1 “Goodbye Don’t Mean I ‘m Gone” Jon Warkentin, MD, MPH State TB Control Officer Tennessee Department of Health Tuberculosis in Tennessee 6 th Annual Fall Symposium – Middle TN APIC Baptist Hospital, Nashville, TN September 13, 2012

2 Disclosure  In accordance with Accreditation Council for Continuing Medical Education (ACCME) guidelines, I, Jon Warkentin, have disclosed that I have no financial relationships with pharmaceutical or medical manufactory companies that would pose a conflict of interest in this presentation.

3 Disclaimer  The presenter is a “TB evangelist,” not an infectious disease clinical specialist  Focus will not be on presenting data from the scientific literature  A call to “best practices” and enhanced public health capacity  “Blues-you-can-use”

Objectives 1.Describe the changing epidemiology of TB in Tennessee 2.Explain the three-tiered hierarchy of TB infection controls 3.Understand the key role of the ICP in preventing TB transmission 4

Pop Quiz 1.Who wrote the song, “Goodbye Don’t Mean I’m Gone”? 2.Name of album? 3.Year of release? 4.How old are you? 5

6 Objective 1.Describe the changing epidemiology of TB in Tennessee

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9 TB as a critical public health issue Worldwide Impact Worldwide Impact   8,000,000 people develop active TB every year   Each one can infect between people in one year just by breathing

10 TB as a critical public health issue Worldwide Impact Someone dies of TB every 15 seconds Worldwide, over 2,000,000 people die annually from TB, mostly in less developed countries

11 TB Case Rates TN and United States, Case Rate per 100,000 Population Year

12 Reported TB Cases Tennessee, Year Number of Cases

13 TB Cases by Gender Tennessee, Percent of Cases Year

14 TB Cases by Age Group Tennessee, Percent of Cases Year

15 TB Cases by Race/Ethnicity Tennessee, TB Cases by Race/Ethnicity Tennessee, Percent of Cases Year *Data do not include missing information; Race is Non-Hispanic and Hispanic is of all races.

16 Foreign-born TB Cases Tennessee, Number of Cases Percentage of Cases Year

17 Countries of Birth for Foreign-born TB Cases, Tennessee, 2011

18 Site of TB Disease Tennessee, Percent of Cases Year

19 TB Cases with HIV Co-morbidity, Tennessee, Number of Cases Percent of Cases Year † † Includes all cases

20 Multi-Drug Resistant (MDR) TB Cases Tennessee, Number of Cases Year ^2011 Acquired MDR data are preliminary. * Initial MDR refers to those patients who were culture positive and that had initial drug susceptibility testing and who were found to have TB resistant to both INH and RIF. ** Acquired MDR refers to those patients who were alive at diagnosis and not initially found to have MDR TB, but developed MDR-TB during therapy.

21 MDR-TB in Tennessee – 2007 case

22 Mortality of TB Cases Tennessee, Number of Cases Year *data are preliminary Note: Includes all causes of death.

23 Summary of TB Epidemiology 1.TB is a burgeoning global epidemic 2.Rate of decline in TB case rate in U.S. has slowed, increasing in some states 3.Pediatric TB disease is sentinel for ongoing TB transmission 4.Migration/immigration link every corner of the globe with Tennessee 5.Substantial racial/ethnic disparities in TN

24 Objective 2.Explain the three-tiered hierarchy of TB infection controls

Three-tiered hierarchy of TB infection control measures 1.Administrative controls 2.Environmental controls 3.Use of respiratory protective equipment 25

1. Administrative controls (a)  First and most important!  Assigning responsibility for TB infection control in the setting  Conducting a TB risk assessment of the setting  Developing and instituting a written TB infection- control plan  Ensuring the timely availability of recommended laboratory processing, testing, and reporting of results to the ordering physician 26

1. Administrative controls (b)  Implementing effective work practices for the management of patients with suspected or confirmed TB disease  Ensuring proper cleaning and sterilization or disinfection of potentially contaminated equipment  Training and educating health-care workers (HCWs) regarding TB, with specific focus on prevention, transmission, and symptoms  Screening and evaluating HCWs who are at risk for TB disease or who might be exposed to Mtb 27

1. Administrative controls (c)  Applying epidemiologic-based prevention principles, including the use of setting-related infection-control data  Using appropriate signage advising respiratory hygiene and cough etiquette  Coordinating efforts with the local or state health department. 28

2. Environmental controls  Primary environmental controls - control the source of infection by using local exhaust ventilation and dilute and remove contaminated air by using general ventilation  Secondary environmental controls control the airflow to prevent contamination of air in areas adjacent to the source (airborne infection isolation [AII] rooms) and clean the air by using high efficiency particulate air (HEPA) filtration, or ultraviolet germicidal irradiation. 29

3. Use of respiratory protective equipment (PPE)  Reduce risk for exposure of HCWs to infectious droplet nuclei that have been expelled into the air from a patient with infectious TB disease  Implementing a respiratory protection program  Training HCWs on respiratory protection  Training patients on respiratory hygiene and cough etiquette procedures 30

31 Objective 3.Understand the key role of the ICP in preventing TB transmission

32 Conditions with Increased Risk for Progression to TB Disease  HIV infection / AIDS  Substance abuse  Recent infection  Previous TB  Diabetes  Silicosis  Corticosteroid tx  Imm. therapy  CA of head/neck  Hemato./RE diseases  ESRD  Certain GI surgeries  Malabsorption synd.  Low body wt. (  10%) Must have a high index of suspicion for active TB disease

33 The key role of the ICP Respiratory isolation! If TB is in the differential diagnosis,If TB is in the differential diagnosis, respiratory isolation is mandatory respiratory isolation is mandatory Recurrent “community-acquired pneumonia” (CAP) – THINK TB!Recurrent “community-acquired pneumonia” (CAP) – THINK TB!

34 The key role of the ICP Release from respiratory isolation Criteria for release from isolation*:Criteria for release from isolation*: 1. Clinical improvement on therapy, AND 2. Three AFB-negative smears, AND 3. At least 14 days of anti-TB therapy Stable AFB+ patients may be released to Stable AFB+ patients may be released to home – but only after appropriate home home – but only after appropriate home assessment by LHD assessment by LHD * For patients without a safe, stable living environment

35 The key role of the ICP Notify local health department! TN Statutes require medical providers, hospitals and labs to call report of all TB suspects to LHD within 12 hrs. TN Statutes require medical providers, hospitals and labs to call report of all TB suspects to LHD within 12 hrs. Contact investigation and case mgt. by LHD can start only after receiving report Early reporting protects children!

36 The key role of the ICP Discharge planning ! Begins on hospitalization Day #1!Begins on hospitalization Day #1! Involve ICN and Social WorkerInvolve ICN and Social Worker Expect visit by LHD case managerExpect visit by LHD case manager Share information and recordsShare information and records Coordinate release to ensure continuity of care by LHDCoordinate release to ensure continuity of care by LHD NEVER release a homeless TB case/suspect from the hospital without consulting LHDNEVER release a homeless TB case/suspect from the hospital without consulting LHD

37 The key role of the ICP Respiratory isolation! AFB smear-negative patients may still be AFB smear-negative patients may still be infectious – protect patients, visitors, staff, infectious – protect patients, visitors, staff, yourself yourself Stable AFB+ patients may be released to Stable AFB+ patients may be released to home – but only after appropriate home home – but only after appropriate home assessment by LHD assessment by LHD

38 Pearls That Work   Rapid reporting of TB suspect to LHD TN Statute requires provider phone report to LHD within 12 hrs. Contact investigation starts only after report   Discharge planning starts on Hosp. Day #1! LHD case manager works with ICN and SW   NEVER release a homeless TB pt. from the hospital before consulting the LHD

39 TB Resources for the Clinician  ATS website – TB diagnosis and classificationTB diagnosis and classification TB treatmentTB treatment Community Acquired Pneumonia (CAP)Community Acquired Pneumonia (CAP)  CDC website – important guidelines Infection control in healthcare facilitiesInfection control in healthcare facilities Contact investigationContact investigation Patient educationPatient education “Core Curriculum” for provider education & CME“Core Curriculum” for provider education & CMEhttp://

Pop Quiz - Answers 1.Who wrote the song, “Goodbye Don’t Mean I’m Gone”? Carole King 2.Name of album? Rhymes & Reasons 3.Year of release How old are you? You gotta be kiddin’ me! 40

Rhymes & Reasons - Revisited Old Lyrics Missing you the way I do You know I'd like to see more of you But it's all I can do to be a mother My baby is in one hand, I've a pen in the other You know my love is always there for the taking And goodbye don't mean I'm gone 41

Rhymes & Reasons - Revisited New Lyrics Missing you TB the way I do You know I'd like to see more of you But it's all I can do to be a mother doctor My baby is X-ray’s in one hand, I've a pen Sputum can in the other You know my love INH is always there for the taking And goodbye don't mean I'm gone 42

43 The Impact of Tuberculosis on Lives, Families, and Communities

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45 Acknowledgements  Dr. Michael Iseman – NJRMC, Denver  Jason Cummins – TTBEP Epidemiologist  TTBEP Program Staff  American Thoracic Society  Centers for Disease Control & Prevention  World Health Organization  Carole King

46 Jon Warkentin, MD, MPH State TB Control Officer Tennessee Dept. of Health Ph: Cell: