The UC San Diego AntiViral Research Center sponsors weeklypresentations by infectious disease clinicians, physicians andre...
TUBERCULOSIS AND HIVSCREENING IN HEALTHCAREWORKERS AT MAPUTO CENTRALHOSPITAL, MOZAMBIQUEFrancesca Torriani, MDSusannah Gra...
Estimatednumber ofcasesEstimatednumber ofdeaths1.4 millionRange: 1.0 – 18.7 million(range: 8.3 –9.0 million)All forms of T...
HIV prevalence and TB incidence in AfricaSource: UNAIDS and WHO Source: WHOHIV prevalence:11.5% in MozambiqueTB incidence
Question 1What is the HIV prevalence in Mozambique?A. 1-4.99%B. 5-9%C. 10-20%D. >20%
Site: Maputo Central Hospital 1500 beds totalMedicine Wards: 112+ beds >65% patients HIV+ Pulm TB: 25-30 cases/mo ca...
TB Infection Control Measures Administrative Measures Risk assessment Infection prevention and control plan Administra...
TB Infection Control Measures:Administrative Measures Screen regularly for TB Respiratory hygiene/cough etiquette Educa...
TB Control at Maputo General Hospital Infection control committee chartered Sept 2011 TB control program chartered in la...
TB Control Team, MCH
Pilot Study Methods - 1 Population: Internal Medicine Department Study Period: 1 week in February 2012 Recruitment: Fly...
Pilot Study Methods – 2 HIV testing (2 rapid tests) and CD4 count (flow cytometry) Chest Xray – read by a radiologist an...
Diagnostic Algorithm for TB Questionnaire Chest Xray Sputum x2 ordered if productive cough Pulmonary TB suspect defini...
Pilot Study DemographicsNo. %Total 156 100.0%SexMale 35 22.4%Female 121 77.6%Age (years)16–29 39 25.0%30–39 56 35.9%40–49 ...
HIV Screening ResultsN = 148/156 (95%) HIV tested
Pilot Study: Active TBTB in 1/156 (0.6%) of HCW Screened• Asymptomatic at screening• Xray: mediastinal adenopathy• Develop...
TB Symptom Screen Results
Pilot Study Radiographic Findings Abnormal Xray in12 HCW Lymphadenopathy Diffuse opacities Nodular opacities “Bronchi...
Abnormal Chest Xrays by HIV Status and Symptoms
Microbiologic Data 19 HCW reported productive cough Only 9 sputum samples obtained: AFB smear – negative in all 9 Myco...
TB diagnosis during screening A single case of TB was diagnosed Generalized lymphadenopathy No cough Initial CXR – med...
CT findings
Cases Diagnosed after Initial Screening Among participants 2 more participants re-presented to the screening clinic Bot...
Pilot Study DiscussionStrong points: Ease of recruitment HIV testing and CD4 countsDifficulties: Obtaining sputum sampl...
Pilot Study DiscussionStrategies for improvement: Concrete diagnostic algorithm & case definition Documentation of follo...
Question 2 Which clinical symptom is the best to screen for TB?1. Fever2. Loss of weight3. Chronic cough4. Night sweats5....
Reid et al Lancet ID 2009
Reid et al Lancet ID 2009Sensitivity and Specificity of Cough as a Symptom of TBAssess for signs and symptoms suspicious f...
The Importance of Early Diagnosis Prevent new infections: Suspect TB when Weight loss >1.5 kg in last month Cough more ...
Screen and identify TB suspectsAssess for signs and symptoms suspicious for tuberculosisNot all patients will spontaneousl...
Impact of Administrative Measures Alone prevent < 10% of future XDR TB Early discharge after 5 days avert 6% Admission ...
Question 3How many sputum samples are sufficient to excludeactive contagious TB?A. 1B. 2C. 3
Diagnose TB Promptly Collect sputum samples (OUTSIDE!) Two sputum samples from every TB suspect (one onthe spot, the sec...
TB Diagnosis When the above symptoms exist – send patientfor AFB examination of the sputum x 2 In this setting a positiv...
Key Points to Prevent TB Transmission Screen regularly Isolate suspect patients and educate about cough hygiene Provide...
Current Progress Occupational Health/TB Screening Office was createdwith defined office space and secure storage for CXRa...
Environmental controls Natural and/ormechanicalventilation Open windows anddoors Fans to dilute/directthe flow to outsi...
Hospital Central de Maputo, Mozambique, Sala de Urgencias
Next StepsThe Study (CFAR Grant): Tuberculosis screening in all HCW at MCH Active and latent TB High-risk latent TB (HI...
Active TB in HCW 2013 Survey Aim: To assess annual incidence of activetuberculosis in health workers at MCH. A publicity...
Active TB in HCW 2013 Survey Results Twenty cases of active TB in HW were reported: 14 pulmonary 5 extrapulmonary 1 pu...
Discussion Given the large number of cases and alarmingly high rate of MDR-TBamong HW, MCH has moved to expand the TB off...
TB infection control plan - UrgenciasPatientsConsultWaitingAdd UV fixturesOperate all ceiling fansBy Anna Levitt
Acknowledgements Elizabete Nunes, MD, PhD Francesca Torriani, MD Philip Lederer, MD Sophia Viegas Koen Hulshof, MD A...
Thank youQuestions and Suggestions?
Tuberculosis Screening in Healthcare Workers at Maputo Central Hospital
Tuberculosis Screening in Healthcare Workers at Maputo Central Hospital
Tuberculosis Screening in Healthcare Workers at Maputo Central Hospital
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Tuberculosis Screening in Healthcare Workers at Maputo Central Hospital

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Francesca Torriani, MD, of UC San Diego Health System presents, "Tuberculosis Screening in Healthcare Workers at Maputo Central Hospital"

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Tuberculosis Screening in Healthcare Workers at Maputo Central Hospital

  1. 1. The UC San Diego AntiViral Research Center sponsors weeklypresentations by infectious disease clinicians, physicians andresearchers. The goal of these presentations is to provide the mostcurrent research, clinical practices and trends in HIV, HBV, HCV, TBand other infectious diseases of global significance.The slides from the AIDS Clinical Rounds presentation that you areabout to view are intended for the educational purposes of ouraudience. They may not be used for other purposes without thepresenter’s express permission.AIDS CLINICAL ROUNDS
  2. 2. TUBERCULOSIS AND HIVSCREENING IN HEALTHCAREWORKERS AT MAPUTO CENTRALHOSPITAL, MOZAMBIQUEFrancesca Torriani, MDSusannah Graves, MDUniversity of California, San DiegoMay 17, 2013AIDS Clinical Rounds – AVRC - UC San Diego
  3. 3. Estimatednumber ofcasesEstimatednumber ofdeaths1.4 millionRange: 1.0 – 18.7 million(range: 8.3 –9.0 million)All forms of TBHIV-associated TB 1.1 million (13%) 430,000 (31%)Why is TB still important in 2013?WomenChildren2.9 million(range: 2.6–3.2 million)0.5 million25% of TB cases are in AfricaHighest rates of cases & deaths relative to population0.5 million
  4. 4. HIV prevalence and TB incidence in AfricaSource: UNAIDS and WHO Source: WHOHIV prevalence:11.5% in MozambiqueTB incidence
  5. 5. Question 1What is the HIV prevalence in Mozambique?A. 1-4.99%B. 5-9%C. 10-20%D. >20%
  6. 6. Site: Maputo Central Hospital 1500 beds totalMedicine Wards: 112+ beds >65% patients HIV+ Pulm TB: 25-30 cases/mo cases in HCW? MDR-TB in HCW 3 cases in 2010 1 case in 2012Patients waiting waiting to be seen in the Emergency Room
  7. 7. TB Infection Control Measures Administrative Measures Risk assessment Infection prevention and control plan Administrative support for the program implementation,including quality assurance Environmental Controls Separate room Negative pressure room Natural ventilation Filtration UV lights Personal Protection N95 respirators
  8. 8. TB Infection Control Measures:Administrative Measures Screen regularly for TB Respiratory hygiene/cough etiquette Educate/Training of patients and staff Triage/Isolate suspect clients Rule out TB without delay Better coordination between TB and HIV services When identified Decrease time patients are hospitalized Defer admission of patients Rapid drug susceptibility assays Involuntary detention if resistance HIV testing
  9. 9. TB Control at Maputo General Hospital Infection control committee chartered Sept 2011 TB control program chartered in late 2011 National TB reference laboratory acquired capacityfor mycobacterial culture and DST in early 2012 Unknown prevalence, incidence of HIV and TB in HCW Recent study of HCW from Northern Mozambique: 43% HIV prevalence 9 new TB cases (2.1% of enrollees).Casas et al. Tropical Med and International Health. Aug 18, 2011.
  10. 10. TB Control Team, MCH
  11. 11. Pilot Study Methods - 1 Population: Internal Medicine Department Study Period: 1 week in February 2012 Recruitment: Flyers and an assembly advocating screening Eligibility Criteria – working in MCH MedicineDepartment Enrollment and consent for HIV testing Questionnaire: Contact/ID, demographic data, symptomsand history of HIV and TB, contacts.
  12. 12. Pilot Study Methods – 2 HIV testing (2 rapid tests) and CD4 count (flow cytometry) Chest Xray – read by a radiologist and a pulmonologist Sputum sample for those with productive cough AFB smear and mycobacterial culture Further standard of care workup (LN biopsy, CT scan) Treatment referrals as appropriate for HIV and TB
  13. 13. Diagnostic Algorithm for TB Questionnaire Chest Xray Sputum x2 ordered if productive cough Pulmonary TB suspect definition Symptoms or radiographic evidence of pulmonary disease TB Case Definitions – WHO Definite: culture positive or 2+ AFB sputum smears Smear Negative: 2 NEG smears, abnormal CXR, no responseto a course of broad-spectrum ABX (unless HIV infected)
  14. 14. Pilot Study DemographicsNo. %Total 156 100.0%SexMale 35 22.4%Female 121 77.6%Age (years)16–29 39 25.0%30–39 56 35.9%40–49 34 21.8%49–59 23 14.7%>60 4 2.6%Time working in Hospital<5 years 52 33.8%5-9 years 34 22.1%10-14 years 17 11.0%15-19 years 6 3.9%>20 years 45 29.2%
  15. 15. HIV Screening ResultsN = 148/156 (95%) HIV tested
  16. 16. Pilot Study: Active TBTB in 1/156 (0.6%) of HCW Screened• Asymptomatic at screening• Xray: mediastinal adenopathy• Developed diffuse adenopathy• Diagnosed via LN aspiration• Hospitalized: TB lymphadenitis
  17. 17. TB Symptom Screen Results
  18. 18. Pilot Study Radiographic Findings Abnormal Xray in12 HCW Lymphadenopathy Diffuse opacities Nodular opacities “Bronchiectasis” Cavitary lesion 2/12 had prior Hx of TB 42% were HIV+ 25% had symptoms
  19. 19. Abnormal Chest Xrays by HIV Status and Symptoms
  20. 20. Microbiologic Data 19 HCW reported productive cough Only 9 sputum samples obtained: AFB smear – negative in all 9 Mycobacterial culture – 8 negative, 1 contaminated
  21. 21. TB diagnosis during screening A single case of TB was diagnosed Generalized lymphadenopathy No cough Initial CXR – mediastinal lymphadenopathy LN biopsy – positive AFB smear Clinical decompensation  hospitalized, treated CT chest – miliary TB + adenopathy
  22. 22. CT findings
  23. 23. Cases Diagnosed after Initial Screening Among participants 2 more participants re-presented to the screening clinic Both were symptomatic Found to have AFB smear positive pulmonary TB Among HCW’s who were not enrolled in our study 3 HCWs presented to the occupational TB screening service Symptoms: productive cough Diagnosed with active pulmonary TB One of them was MDR-TB
  24. 24. Pilot Study DiscussionStrong points: Ease of recruitment HIV testing and CD4 countsDifficulties: Obtaining sputum samples Tracking and quality of sputum cultures Diagnostic work up of TB suspects Maintaining confidentiality
  25. 25. Pilot Study DiscussionStrategies for improvement: Concrete diagnostic algorithm & case definition Documentation of follow-up and treatment Supervised sputum collection Better communication with TB lab Secure storage space for Xrays and other records Defined office space and hours for follow-up
  26. 26. Question 2 Which clinical symptom is the best to screen for TB?1. Fever2. Loss of weight3. Chronic cough4. Night sweats5. ≥2 symptoms
  27. 27. Reid et al Lancet ID 2009
  28. 28. Reid et al Lancet ID 2009Sensitivity and Specificity of Cough as a Symptom of TBAssess for signs and symptoms suspicious for tuberculosis
  29. 29. The Importance of Early Diagnosis Prevent new infections: Suspect TB when Weight loss >1.5 kg in last month Cough more than 2 weeks Night sweats more than 2 weeks Fever more than 2 weeks Other: anorexia, hemoptysis, pleuritic chest pain A diagnosis of TB should fast track patients to ARVs <200 Initiate TB treatment and ARVs <50 Initiate TB treatment and ARVs immediately
  30. 30. Screen and identify TB suspectsAssess for signs and symptoms suspicious for tuberculosisNot all patients will spontaneously report cough!Therefore you should ask:Do you have a cough? If yes, then ask: How long have you been coughing for?Ask for additional signs or symptoms compatible with TB Do you cough up blood? Have you had night sweats? Have you had a fever?Measure current temperature Have you lost weight? How much?Measure weightAsk about previous history of TB in the patient, family orwork contacts
  31. 31. Impact of Administrative Measures Alone prevent < 10% of future XDR TB Early discharge after 5 days avert 6% Admission deferral of 25% clients prevented 7% Rapid drug susceptibility assays prevented 3% Involuntary detention without separate facilities build uplead to an INCREASE 3%Basu et al, Lancet 2007;370:1500-7
  32. 32. Question 3How many sputum samples are sufficient to excludeactive contagious TB?A. 1B. 2C. 3
  33. 33. Diagnose TB Promptly Collect sputum samples (OUTSIDE!) Two sputum samples from every TB suspect (one onthe spot, the second one day after) Two sputum samples identify 95% of smear positivecases! Give instructions to patients on Purpose of the sputum collection How to cough up How to handle the container Instruct them to collect 2nd sputum outsideNelson, JCM, 1998;36:467; Wilmer, Can J Infect Dis Med Microbiol , 2011;22:e1
  34. 34. TB Diagnosis When the above symptoms exist – send patientfor AFB examination of the sputum x 2 In this setting a positive AFB is sufficient toprovide a diagnosis of TB If sputum AFB is positive = patient is contagious Handful of patients who are sputum negative, ifthere is a high enough suspicion for TB, mayconsider empiric treating
  35. 35. Key Points to Prevent TB Transmission Screen regularly Isolate suspect patients and educate about cough hygiene Provide HIV and TB diagnostic and treatment services Promote mask compliance (protects you and your patients) Ensure good natural ventilation Alert clients ahead of time that windows will be open andencourage them to bring a jacket and/or blanket Know your status
  36. 36. Current Progress Occupational Health/TB Screening Office was createdwith defined office space and secure storage for CXRand other records Needs assessment for TB infection control in EmergencyRoom was done F-A-S-T: FINDING TB cases ACTIVELY by coughsurveillance and rapid diagnosis, SEPARATION andexposure reduction until effective TREATMENT starts TB infection control plans with support from the hospitaldirector
  37. 37. Environmental controls Natural and/ormechanicalventilation Open windows anddoors Fans to dilute/directthe flow to outside Filtration UV irradiation Isolation facilities forMDR or XDR patients Basu et al, Lancet 2007;370:1500-7
  38. 38. Hospital Central de Maputo, Mozambique, Sala de Urgencias
  39. 39. Next StepsThe Study (CFAR Grant): Tuberculosis screening in all HCW at MCH Active and latent TB High-risk latent TB (HIV, high-reactors)The Ultimate Goal: Incorporation of routine TB screening intooccupational health at MCH Comprehensive TB control program at MCH
  40. 40. Active TB in HCW 2013 Survey Aim: To assess annual incidence of activetuberculosis in health workers at MCH. A publicity campaign with posters anddepartmental trainings advocating earlyidentification, triage, and treatment of TB suspects,cough etiquette and appropriate mask use. Twelve months after the initial screen, physicians inthe medicine department who treat TB weresurveyed via phone to report cases of TB in healthworkers from MCH.
  41. 41. Active TB in HCW 2013 Survey Results Twenty cases of active TB in HW were reported: 14 pulmonary 5 extrapulmonary 1 pulm and extra pulm 19 new cases and one re-treatment Three new cases (16%) were MDR-TB 13/20 (65%) AFB smear + 3/20 (15%) AFB smear - 4 did not provide samples HIV status 4 (20%) HIV+ 10 (50%) HIV – 6 unknown Healthcare workers included medical students, orderlies, nurses, andphysicians in at least 8 different departments
  42. 42. Discussion Given the large number of cases and alarmingly high rate of MDR-TBamong HW, MCH has moved to expand the TB office to address gapsidentified in current screening and treatment practices. Gaps include: No active case-finding Lack of sputum specimens for those patients without chronic cough Unknown HIV status in 30% of HCW diagnosed with TB To address these, the TB office was allocated space and equipment forsputum induction. Outside funding was secured to screen for active and latent TB and HIV in500 HW with a plan for annual screening in the future. Furthermore, to curb transmission, hospital allocated funding for phase 1 ofa two-phase plan for an ultraviolet germicidal irradiation installation andtriage-isolation protocol in Urgent Care.
  43. 43. TB infection control plan - UrgenciasPatientsConsultWaitingAdd UV fixturesOperate all ceiling fansBy Anna Levitt
  44. 44. Acknowledgements Elizabete Nunes, MD, PhD Francesca Torriani, MD Philip Lederer, MD Sophia Viegas Koen Hulshof, MD Anna Levitt, PE Joaquim Aracua, MD Anilsa Daniel, MD Catarina David, MD Anila Hassane, MD
  45. 45. Thank youQuestions and Suggestions?

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