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 The purpose of this presentation is to awaken an awareness and continued existence of tuberculosis in our world and community.

 Human remains unearthed contain markers for TB as far back as 9000 BC!

In 2013  9 million developed TB disease!! - 56% in South-East Asia, Western Pacific - 25% were in African Region million died from this disease  - 360,000 were HIV positive  - 480,000– MDR (multi drug resistant) 3.5% were new cases and 20.5% previously treated cases  Death is preventable if diagnosed, treated quickly and appropriately

 By 2025: reduce case incidence by 50% & death rate by 75%  By 2035 : achieve 90% reduction in case incidence & 95% reduction in death rates  No catastrophic costs to families due to TB treatment

TOTAL CASES - 9,412 (2.2% decrease) (MS CASE RATE –74) (13% increase) US BORN CASES - 3,114 (33%) (MS –49 (75%) FOREIGN BORN CASES – 6,181 ( 65%) (MS –16 (25%)

DC *Updated as of June 11, CDC DC >50% 25%–49% <25%

Mississippi Population: 2,984,926*  TB cases 2014: 74 (a 13% increase)  Case Rate 2.2 %/ 100,000  596 persons suspected of tuberculosis  378 atypical mycobacterial disease  1790 TBI * 2010 Census

2014 Cases By District

 HIV epidemic (1.4 million co-infected) (27%)*  Increased immigration  Complacency about TB; departure from policy  Lack of resources; “orphan disease” (CDC)  Deterioration of the health care infrastructure  Homeless increase (12% TB cases)*  LTC facilities (5.0%)  Substance abuse * % in MS

Member of Acid Fast Bacilli (AFB) Family of Diseases

 Follows air currents.  Droplets containing TB bacilli are inhaled, enter the lungs, and travel to the alveoli.  Infection occurs.

 Immune system contains/limits bacilli growth OR  There is an ineffective immune response and the patient progresses to primary disease

 Close contacts of person with TB disease  Foreign born persons from areas where TB is common  Residents, employees of high risk congregate settings  HCW who serve high risk patients

 Certain racial/ ethnic minority populations  Children exposed to adults  Persons who inject illicit drugs  Persons who travel outside US

TB Infection (TBI)*  Positive TB skin test or blood assay test (IGRA)  Normal Chest x-ray  Alive, inactive bacteria present  No S/S  Not contagious; not sick *Recommend treatment to prevent active disease TB Disease **  Positive TB skin test/blood assay test (IGRA)  Abnormal Chest x-ray  Active TB bacteria in body  S/S of TB  Positive AFB Smear  Positive MTB Culture  Contagious; sick **Must take multiple drug treatment

 Mantoux (old) Administered intradermally using.1 ml PPD resulting in > 6 mm tense, blanched wheal Read at hrs later by feeling at site of injection for induration Report induration in MM Subjective results  IGRA (new) Interferon Gamma Release Assay (blood test): QuantiFeron TB Gold In Tube (QFT) and Tspot - Draw blood - Send to lab for testing - Identifies presence/absence of infection - More specific for TB infection - One patient visit - No interpretation problems - No adverse reaction

 If chest xray negative for active TB disease, then evaluate for treatment for TBI: New Treatment Rifapentine\Isoniazid: 3HP Directly observed only One dose every 7 days for 12 weeks Must be complete in 16 weeks Not appropriate for some individuals Weekly/monthly nurse assessment is critical Proven effective as daily INH X 9 months Decrease in hepatotoxicity Increased completion rate 85-87%

 HIV infection ( X greater risk) (29% cases)  X-ray evidence of old, untreated TB  Substance abuse (esp. drug injection)  Recent infection with M. TB  Diabetes (3X greater risk) (9% cases/11.8% TBI)  Silicosis  End-stage renal disease  Tobacco use and alcohol abuse (1/12/11) (Includes exposure to second hand smoke!)

 Immunosuppressive therapies - Prolonged corticosteroid therapy(> 15 mg qd > 3 wks) -Anti TNF agents ( ie:Remicaide, Enbrel, Humira) - Any immunosuppressive therapy  Certain cancers - head and neck - Leukemia - Hodgkin’s  10% or more underweight - intestinal bypass or gastrectomy - chronic malabsorption syndromes

 Productive, prolonged cough >3 weeks  Hemoptysis  Chest pain  Fever  Chills  Night sweats  Easy fatigability  Loss of appetite  Weight loss

 Medical history; s/s of pulmonary disease  Physical examination of overall condition  Test for M. tuberculosis infection  Chest radiograph (suggestive of TB; never diagnostic)  Bacteriologic exam of sputum specimens - Smear classification and results - Culturing and identification; Gold standard - Drug-susceptibility testing

 Cure individual patient  Minimize risk of death/disability  Reduce transmission to other persons

 Standard treatment is 4 drugs.  Responsibility for successful completion of therapy is assigned to health-care provider! (Not the patient).  Vital component that ensures patients adhere to therapy.  Watch patient swallow each dose of anti-TB drugs  Can reduce development of drug resistance, treatment failure or relapse

 Increase in HIV (+) and diabetes  Rapid spread of antibiotic-resistant TB germs MDR – resistant in INH and RIF (3.5%) XDR - MDR + fluoroquinolones, injectables  Immigration from TB high burden countries  Lack of adequate funding for TB control programs resulting in loss of experienced staff  Need for new treatments, drugs, a vaccine

 Failure to report possibility of TB disease: - when patient exhibits s/s with questionable chest xrays  Declining awareness of possible TB disease  Adequate access to health care  Complacency

Decreased funding: _ 60% of States have been forced to cut TB Control Budgets since 2009 which results in decreased staffing which leads to - Less ability to provide DOT medication - Less ability to deliver optimal therapy in drug resistant TB - Less ability to do contact investigation - Less ability to investigate TB outbreaks

 Questions?

 Global Tuberculosis Report, 2014; World Health Organization  Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report (MMWR), Trends in Tuberculosis, 2013 and 2014  Stop TB USA, The U.S. Partner in the Global Stop TB Partnership, August 18, 2015  MS State Department of Health, Office of Tuberculosis Control and Refugee Health, TB Manual of Policy and Procedure