1. Beyond Sputum Cups and Four Drugs The Responsibility of the Practicing Clinician in the Community Control of Tuberculosis V. R. Koppaka, MD, PhD Division of TB Control

2. “...protection, improvement, and preservation of the public health and of the environment are essential to the general welfare of the citizens of the Commonwealth. For this reason, the State Board of Health and the State Health Commissioner, assisted by the State Department of Health, shall administer and provide a comprehensive program of preventive, curative, and restorative services...and abate hazards and nuisances to the health and...” VAC §32.1-2

3. Priorities in Control of Tuberculosis D etection of all cases of tuberculosis disease T reat all cases of active tuberculosis disease C omplete treatment of all cases of active disease and their infected contacts

4. TB Control: Physician Roles Efficient case detection Appropriate and adequate treatment Communication with health authorities TB prevention Advocacy

5. Active Tuberculosis Disease Bacteriologically-Defined M. tuberculosis present in any bodily fluid, or tissue. Confirmed by: –Culture –Nucleic acid detection –Acid Fast SmearClinically-Defined Clinical evidence –Symptoms –Radiography –TST result Response to therapy VAC §32.1-49.1

6. Management of Tuberculosis Early diagnosis and treatment based on clinical features, radiography, bacteriology Baseline and monthly clinical assessment: –Treatment response –Adherence –Drug intolerance Maintain and update written treatment plan and record of adherence (VAC §32.1-50.1) Submission of initial and subsequent reports to LHD

7. Statement of Responsibility “Because in the treatment of tuberculosis the benefits accrue to society as well as to the patient, any provider undertaking to treat a patient with tuberculosis is taking on a public health function in which she/he is assuming responsibility for successful completion of therapy.” ATS/CDC/IDSA Guidelines for Treatment of Tuberculosis, 2002

8. Disease Reporting Every physician practicing in this Commonwealth who shall diagnose or reasonably suspect that any patient of his has any disease required by the Board to be reported and every director of any laboratory doing business in this Commonwealth which performs any test whose results indicate the presence of any such disease shall make a report within such time and in such manner as may be prescribed by regulations of the Board. VAC § 32.1-36

9. Reporting of Tuberculosis Disease Who:Physician Health Care Facility Laboratory What:Patient characteristics Diagnostic information Treatment/follow-up information When:Within 24 hours (initial report) Within 1-2 weeks (secondary report) How:Telephone/fax/(internet) VAC § 32.1-50 B, C

10. TB Disease: Required Subsequent Reports Treatment ceases –Fails to keep treatment appointment –Relocates with transfer of care –Discontinues treatment on or against medical advice Regimen changes Clinical status changes As updates become available VAC §32.1-50 D

11. TB Treatment Plans Required for all patients receiving treatment for TB disease Local health director approval mandatory for –All inpatients prior to discharge –HIV co-infected –Confirmed or suspected rifampin resistance –History of prior TB treated or untreated –Demonstrated history of nonadherence VAC §32.1-50.1

12. TB Treatment Plan Elements Tailored to patient’s medical and social needs Updated at least monthly Must include at minimum: –Verified patient address –Name of MD responsible for care –Drug regimen and estimated completion date –Written record of adherence VAC §32.1-50.1

13. Tuberculosis 2002: Global Emergency 1/3 of the world’s population infected 8 million new cases of active disease per year 2-3 million deaths per year 80% of global morbidity found in just 22 countries One person is newly infected every second and one person dies every 10 seconds Rising incidence of drug-resistant disease Billions of dollars in lost productivity

14. “A fundamental human right”

15. “We are now at a critical juncture…” “On the one hand, control of tuberculosis in the United States has been regained and we are at an all-time low in the number of new cases. On the other hand, we are particularly vulnerable again to the complacency and neglect that comes with declining numbers of cases. Now is the time to commit to the abolition of the recurrent cycles of neglect followed by resurgence that have been the history of tuberculosis.... But to meet this goal, aggressive and decisive action beyond what is now in effect will be required." p. viii Institute of Medicine. Ending Neglect. 2000