Tuberculosis and HIV screening in healthcare workers at Maputo Central Hospital, Mozambique

1. TUBERCULOSIS AND HIV
SCREENING IN HEALTHCARE
WORKERS AT MAPUTO CENTRAL
HOSPITAL, MOZAMBIQUE
Susannah Graves and Kristen Lee
Presented by Francesca Torriani
Internal Medicine Residency Program
University of California, San Diego
Sept 18, 2012

2. Background
HIV prevalence: TB incidence
11.5 in Mozambique
Source: UNAIDS and WHO Source: WHO

3. Site: Maputo Central Hospital
 1500 beds total
Medicine 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 2012
Patients waiting waiting to be seen in the Emergency Room

4. Background & Significance
 Infection control committee chartered Sept 2011
 National TB reference laboratory recently acquired
capacity for mycobacterial culture and DST
 Currently no TB control program
 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.

5. Methods
 Population: Internal Medicine Department
 Study Period: 1 week in February 2012
 Recruitment: Flyers and an assembly advocating screening
 Eligibility Criteria – working in MCH Medicine Department
 Enrollment and consent for HIV testing
 Questionnaire: Contact/ID, demographic data, symptoms and history of
HIV and TB, contacts.

6. Methods
 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

7. Diagnostic Algorithm for TB
 Questionnaire
 Chest Xray
 Sputum x2 ordered if productive cough
 Pulmonary TB suspect definition
 Symptoms or radiographic evidence of pulm disease
 TB Case Definitions – WHO
 Definite:culture positive or 2+ AFB sputum smears
 Smear Negative: 2 NEG smears, abnormal CXR, no response
to a course of broad-spectrum ABX (unless HIV infected)

8. Demographics
No. %
Total 156 100.0%
Sex
Male 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%

9. HIV prevalence
No. %
HIV testing 148 95.0%
Results
positive 25 16.9%
negative 122 82.4%
indeterminate 1 0.7%
"pending" 4 2.6%
Of HIV positive:
new diagnoses 10 40.0%
CD4 count avail 22 88.0%

10. TB symptoms
Tuberculosis Symptoms No. %
Cough >3 weeks 24 15.4%
Productive cough 19 12.2%
Hemoptysis 0 0.0%
Chest pain 9 5.8%
Weight loss 14 9.0%
Fatigue 10 6.4%
Sweats 6 3.8%
Fever 3 1.9%
Asymptomatic 129 82.7%

11. Radiographic Findings
 Abnormal Xray in12 HCW
 Lymphadenopathy
 Diffuseopacities
 Nodular opacities
 “Bronchiectasis”
 Cavitary lesion
 2/12 had prior Hx of TB
 42% were HIV+
 25% had symptoms

12. Microbiologic Data
 19 HCW reported productive cough
 Only 9 sputum samples obtained:
 AFBsmear – negative in all 9
 Mycobacterial culture – 8 negative, 1 contaminated

13. 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

14. CT findings

15. Cases found 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
 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

16. Discussion
Strong points:
 Ease of recruitment
 HIV testing and CD4 counts
Difficulties:
 Obtaining sputum samples
 Tracking and quality of sputum cultures
 Diagnostic work up of TB suspects
 Maintaining confidentiality

17. Discussion
Strategies 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

18. Current Progress
 Occupational Health/TB Screening Office was
created with defined office space and secure
storage for CXR and other records
 Needs assessment for TB infection control in
Emergency Room was done
 F-A-S-T: FINDING TB cases ACTIVELY by cough
surveillance and rapid diagnosis, SEPARATION and
exposure reduction until effective TREATMENT starts
 TB infection control plans with support from the
hospital director

19. TB infection control plan
By Anna Levitt

20. By Anna Levitt

21. Future Directions
The Study (CFAR Grant, pending approval from NIH IRB):
 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 into occupational
health at MCH
 Comprehensive TB control program at MCH

22. TB Control Team, MCH

23. 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

24. Questions and Suggestions