TB and HIV screening in healthcare workers in a Mozambique hospital
TUBERCULOSIS AND HIVSCREENING IN HEALTHCAREWORKERS AT MAPUTO CENTRALHOSPITAL, MOZAMBIQUE Susannah Graves and Kristen Lee Presented by Francesca Torriani Internal Medicine Residency Program University of California, San Diego Sept 18, 2012
Background HIV prevalence: TB incidence 11.5 in MozambiqueSource: UNAIDS and WHO Source: WHO
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 2012 Patients waiting waiting to be seen in the Emergency Room
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.
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.
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
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)
Demographics No. %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%
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%
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
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
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
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
Future DirectionsThe 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