1. health and fitness

1/6/2012
UNIDOS Binational TB
Conference
How to Conduct a Binational TB
Contact Investigation
Veronica Dominguez, RN, BSN
November 16, 2011
Veronica Dominguez, RN, BSN has
the following disclosures to make:
• There are no conflicts of interest to
disclose.
• No relevant financial relationships with
any commercial companies pertaining
to this educational activity.
City of Laredo Health Department
1
1/6/2012
Conducting a Binational
TB Contact Investigation
Veronica Y. Dominguez, RN, BSN
City of Laredo Health Department
Catalina Navarro, RN, BSN
Heartland National TB Center
City of Laredo
Health Department
Objective

Identify the components of a Binational
contact investigation
◦
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◦
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Initiation of a contact investigation
Investigation and interviewing of index patient
Contact priorities and evaluation
Treatment
Data management and communications across
the border
◦ Confidentiality
City of Laredo Health Department
2
1/6/2012
What is a Contact Investigation?

A Systemic Process to
identify contacts
exposed to an
infectious TB case, find
and assess them, and, if
necessary, treat them.
Contact
Contact
Contact
Contact
Contact
Contact
Contact
City of Laredo Health Department
TB Contact Investigation

One of the highest priorities for TB
programs
◦ Second in importance only to detection and
treatment of TB disease

A Crucial Prevention Strategy
◦ On average, 30% of contacts will have latent TB
infection (LTBI)
◦ 1% of contacts will have TB Disease
◦ Of those infected, approximately ½ will develop
active TB disease within 2 years
City of Laredo Health Department
City of Laredo Health Department
3
1/6/2012
Benefits of a Contact Investigation?


Find and treat
additional TB cases
(potentially stopping
further transmission)
Find and treat persons
with LTBI to prevent
future cases
City of Laredo Health Department
Source-Case Investigations?
Moves in the opposite
direction of a contact
investigations
 (same principles apply)

City of Laredo Health Department
4
1/6/2012
Source-Case Investigations
Seeks the source of recent M. tuberculosis
infection
 Children <5 years with TB disease
typically indicate recent infection
 Sentinel public heath event

Contact Investigation
Responsibilities
Health Departments are responsible for
conducting contact investigations
 Contact investigations are complicated
activities that require

◦ Many interdependent decisions
◦ Time-consuming interventions
City of Laredo Health Department
City of Laredo Health Department
5
1/6/2012
Binational Patient?

Defined as meeting at least one of the following criteria:
◦ Patient lives in Mexico but has relatives in the U.S.
◦ Patient has dual residency in the U.S. and Mexico
◦ Patient has contacts on both sides of the border, in the U.S. and
Mexico
◦ Patient started treatment in the U.S. but returns to live in
Mexico
◦ TB patients referred from the U.S. for treatment or follow-up in
Mexico.
City of Laredo Health Department
Initiating a
Contact
Investigation
Binational Nurse Assessing Living Conditions
City of Laredo Health Department
City of Laredo Health Department
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1/6/2012
Initiating a Contact Investigation

Should be considered if the index patient has
◦ Confirmed or suspected pulmonary, laryngeal, or pleural TB
◦ CXR consistent with pulmonary TB

Recommended if
◦ Sputum smear + for AFB
◦ Cavitary CXR (AFB smear -)

Highest Priority
◦ AFB smear or culture + sputum and
◦ Cavitary TB
*Acid-fast bacilli
†Nucleic acid assay
§Approved indication for NAA
¶Chest radiograph
City of Laredo Health Department
7
1/6/2012
Contact Investigation
Protocol Comparison

Mexico
◦ Study of Symptoms
◦ Bacilloscopy of sputum
from coughers
◦ X-rays in symptomatic
adults with positive BAAR
and in all those <15 yrs old
with symptoms

United States
◦ Symptoms screening, TST,
and x-rays (if needed)
◦ Sputum AFB smear and
culture in individuals with
abnormal x-rays,
symptomatic or not
◦ X-ray if TST reactive (≥
5mm), symptomatic, and in
children < 4yrs regardless
of TST skin test results
Investigating and
Interviewing of the Index Patient
and Sites of Transmission
City of Laredo Health Department
8
1/6/2012
Comprehensive Index Patient
Information
Foundation of a contact investigation
 Information to be gathered includes

◦
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Disease characteristics
Onset time of illness
Names of contacts
Exposure locations
Current medical factors (e.g., initiation of tx,
drug susceptibility results)
Data to Collect
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History of previous exposure
or infection
History of previous disease
and treatment
Anatomical site of TB disease
Symptoms of illness
Date of onset
Chest X-ray results
City of Laredo Health Department
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Bacteriologic results
Anti-TB chemotherapy
regimen
HIV results
Patient's concurrent medical
conditions
Other diagnoses
Demographic information
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1/6/2012
Contact Priorities
and Evaluation
Binational patient and her contacts
City of Laredo Health Department
Prioritizing of Contacts
Patient has pulmonary, laryngeal, or pleural TB with
cavitary lesion on chest x-ray or is AFB sputum smear
positive
Priority
Household Contacts
High
Contacts <5 yrs of age
High
Contacts with medical risk factors (e.g., HIV)
High
Contact with exposure during medical procedure
(bronchoscopy, sputum induction, or autopsy)
High
Contact is ≥5 years and ≤15 years of age
Medium
Any contact not classified as high or medium priority is assigned a low priority
City of Laredo Health Department
City of Laredo Health Department
10
1/6/2012
Treatment for Latent Tuberculosis
Infection (LTBI)
Treatment of Latent TB Infection

Mexico

Contacts who are <5 yrs with or
without BCG:
◦ Daily administration of INH for 6
months

For contacts between the ages of
5 and 14, not vaccinated with
BCG:
◦ Daily administration of INH for 6
months

For contacts with HIV infection
or other immunosuppressive
conditions older than 15 years of
age:

United States

Without concern for age, both
the persons infected as well as
those who are considered to
have high risk of developing
active tuberculosis should be
treated for LTBI:
◦ Daily administration of INH for 9
months; or
◦ Administration of INH 2 times a
week for 9 months with treatment
strictly supervised (DOPT)
◦ Daily administration of INH for 12
months
* Diario Oficial Martes 27 de septiembre del 2005
City of Laredo Health Department
City of Laredo Health Department
11
1/6/2012
Data Management and Communications
Across the Border
City of Laredo Health Department
Data Management
Registry
 Medical Record of each active case

◦ Contact investigation data
City of Laredo Health Department
12
1/6/2012
Communications
Referrals
Quarterly meetings with health care personnel
from both sides of the border
 Phone conferences
 E-mail
 Weekly visits
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Patient Updates
Lab results
Chest X-rays
Sputums
TB-400s
Consultation letters
Confidentiality
City of Laredo Health Department
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1/6/2012
Safeguarding Confidentiality
Challenging and difficult during contact
investigations
 Essential to maintaining credibility and
trust
 Constant attention required to maintain
confidentiality
 Specific policies for release of confidential
information related to contact
investigations are recommended

City of Laredo Health Department
Case Study
City of Laredo Health Department
City of Laredo Health Department
14
CI USA
UNIDOS Binational TB
Conference
How to Conduct a Binational TB
Contact Investigation
Catalina Navarro, RN, BSN
November 16, 2011
Catalina Navarro, RN, BSN has the
following disclosures to make:
• There are no conflicts of interest to disclose.
• No relevant financial relationships with any
commercial companies pertaining to this
educational activity.
1
CI USA
Contact Investigation in a
Binational Project
Case study
Catalina Navarro RN, BSN
Heartland National TB Center
November 16, 2011
Texas Binational Projects
• Los Dos Laredos:
Laredo (Texas) and Nuevo Laredo (Mexico)
• Grupo sin Fronteras
Brownsville-Harlingen-McAllen (Texas) and Matamoros-Reynosa (Mexico)
• Projecto JUNTOS:
El Paso (Texas) Ciudad Juarez (Mexico), and Las Cruces (New Mexico)
• Projecto Esperanza y Amistad:
Eagle Pass (US) and Piedras Negras Y Ciudad Acuña (Mx)
2
CI USA
Texas-Mexico Projects
Juntos
Esperanza y Amistad
Los Dos Laredos
Sin Fronteras
Los Dos Laredos Binational
3
CI USA
Los Dos Laredos Binational Project
Activities:
• Provide expert consultation on
complicated cases (especially MDR)
• Mentoring Nurse Case Management
• Binational Outreach nurses in Nuevo
Laredo
– Patient Care
– DOT
– Home visits
– Contact Investigation
– Communication
– Education
Los Dos Laredos Binational Project
Ongoing meetings in
Laredo, Texas
4
CI USA
Challenging Binational Contact Investigation
Case with Drug Resistant TB
2004
28 y/o male with long history of
substance abuse, crack,
cocaine, diagnosed with TB
while incarcerated in Nuevo
Laredo Mx. TB treatment
started but not completed
2005
Health Department followed
patient, sputum taken AFB
smear (+), abandoned TB
treatment (2nd time)
2007
(May)
TB treatment initiated but pt
abandoned TB treatment (3rd
time)
5
CI USA
Challenging Binational CI Case with drug
resistant TB: Household Contacts
Plata-Galvez, Melanie
1 y/o
Laredo Texas, USA
September 2007
5 y/o niece
LTBI
Sister
13 y/o niece
TB Case
27 y/o sister
Refused
MOM
53 y/o LTBI
17 y/o brother
TB Case
Treated
31 y/o Male
TB case
Pansusceptible
Index case
10 y/o nephew
LTBI
22 m/o niece
LTBI
5 y/o nephew
LTBI
6 y/o nephew
LTBI
2 y/o niece
LTBI
Active TB Case
LTBI treatment
Treatment abandoned
Refuses screen/treatment
Challenging Binational CI Case with drug resistant TB:
Household Contacts
5 y/o niece
LTBI
Laredo Texas, USA
September 2007
Sister
13 y/o niece
TB Case
4 classmates
And friends
10 y/o nephew
27 y/o sister
Refused
MOM
53 y/o LTBI
17 y/o brother
TB Case
Treated
31 y/o Male
TB case
Pansusceptible
LTBI
22 m/o niece
LTBI 28
Classmates,
friends,
5 y/o nephew
teachers
LTBI
6 y/o nephew
LTBI
2 y/o niece
LTBI
6
CI USA
Index Case TB Treatment History:
Acquisition of MDR-TB
November 2007 patient moved to
Nuevo Laredo, Mexico. Treated by
Binational Project for two weeks
and abandoned TB treatment. (4th
time)
September 2008 Pt was seen in
Valverde detention Center, Texas,
US. Sputum sample was collected.
Pt deported to Mexico one week
later
November 2008 culture from
September reported MDR-TB
Outcome of Patient with
MDR-TB
Miercoles 28 de Enero de 2009
January, 2009 patient was found
dead in Nuevo Laredo.
Not injuries, pt died of MDR-TB
7
CI USA
Challenging Binational CI Case with drug resistant TB:
Household TB Cases
Plata-Galvez, Melanie
1 y/o
Nuevo Laredo, Mexico September 2010
5 y/o sister
LTBI
Mom 31 y/o
16 y/o
TB Case
(relapse)
Index case
Grandma
56 y/o LTBI
3 y/o sister
LTBI
1 y/o baby girl
LTBI
Born in US.
December 2009
16 y/o Hispanic female with history of TB treatment in 2008 , presented with
signs and symptoms of TB Sept 2010
–Weight 38 Kg
–Severe anemia (H&H 19/6) required transfusions.
–Chest X-Ray extensive cavitary left lung disease
–AFB sputum from Sept/10 (+) Cx. (+) MTB Resistant to INH (low level)
16 y/o Female with Active TB Household Contact of
MDR-TB Patient
8
CI USA
October 27/10
February 22/11
Chest X-Ray comparison: Interval increase in lucency in the right and left lung.
Outcome of 16 y/o female Household
Contact of MDR-TB
Plata-Galvez, Melanie
1 y/o
5 y/o sister
LTBI
Mom 31 y/o
16
y/o
16 y/o
DRDied
TB Case
Grandma
56 y/o LTBI
1 y/o baby girl
LTBI
Born in US.
December 2009
3 y/o sister
LTBI
March 23, 2011: Patient taken to ER where she died.
Possible cause of death: Pneumothorax
9
CI USA
Additional Active TB Cases: Household
Contacts of MDR-TB Patient
Plata-Galvez, Melanie
1 y/o
Nuevo Laredo, Mexico March 2011
Grandma 56 y/o
LTBI
Mom 31 y/o
Mom 31 y/o
TB Case
21 y/o aunt
21
y/o Aunt
TB case in 2009
MDR-TB case
Abandoned
Rx
Pregnant
20 y/o uncle
TB Case
5 y/o sister
LTBI
16 y/o female
death
1 y/o daughter
LTBI
3 y/o sister
LTBI
2 y/o
LTBI
5 y/o
LTBI
Baby
Migration of MDR-TB infectious
Pregnant Patient to US to Deliver
10
CI USA
Challenges
• Difficult to trace contacts due to:
– Reluctance to reveal contact names
– Threat to individual privacy
– Criminal activities of TB patients
– Violence
– Stigma
– Fragmented information
Conclusions
• Poor adherence to treatment leads to acquisition of drug
resistant.
• TB is spreading due to poverty, overcrowding, and
malnutrition.
• Ethical dilemmas about TB treatment
• The situation of TB on the border is worsening because
this region doesn’t function as a binational
epidemiological unit.
• Lack of uniformity between the TB control programs
Pan American Health Organization/World Health Organization. The Situation of Tuberculosis
on the United States- Mexico Border El Paso, TX: PAHO/WHO. March 2011
11
CI USA
“…However, with 1.7 million people dying from
tuberculosis last year - including 380 000 women,
many of whom were young mothers - these
successes are far too fragile. No government is
doing too much in TB. Commitments are being
short-changed. If governments are genuinely
committed to stopping TB, they must seize all the
opportunities that are available right now and all
the opportunities that may come in the near
future."
Dr Mario Raviglione, Director of the WHO Stop TB Department.
“If you ignore the problem, TB
doesn’t go away, it gets worse,”
Dr Michael E. Kimerling, Senior Program Officer for TB at the Bill & Melinda Gates Foundation
12
CI USA
To review
HCW Vs. TB
13