1. Last Update: April 4, 2004 Division of Tuberculosis Control Virginia Department of Health Richmond, Virginia Tuberculosis Infection & Disease: Fundamentals for Legislators

2. Last Update: May 28, 2004 Tuberculosis (TB): A Disease of Public Health Significance Potentially fatal disease transmitted by close contact Long, multidrug treatment regimens increase potential risk of nonadherence Serious impact on community if TB treatment is improper and/or inadequate Disproportionate impact on persons with inadequate access to health care

3. Last Update: May 28, 2004 Current TB Challenges in Virginia Increasing proportion of TB patients born outside the US 48 different countries of origin in 2003 At least 20 primary languages, other than English, spoken in 2003 High incidence of drug-resistant TB cases 21 deaths from TB in 2003 TB is a curable disease

4. Last Update: May 28, 2004 The Public Health Departments Role Recognized expert in TB control for the local community Resource for the latest on testing and treatment standards Has access to medical experts at CDC for consultation on complicated TB cases Provides follow-up care to persons diagnosed with TB Has ultimate responsibility for TB control in Virginia Has authority to legally enforce the VA Health Code Requires compliance to TB treatment, www.vdh.state.va.us/epi/tb/guidebook.htm Assists in interjurisdictional referrals for patients who move residences

5. Last Update: May 28, 2004 VA Division of TB Control (DTC) Role of the Central Office in Richmond Mission of the DTC Provide leadership in overcoming barriers to protect the people of Virginia from tuberculosis Objectives of the DTC Detect all cases of TB disease Treat all cases of active TB disease Complete treatment of all cases of active TB disease and their infected contacts

6. Last Update: May 28, 2004 Virginia TB Control Laws: Key Points Require reporting of TB disease Require treatment and adherence to TB treatment Allow isolation of infectious TB disease patients who refuse treatment and/or put the public at risk for TB infection

7. Last Update: May 28, 2004 How TB is Transmitted TB is caused by Mycobacterium tuberculosis (tubercle bacillus) When a person with active, infectious TB disease coughs, sneezes, laughs, sings, etc., s/he expels the TB bacteria into the air TB spreads when another person breathes in the air that contains the TB bacteria Prolonged contact with an infectious TB disease patient is needed for TB transmission to occur

8. Last Update: May 28, 2004 Factors That Determine the Transmission of TB Infectiousness of the person with TB disease The more infectious a person, the more likely the TB will be transmitted to others who are in close contact with this individual Environment in which exposure to TB occurs Room size and ventilation -- Transmission of TB is likely to occur in rooms that are small and with poor ventilation Continues on the next slide…

9. Last Update: May 28, 2004 Factors That Determine the Transmission of TB (2) Length of time spent with the infectious TB patient The longer the time spent with an infectious TB patient, the more likely TB transmission will occur Virulence (strength) of the TB bacteria The stronger the TB bacteria, the more likely the transmission of TB infection will occur

10. Last Update: May 28, 2004 Pathogenesis of TB TB occurs most commonly in lungs (85% of the time), but can occur in other parts of the body TB in the lungs = pulmonary TB TB outside the lungs = extrapulmonary TB A person with TB infection and a normal immune system has a 10% chance of developing active TB disease in his/her lifetime This risk is greatest within the first 2 years after acquiring TB infection

11. Last Update: May 28, 2004 TB Infection - Latent TB Infection (LTBI) Occurs when TB bacteria are in the body, but are inactive Does not result in any clinical symptoms of active TB disease Is not infectious to others Produces a positive reaction to the TB Skin test Presents a normal chest X-ray

12. Last Update: May 28, 2004 Active TB Disease Occurs when the inactive TB bacteria in the body (LTBI) become active May be infectious Has clinical symptoms (see next slide)

13. Last Update: May 28, 2004 Symptoms of Active TB Disease Prolonged cough (may produce sputum)* Chest pain* Hemoptysis* Fever Chills * Symptoms commonly seen in cases of pulmonary (lung) TB Night sweats Fatigue Loss of appetite Weight loss or failure to gain weight

14. Last Update: May 28, 2004 Persons at Higher Risk for Becoming Infected with TB Close contacts of persons known or suspected to have active, infectious TB disease Foreign-born persons from areas in the world where TB is common Residents and employees of high-risk congregate settings Health care workers (HCWs) who serve high-risk clients Medically underserved, low-income populations High-risk racial or ethnic minority populations Children exposed to adults in high-risk categories Persons who inject illicit drugs

15. Last Update: May 28, 2004 If Infected with TB, Factors That Could Increase the Risk for Developing TB Disease These high-risk persons should be tested for TB infection, and if positive, treated. HIV infection Substance abuse Recent TB infection Low body weight (10% or more below the ideal) Diabetes mellitus Silicosis Prolonged corticosteroid therapy Other immunosuppressive therapy End-stage renal disease Cancer of the head or neck

16. Last Update: May 28, 2004 TB and HIV Coinfection: A Concern For persons infected with TB, HIV positive status is the strongest risk factor for developing active TB disease In persons who are HIV positive and have TB infection, the chances of developing TB disease increases from 10% in a lifetime to 7% to 10% each year!

17. Last Update: May 28, 2004 Role of Epidemiology in TB Control Epidemiology is the study of the distribution and determinants of disease in human populations Epidemiological data tell us: who in the population is most at risk for developing TB disease what risk factors these individuals possess where TB disease is most prevalent how to best protect the public from the spread of TB disease

18. Last Update: May 28, 2004 TB Cases Reported in Virginia, 1992-2003 See Notes pages for an explanation of this graph. [In the menu bar, click View, then Notes Pages.] 332 in 2003

19. Last Update: May 28, 2004 Percent of TB Cases by Age and Sex Virginia, 2003 Click on View and Notes Pages to read the explanation of the graph.

20. Last Update: May 28, 2004 Percent of TB Cases in Virginia, by Region 2002 and 2003 20022003

21. Last Update: May 28, 2004 Goal of Screening for LTBI Find persons with LTBI who would benefit from treatment to prevent the development of TB disease Find persons with TB disease who would benefit from treatment [Persons at no risk for TB infection should not be tested for TB]

22. Last Update: May 28, 2004 Mantoux Tuberculin Skin Test (TST) A test for TB infection only Preferred test for TB infection Clinician performs procedure An injection TB skin test result (positive, negative) based on: Size of the induration (swelling) and, Persons risk factors for TB

23. Last Update: May 28, 2004 Basic Principles of TB Treatment Goals of treatment for TB disease are: Provide the safest, most effective therapy in the shortest possible time Give multiple drugs to which the TB bacteria are susceptible Ensure patient adherence to therapy

24. Last Update: May 28, 2004 Treatment of LTBI Treating LTBI prevents the development of TB disease, especially for persons at high risk for developing TB disease if infected with TB Usual medication regimen for treating TB infection Isoniazid (INH) for 9 months is optimal 6 months of INH is acceptable Rifampin for 4 months is alternative in certain circumstances

25. Last Update: May 28, 2004 Treatment of TB Disease Usual medication regimen Minimum of 6 months of therapy, sometimes longer Initial 4 drug therapy standard, and they are: Isoniazid (INH) Rifampin Pyrazinamide (PZA) Ethambutol Medications may need to be changed if the TB is drug resistant to any medication listed above

26. Last Update: May 28, 2004 Causes of Drug Resistance Physician prescribes an inappropriate drug regimen Patients do not take their TB medications exactly as instructed If you become infected with TB that is already drug-resistant

27. Last Update: May 28, 2004 Directly Observed Therapy (DOT) What is DOT? DOT is when a health care worker watches a TB patient swallow each dose of the prescribed drugs DOT is recommended for all persons who have TB disease Health care worker will conduct DOT at a time and place convenient for the patient

28. Last Update: May 28, 2004 Benefits of DOT DOT prevents drug resistance by eliminating opportunities for non-adherence to TB therapy among patients with TB disease DOT allows for the rapid identification of problems patients may experience with their TB medications Allows early interventions to assure accurate and correct TB therapy and patient adherence to TB therapy

29. Last Update: May 28, 2004 For More Information… Division of TB Control Virginia Department of Health Madison Building, First Floor 109 Governor Street Richmond, VA 23219 804-864-7906 (Telephone) 804-371-0248 (Fax) http://www.vdh.virginia.gov/epi/tb Centers for Disease Control and Prevention Division of TB Elimination http://www.cdc.gov/nchstp/tb/default.htm