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![Page 1: Tuberculosis in the 21 st Century Scott Lindquist MD MPH Tuberculosis Medical Consultant Washington State DOH and Kitsap County Health Officer.](https://reader036.fdocuments.us/reader036/viewer/2022062301/56649ebc5503460f94bc5553/html5/thumbnails/1.jpg)
Tuberculosis in the 21st Century
Scott Lindquist MD MPHTuberculosis Medical Consultant
Washington State DOH
and
Kitsap County Health Officer
![Page 2: Tuberculosis in the 21 st Century Scott Lindquist MD MPH Tuberculosis Medical Consultant Washington State DOH and Kitsap County Health Officer.](https://reader036.fdocuments.us/reader036/viewer/2022062301/56649ebc5503460f94bc5553/html5/thumbnails/2.jpg)
Feedback Poll
A. Balanced
B. Overblown
C. Confusing
D. None of the above
In my opinion, the recent media coverage of the case of drug resistant tuberculosis involving international travel was:
![Page 3: Tuberculosis in the 21 st Century Scott Lindquist MD MPH Tuberculosis Medical Consultant Washington State DOH and Kitsap County Health Officer.](https://reader036.fdocuments.us/reader036/viewer/2022062301/56649ebc5503460f94bc5553/html5/thumbnails/3.jpg)
In the World
• One out of every three persons has been infected with tuberculosis. . . .
• Our story begins . . . .
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Person
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Reported TB Cases by Race/Ethnicity* United States, 2005
Hispanic or Latino(29%) Black or
African-American(28%)
Asian(23%)
White(18%)
American Indian or Alaska Native
(1%)
Native Hawaiian orOther Pacific Islander
(<1%)
*All races are non-Hispanic. Persons reporting two or more races accounted for less than 1% of all cases.
![Page 6: Tuberculosis in the 21 st Century Scott Lindquist MD MPH Tuberculosis Medical Consultant Washington State DOH and Kitsap County Health Officer.](https://reader036.fdocuments.us/reader036/viewer/2022062301/56649ebc5503460f94bc5553/html5/thumbnails/6.jpg)
*Updated as of March 29, 2006.
19991998
>65
Age Group (years)
0
5
10
15
20
1993 1994 1995 1996 1997 2000 2001 2002 2003 2004 2005
<15 15–24 25–44 45–64
TB Case Rates* by Age Group United States, 1993–2005
Ca
ses
per
10
0,0
00
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Estimated HIV Coinfection in Persons Reported with TB: United States, 1993–2004*
*Updated as of March 29, 2006.
Note: Minimum estimates based on reported HIV-positive status among all TB cases in the age group.
% C
oin
fect
ion
0
10
20
30
1993 1995 1997 1999 2001 2003
All Ages Aged 25–44
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% w
ith
Tes
t R
es
ult
s
*Updated as of March 29, 2006.
Note: Includes TB patients with positive, negative, or indeterminate HIV test results and persons from California reported with AIDS. (HIV test results are not reported from California)
Reporting of HIV Test Results in Persons with TB by Age Group: United States, 1993–2004*
0
20
40
60
80
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
All Ages Aged 25–44
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Adult TB Cases by Homeless Status* 1994-2001
Adult TB case = TB in person aged >18 years * Homeless within year prior to TB diagnosis
Ho
mel
ess
0
2
4
6
8
10
1994 1995 1996 1997 1998 1999 2000 2001
%
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Adult TB Cases by Correctional Facility Status,* 1993-2001
Adult TB case = TB in person aged >18 years old* Resident of correctional facility at the time of TB diagnosis
% C
orr
ecti
on
al F
ac
ility
1993 1994 1995 1996 1997 1998 1999 2000 20010
2
4
6
8
10
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Selected Risk Factors: Ten-Year Period, WA 1993-2005
0
10
20
30
40
50
1994-1995 1996-1997 1998-1999 2000-2001 2002-2003 2004-2005
% o
f C
ases
UnemployedHomelessAlcoholPrevious Diagnosis
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Place
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TB Case Rates*: United States, 2005
< 3.5 (year 2000 target)
3.6–4.8
> 4.8 (national average)
D.C.
*Cases per 100,000.
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TB Low-Incidence States,* 1990–2000
* <3.5 TB cases per 100,00 population (Year 2000 target)
Nu
mb
er
of
Lo
w-
Inci
den
ce
Sta
tes
0
5
10
15
20
25
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
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Countries of Birth of Foreign-born Persons Reported with TB: US, 2005
Mexico(25%)
Philippines(11%)
Vietnam (8%)India
(7%)China (5%)
Haiti (3%)
Guatemala(3%)
OtherCountries
(38%)
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Trends in TB Cases in Foreign-born Persons: US, 1986–2005*
No. of Cases Percentage
*Updated as of March 29, 2006.
0
2,000
4,000
6,000
8,000
10,000
86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 050
10
20
30
40
50
60
No. of Cases Percentage of Total Cases
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59% 63% 60%70% 72% 69% 66% 68% 67%
73%61%
0%
15%
30%
45%
60%
75%
90%
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Proportion of Foreign-born Cases:WA, 1996-2006
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Drug Resistance
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Drug Resistance Definitions
• Primary drug resistance
Applies to previously untreated patients who are found to have drug- resistant organisms, presumably because they have been infected from an outside source of resistant Mycobacterium tuberculosis.
• Acquired drug resistance
Applies to patients who initially have drug-susceptible bacteria that become drug-resistant due to inadequate, inappropriate, or irregular treatment or, more importantly, because of non-adherence in drug taking.
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Multidrug-Resistant Tuberculosis (MDR)
• Resistance to at least two of the best anti-TB drugs, isoniazid and rifampicin.
• These drugs are considered first line agents.
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Extensively Drug Resistant TB (XDR TB)
• This is a rare type of multidrug-resistant
tuberculosis.
• It is resistant to almost all drugs used to treat
TB, including all first line agents and the best
second-line agents: fluoroquinolones and at
least one of three injectable agents (amikacin,
kanamycin, or capreomycin).
• There have been only 49 cases in the US
since 1993.
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Primary Isoniazid Resistance in U.S.-Born vs. Foreign-Born Persons: US, 1993–2005*
*Updated as of March 29, 2006.
Note: Based on initial isolates from persons with no prior history of TB.
% R
esis
tan
t
02468
101214
1993 1995 1997 1999 2001 2003 2005
U.S.-born Foreign-born
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Primary Anti-TB Drug Resistance: WA, 1996-2006
Note: Based on initial isolates from persons with no prior history of TB. MDR TB defined as resistance to at least isoniazid and rifampin.
0%
5%
10%
15%
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
INH MDR TB
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Primary MDR TB: US, 1993–2005*
*Updated as of March 29, 2006.
Note: Based on initial isolates from persons with no prior history of TB. MDR TB defined as resistance to at least isoniazid and rifampin.
No. of Cases Percentage
0
100
200
300
400
500
93 94 95 96 97 98 99 00 01 02 03 04 05
0
1
2
3
No. of Cases Percentage
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Primary MDR TB: WA,1996-2006
Note: Based on initial isolates from persons with no prior history of TB. MDR TB defined as resistance to at least isoniazid and rifampin.
No
. o
f C
ases
1.1% 2.0%0.0% 1.0% 2.0% 2.0% 0.4% 0.0% 0.4% 1.1% 2.0%
0
5
10
15
20
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
0%
10%
20%
30%
40%
50%
No. of MDR cases% of Total
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Primary MDR TB in US-born vs. Foreign-born Persons with TB, 1993-2001
Note: Based on initial isolates from persons with no prior history of TB.MDR TB defined as resistance to at least isoniazid and rifampin.
% P
rim
ary
MD
R T
B
0
1
2
3
1993 1994 1995 1996 1997 1998 1999 2000 2001
US-born Foreign-born
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New Diagnostics
• Quantiferon
• MTD testing
• Universal genotyping
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Commonly Asked TST Questions (1 of 2)
• How do you know and ensure that the medical community using the TST is properly trained?
• Can you place a TST on a Thursday and read on a Monday?
• Who needs a two-step test and why?
• What is the boosted response?
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Commonly Asked TST Questions (2 of 2)
• What if the longitudinal reading of the TST is 12mm and the horizontal (official reading) is 8mm? Is that considered positive?
• Can I accept a negative reading if the patient said there was absolutely no reaction and there is no reaction on day four after the test?
• We switched products from tubersol to aplisol, and I noticed more “positives.” We retested with tubersol, and all were negative. Which test do I believe?
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The Answer
• Quantiferon
Blood-based testing method
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MTD
• Mycobacterium Tuberculosis Direct Test (MTD)
• Nucleic acid amplification
• Sensitivity 85.7%–97.8%
• Criteria for use:
Smear-positive cases
Highly suspicious cases
If it will change treatment
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Universal Genotyping
• All TB cultures from WA state now sent to CDC for genotyping “fingerprinting”
• Spoligotyping
• MIRU pattern
• Goal is to detect clusters
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No
. C
ases
Homeless TB Cases in King County by Treatment Start Date
2002Treatment Start Date
2003 2004
0
1
2
3
4
5
6
7
8
Jan Mar May Jul Sep Nov Jan Mar May July Sept Nov Jan Mar May July Sept
Non-outbreak RFLP Outbreak RFLP
No known epi link (RFLP pending) Second RFLP clusterEpi-link (RFLP pending) Clinical case
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Treatment
• DOT (consistency is key)
Latent TB infection nine months
Pulmonary six months
Meningitis 12 months
Adenopathy six months
Bone/Joint 12 months
• Monthly weight check
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Treatment Evaluation
• HIV screen
• Hep B and C (if risk factors)
• AST
• ALT
• Bilirubin
• A.Phos.
• Creatinine
• Platelets
• Vision testing (if Ethambutol used > 2 mo.)
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Ongoing Diagnostic Monitoring
• Monthly sputum collection (until two negative smears).
• Look for smear positive cases after initial two months of therapy.
• Liver function tests if abnormalities on screening or risk factors for hepatitis.
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DOT or Not to DOT
• Strongly recommended.
• Patient centered approach is more successful.
Social service support
Treatment incentives and enablers
Housing assistance
Substance abuse treatment
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TB Case #1:“Doc, can he fly home?”
• 17-year-old male exchange student from Azerbaijan.
• BCG at birth.
• One month of cough, hemoptysis, weight loss, and acute chest pain.
• He presents to your office. . .now what do you do?
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Feedback Poll
What is your first step?
A. Place a PPD and order a chest radiograph
B. Place this patient in an N-95 mask
C. Start four drug therapy
D. All of the above
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Results
• PPD 19 mm
• Cavitary right upper lobe on radiograph
• AFB smears all negative
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The Rest of the Story
• Sputum MTD was positive
• Repeat of the AFB at state lab was positive
• INH, Rifampin, PZA and Ethambutol started
• Patient instructed not to fly home
• Held from last two days of high school
• Contact investigation begun
• Host family asks to have him removed from home. . . .
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Further Dilemmas
• Where can he go?
• When can he fly home?
• How certain are you that this is not XDR?
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Feedback Poll
Can he fly home?
A. Yes
B. No
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Contact Dr. Lindquist
You can call Dr. Lindquist with your TB-related questions at:
360-337-5237
206-718-2664
Or contact him by e-mail at: