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Tuberculosis
Elissa Schechter-Perkins MD, MPH, DTMH
Assistant Professor of Emergency Medicine
Boston university School of Medicine
Emergency Department Diagnosis, Treatment, and Infection Control
Topics of Discussion
! Suspicion of TB
! Initial Management
! Infection Control
Who Might have Tuberculosis
Worldwide
United States
: Leading infectious cause of death Affects over 1/3 of the world’s population
1,700,000 die every year from it
: Increased from 1980s-1993 2010 3.6 cases/ 100,000 people
11,182 Massachusetts
http://www.cdc.gov/tb/statistics/reports/2010/pdf/report2010.pdf
Who Might have Tuberculosis
Worldwide
United States
: Leading infectious cause of death Affects over 1/3 of the world’s population
1,700,000 die every year from it
: Increased from 1980s-1993 2010 3.6 cases/ 100,000 people
: Massachusetts 2010 3.3 cases/100,000 people
222
11,182
2010 Annual Statistical Report, Division of Tuberculosis Prevention and Control, Bureau of Infectious Disease Prevention, Response and Services, MA Department of Public Health
Why the ED�We See It
TB Risk Factor Percentage (in US)
Racial/Ethnic Minorities Hispanic/Latino
Asian/Pacific Islander Black/African American
29% 28% 25%
Foreign Born 59%
2009 Annual Statistical Report, Division of Tuberculosis Prevention and Control, Bureau of Infectious Disease Prevention, Response and Services, MA Department of Public Health
Why the ED�We See It
TB Risk Factor Percentage in MA
(Case Rate)
Substance Abusers 9%
Homeless 3%
(24.9/100,000)
Correctional Facilities 2%
(20/100,000)
Nursing Homes 2%
*Information limited by incomplete HIV reporting
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Why the ED�We See It
! Most likely to have tuberculosis: ethnic Minorities, Foreign Born, those with HIV, drug users, nursing home patients, homeless patients, prisoners, Chronic illnesses such as Diabetes and Renal Failure
! Most Likely to have ! no “usual source of care”
! Acute illnesses requiring urgent medical attention
! Most Likely to show up to an ED near you
High Risk
Why the ED�We See It
Ethnic Minorities Foreign Born HIV Drug Users Nursing Home Homeless Prisoners Chronic Disease
Why the ED�We Miss It
! In a 30 month time period, 44 contagious TB patients made 66 ED visits prior to TB diagnosis
Sokolove, PE et al. “The Emergency Department Presentation of Patients with Active Pulmonary Tuberculosis.” Academic Emergency Medicine Volume 7 Issue 9, September 2000
Why the ED�We Miss It
! Nearly 50% of newly diagnosed TB cases had antecedent ED visit in previous 6 months ! An average of 2.2 visits
! As approached diagnosis, more likely to have an ED visit
! ED Visitors are the most sick of all TB patients
Long, R et al. “The emergency department is a determinant point of contact of tuberculosis patients prior to diagnosis.” The International Journal of Tuberculosis and Lung Disease. 6(4):332–339. April 2002.
Why the ED�We Miss It
! Not Improving - at least in MA ! Between 2008 and 2010:
! 144/650 documented TB cases sought care in an ED
! only 10 had TB diagnosed (7%)
! More than 35 of them had multiple ED visits
Patricia A. Iyer, MSN, RN, BC, et al. Massachusetts Department of Public Health, Tuberculosis Prevention and Control
Why the ED�We Miss It
And it could be your ED
Not just urban areas
In 2009, 116 TB patients visited different EDs throughout MA
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Sue Etkind, R.N., MS Director, Division of TB Prevention and Control
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Why the ED�We Miss It
! In hospitalized patients, the median interval from admission to initiation of medications was 6 days
! 75% of patients had a delay of at least 24 hours
Rao VK, Iademarco EP, Fraser VJ, et al. Delays in the suspicion and treatment of tubercu- losis among hospitalized patients Ann Intern Med. 1999;130:404-411.
Why the ED�We Miss It
! Clinical presentation of TB can be variable and non-specific ! Cough present in only 64%
! Cough was Chief Complaint in only 20%
! Only 36% had respiratory complaint at triage
Sokolove, PE et al. “The Emergency Department Presentation of Patients with Active Pulmonary Tuberculosis.” Academic Emergency Medicine Volume 7 Issue 9, September 2000
Why the ED�We Miss It
! Clinical presentation of contagious TB patient may not even be related to TB
Sokolove, PE et al. “The Emergency Department Presentation of Patients with Active Pulmonary Tuberculosis.” Academic Emergency Medicine Volume 7 Issue 9, September 2000
Why the ED�We Miss It
! Even worse for children ! 60 children seen in clinic had been seen in
ED previously
! 27% had extra-thoracic disease
! Frequently accompanied by adult with undiagnosed pulmonary TB
Andrea T. Cruz et al. Emergency Department Presentation of Children With Tuberculosis. Academic Emergency Medicine 2011; 18:726–732
Muñoz FM, et al. Tuberculosis among adult visitors of children with suspected tuberculosis and employees at a children’s hospital. Infect Control Hosp Epidemiol. 2002; 23:568–72
Why the ED�We Miss It
! Definitive diagnosis is frequently not possible in the ED ! Culturing the organism can take days to
weeks
! Ziehl-Neelson staining, which identifies Acid Fast Bacilli, is only 50-80% sensitive
Why the ED�We Spread It
Rothman, RE et al. “Communicable Respiratory Threats in the ED: Tuberculosis, Influenza, SARS, and Other Aerosolized Infections.” Emergency Medicine Clinics of North America. 24(4) 2006.
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Why the ED�We Spread It
! Between Patients
! From Patients to Health Care Workers
! From Patients to Family Members
Why the ED�We Spread It
! Emergency Department Infrastructure ! Overcrowding in the Waiting Room
! Boarding in ED Hallway or Room without sufficient Ventilation Precautions
Between Patients
Why the ED�We Spread It
! Acuity in the ED ! Intubation
! Induced Sputum
! Nebulized Medications
! Atypical Presentations
PATIENTS->STAFF
Why the ED�We Spread It
! Emergency Department staff at risk ! TST Conversion from 1-12%
! Higher than other hospital workers
PATIENTS->STAFF
6* more likely
Why the ED�We Spread It
! In Peru ! High prevalence of TB
! Virtually no infection control measures
! 56% of staff baseline Quantiferon positive
! 30% of staff that had tested negative converted in one year period
PATIENTS->STAFF
A. R. Escombe, et al. Tuberculosis transmission risk and infection control in a hospital emergency department in Lima, Peru. INT J TUBERC LUNG DIS. 2010. 14(9):1120–1126
Why the ED�We Spread It
! Patients go upstairs
! Patients go home
PATIENTS->Family
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Topics of Discussion
! Suspicion of TB
! Initial Management
! Infection Control
Case #1
! CC: Cough, fever
! HPI: 35 y/o male with 4 days of cough productive of yellow sputum
! PMH: None
! Meds: None
! Exam: Febrile, well appearing, coughing. Rales at Right Lung Base
Community-Acquired Pneumonia
! Organisms: ! S pneumoniae
! h flu
! Atypicals
Ethnic Minorities Foreign Born HIV Drug Users Nursing Home Homeless Prisoners
Community-Acquired Pneumonia
! High level Drug Resistant strep Pneumoniae
Case #2
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Community-Acquired Pneumonia
Community-Acquired Pneumonia
! Don’t we use Respiratory Fluoroquinolones to treat resistant TB??
! Can this be a problem??
Community-Acquired Pneumonia
! Partially treated Tuberculosis ! Delay in Diagnosis
! Development of Resistant Tuberculosis
Fluoroquinolone Risk
Community-Acquired Pneumonia
! Appears to be more theoretical
Fluoroquinolone Risk
Community-Acquired Pneumonia
! Of 428 Pts diagnosed with Pulmonary Tuberculosis: ! 17% of patients had been prescribed a
Fluoroquinolone in Previous 6 Months
! Most within 90 days of diagnosis
! Only 3/74 who had been treated had resistant TB ! All had received more than one course of
Fluoroquinolones
Fluoroquinolone Risk
Long, Richard Et Al. “Empirical Treatment of Community Acquired Pneumonia and the Development of Fluoroquinolone-Resistant Tuberculosis.” Clinical infectious Disease. 48:1354-1360. 2009.
Community-Acquired Pneumonia
Fluoroquinolone Risk
! Among Fluoroquinolone Resistant Tuberculosis, Majority Appear to be in MDR-TB ! Likely secondary to Multi-Drug Regimen
! Not Due to Isolated Fluoroquinolone Use in the Community
Huang TS, et al. “Trends in fluoroquinolone resistance of Mycobacterium tuberculosis complex in a Taiwanese medical centre: 1995–2003.” Journal of Antimicrobial Chemotherapy. 56:1058–62. 2005
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! Might be a Bigger Problem if ! Prevalence of TB Increases
! Use of fluoroquinolones Increases
! Consider Trying Alternative Regimens
Community-Acquired Pneumonia
Fluoroquinolone Risk
Community-Acquired Pneumonia
! Consider Missed TB if Patient Returns After Failing Course of Fluoroquinolones
Fluoroquinolone Risk
Case #3
! 46 year old homeless male, Born in Peru, complains of cough,fever, night sweats, and weakness for 1 month
Clinical Suspicion ! We Learned:
! Cough >2 weeks Duration
! Dyspnea
! Fevers/chills
! Night Sweats
! Weight Loss
! Hemoptysis
! We See: ! Variable Clinical Presentation
High Suspicion of TB
! Decision to initiate treatment ! Epidemiologic information
! Clinical, Pathologic, and Radiologic Findings
! Microscopic Findings of Acid Fast Bacilli
! Cultures for Mycobacteria
High Suspicion of TB
! Chest XRay ! Looking primarily for Active pulmonary
tuberculosis
In the Emergency Department
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High Suspicion of TB
! Sputum Sample ! Looking for AFB on Smear (Ziehl-Neelson
Stain)
! Sensitivity of 60% in Culture Positive Pts
! Depends on skill of lab tech
! Depends on Bacillary Load
! Rapid
In the Emergency Department High Suspicion of TB
! Sputum Sample ! Looking for AFB on Smear (Ziehl-Neelson
Stain)
! Rapid
! Sensitivity of 60% in Culture Positive Pts
! Depends on skill of lab tech
! Depends on Disease Burden
! Culture
! Slower Results
! Gold Standard
In the Emergency Department
High Suspicion of TB In the Emergency Department
! Other Methods ! PPD
! QuantiFERON® Gold
High Suspicion of TB
! Disposition? ! Can be treated as Outpatient
! NOT SO EASY!!
! Not Ill Appearing
! Appropriate Social Situation
! Contact with Local TB program
In the Emergency Department
! Most Will Be Admitted
Case #4
! 46 year old female, noncompliant with HIV meds, complains of cough for 1 month
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Tuberculosis AND HIV
! Occurs at ANY CD4 Count (only 11.4%of TB patients have HIV)
! Degree of immunosuppression influences clinical, radiographic, and histopathologic presentation of TB ! CD4>350: Appears as typical TB (RUL, +/-
cavitations) ! CD4<200: Extrapulmonary manifestations,
sepsis syndrome with (-) CXR, no granulomas or cavitations, miliary TB
! 1/3 of AIDS patients have primary TB
! 2/3 have Reactivation TB ! 7-10% annual risk in HIV-infected patients with
positive tuberculin skin test (TST) ! In HIV uninfected, 5-10% lifetime risk
! Faster Progression of HIV
! More Severe TB in HIV
Tuberculosis AND HIV
! Sputum Smear AND culture
! Need 3 (Decreased sensitivity when immunocompromised)
Tuberculosis AND HIV
! Treatment Depends on Whether on ARV ! IF CD4 <50, may start ARV as well as TB Regimen
! If CD4 50-100, Will likely start ARV after induction phase of TB Regimen
! if CD4>200, will likely wait until after TB treatment has finished
Tuberculosis AND HIV
! Caution if already on ARV ! Liver failure (check LFTS!)
! IRIS
Tuberculosis AND HIV Case #5
! CC: Back Pain
! HPI: 19 y/o male from Vietnam with gradually increasing back pain
! PMH: None
! Meds: None
! Exam: Uncomfortable, Significant Tenderness over back
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More Tuberculosis
! Can be Anywhere
! Does NOT require isolation unless it is pulmonary or laryngeal, or in a wound that will be I&D’d
Topics of Discussion
! Suspicion of TB
! Initial Management
! Infection Control
Why Bother
! 6 Fold Decrease in Development of LTBI After Beginning Infection control program with Administrative, Engineering, and Respiratory Protection elements
Behrman A, Et Al. “Tuberculosis exposure and control in an urban emergency department.” Annals Emergency Medicine. 3(3):370–5. 1998.
Back to Basics ! Spread by droplet nuclei
(airborne particles)
! From Patients with Pulmonary or Laryngeal TB
! Cough, Sneeze, Shout
! Aerosolized from TB wounds ! Abscesses I&D’d
! 1-5 µm
! Normal air currents keep particles airborne for prolonged periods
High Risk Transmission ! Exposure to TB in small, enclosed spaces
! Inadequate local or general ventilation that results in insufficient dilution or removal of infectious droplet nuclei.
! Recirculation of air containing infectious droplet nuclei.
! Inadequate cleaning and disinfection of medical equipment
! Improper procedures for handling specimens.
Hierarchy of Infection Control
Centers for Disease Control and Prevention. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR 2005;54(No. RR-17)
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Infection Control ! Administrative controls
! reduce risk of exposure via effective IC program
! Environmental controls: ! prevent spread and reduce concentration of
droplet nuclei
! Respiratory protection controls: ! further reduce risk of exposure in special
areas and circumstances
Administrative Controls
! Test and evaluate HCWs at risk for TB or for exposure to M. tuberculosis
! Train HCWs about TB infection control
! Ensure proper cleaning of equipment
! Use appropriate signage advising cough etiquette and respiratory hygiene
Respiratory Protection (RP) Controls
! Implement RP program ! Protocols
! Training
! Mask Fitting
! Minimum respiratory protection is a filtering facepiece respirator ! nonpowered, air-purifying, half-facepiece,
! N95 disposable
Environmental Controls
! Control source of infection
! Dilute and remove contaminated air
! Prevent Spread of Infectious Droplet Nuclei
! Reduce Concentration of Infectious Droplet Nuclei
! Control airflow (clean air to less-clean air)
! High Air Flow (At Least 6 Air Changes/Hour)
! Air Cleaning Methods
! High Energy Particulate Air Filtration (HEPA)
! Ultraviolet Germicidal Irradiation (UVGI)
! Negative Pressure
! Air Exhausted to the outside
Environmental Controls Environmental Controls
! Airborne Infection Isolation Rooms (“TB Room”)
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! 1995 Most ED’s did not have adequate environmental Measures ! 1.7% of Triage/Waiting Areas
! 19.6% of EDs
! Have things changed since then??
Environmental Controls
Moran, GJ et al. “Tuberculosis infection-control practices in United States emergency departments.” Annals of Emergency Medicine. 26(3) 283-289. 1995;
Resource utilization
! If The ED Has Isolation Rooms
! The Trick is getting the Appropriate Patients into these Rooms
Protocols for Identifying, Evaluating, and Managing Infectious TB Patients
Triage
! Important and Vulnerable point of Entry into the ED and the Hospital
! Effective Strategy here will Minimize Nosocomial Infections Throughout ED and Entire Hospital
Triage
! Initial Patient Encounter
! Consider Infection Control Measures on Arrival ! Masking
! ED Isolation Room
! Notification of Staff Members
Difficulties
! Triage Procedures Have met with Limited Success ! In Sensitivity
! In Specificity
! Problem is that Talking to the Patient is Just Not Sufficient
Plan?
! Mask Everybody With a Cough ! Droplet Precautions Sufficient for most
Bacteria/Viruses
! Large Droplets
! Don’t Remain Suspended in the Air
! “TB Rooms” for Those with high-risk epidemiologic factors
! High-Risk Procedures Done only in Rooms with Non-Recirculated Air
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Admission to Hospital
! If ED Does not have Isolation Room: ! Rapid Identification of possible Cases
and Rapid Admission to Hospital Bed
Admission to Hospital
! If ED Does have Isolation Room: ! Screen High-Risk patients in ED to
Determine Who Needs an Isolation Bed
Decision Instrument ! History of Tuberculosis
! Immigrant
! Homeless
! History of Incarceration
! Recent Weight Loss
! Chest Radiograph with Apical Infiltrate
! Chest Radiograph With Cavitary Lesion
Moran, Gregory G et al. “Decision Instrument for the Isolation of Pneumonia patients with Suspected Tuberculosis Admitted Through US Emergency Departments.” Annals of Emergency Medicine. 53(5) 2009
Decision Instrument
! Sensitivity: 96.4%
! Specificity: 48.7%
Decision Instrument
! Effectiveness (Post-test Probability) will always depend on your prevalance ! Peru
! High prevalence area, not found to be sufficient
! Urgent care area that has never had a case of TB
! You will be isolating a large number of ultimately negative pts
Lely Solari, et al. Evaluation of Clinical Prediction Rules for Respiratory Isolation of Inpatients with Suspected Pulmonary Tuberculosis. Clinical Infectious Diseases 2011;52(5):595–603.
What Have We Learned