Microbiologists from Mexico at South Texas Microbiologists from Mexico at South Texas Hospital LabHospital Lab

““Microbiólogos de México en el laboratorio de Microbiólogos de México en el laboratorio de

South Texas Hospital”South Texas Hospital”

BI-NATIONAL MDR-TB CASES BY YEAROctober 1994 - December 1999

25

86

100

92

83

67

0

20

40

60

80

100

120

1994 1995 1996 1997 1998 1999

TB infectionTB infection

Populations in US more likely to have Populations in US more likely to have TB infectionTB infection– Foreign born from countries where more Foreign born from countries where more

people have TB diseasepeople have TB disease– Inmates of correctional facilitiesInmates of correctional facilities– Residents of low income neighborhoodsResidents of low income neighborhoods– Substance abusersSubstance abusers– HomelessHomeless

TuberculosisPatient characteristics, 1998-1999

CharacteristicNon-border

countiesBorder

counties

National originForeign-born 35.0% 59.0%

Born in Mexico 46.4% 87.7%

Risk factorsHIV infection 10.9% 6.4%

Homeless 7.2% 3.4%

Incarceration 11.3% 9.2%

Diabetes 10.2% 24.5%

Alcohol abuse 15.8% 12.9%

IV drug abuse 2.1% 1.8%

TuberculosisPatient characteristics, 1998-1999

CharacteristicNon-border

countiesBorder

counties

RaceWhite 23.0% 3.5%

African-American 29.2% 0.4%

Hispanic 37.0% 94.3%

Other 10.8% 1.8%

Age Group (yrs)

19 and younger 8.8% 16.7%

20 - 39 34.8% 26.8%

40 - 59 35.3% 28.0%

60 and older 21.1% 28.5%

Barriers to TB EliminationBarriers to TB Elimination

Importation of CasesImportation of Cases AIDS/TBAIDS/TB Drug ResistanceDrug Resistance Unmotivated/Noncompliant PatientsUnmotivated/Noncompliant Patients Undetected CasesUndetected Cases

TB InfectionTB Infection

TB infection means that tubercle TB infection means that tubercle bacilli are in the body but under bacilli are in the body but under controlcontrol

TB infection detected by tuberculin TB infection detected by tuberculin skin test (Mantoux test)skin test (Mantoux test)

TEXAS DEPARTMENT OF TEXAS DEPARTMENT OF HEALTHHEALTH

PUBLIC HEALTH REGION 11PUBLIC HEALTH REGION 11

NO NO

TINE TINE

TEST TEST

Comparison of TB Infection Comparison of TB Infection and TB Diseaseand TB Disease

SymptomsPPD Skin testChest x-rayM. TuberculosisContagiousEffective treatment

TB InfectionNoPositiveStableDormantNoOne drug

TB DiseaseYesPositiveWorseningRapid growthYesMultiple drugs

PPDPPD

95% of Positive PPD’s in persons 95% of Positive PPD’s in persons with with BCG over 5 years earlier is BCG over 5 years earlier is really really

TB InfectionTB Infection

BCGBCG fades fades withwith time.time.

Preventive TherapyPreventive Therapy

Substantially reduces infected person’s Substantially reduces infected person’s risk of developing clinical tuberculosisrisk of developing clinical tuberculosis

Consists of 6-12 months of daily Consists of 6-12 months of daily isoniazidisoniazid

9 months preferred9 months preferred Patients must be monitored monthly for Patients must be monitored monthly for

symptoms of toxicity and compliance symptoms of toxicity and compliance

High-Risk Groups to Target High-Risk Groups to Target for Preventive Therapyfor Preventive Therapy

(Regardless of age)(Regardless of age)

Infants and Persons with HIV Infection Infants and Persons with HIV Infection Close contacts of infections tuberculosis casesClose contacts of infections tuberculosis cases Recent skin test converters Recent skin test converters

(Or 10mm increase for persons< 35 years old)(Or 10mm increase for persons< 35 years old)Estimate the likelihood of completion before startingEstimate the likelihood of completion before starting

Who Is A Suspect?Who Is A Suspect?

Cavitary diseaseCavitary disease Positive smearPositive smear Fibronodular or miliary with Fibronodular or miliary with

symptonssymptons TB drugs contemplatedTB drugs contemplated

Predominate Site of DiseasePredominate Site of Disease

SiteSitePulmonaryPulmonaryLymphaticLymphaticPleuralPleuralBone and/or JointBone and/or JointGenitourinaryGenitourinaryMiliaryMiliaryMeningealMeningealPeritonealPeritonealOtherOther

PercentagePercentage<85.4<85.44.44.43.63.61.21.21.21.21.21.21.01.00.70.71.11.1

Culture Before TherapyCulture Before Therapy

SputaSputaGastricGastricUrineUrineBiopsy: direct to pathology, no Biopsy: direct to pathology, no

preservativepreservative

Smear ExaminationSmear Examination

Strongly consider TB in patients with smears Strongly consider TB in patients with smears containing acid-fast bacilli (AFB)containing acid-fast bacilli (AFB)

Use follow-up smear examinations to assess Use follow-up smear examinations to assess patient’s infectiousness and response to patient’s infectiousness and response to therapytherapy

Expect results within 24 hours of specimen Expect results within 24 hours of specimen collectioncollection

Use the entire clinical picture and be alert to Use the entire clinical picture and be alert to false positives and false negativesfalse positives and false negatives

InfectiousnessInfectiousness Greater in patients who:Greater in patients who: are coughing,are coughing, are undergoing cough-inducing or aerosol-are undergoing cough-inducing or aerosol-

generating procedures, orgenerating procedures, or have sputum smears positive for acid-fast bacilli have sputum smears positive for acid-fast bacilli

and theyand they are not receiving therapy,are not receiving therapy, have just started therapy ( 2-12 weeks) orhave just started therapy ( 2-12 weeks) or have a poor clinical or bacteriologic response to have a poor clinical or bacteriologic response to

therapy.therapy. Return to public contact depends on risk to others.Return to public contact depends on risk to others.

Risk of Inhaling Risk of Inhaling Mycobacterium Mycobacterium

TuberculosisTuberculosis1.1. Concentration of viable bacteria in Concentration of viable bacteria in

the airthe air

2.2. Volume of contamination air inhaledVolume of contamination air inhaled

3.3. Duration of breathing contaminated Duration of breathing contaminated airair

Increased Number Of Viable Increased Number Of Viable Bacteria In The Air:Bacteria In The Air:

1.1. Cavitary diseaseCavitary disease

2.2. Smear-positive diseaseSmear-positive disease

3.3. CoughCough

4.4. Time until isolationTime until isolation

5.5. Time until effective treatmentTime until effective treatment

Chest RadiographChest Radiograph

Abnormalities often found in apical or Abnormalities often found in apical or posterior segments of upper lobe or in posterior segments of upper lobe or in segments of lower lobesegments of lower lobe

May have unusual appearance in HIV-May have unusual appearance in HIV-infected persons with pulmonary TBinfected persons with pulmonary TB

Cannot confirm diagnosis of TB, but may Cannot confirm diagnosis of TB, but may used to rule out pulmonary TB in a person used to rule out pulmonary TB in a person with a positive skin test reaction and no with a positive skin test reaction and no symptoms of diseasesymptoms of disease

Standard TB TreatmentStandard TB Treatment

Use Four (4) Drugs for Initial TherapyUse Four (4) Drugs for Initial Therapy

INHINH RIFRIF EMBEMB PZA*PZA*Use of Insufficient Drugs or Doses is Use of Insufficient Drugs or Doses is

Often FatalOften Fatal*PZA is only effective for first two *PZA is only effective for first two

months but essential for six-month months but essential for six-month treatmenttreatment

*Not used during pregnancy in U.S.*Not used during pregnancy in U.S.

Never treat “a little TB” with a Never treat “a little TB” with a single drug. single drug.

Nunca trate “un poquito de Nunca trate “un poquito de tuberculosis” con una sola tuberculosis” con una sola

medicina.medicina.

Currently Available and Currently Available and Experimental Agents for Experimental Agents for

Tuberculosis ChemotherapyTuberculosis Chemotherapy Experimental drugs (variable efficacy and Experimental drugs (variable efficacy and

toxicity; not approved in the United States toxicity; not approved in the United States for use in tuberculosis)for use in tuberculosis)

Rifabutin (ansamycin LM-427Rifabutin (ansamycin LM-427 OfloxacinOfloxacin CiprofloxacinCiprofloxacin ClofazimineClofazimine

Second-Line DrugsSecond-Line Drugs

CycloserineCycloserine EthionamideEthionamide KanamycinKanamycin CapreomycinCapreomycin Para-aminosalicylic acidPara-aminosalicylic acid AmikacinAmikacin

ChallengesChallenges Border communication network with Border communication network with

secure web site and health alert networksecure web site and health alert network Exchange information on all missing Exchange information on all missing

patients as they often cross the borderpatients as they often cross the border Specimens, medications, patients crossing Specimens, medications, patients crossing

US and Mexico customs and immigrationsUS and Mexico customs and immigrations Provision of affordable MDR medicationProvision of affordable MDR medication Border center of excellence with expertsBorder center of excellence with experts Attention to jails and high risk populationsAttention to jails and high risk populations Contact investigation and preventionContact investigation and prevention Infection control to protect patients and Infection control to protect patients and

staffstaff Training of public and private cliniciansTraining of public and private clinicians

La Frontera Chica: Rio Grande-Camargo, La Frontera Chica: Rio Grande-Camargo, Roma-Miguel AlemanRoma-Miguel Aleman

South to INS or north to TCID in South to INS or north to TCID in San Antonio?San Antonio?

Hasta el sur a INS o norte al hospital in San Hasta el sur a INS o norte al hospital in San Antonio?Antonio?