Karen J Marienau , MD, MPH Centers for Disease Control and Prevention kqm5@cdc.gov

1. CDC 2011 Protocol for Flight-Related Tuberculosis Contact Investigations TB PEN Webinar Aug 7, 2013 Karen J Marienau, MD, MPH Centers for Disease Control and Prevention kqm5@cdc.gov

2. Overview • Background of flight-related tuberculosis (TB) contact investigations (CIs) • Changes to CDC protocol for flight-related tuberculosis contact investigations (TBCIs) that were implemented in July 2011 • Preliminary results of TBCIs conducted under the CDC 2011 protocol in comparison to those conducted under the CDC 2008 protocol

3. BackgroundAirline TBCIs • World Health Organization (WHO) provided guidelines for flight-related TBCIs in 2006 (updated in 2008*) • Public health benefits of airline TBCIs are not well established • Airline TBCIs are time-consuming, costly, and compete for resources with other TB prevention and control efforts with well-established benefits *http://www.who.int/tb/publications/2008/WHO_HTM_TB_2008.399_eng.pdf

4. BackgroundAirline TBCIs (cont.) • Two of 13 studiesa showed reliable evidence of Mycobacterium tuberculosis transmission • Two CDC reviewsb,cof TB CIs conducted in the US were inconclusive, but suggested risk of transmission was low • No documented cases have been reported of TB disease resulting from exposure during air travel aAbubakar, I. Tuberculosis and air travel: a systematic review and analysis of policy. Lancet Infect Dis. 2010:10:176-83 bKornylo-Duong K,, et al. Three air travel-related contact investigations associated with infectious tuberculosis, 2007–2008. Travel Med Infect Dis (2010);8:120-8 cMarienau KJ, et al. Tuberculosis investigations associated with air travel: US CDC Jan 2007-June2008. Travel Med Infect Dis (2010);8:104-12

5. Flight-related TBCIs in the United States • Quarantine branch staff • Determine whether the case meets protocol criteria for conducting a TBCI • Obtain passenger contact information from airline and Customs and Border Protection • Provide information to US state health departments • US health departments • Locate and evaluate passenger contacts according to national guidelines* • Report results to DGMQ (voluntary) *Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosis: Recommendations from the National Tuberculosis Controllers Association and CDCMMWR 2005; 54 (No. RR-15, 1-37)

6. Comparative Cost-Benefit Analysis To evaluate the cost-benefit of TBCIs for preventing TB disease following exposure during air travel we: • Identified 3 potential alternatives to the CDC 2008 protocol for flight TBCI • Selected one potential alternative protocol to the 2008 CDC protocol for comparative risk and economic analyses

7. Comparative Cost-Benefit AnalysisCDC 2008 Protocol vs. CDC 2011 Protocol • Risk analyses: • Epidemiology of TBCIs conducted from 2007 to 2009 to predict numbers and clinical characteristics of index cases and number of passenger contacts • Outcomes data from TBCIs from Jan 2007 to Jun 2008* to predict passenger contact outcomes • Economic analyses: • Estimate the immediate costs of TBCIsfor health department and DGMQ • Return on Investment Model to estimatethe long-term impact of airline TBCIs related to reducing future cases of TB disease: (Gain of investment – Cost of investment) / (Cost of investment) *MarienauKJ, Burgess GW, Cramer EH, et al. Tuberculosis Investigations associated with air travel: US CDC Jan 2007-June2008. Travel Med Infect Dis 2010;8:104-12

8. Comparison of 2008 and 2011CDC TB Protocols for Flight-Related Tuberculosis Contact Investigations

9. Results of Comparative Risk and Economic Analyses for CDC 2008 and 2011 Protocols • Risk of acquiring latent TB infection (LTBI) on a flight: 2008 vs. 2011 criteria • 2008 criteria: risk range was 1.1% - 24% • 2011 criteria: risk range was 1.4% - 19% • Economic impact– Immediate • 2011 protocol would result in about half as many TBCIs, and approximately 50% reduction in HD costs • Economic impact – Long term • Return on investment comparable for the two protocols

10. Risk and Economic Analyses Outcomes • Our analyses predicted that public health resources would be conserved with minimal negative effect on TB prevention and control if the 2008 CDC flight-related TBCI protocol was replaced by the 2011 CDC Protocol • The 2011 CDC protocol was implemented July 1, 2011, with endorsement by CDC’s Division of TB Elimination and the National TB Controllers Association

11. 2011 CDC TB Air Travel Protocol • Implemented July 1, 2011 • Criteria for initiating a TBCI • Index case • diagnosed ≤ 3months after flight • Sputum smear positive AND cavitation on CXR OR • Multidrug-resistant isolate • Flight • ≥ 8 hours long (gate-to-gate) • ≤3 months of notification of index case to CDC • Considerations for doing a CI even if criteria not met • Cavitation on CT scan but not on CXR, or no CXR • More than expected close household contacts with positive screening tests • Laryngeal TB

12. Comparison: 2008 Protocol Last 18 months and 2011 Protocol First18 Months *Excludes 5 cases, 51 flights, and 1549 passengers (911 passengers assigned to states) from contact investigations done for outbound flights because DGMQ stopped doing CIs on outbound flights in May 2011. Since then DGMQ notifies the country where flight arrived of the TB case, and they conduct a CI according to their national policy . Preliminary data

13. Acknowledgments • State and local TB control program staff • National TB Controllers • DTBE: Ken Castro, Tom Navin, Phil Lobue, Maryam Haddad, Sundari Mase, John Jereb • CDC Quarantine Station staff involved in TBCIs • Quarantine Branch staff involved in risk and economic analyses of 2011 protocol: • Elaine Cramer, Maggie Coleman, Nina Marano, Marty Cetron • Quarantine Branch staff that assisted with data entry/analyses • Chris Schembri , Jenna Kirschenman, and Faith Washburn

14. The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention QUESTIONS? THANK YOU!