1. What are we doing about TB infection control? Bess Miller, M.D., M.Sc. Associate Director, TB/HIV Global AIDS Program Centers for Disease Control and Prevention PEPFAR Track 1.0 ART Program Meeting Atlanta, Georgia September 24-25, 2007 CS113808

2. Acknowledgments Chris Dye, Abigail Wright – WHO Allyn Nakashima Anand Date Monita Patel Barbara Marston Alyssa Finlay Kevin Cain Paul Jensen Naomi Bock

3. Outline of Presentation Do we have a problem? How does PEPFAR support TB infection control? What can you do? Where can you get help?

4. Do we have a problem?

5. Yes

7. 1539 patients evaluated 542 with TB997 without TB 221 MDRTB (39%)321 Susceptible 53 (10%) XDRTB 44 HIV+ 52/53 died Extensively Drug Resistant (XDR) TB Recent Outbreak in Kwazulu Natal, SA Gandhi NR, et al, Lancet 2006 From C Wells

8. Estimated TB incidence rate, 2005 No estimate 0–24 50–99 100–299 300 or more 25–49 Estimated new TB cases (all forms) per 100 000 population The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2006. All rights reserved

9. Estimated HIV prevalence in new TB cases, 2005 No estimate 0–4 20–49 50 or more 5–19 HIV prevalence in TB cases, 15–49 years (%)

10. HIV Prevalence is the Driver of TB/HIV Russia - 1987- 2005 0.6 Russia Federal AIDS Centre 2005

11. Estimated rates of MDR among new TB cases 2004

12. Estimated rates of MDR among previously treated TB cases, 2004

13. Countries with XDR-TB Confirmed cases as of July 2007 Czech Republic The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2005. All rights reserved Ecuador Georgia Argentina Bangladesh Germany Republic of Korea Armenia Russian Federation South Africa Portugal Latvia Mexico Peru USA Brazil UK Sweden Thailand Chile Spain Islamic Republic of Iran China, Hong Kong SAR France Japan Norway Canada Italy Netherlands Estonia Lithuania Ireland Romania Israel Azerbaijan Poland Slovenia Based on information provided to WHO Stop TB Department - July 2007

14. Reasons for unsuccessful treatment under DOTS 0102030 AFR AMR EMR EUR SEAR WPR Percent of cohort Died Failed Defaulted Transfered Not evaluated

17. Higher risk of TB infection and disease are associated with work in health care settings Menzies D, Joshi R, Pai M; IJTLD 2007: 593-605 Corbett EL, Muzangwa J, Chaka K, et al; CID 2007: 317-323 Kassim S, Zuber P, Wiktor SZ, et al; IJTLD 2000: 321-326

18. How does PEPFAR support TB Infection Control?

23. TB infection control in the era of expanding HIV care and treatment Describes –Work practice and administrative controls –Environmental controls –Personal respiratory protection Sample infection control plan Sample monitoring tools Training material (powerpoint presentation)

24. Source: WHO addendum on Tb infection control Screen Educate Separate Provide HIV Services Investigate for TB or Refer

25. PEPFAR funds support: Development of national TB infection control policies and guidelines for facility level Assessments and renovations of facilities (TB and HIV) INTENSIFIED TB CASE FINDING and referrals with tracking systems for diagnosis and treatment of TB Evaluation of TB among health care workers Source - ’07 Plus up funding activities, COP ’08 draft activities

26. PEPFAR funds support: Training of personnel STRENGTHENING TB LABORATORY SERVICES Technical assistance Surveys of drug-resistant TB Source - ’07 Plus up funding activities, COP ’08 draft activities

27. What can you do? Support and evaluate intensified TB case finding at all HIV service sites (aka TB screening) Assure that TB suspects receive diagnostic and treatment services. Evaluate referral systems. Find out where HIV-infected TB patients are receiving care. Do AIDS patients and TB patients share air space in corridors and waiting rooms? Put up cough etiquette posters and buy tissues. Build an outdoor waiting area (Bring a hammer and nails.) Assess hospital wards. Is there cohorting of TB patients? Is rapid discharge of TB patients encouraged?

28. What can you do? Emphasize administrative and work practice controls. In an inner city hospital in Atlanta, Georgia, tuberculosis exposures and tuberculin skin test conversions declined substantially after mandatory isolation of TB patients, TB suspects, and persons with HIV infection who had an abnormal CXR. Blumberg HM, Watkins DL, Berschling, et al, Ann Intern Med 1995; 658-663

29. What can you do? Assist with program monitoring and evaluation Some measures commonly used include –Tuberculin skin testing programs for HCW –Evaluation of  Screening and triage processes  Separation of potential transmitters  Turn-around time for sputum smear microscopy results  Turn-around time for symptomatics to begin treatment  Length of stay in hospital  TB treatment completion rates

32. Where can you get help? National TB Control Programs Technical consultation –GAP TB/HIV Team –USAID TB/CAP-funded projects –DTBE consultant and trainer WHO TB Infection Control Sub-working Group Other PEPFAR country programs

33. This helps too.