1. Tuberculosis Update for Indiana – 2017
Bradley Allen, MD, PhD, FACP, FIDSA
Indiana University School of Medicine Division of Infectious Diseases Roudebush VAMC Indianapolis
March 2017

2. Disclosures
Medical Consultant, TB Control Program Indiana State Department of Health
Clinical trials with Merck, Genzyme and Romark
Have personally endured over 36 Tuberculin skin tests (all negative or perhaps misinterpreted)
Major thanks to Kelly White, ISDH TB Control Program Epidemiologist, for Indiana data updates!

3. Outline/Objectives
1) Learn the current Tuberculosis Incidence World, U.S. and Indiana 2) Review the definition of Latent Infection versus Active TB Disease 3) Contrast New TB Testing and Screening Guidelines Dr. Deb McMahan 4) Compare current LTBI Treatment options Dr. Eva Muloma 5) Review available County and State Support Systems

5. Global/U.S. TB Burden, 2016
An estimated 10.4 million new TB disease cases
1.4 million deaths due to TB disease
Additional 0.4 million deaths from TB among HIV-positive people
The rate of decline in remains low at 1.5% per year
Must accelerate to 4-5% annual decline by 2020 to reach first milestone of End TB Strategy
Estimated million persons in U.S. TB infected
Source: WHO Global Tuberculosis Report 2016

6. TB Epidemiology, worldwide
Africa has the highest incidence rate (275 per 100,000 population, v. ~ 3.0 U.S.)
Some regions of Africa have rates up to 500!
Largest number of cases from Asian Countries:
India, Indonesia, China, Nigeria, Pakistan and South Africa account for 60% of global cases in 2015
Three countries (China, India, and Russian Federation) account for 45% of MDR-TB

9. Factors Contributing to the Increase
in TB Morbidity:
Deterioration of the TB public health infrastructure
HIV/AIDS epidemic
Immigration from countries where TB is common
Transmission of TB in congregate settings
homeless shelters, prisons, etc.

11. Remember to check HIV status on EVERY new diagnosis of TB infection

13. Impact of culture v. smear screening of immigrants to the U.S.
Classification:
Class A : Pos. smear and abnl CXR
Class B1: Neg. smears with abnl CXR
Class B2: Neg. smears with CXR suggesting latent disease
Ann Intern Med. 2015;162(6): doi: /M

14. 2016 Cases = 109 Incidence Rate = 1.7/100,000 Contrast rate to: 1.7
U.S. – 3.0
Global - 160
1.7
1.4
109 94
Down 16% over past ten years, but increase of 7% in last five or so. Dropped 6% from 2015 to 2016

16. Increase in foreign born percentage from 2015 (69. 7 up from 57
Increase in foreign born percentage from 2015 (69.7 up from 57.8% of cases). Slight increase in Asian race % due to increased foreign born cases

17. Increase in cases from Philippines compared to previous years

18. State of Indiana Tuberculosis - 2016
Race and Ethnicity-specific Incidence Rates*
White, not Hispanic or Latino = 0.8
Black or African-American = 2.8
Hispanic or Latino, all races = 5.5
Asian = 35.3
Males = 2.0
Female = 1.3
Asian incidence rate increased from 2015 to 2016
*Per 100,000 population

19. Thank you for all your hard work in improving our HIV screening rates!
Percentage of TB Cases by HIV Testing Status & Age Group Indiana, 2015
HIV Testing Status
≥ 15 Years
25-44 Years
Test Results Known
89.3%
92.7%
Testing Not Offered
5.4%
2.4%
Refused Testing
4.9%
Percentage of TB Cases by HIV Testing Status & Age Group Indiana, 2016
HIV Testing Status
≥ 15 Years
25-44 Years
Test Results Known
94.1%
98.0%
Testing Not Offered
3.9%
2.0%
Refused Testing
0.0%
2016 saw an increase in known HIV status amongst the highest risk group. Both the testing not offered group and the refused group declined!
Thank you for all your hard work in improving our HIV screening rates!

20. Kudos to everyone!
Over 90% DOT

21. ~ 30 % of heavily exposed persons will become infected
LTBI X X X
~ 30 % of heavily exposed persons will become infected
Small, NEJM 2001
Small, NEJM 2001

22. Treatment of TB Disease
Increased dosing frequency is better
7 or 5 days a week dosing more effective
3 times weekly is acceptable
2 times weekly not routine any more

23. Treatment of LTBI
3 HP dosing gaining momentum
12 weekly doses by DOT
INH plus rifapentine
Other rifampin based regimens coming

24. Clever Ideas for 3 HP Tracking
Date:
Dose:
__/__
__1__
__2__
__3__
__4__
__5__
__6__
__7__
__8__
__9__
__10__
__11__
__12__
Loss of Appetite □
Nausea or vomiting
Yellow eyes or skin
Diarrhea
Rash or hives
Fever or chills
Sore muscles
Numbness or Tingling
Fatigue
Dizziness/fainting
Abdominal pain
Other _______________
Rx stop or held (complete adverse reaction log)
No adverse reaction
Current Weight kg
Blood Pressure /
Provider Initials*

26. Questions?

27. References/Resources
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 MMWR Dec. 30, 2005 / 54(RR17);
CDC – TB 101 for Health Care Workers
CDC Core Curriculum on Tuberculosis – updated
Dr. Neil Schluger. CDC-sponsored trial comparing TST with QFT and T.SPOT in 2500 HCWs (NYC, Baltimore, Houston, Denver)
Slater M, Parsonnet J, Banaei N Investigation of false-positive results given by the QuantiFERON-TB Gold In-Tube assay. J Clin Microbiol Sep;50(9):
Pai M et al, Serial testing of health care workers for tuberculosis using interferon-g assay. AJRCCM 2006

28. References/Resources
Meta-analysis: New Tests for the Diagnosis of Latent Tuberculosis Infection: Areas of Uncertainty and Recommendations for Research Dick Menzies, MD, MSc; Madhukar Pai, MD, PhD; and George Comstock, MD, DrPH Ann Int Med 2007, 146:
Martinson NA, Barnes GL, Moulton LH, et al. New regimens to prevent tuberculosis in adults with HIV infection. N Engl J Med 2011;365:11–20.
Recommendations for Use of an Isoniazid-Rifapentine Regimen with Direct Observation to Treat Latent Mycobacterium tuberculosis Infection. MMWR December 9, 2011 / 60(48);

29. Number & Percentage of TB Cases by Risk Factor Indiana, 2016
Number of Cases
Percent of Cases
Resident of Correctional Facility 1
0.9%
Homelessness
0.0%
Resident of Long-Term Care Facility 2
1.8%
Injecting Drug Use
Non-Injecting Drug Use 7
6.4%
Excess Alcohol Use 13
11.9%
88/109 or 80% do not have one of the above risk factors. However, 64/88 are Foreign Born and of the remaining 24, 18 had another risk factor (Immunosuppression, Diabetes, contact to a case, etc.) Only 6/109 had truly no documented risk factor.

30. MUST BE DONE WITHIN A DOT PROGRAM*** Isoniazid
Dosage for a combination regimen of isoniazid and rifapentine in 12 once-weekly doses under direct observation for treating latent Mycobacterium tuberculosis infection. MMWR December 9, 2011
MUST BE DONE WITHIN A DOT PROGRAM***
Isoniazid
15 mg/kg rounded up to the nearest 50 or 100 ;
900 mg maximum
Rifapentine
10.0–14.0 kg mg
14.1–25.0 kg mg
25.1–32.0 kg mg
32.1–49.9 kg mg
≥50.0 kg mg maximum
INH is formulated as 100 mg and 300 mg tablets. Rifapentine (RPT)is formulated as 150 mg tablets, new formulations and fixed-dose INH-RPT combos are in development.