1. The Effects of Tuberculosis Internationally

2. Tuberculosis Control In Vulnerable Groups Bulletin of the World Health Organization TB is an in important public health problem in industrialized countries Most cases occur in minority groups Immigrants who arrive from high endemicity

3. WHO Bulletin Association between TB and poverty is mediated by ; Overcrowding Poorly ventilated housing Malnutrition Smoking Stress Social deprivation

4. Displaced populations Large groups of refugees affects TB control in receiving country. Poor living conditions and overcrowding in refugee settlements increase the risk of TB

5. MMWR March 20, 2014 Morbidity and Mortality Weekly Report Cases and rates of TB continue to fall in the US Foreign – Born and racial/ethnic minorities are keeping TB elimination out of reach TB rate for foreign born individuals is 13 times higher than among individuals born in the US. The proportion of TB cases in foreign-born group continues to increase.

6. New TB Screening CDC recommendations for overseas tuberculosis screening of immigrants and refugees has improved diagnosis prior to arrival Sputum more sensitive screening Chest x-ray $15 million decrease in US Health Care costs

7. TB screening overseas Guidelines require testing of children ages 2 – 14 who are arriving from countries with high rates of TB The 2007 guidelines are require the use of DOT Direct Observed Therapy. This is considered the gold standard

8. Incidence The four greatest immigrant magnet states have over half the TB cases in the U.S. 1992 27 % TB cases in the U.S. are foreign born: Hawaii 83% of cases Washington State 48% of cases California 61% of cases The Queens, New York, Health Dept. 81% of new TB cases in 2001 to immigrants

9. Impact on the Unites States Immigrants/refugees, these groups intend to reside in the U.S. Nonimmigrant visitors students, exchange visitors temporary workers, tourists, business travelers. Only immigrants and refugees are screened.

10. Positive Patient Recently a visiting student from Singapore tested positive for active TB Required hospitalization Collection of Sputum Medication Contact investigation work, church, family

11. Basic principles of TB Control Early and accurate detection, diagnosis and reporting of TB cases leading to initiation and completion of treatment Identification of contacts of patients with infectious TB Identification of those patients with LTBI and at risk for progression to TB disease

12. Delays in Obtaining Health Care Homeless patients Fear of Immigration authorities Those who speak language other than English Cultural factors, social stigma of TB

13. Importance of Tb Training and Education Deficiencies in clinical knowledge and practice Staffing and workforce concerns New guidelines and recommendations Education of new contributors to TB control Diminished teaching about TB in medical and nursing schools

14. Civil Surgeon Licensed physicians conduct health screening including LTBI and active TB on foreign born persons living in the US for permanent residency Civil surgeons receive immigration-focused training

15. Drug –resistant TB Refers to an isolate of M. Tuberculosis that is resistant to one of the first-line antiTB drugs: Isonaizid Rifampin Pyrazinsmide Ethambutol Streptomycin

16. Multidrug-resistant TB MDR-TB Multidrug resistant TB refers to an isolate of M.Tuberculosis that is resistant to at least isoniazid and rifampin and possibly additional agents

17. Extensive Drug Resistant XDR-TB This refers to an isolate of M.Tuberculosis that is resistant to at least Isoniazid, rifampin and fluroquinolones as well as either aminoglycosides (amikacin, kanamycin or capreomycin or both

18. Totally drug-resistant TB TDR-TB refers to an isolate of M.tuberculosis resistant to all locally tested medications

19. Primary Drug Resistance Primary drug resistance is said to occur in a patient who has never received ant-TB therapy

20. Secondary drug Resistance Secondary drug resistance refers to the development of resistance during or following chemotherapy in patients who had previously had drug-susceptible TB

21. CDC’s Do Not Board and/or Lookout Lists Explained U.S. Federally Quarantinable Communicable Diseases Cholera Viral hemorrhagic fevers Diphtheria Sever acute respiratory (SARS) Infectious TB Plague Influenza novel or reemerging influenza causing or with potential to cause a pandemic Smallpox Yellow fever

22. Definitions Do Not Board (DNB) List Travel restriction tool: Prevents people who meet specific criteria from obtaining a boarding pass for any flight inbound to, outbound from, or within the United States Implented by the TSA Does NOT prevent passengers from boarding ships, trains, or buses

23. DNB/LO at a Glance DNB LO Boarding pass denied Traveler evaluated For any flight inbound to, evaluated when Outbound from, or within entering US at US a border Implemented by TSA Enforced by Customs and Border Protection

24. NOTE People on the Do Not Board list are not part of the No Fly List The Do Not Board list is designed to protect the public’s health The No Fly list is intended for law enforcement purposes, such as terrorist threats.

25. Criteria for DNB/LO Removal Removal is facilitated when person is determined to be NONINFECTIOUS

26. Wall Street Journal October 29, 2014 Few diseases need new medicines as much as tuberculosis. Some medications are 40 years old Funding for R&D rose annually 2005-2012 Most cuts came from private sector donors Bedaquiline, Johnson & Johnson Awaiting regulatory approval outside US where 450,000 annual drug resistant TB occur

27. Delamanid Otsuka Pharmaceutical failed to get approval from European Union committee in July Pfizer Astra-Zeneca Bill & Melinda Gates President Obama in 2014 budget proposed a 19% cut to $191 Million

28. Goal Currently, most cases are diagnosed via the longtime sputum smear microscopy method. Doctors need a test that can be used to diagnose patients in the examination room and begin treatment right away.