Community-Driven Tuberculosis Interventions for Aboriginal

Communities

Jessica Harper & Nash DhallaFebruary 19, 2015

Hyatt Regency Vancouver

Conflict of Interest:

Neither presenter (Nash Dhalla, RN, BScN or Jessica Harper, RN, BScN) have any affiliation financial or otherwise, with a commercial or other industry interest that may bias our presentation.

Outline

1. TBSAC: Who we are2. What is TB?3. TST vs IGRA4. Feasibility of Portable

Incubator in LTBI testing

5. Challenges6. Next Steps

TB Services in BC• Centralized: pharmacy, labs, database, physician

consultant, and nurse consultant services provided by TB Services, BC Centre for Disease Control

• TB Services for Aboriginal Communities (TBSAC): provides TB services to Health Centers located on-reserve, funded and delivered in partnership with First Nations Health Authority (FNHA).

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TB Services

First Nations Communities

TB Services for Aboriginal

Communities

First Nations Health Authority

Community Health NurseCommunity Health WorkerDOT WorkersHealth DirectorsCommunity Members

CDC Coordinator-TB, Funding, Education, Resources

Physician ConsultationNurse ConsultationCase ManagementPharmacy, Lab, Diagnostics, X-Ray, Surveillance, Training and Education

TB TeamBCCDC (TBSAC)• Dr. Victoria Cook, TBSAC

Physician• Shawna Buchholz, Clinical

Nurse Educator• Nash Dhalla, Nurse

Consultant• Karen Beinhaker, Nurse

ConsultantFNHA, Health Protection

• Jessica Harper, CDC Coordinator, TB

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Background: What is TB?

• Mycobacterium tuberculosis• Airborne disease• Generally infects the lungs• In BC: incidence rate of ~7 per 100 000• Symptoms: coughing, fever, weight loss, night sweats• Curable and Preventable!

Background: What is LTBI?

• “Sleeping” Latent TB infection (LTBI):– Infected with bacteria? YES– Symptoms present? NO– Infectious? NO

• A healthy individual infected with LTBI has a 5-10% risk of developing active TB over their lifetime

(BCCDC TB Control Manual, 2012)

Background: Diagnosing & Treating LTBI

• Tuberculin Skin Test (TST) is an intradermal injection of 0.1ml of purified protein derived from M.Tuberculosis bacteria

• Follow up Chest X-ray to check for active TB

Background: Diagnosing & Treating LTBI

• Recommended for preventative therapy:– Isoniazid for 9 months –270 doses OR– Rifampin for 4 months –120 doses

• Decision to start treatment is based on:– Context of TST – likelihood of false positive– Reason client was being tested– Risk of progression to active disease– Ability to adhere to medication– Possible intolerance to medication– Alcohol use, desire for pregnancy, etc.

(BCCDC TB Control Manual, 2012)

The IGRA Test• Interferon Gamma

Release Assay (IGRA)• Detects interferon gamma

released from WBC• Two tests: Quantiferon

Gold and T-Spot• BC: offered in Vancouver,

New Westminster, Victoria, Prince George and Kelowna

IGRA vs. TST

(TB Manual: Interferon Gamma Release Assay Testing Guideline for Diagnosis of Latent Tuberculosis Infection by Physicians, 2013, pg. 2)

TST vs. IGRATST IGRA

Good for serial testing Not as good for serial testing

Inexpensive More expensive

Universally accessible Skill, equipment and timeframe needed limit accessibility

Low specificity in certain populations (BCG-60%)

High specificity in all populations

Two visits One visit

Variability in test interpretation by reader *****

Low variability in test interpretation by reader

WHY IGRA?

• To identify the proportion of patients in whom treatment for LTBI could be avoided because an IGRA test was negative yet a TST test was positive.

• To determine if there is a statistically significant difference in treatment adherence between BC residents who have had LTBI confirmed with an IGRA test and those whose diagnoses was made using a TST only.

IGRA Feasibility In First Nations Communities

• Currently IGRA is offered at the BCCDC, in New Westminster, Victoria, Kelowna and Prince George

• Increase access to testing for patients who are less likely/able to travel for testing:– Remote communities – Outbreak investigation– Enhanced communities

• Identify and treat true LTBI• Are communities interested in the IGRA test?

IGRA testing: Feasibility

• TBSAC Team & Community Leaders discussed IGRA– Based on enhanced community survey– Strong links with HCP– Geographic location – IGRA available in Canada 2007 with strong

evidence base– BCG Factor– Community engagement

Results: Feasibility TestCommunity approvalMeet with BCCDC lab to agree on expectations of

how samples are deliveredDevelop detailed protocol on sample collection,

processing and transportation to lab– Confirm site visit date(s)– Conduct site visit & feasibility test– Determine results– Summarizing results– Lessons learned

Vision of the FNHA

In partnership with BC First Nations Communities the FNHA TBSAC program is working towards the Vision of:

“Healthy, Self-determining and Vibrant BC First Nations Children, Families and Communities.”

Acknowledgements BCCDC- Zoonotic LabYvonne SimpsonMuhammad MorshedQuantine Wong

FNHA and TBSAC teamApril MacNaugtonDr. Isaac SobolDr. Victoria Cook Jane LopezMaggie Wong Shawna BuchholzKaren Beinhaker

• First Nations Communities • Healthcare Professionals• Community members• Community leaders

Thank You!

Contact InformationTBSAC Nurses: • Nash Dhalla: (604)707-2695Nash.dhalla@bccdc.ca• Karen Beinhaker: (604)707-

2732karen.beinhaker@bccdc.ca• Shawna Buchholz: (250)878-

4928Shawna.buchholz@bccdc.caFNHA Nurse:• Jessica Harper: (604)693-6955jessica.harper@fnha.ca

TBSAC Fax: (604)707-2690TBSAC Toll Free: 1-888-569-2299

FNHA Health Protection Toll Free:1-844-364-2232

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Thank You!