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National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine
Karen J Marienau, MD, MPHCenters for Disease Control and Prevention
kqm5@cdc.gov
CDC 2011 Protocol for Flight-Related
Tuberculosis Contact Investigations
TB PEN WebinarAug 7, 2013
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
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
BackgroundAirline TBCIs (cont.)
Two of 13 studiesa showed reliable evidence of Mycobacterium tuberculosis transmission
Two CDC reviewsb,c of 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 travelaAbubakar, 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
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 CDC MMWR 2005; 54 (No. RR-15, 1-37)
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
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 TBCIs for health
department and DGMQ Return on Investment Model to estimate the long-term
impact of airline TBCIs related to reducing future cases of TB disease:
(Gain of investment – Cost of investment) / (Cost of investment)
*Marienau KJ, 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
Comparison of 2008 and 2011CDC TB Protocols for Flight-Related Tuberculosis
Contact Investigations
Criteria 2008 CDC Protocol 2011CDC Protocol
Diagnosis relative to flight date
Within 3 months of flight
Within 3 months of flight
Time since flight when CDC notified
Within 6 months of flight
Within 3 months of flight
Isolate: susceptible to isoniazid (INH) or rifampin (RIF)
Sputum smear +, chest radiograph (CXR) with/without cavitation; OR sputum smear - and CXR with cavitation
Sputum smear + ANDCXR with cavitation
Isolate: multidrug-resistant (resistant to INH and RIF)
All All
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
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
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
Comparison: 2008 Protocol Last 18 months and 2011 Protocol First18
Months
Numbers Jan 1, 2010-June 30, 2011* (2008
Protocol)
July 1, 2011-Dec. 31, 2012 (2011
Protocol)
TB Cases 119* 52
Passenger contacts (total) 3798* 1620
Passenger contacts (Assigned to US
health departments)
2790* 1096
*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
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
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine
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!
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