UNIDOS Binational TB Conference How to Conduct a Binational TB
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 ◦ ◦ ◦ ◦ ◦ 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 6 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 ◦ ◦ ◦ ◦ ◦ 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 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 Bacteriologic results Anti-TB chemotherapy regimen HIV results Patient's concurrent medical conditions Other diagnoses Demographic information 9 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 ◦ ◦ ◦ ◦ ◦ ◦ Patient Updates Lab results Chest X-rays Sputums TB-400s Consultation letters Confidentiality City of Laredo Health Department 13 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
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