB) known as Mycobacterium Tuberculosis Complex (MTBC) an airborne organism that most commonly affects the lungs, but can affect any part of the body

Active TB Active Pulmonary – affects the lungs and connective airways, can be infectious or non-infectious Active Non–Pulmonary – affects other parts of the body (lymph nodes, CNS, meninges, ocular, pericardial, abdominal, bones/joints, genitourinary, miliary, great vessels, bone marrow), non-infectious Lymph node/scrofula – common in clavicular lymphnodes Ocular – difficult to diagnose as obtaining specimens is difficult, often present with decreased visual acuity and often have signs of systemic TB (miliary) Miliary/disseminated, wide spread dissemination of bacteria Skin/bone marrow/great vessels – rare, treat empirically while waiting lab results

How is TB Spread? mostly through inhalation of droplet nuclei. (coughing, sneezing, singing, etc) very rarely through ingestion (mostly in the past with unpasteurized milk)

Active Pulmonary TB Disease Infectious or non-infectious Infectious Non-Infectious Smear positive -isolation x 2 weeks Smear negative Culture positive May have an Abnormal CXR Start Treatment ASAP

Latent TB Infection (LTBI) Inactive TB – Infection, NO Disease Mantoux is positive (> 10mm) CXR is usually normal Prophylaxis treatment offered and encouraged for <15 years old as most susceptible age group

Latent TB Infection (LTBI) Treatment determined on case by case basis for 15-35 years old >35 years old encouraged to monitor for top three signs & symptoms of early TB disease as benefits of treatment do not outweigh the risks (i.e. medication induced hepatitis, thrombocytopenia)

Symptoms of TB Early Signs of TB Signs of Advanced TB Cough for more than 1 month Unexplained fever for more than 1 week Recurring pneumonia that does not respond to antibiotics Signs of Advanced TB Night sweats Weight Loss Fatigue Rash

Diagnostic Tests Sputum and/or other body fluids for AFB Mantoux skin test – gold standard for diagnosing LTBI Chest X-ray CT Scans IGRA (Interferon-Gamma Release Assays) If coughing, collect 3 consecutive early morning sputums. Send to Provincial Lab/ Saskatoon Lab for AFB testing. If child, arrange for gastric washings. If non pulmonary send fluid/tissue sample for testing.

Mantoux Tests Also called: Tuberculin Skin Tests (TST) TB Skin Test PPD Test

Mantoux Tests Indicates TB infection only – does not mean person has TB disease Elicits cellular immune response to PPD antigen, causing a delayed hypersensitivity reaction.

Mantoux Tests 5 units(0.1ml) of Tuberculin (PPD) injected intradermally, 3-4 fingers down from the anticubital space

Mantoux Tests Measure transverse diameter of induration only (not erythema) Record in mm No induration is recorded as 0mm

Interpreting Mantoux Tests History of BCG is not considered Significant Reaction if: 10mm or greater 5mm or greater in contacts to infectious TB, HIV positive, pre school children

Treatment – In the Early Days Sunshine & fresh air!

Treatment - Now 1st Line Drugs 2nd Line Drugs Isoniazid (INH) Rifampin (RMP) Ethambutol (EMB) Pyrazinamide (PZA) 2nd Line Drugs Moxifloxacin Levofloxacin Amikacin Occurs in places such as Russia, Phillipines, Other medication used for treatment include: streptomycin, fluoroquinolone, injectable agents (amikacin, kanamycin, capreomycin, ethionamide, clofazamine, para-aminosalicylic acid, cycloserine, PZA, EMB)

Treatment – Active TB (or suspected) INH and RMP (standard) 28 daily doses followed by twice weekly doses for 8 months Ideal total of 98 doses within 9 month time frame 4 drug therapy if drug resistance suspected until drug sensitivity results are obtained (2-6 weeks)

Treatment – LTBI INH and RMP (standard) 6 months of twice weekly medication Ideal total of 52 doses within the 6 month time frame

Treatment in Saskatchewan All treatment is provided by directly observed therapy (DOT). WHY? to prevent drug resistance to prevent relapse of TB to ensure treatment completion

TB kills more people than any other infectious disease Interesting Facts… After HIV/AIDS, TB kills more people than any other infectious disease WHO 2008

1/3 of the world’s population is infected with TB Did you know??? 1/3 of the world’s population is infected with TB Canadian Tuberculosis Standards 2007

Prevalence WORLD 9.4 million new cases of active TB in 2008 1.3 million people die each year from TB CANADA 1600 new cases in 2008 SASKATCHEWAN 93 new active cases in 2008 WHO Public Health Agency of Canada

TB in Canada BC, Ontario and Quebec made up 69% of total cases Nunavut had the highest rates PEI reported no cases!

TB in Canada Foreign born – 62% of cases Canadian Aboriginal – 21% of cases Canadian Non Aboriginal – 13% of cases

TB in Saskatchewan - 2009 2 Cases of TB Meningitis 1 death caused by TB – found on autopsy 2 case of multi-drug resistance (INH and RMP)

TB in Saskatchewan Canadian Aboriginal – 72 cases Foreign Born – 11 cases Canadian Non-Aboriginal – 9 cases

Multi-drug resistant (MDR-TB) TB bacteria resistant to INH and RMP with or without resistance to other first or second line drugs WHO

MDR-TB World Wide 0.5 million cases of MDR-TB in 2007 27 countries account for 85% of cases (15 countries are in European Regions) Top 5 countries affected: India, China, Russia, South Africa, Bangladesh WHO

Extensively Drug Resistant (XDR-TB) TB bacteria resistant to at least INH and RMP from the first line drugs plus resistance to any fluoroquinolone and at least one of three injectable second line drugs (capreomycin, kanamycin and amikacin) WHO

XDR-TB By 2008, 55 countries reported at least 1 case of XDR-TB WHO

Total Drug Resistance new term used in an article based on a case in Iran a case of TB that is essentially resistant to all antibiotics known to effectively treat TB

THINK TB! Assess for symptoms Cough with sputum for more than 1 month. Unexplained fever for more than 1 week. Pneumonia not improving with antibiotic treatment.

THINK TB! Obtain CXR Obtain sputum (body fluid) for AFB testing. Send to Provincial Lab. Contact TB Control with questions and for further instructions

“The most common physical finding in pulmonary TB is a… totally normal examination.” Canadian TB Standards, 2007

Questions???

Contact Information Toll Free Number – 1-866-780-6482 Saskatoon Office – 655-1740/655-1741 Prince Albert Office – 765-4260 Regina Office – 766-4311