The Challenges of Multi-Drug Resistant (MDR) Tuberculosis Investigation and Follow-up: The Challenges of Multi-Drug Resistant (MDR) Tuberculosis Investigation and Follow-up Aaron Aitchsion, PHN Middlesex-London Health Unit


What’s Involved in a TB investigation?: What’s Involved in a TB investigation? 1. Isolate the case 2. Establish a treatment regime 3. Establish compliance with treatment regime 4. Establish period of infectivity 5. Determine degree of infectiousness 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts”


What’s challenging in a TB investigation?: What’s challenging in a TB investigation? Communication language barriers risk Cross Jurisdictional referrals Stigma iPHIS


What’s challenging in a MDR-TB investigation?: What’s challenging in a MDR-TB investigation? Treatment of the case Prophylaxis of those exposed to the case Stigma MDR-TB is a result of a breakdown in: 1. Isolate the case 2. Establish a treatment regime 3. Establish compliance with treatment regime 4. Establish period of infectivity 5. Determine degree of infectiousness 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts”


Identifying the case: Identifying the case Father flagged for Immigration Medical Surveillance for Inactive TB Interview: smoker’s cough + previous treatment for lung infection (denied TB diagnosis) Administered TB skin test  Sent for Chest x-ray


Slide8: Cavitating lesion + lived in top 23 high-burden countries 1. Isolate the case 2. Establish a treatment regime 3. Establish compliance with treatment regime 4. Establish period of infectivity 5. Determine degree of infectiousness 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts”


Isolating the case: Isolating the case Language barrier (interpreter exposures) Strain on family son’s interpretation = shoot the messenger new to country and lose head of household Admitted to negative pressure Obtain sputum for laboratory analysis Wait for results


Treatment: Treatment 1. Isolate the case 2. Establish a treatment regime - standard four drug therapy 3. Establish compliance with treatment regime 4. Establish period of infectivity 5. Determine degree of infectiousness 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts” 1. Isolate the case 2. Establish a treatment regime - standard four drug therapy 3. Establish compliance with treatment regime - acute care 4. Establish period of infectivity 5. Determine degree of infectiousness 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts”


Infectivity: Infectivity 1. Isolate the case 2. Establish a treatment regime - standard four drug therapy 3. Establish compliance with treatment regime - acute care 4. Establish period of infectivity - cough present since arrival to Canada 5. Determine degree of infectiousness 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts” 1. Isolate the case 2. Establish a treatment regime - standard four drug therapy 3. Establish compliance with treatment regime - acute care 4. Establish period of infectivity - cough present since arrival to Canada 5. Determine degree of infectiousness - smear = numerous (highly infectious) 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts”


Infectivity: Infectivity 1. Isolate the case 2. Establish a treatment regime - standard four drug therapy 3. Establish compliance with treatment regime - acute care 4. Establish period of infectivity - cough present since arrival to Canada 5. Determine degree of infectiousness - smear = numerous (highly infectious) 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts” Resistant to INH and Rifampin 2nd line drugs West Park Treatment facility


Challenges in determining contacts?: Challenges in determining contacts? Transmission factors related the case Transmission factors related to shared air space Transmission risk factors related to exposed person Case was smear (numerous) Previous treatment failure Huge cavity on CXR Denial of diagnosis Symptomatic (cough) Over 6 years old


Slide14: Small classrooms Contact 5 days a week High risk for previous infection Less shared space High risk for previous infection Common volume of air Re-circulated air Ultraviolet radiation?


Issues with Contact Tracing: Issues with Contact Tracing 1. Isolate the case 2. Establish a treatment regime - 2nd line drugs 3. Establish compliance with treatment regime - West Park 4. Establish period of infectivity - cough present since arrival to Canada 5. Determine degree of infectiousness - highly infectious 6. Establish “contacts” - family / airplane / settlement house / ESL School 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts” 1. Isolate the case 2. Establish a treatment regime - 2nd line drugs 3. Establish compliance with treatment regime - West Park 4. Establish period of infectivity - cough present since arrival to Canada 5. Determine degree of infectiousness - highly infectious 6. Establish “contacts” - family / airplane / settlement house / ESL School 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts”


Our Plan of Action: Our Plan of Action Multiple teleconferences with experts from around the world Greater than 1 hour of face-to-face contact Rx PZA and ETBI for 6 months Moxifloxacin substituted for PZA or ETBI if side effects developed CXR’s at 0, 3, 6, 12, 18, 24 months


The research says…: The research says… Fraser et al Int Jouranl of TB (2006). Systemic review of comparative studies of people treated and not treated of LTBI following MDR-TB exposure Presented combinations of PZA/ETBI, PZA and a quinolone, ETBI and a quinolone, Quinolone alone Serious adverse effects can affect adherence causing prolonged treatment, further development of resistance and relapse. The balance of benefits and detriments is far from clear and should be addressed in a randomized controlled trial.


Our Plan of Action: Our Plan of Action Baseline and monthly blood tests (CBC, BUN, creatinine, uric acid, HIV, Hepatitis screening and LFT’s) Opthalmologic assessment with dilation at 0, 3, and 6 months with Ishihara color tests performed monthly Twice monthly symptom and side effect review


Slide19: TBST PZA + ETBI TBST Offer INH TBST PZA + ETBI Referred flight manifest to PHAC


Slide20: 33 TBST+ 19 of 33 complete PZA/ETBI Entire family TBST+ 1 secondary case 3 of 12 complete PZA/ETBI Unknown Many TBST+ Majority complete INH


The Clinic Challenges: The Clinic Challenges At least 7 different languages Minimal literacy in mother tongue Cultural taboos of TB and gender Index family persecution (moved) New immigrant population mobility Risk factors for TB already Healthcare issues unrelated to TB


The Family results…: The Family results… Index case + 1 secondary case (not MDR) 12/12 TBST (+) (further evidence of infectiousness) 3/12 completed prophylaxis Family re-located due to stigma (media) Index case remains defiant of TB diagnosis


The “other” results…: The “other” results… Many interpreters TBSTed with 3 positive and several previously positive Only one offered MDR prophylaxis and did not complete (INH for others) Only one settlement house contact offered MDR prophylaxis – completed (INH for others)


The Side Effects: The Side Effects Elevated liver enzymes (abdominal pain) Headache Fatigue Alterations in mood Yeast infections Joint aches


In Conclusion...: In Conclusion... 1. Isolate the case 2. Establish a treatment regime - 2nd line drugs 3. Establish compliance with treatment regime - West Park 4. Establish period of infectivity - cough present since arrival to Canada 5. Determine degree of infectiousness - highly infectious 6. Establish “contacts” - family / airplane / settlement house / ESL School 7. Co-ordinate follow-up of “contacts” - clinics 8. Offer prophylaxis to “contacts” - INH and PZA/ETBI (Moxi)


All TB Investigations are challenging...: All TB Investigations are challenging... 1. Isolate the case 2. Establish a treatment regime 3. Establish compliance with treatment regime 4. Establish period of infectivity 5. Determine degree of infectiousness 6. Establish “contacts” 7. Co-ordinate follow-up of “contacts” 8. Offer prophylaxis to “contacts” Communication Cross Jurisdictional referrals Stigma iPHIS