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