Tuberculosis – Regulations and control in Norway- of relevance

for approved doctors outside Norway

Dept director Karin Rønning MD

NIPH, Dept for infectious diseases epidemiology

NMA/ NCMM Approved doctors meeting, Bergen 2014

Powerty

Crowded housing conditions

Coinfection with HIV

Other immunosuppresant

treatments and conditions

Small children (<2)

Risc factors for TB infection

Appr 30% of the world

popultaion are infected

with TB (latent TB)

• M. tuberculosis spreads from person to person by droplets inhaled

• 5-10 % of those infected get sick

– A few during the first weeks

– Most during the first 1-2 yrs

– Risk 5-10% during the lifetime

TB transmission

Droplets containing M.tuberculosis

bronchioleblood vessel

tubercle bacilli

alveoli

2

M.Tb multiplies in alveoli, with onset of infection

TB disease

shell breaks down and tuberclebacilli escape

multiply(in this example,TB disease develops in the lungs)

and

5

• If the immune system cannot keep the M.tb under

control, the bacteria starts to duplicate rapidly and

causes disease

• The process might start in different organs

Localizations of disease

Most commonly:

Brain

Lymph node

Pleura

Lung

SpineKidney

Bone

Larynx

Dr. Ulf Dahle, NIPH)

Top 10 countries with TB patients

• India

• China

• Indonesia

• Nigeria

• South Africa

• Bangladesh

• Ethiopia

• Pakistan

• Philippines

• Democratic Republic of the Congo

• The rest of Africa..

Law/Regulations

Guidelines

NIPH- how to…

Infection control measures

Screening- whom?

Contact tracing

Obligations and rights for patients

Treatment of latent TB-

whom?

From the Norwegian

TB control of

relevance for You

Who should be screened following Norwegian TB regulations

• §1.2 Jurisdiction • §3.1.a TB screening of all that will stay in Norway > 3 mths

coming from a country with TB insidence >40/100´/ year

• Regulations also covers employees/ seafarers going to work on mobile Norwegian oil installations at sea, on Norwegian ships and aircrafts wherever they are located

– the screening of seafarers should primarily be done do exclude contagious TB • Pulmonary TB (CXR)

TB screening of seafarers

• Regulation on TB with comments

• Regulation for health examination of seamen (2014)

– Not risk group aspect, but security aspects

– Contagious diseases are contra indication regarding work on a ship, and should be avoided

Good practice for TB control and treatment- Norwegian guidlines

Where is

given the

methods of

TB screening

and TB

treatment

FORM FOR MEDICAL EXAMINATION

Regulation on medical examinations of employees on Norwegian ships or moveable installations offshore -

2014

ICD10 codes

A00-B99

Certain infectious diseases

A15-16

Pulmonary TB Contagious, relapse

T- Pos screening or history- until examined If infectious- until treatment is stabilized and the patient is documented non- contagious (3 neg sputum microscopies) P- Relapse, or serious lung sequelae

NA Completed treatment following Norwegian guidelines and/or WHO Treatment TB guidelines

Test follows Norwegian regulations and guidelines

DOT? Direct observed treatment Treatment plan

What kind of methods for TB examinations?

How to exclude contagious lung TB

• CXR!

• Clinical history

– Cough > 3 weeks

– Weight loss

– Fever

– Chest pains

– Feeling of illness

• HIV+ may have no CRX changes

• Pulmonary TB is the only contagious form of TB

Methods for screening

• CXR

– Active TB or scars from former TB (latent TB?)

• TB infection- IGRA´s

– Mantoux (TST)

– IGRA (Quantiferon-QFT, T Spot TB)

Mantoux and IGRA tests

Measures immunilogical responce

to TB antigens in the kits or in the

TST solution

Mtx (TST) / IGRA- tests

• Cannot be used to diagnose active TB disease

– 20% of those with active disease have anergy

– Will not reverse to zero after treatment

• Can be used to diagnose TB infection- latent TB

– Of no use if no intention to treat latent TB

– TST difficult to interpret if BCG vaccinated or repeated tests with TST

Conclusions

• TB control of seafarers is not obligatory per se following the Norwegian TB regulation

– Follows a risk group aspect

– Seamen recruited from High incidence countries are often at risk of beeing infected in their childhood

• Contageous diseases are contraindication for working on ships and installations

• Main screening method should be CXR

• Mantoux/IGRA normally not indicated