Time to Review Your Hospital Tuberculosis Control Plan: Updated CDC Guidance

This is a guest post by Jorge Salinas, MD, Hospital Epidemiologist at University of Iowa Hospitals and Clinics.

The National Tuberculosis Controller Association (NTCA) and the Centers for Disease Control and Prevention (CDC) just published their updated guidance for the prevention of M. tuberculosis (TB) transmission in healthcare settings.

The previous guidelines (2005) called for tuberculosis screening for all healthcare workers upon hire and yearly if working in medium-risk settings. The setting risk was calculated based on the number of TB cases seen in the previous year. While most United States Hospitals were considered low risk, many large academic medical centers and hospitals in states with a higher incidence of TB were considered medium-risk. Fortunately, a number of studies performed in developed settings show that the rate of latent TB infection among healthcare workers is not different than the general population. In the updated guidance, hospitals previously considered medium-risk would continue testing upon hire but discontinue yearly TB screening (tuberculin skin testing or interferon gamma-release essay). This recommendation is welcomed as employee health resources can then be allocated to other emerging concerns (e.g., maximizing immunizations among healthcare workers).

The new guidance does not reduce the requirement for fit testing likely because the current TB infection prevention measures (administrative and environmental controls and personal protective equipment use) are likely the reason for such low levels of TB transmission among healthcare workers. As more data is gathered, next research steps could involve studying the necessary frequency of fit testing or the best method used (qualitative or quantitative methods).

These new recommendations will need to be accompanied by adequate contact investigations in healthcare settings. In the past, even if some contacts were not identified, the routine yearly screening would detect those patients within one year of the exposure. Now, an unidentified contact could go unnoticed until TB disease occurs. This increases the importance of training and knowledge of TB contact investigations in healthcare settings. However, TB contact investigations in healthcare settings are not straightforward: healthcare workers may have baseline positive skin testing and it is difficult to quantify the exposure risk (there is no standard recommended threshold for distance from patient or duration of exposure). Even if there was a recommended threshold, it would likely vary depending on other factors such as patient infectiousness (cavities, smear positivity) and healthcare worker immune status. Out of caution, healthcare workers may also tend to overreport exposures potentially overwhelming infection prevention programs. Another unique aspect of TB in healthcare settings involves extrapulmonary TB. Although in public health settings extrapulmonary TB is deemed likely not transmissible, it may lead to exposures in healthcare settings, especially during wound care, or procedures that may generate aerosols or splashes (irrigation, or bone surgery).

Congratulations and thank you to NTCA and CDC for their updated recommendations in light of new evidence. Those on the frontlines (Employee Health and Infection Prevention programs) will be able to reallocate resources and put their TB contact investigations skills to test.

FS for CS - When The Public Helped Fight Tuberculosis

This past weekend, there were lots of public tributes for Ol' Blue Eyes, as Frank Sinatra would have been 100 years old.  Given the season and limited public health funding for tuberculosis research and programs, I wanted us to remember a time when the public was directly involved in an infectious disease (i.e. TB) fight. The Christmas Seals were first issued in 1907 to fight tuberculosis, but are now used more broadly to fund respiratory disease research. Maybe it's time to bring back campaigns to fight underfunded infectious disease research programs? MDRO Seals? Happy Christmas everyone.

TB Infection Control in Resource-Limited Settings

CDC has produced a new PEPFAR-funded video, as part of an implementation package, designed to assist with TB infection control. It's based on recent (2009) WHO guidelines. There is also an active discussion group that covers TB infection control. h/t Philip Lederer

 

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Florida Governor Rick Scott's Huge TB Outbreak

There is a huge outbreak of TB in the Jacksonville, Florida area. I offer these infection control suggestions to the CDC and others for dealing with Florida's "problem" along with a timeline of the events surrounding the outbreak:

1) Build a huge wall between Georgia/Alabama and Florida.  We can't allow people with TB to get out of Florida, since that would make healthcare interstate commerce.  We know interstate commerce of healthcare is no longer possible since the SCOTUS just told us so. Gosh, if only this was a Broccoli Mosaic Virus outbreak - oh, the irony...

2) Ban all flights out of Florida - see #1 above.

3) Don't send any EIS officers or others to help, because this is a state's rights issue. We also know that everything the Federal Government does is bad, especially healthcare. Plus, this help will be perceived as a play by the Federal Government to take over the entire State - the slippery slope.

TB Outbreak facts:

1) The current outbreak of a strain called FL 046 initially infected at least 15 mental health facility residents and three non-residents and killed two in 2008 per a recently published study in June's American Journal of Psychiatry. Per the report, one patient circulated among a hospital, correctional facility, homeless shelter and an assisted living facility with a horrible cough that was recorded but never treated. The good-natured CDC even sent $275K to deal with said outbreak.

2) February 2012: Duval County Health Department (Jacksonville) asks CDC for help given huge spike in TB cases. This is not typically done without first contacting the state health department, no?

2) March 2012: Governor Rick Scott signs an order to shrink the Department of Public Health and close Florida's only TB hospital, AG Holley State Hospital, which had treated TB in the state for 60 years. Duval County Health Department's budget fell from $61 million to $46 million just as the outbreak became known.

3) April 5, 2012: CDC's Dr. Robert Luo releases a 25-page report describing Jacksonville’s outbreak that potentially impacts 3,000 people. Of these only 253 people had been evaluated. There were 99 confirmed cases, 13 deaths. Of the cases contacted and evaluated, only two-thirds could be linked to exposure at homeless shelters and other high-risk settings, suggesting that the TB strain had spread to the general public.

4) April 13-16, 2012: SHEA holds it's spring conference in Jacksonville.

5) July 2, 2012: The AG Holley State TB Hospital officially closes

6) July 8, 2012: Word begins to leak out of a huge spike in Florida TB cases.

To sum things up: the CDC report is released nine days after the cuts and closure bill is signed by Governor Scott.  The report is ignored and then the hospital closes.  Word of the outbreak final spreads 6 days after the hospital closes. Interesting timing.

Sources: Palm Beach Post, July 8th and International Business Times, July 9th, 2012

Image source: the null hypothesis blog

Addendum: Infectious diseases are the great equalizer - i.e. they don't care if you are rich or poor.  If the poor cannot afford good medical and mental-health care, it's only a matter of time before our whole country suffers. The poor can't spread heart disease to the rich, but TB and other difficult to treat infectious pathogens are another matter.  Public health can't be made into a political football or we all suffer, as the residents of Florida now are.

The true discoverer of streptomycin is discovered

Dr. Selman Waksman won the 1952 Nobel Prize for the discovery of streptomycin, the first effective TB therapy. However, he might not have actually discovered the drug. Long lost to history, his student at Rutgers, Albert Schatz probably deserved most, if not all of the credit.

Peter Pringle, in a recent NY Times article and his new book, Experiment Eleven, describes the efforts Waksman made to claim the discovery for himself and discredit Schatz.  The mystery is solved when he discovered a small unopened box in the Rutgers University archives that contained the Schatz's lab notebooks...and the truth. It will be interesting to see if the Nobel Assembly awards a medal posthumously to Dr. Schatz, who died in 2005.

image credit: NYTimes

Baltimore Hooters' waitress contracts...TB?

The Baltimore Sun Paper reports that a 19-year old worker at the Inner Harbor Hooters contracted TB from a co-worker. Since that time she has been under quarantine and subject to directly observed therapy. Per the article: "multiple other members of the Hooters staff were confirmed to have latent or nonactive tuberculosis after the restaurant and the Health Department scheduled two separate testings for staff at downtown hotels last October and in March."

Still, I think you should plan your trip to Baltimore.  The Inner Harbor is beautiful in June and the Orioles are in first place. And on the plus side in this case, the woman was awarded workers' compensation from Hooters to cover lost wages and mounting medical expenses and Baltimore TB cases continue to decline with about 32 cases/year down from 60 in 2001. Back those bags and head to Charm City.

h/t Dan Morgan

TB: "In some areas we have probably already lost the battle"

A recent article in the British newspaper, The Observer, reports on the disturbing situation with multi-drug resistant tuberculosis. The article points out the current situation of increasing MDR cases is a result of loss of funding for TB, mismangement of infected patients, and the terrible situation of so few effective antibiotics.

Photo: Alexander Joe/AFP

Today is World TB Day

• 1/3 of the world's population is infected with Mycobacterium tuberculosis
• Nearly 1.5 million people globally die due to tuberculosis yearly
• With regards to deaths due to infection, TB is second only to HIV

Science Friday (the 13th): TDR-TB

Maryn McKenna (@marynmck) of Superbug fame will be on Science Friday (Hour 1: 2-3pm ET) tomorrow to discuss Totally Drug-Resistant TB.  She has had some very informative posts recently on the topic, including discussion of the two earliest known patients in Italy who died in 2003.  She also reports on the latest twelve TDR-TB cases in a single Indian hospital and points us to an ahead-of-print letter in CID posted in December that discusses the diagnosis and care of the first four of these patients in India.  Turn on, tune in...


Superbug post #2: Earliest Cases of TDR-TB
Superbug post #1: Latest Cases of TDR-TB in India

(Eli @eliowa)

Rats!!! I think you have Tuberculosis

Gambian pouched rat before ID rounds

We recently reported that the WHO endorsed the use of Cepheid's rapid TB test that carries a $17,000 fixed device cost and $17/test cost in developing countries.  The device would cost $64,000 in the US.  In yesterday's NY Times there was an article discussing a recent report in The American Journal of Tropical Medicine and Hygiene by Alan Poling at Western Michigan University that found that the Gambian pouched rat was far better than standard microbiological tests for TB diagnosis. In 10,523 patient, the rats trained to smell the sputum samples found 44% more cases. Sensitivity was reported as 86.6% and specificity was 93%.

Wow.  I hope these results can be validated in other settings.  If these rats are equally or more accurate than standard or rapid TB tests with minimal costs, there is no reason why they would have to be limited to resource-poor settings, right? Compared to a $64k rapid test plus test costs, I bet the rats would be very cost-effective; especially if they are more effective. It would be pretty cool to see ID clinicians carrying 15 pound rats around with them on rounds. 

Poling A. et al AJTMH, December 2010
NY Times article, January 3, 2010

WHO backs rapid test for TB - If only we had rapid treatment

I heard on NPR this morning that the WHO (Keith Moon died 32 years ago) is supporting the new rapid TB test made by Cepheid (MTB/RIF test).  You can read more about the test characteristics in the recent NEJM article. They reported 98% sensitivity in smear-positive patients but only 73% sensitivity in smear-negative patients after a single test.  Sensitivity rises to 85% after a second test and to 90% after a third test.  The test was very good at identifying rifampin-resistant and rifampin-sensitive strains (both around 98% of the time).

The NPR article states that the processor costs $64,000 in US but could be $17,000 for developing countries.  Tests will cost $17.  If you need to do three tests in smear-negative patients to rule out TB with a sensitivity of 90%, it would cost $51. I wonder if developing country budgets can absorb that cost?

Don't wait in a doctor's waiting room

I should have said don't wait too long in the "waiting area of healthcare premises" especially if another occupant/patient has measles, as the authors of a new study in BMC Infectious Diseases report.  The authors analyzed the likelihood of acquiring TB, influenza or measles during stays of 30 or 60 minutes in a standard waiting room using a mathematical model simulation.  One caveat is that they assumed one person in the waiting room was infectious with one of the organisms. Thus, while the results provide nice theoretical estimates of airborne transmission for these highly (measles), moderately (influenza) and minimally (TB) infectious organisms, they don't adjust for the probability of an occupant having the infection in the first place (influenza>TB>measles).   

With that important caveat, the likelihood of acquiring TB during a 30 minute stay in a waiting room was 0.3% and was 0.8% for a 60 minute stay.  For influenza, the numbers were 2.6% and 6.6% at 30 and 60 minutes and were 13% and 31% for measles.  With those numbers, if there is measles in the community at all, it's probably best to avoid any waiting area (unless you've been vaccinated). Nothing surprising in the results, really, but still worth quantifying and thinking about.  During the H1N1 season last year, I was always worried about transmission in the various hospital waiting areas.  In those situations, it was likely that >1 person had infectious influenza in the waiting room.  I hope future studies analyze the impact of # of infectious occupants and likelihood of those infectious occupants being present during various seasons (RSV, Influenza etc).

Once last thought.  Next time a clinician keeps you waiting, you might mention that he/she has put you at increased risk for getting sick.


Beggs et al. BMC ID article

Sunday reading

A couple recent New York Times articles relevant to infection prevention are worth a read. The first reports on an Annals of Internal Medicine paper describing how cost and reimbursement serve as barriers to the uptake of the adult varicella zoster virus (VZV, shingles) vaccine. The second is a fascinating story about the last of the old-time TB sanitariums. Although directly observed therapy (DOT) outside the hospital is the current model, there are some for whom prolonged inpatient care is needed, including those with dual diagnoses or extremely-drug resistant TB for whom simple outpatient DOT regimens are not feasible.

NY Times article on VZV vaccine
Annals paper describing barriers to vaccine uptake
NT Times article on A.G. Holley TB hospital

Treatment of latent tuberculosis: efficacy vs effectiveness

I've blogged before about the poor options we have for treating latent tuberculosis. The standard regimen, 9 months of isoniazid (INH), is too long and too toxic for the treatment of tuberculosis that is not active. For patients that aren't immunosuppressed and not recent skin test converters, the risk for developing active tuberculosis is only about 5%. Though the data for efficacy are not as robust, the 4-month daily rifampin regimen is much easier and better tolerated, and I have become more comfortable with this regimen. Because of the referral nature of my practice, the patients referred to me for evaluation of latent tuberculosis often have elevated liver enzymes at the outset or may not want to wait 9 months to complete the standard regimen before starting a therapy they feel is important (e.g., TNF-alpha inhibitors or other immunosuppressants).

A new study reported in this month's Chest examines completion rates of latent TB treatment courses. The investigators found that less than half of persons started on a treatment course actually finish it. About 45% complete a 9-month course of INH, 55% complete a 6-month course of INH, and nearly 65% complete the 4-month rifampin regimen. This leads me to wonder: even if 9 months of INH were ultimately proven to be more efficacious, perhaps 4-months of rifampin is more effective. Efficacy refers to how well a therapy works under ideal conditions (i.e., you take all the doses as prescribed), whereas effectiveness refers to how well a therapy works under real-world conditions (i.e., how well does the drug work when compliance is factored in). Given the toxicities of INH and the longer duration of treatment, coupled with the results of this survey, it's not far-fetched to conclude that what is considered our most efficacious regimen for latent tuberculosis may be our least effective.

TB Vaccine effective in HIV+ with BCG history

This study, to be published in an upcoming issue of AIDS, tested the effect of an inactivated whole cell mycobacterial vaccine, Mycobacterium vaccae, in HIV+ (CD4+>200) outpatients in Tanzania who also had a history of childhood BCG vaccination. Ford von Reyn and his Dartmouth and Tanzanian colleagues completed a double-blind placebo controlled trial testing the effect of 5 intradermal injections on subsequent disseminated and definite TB. Vaccinated patients had reduced disseminated TB (HR=0.52, p = 0.16), and definite tuberculosis (HR=0.61, p = 0.03). The study was stopped early do to significant protective effect but it prevented the assessment of longer-term effects.

When the treatment is worse than the disease

The University of Missouri Health Care System is re-evaluating its current policy on healthcare workers with latent tuberculous infection, which currently encourages but does not mandate treatment. The impetus for the review is a healthcare worker who had tested positive for latent tuberculosis via positive skin testing many years ago but declined to be treated, and recently developed active disease, exposing over 200 persons to tuberculosis. I suspect that most hospitals have similar policies and am not aware of a hospital that either prohibits those with latent but untreated infection from working or mandates treatment of latent tuberculosis. By definition, latent tuberculosis is not contagious but every person with latent infection has a small chance of developing active infection, which is contagious.

Isoniazid (INH), the standard drug used to treat latent tuberculosis given daily for nine months, is not an innocuous drug. In just the past few years, I have seen two deaths (both persons in their early 40s) and another healthy man who required a liver transplant due to the liver toxicity caused by the drug. Thus, I believe the drug is too toxic to require latently infected healthcare workers to be treated. Like the vast majority of healthcare workers, I have a TB skin test placed yearly. But I have decided that should my skin test convert to positive, I would not take INH because I believe it is too dangerous. We sorely need safer drugs for this condition. And we need better tests to detect latent tuberculosis--those currently available have many false positives and false negatives.

TB: Still the bane of the hospital epidemiologist

Today’s Chicago Tribune tells the story of a pediatrics resident with active tuberculosis who may have exposed over 300 patients to the disease at 3 hospitals in the Chicago area. Given the insidious nature of tuberculosis and the pressure doctors feel to come to work when ill (both externally and internally driven), it’s not so difficult to see how this unfortunate situation could happen.