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
WHO Bulletin • Association between TB and poverty is mediated by ; • Overcrowding • Poorly ventilated housing • Malnutrition • Smoking • Stress • Social deprivation
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
MMWR March 20, 2014Morbidity 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.
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
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
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
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.
Positive Patient • Recently a visiting student from Singapore tested positive for active TB • Required hospitalization • Collection of Sputum • Medication • Contact investigation work, church, family
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
Delays in Obtaining Health Care • Homeless patients • Fear of Immigration authorities • Those who speak language other than English • Cultural factors, social stigma of TB
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
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
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
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
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
Totally drug-resistant TB • TDR-TB refers to an isolate of M.tuberculosis resistant to all locally tested medications
Primary Drug Resistance • Primary drug resistance is said to occur in a patient who has never received ant-TB therapy
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
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
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
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
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.
Criteria for DNB/LO Removal • Removal is facilitated when person is determined to be NONINFECTIOUS
Wall Street JournalOctober 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
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
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.