Tuberculosis: The Invisible Threat

TUBERCULOSIS
“The Invisible Threat”
Jean-Michel Brevelle
Sexual Minorities Program Manager
Infectious Disease Prevention and
Health Services Bureau
Last updated January 8, 2018

Acknowledgements
2
 The video is taken from YouTube at
https://www.youtube.com/watch?v=EBdC9H00
BHY
 The rest is mostly from the CDC website at
http://www.cdc.gov/tb/
Last updated 1/8/2018Infectious Disease Prevention and Health Services Bureau

Learning Objectives
3
At the end of this presentation, you will be able to:
 Define Tuberculosis
 Distinguish the difference between Latent TB
infection and Active TB disease
 Discuss modes of transmission
 Identify signs and symptoms of TB disease
 Discuss treatment options and their importance

Key Points
 Tuberculosis (TB) is a disease caused by
bacteria that spread in the air. TB can spread
from person to person.
 Once in the body, TB can be inactive or active.
Inactive TB is called latent TB. Active TB is called
TB disease.
 TB usually affects the lungs, but TB-causing
bacteria can attack any part of the body,
including the kidneys, spine, or brain. If not
treated, TB disease can cause death.
4

Key Points
 HIV weakens the immune system, increasing the
risk of TB in people with HIV.
 People infected with both HIV and TB should be
treated for both diseases. The choice of
medicines to treat HIV/TB coinfection depends
on a person’s individual circumstances.
5

Famous People Diagnosed and/or Died with
TB
6
Edgar Allan Poe (1809 -
1849), poet, fiction writer,
and literary theorist was
know to suffer from
tuberculosis.
Henry David Thoreau
(1817 – 1862), most
famous for his book
Walden, died of TB at age
45.
Vivien Leigh, British-
born actress died in
1967 of TB.
Chick Webb of Baltimore, Maryland, was
an innovative bandleader at the inception
of hot swing in the late 30’s. His band was
the house band at the famous Savoy
Ballroom in Harlem. He discovered
vocalist Ella Fitzgerald, and was a major
influence of drummer Buddy Rich. He
suffered from spinal tuberculosis since
childhood, and complications eventually
wore him down in 1939.

Fast Fact
7

The Global Threat of TB
 Although TB is preventable and treatable, it is
not just a disease of the past. It is still one of the
world's deadliest diseases.
 An estimated one third of the world's population
is infected with M. tuberculosis .
 In 2016:
 10.4 million people around the world became sick
with TB disease.
 There were 1.7 million TB-related deaths
worldwide.
8

TB in the United States
 9,272 cases of TB were reported in the US in 2016.
That’s a 2.9% decrease from 2015.
 About 14% of US cases are attributed to recent
infection, as opposed to reactivation of longstanding
untreated illness.
 As many as 2 million Americans have latent TB
infection; they are not sick but carry the bacterium.
 1/3 of PLWH are co-infected with TB. TB is a leading
cause of death among PLWH.
9

Where is TB in the U.S.?
 9 states, the District of Columbia (DC), and New
York City reported incidence rates above the
national average.
 TB case counts were highest in California, Texas,
New York (including New York City), and
Florida. These four states accounted for just over
half of the total cases in the United States.
10

Who is Most Affected?
 In the US in 2016, 68.5% of TB cases were
among foreign born persons.
 In 2016, seven countries accounted for 64% of
all TB cases: India, Indonesia, China, Philippines,
Pakistan, Nigeria, and South Africa.
11

Maryland Fact File
12
 In 2016 Maryland reported 220 cases. This is an
increase over 2015.
 23 were in Baltimore City, 22 in Baltimore county,
74 in Montgomery county, and 50 in Prince
George’s county.
 The State case rate is 3.7 per 100,000 which puts
MD in the medium to high range for cases.

History of Tuberculosis
13
 The origins of TB are in the
first domestication of cattle
about 10,500 years ago.
 Domestication of cattle also
gave humanity the viral poxes.
 It may have been passed to
humans thru the animal’s
flesh or milk.
 It also affects birds, fish,
reptiles, dogs, and cats.
All cattle are descended from
as few as 80 animals that
were domesticated from wild
ox in the Near East some
10,500 years ago, according
to a new genetic study.
Tuberculosis (TB) is one of the world’s oldest and deadliest diseases.

14
Evidence found for
tuberculosis infection in
human remains from the
Neolithic era (8,800 BCE).
Signs of TB found in Egyptian
mummies dated between 3,000
and 2,400 BCE.
Evidence indicates that
hospitals for TB
existed in Egypt as
early as 1,500 BCE.

15
The first references to
tuberculosis in Asian
civilization is found in the
Indian Vedas (1,500 BCE).
The Sushruta Samhita, an
Indian medical text written
around 600 BCE,
recommends that the
disease be treated with
breast milk, various meats,
alcohol and rest.
The first classical
(Greek) text to mention
the disease is
Herodotus' Histories in
which he relates how
Xerxes’ greatest general
abandoned the
campaign against the
Spartans due to
consumption (480 BCE).

 Before the Industrial
Revolution (1760-1840),
folklore often associated
tuberculosis with vampires.
 When one member of a
family died from it, the other
infected members would lose
their health slowly.
 People believed this was
caused by the original person
with TB draining the life from
the other family members.
16

 Historically known by a
variety of names,
including:
 Consumption
 Wasting disease
 White plague
 TB was a death
sentence for many.
17
La Miseria by Cristóbal Rojas (1886). Rojas was suffering from tuberculosis, when
he painted this. Here he depicts the social aspect of the disease, and its relation
with living conditions at the close of the 19th century.

 Until mid-1800s, many believed
TB was hereditary.
 1869 Jean-Antoine Villemin
proved TB was contagious.
 March 24, 1882 Robert Koch
discovered M. tuberculosis, the
bacterium that causes TB.
 His belief that cattle and
human TB were different,
delayed identifying milk as a
source of infection.
Pasteurization later eliminated
this source.
18
Mycobacterium tuberculosis
Image credit: Janice Haney Carr

 Before antibiotics, many
patients were sent to
sanatoriums. TB patients who
could not afford sanatoriums
often died at home.
 1859 – The first sanatorium
opened in Poland, with
another opening in the U.S. in
1884.
 Patients followed a regimen of
bed rest, open air, and
sunshine . (UV light affects
organism.)
19
Sanatorium patients resting outside

 1906- first success at immunizing against TB;
first used in humans in 1921, France.
 1944 – the development of the antibiotic
streptomycin made treatment a possibility.
“Patricia”, a 21 year old was the first patient to
be successfully treated.
 1944 - earliest use of the drug PAS.
 1952- Seaview Hospital, NY, use new wonder
drug called isoniazid to treat.
20

 Over 20 drugs used to treat TB
 Most drugs developed more than 40 years ago
 Two new drugs under development
 WHO and the U.S. Department of Health and
Human Services have plans to end tuberculosis.
 Neither are on track to meet their goals for the
current year
 Drug shortages, underfunding, and lack of
implementing key plan components are given as
reasons for not meeting goals
21

Transmission of TB
 TB bacteria are spread through the air from one
person to another.
 The TB bacteria are put into the air when a
person with TB disease of the lungs or throat
coughs, speaks, shouts, laughs or sings. People
nearby may breathe in these bacteria and
become infected.
22

TB is NOT Transmitted by
 shaking someone's hand
 sharing food or drink
 touching bed linens or toilet seats
 sharing toothbrushes
 kissing
23

Infection Process
 When a person breathes in TB bacteria, the
bacteria can settle in the lungs and begin to
grow. From there, they can move through the
blood to other parts of the body, such as the
kidney, spine, and brain.
 TB disease in the lungs or throat can be
infectious. This means that the bacteria can be
spread to other people. TB in other parts of the
body, such as the kidney or spine, is usually not
infectious.
24

Probability of Transmission
 Multiple factors determine how likely an
exposure becomes an infection:
 Infectiousness of person with TB
 Environment in which exposure occurred
 Duration of exposure
 Virulence of the organism
 The transmission rule is:
 8 hours
 6 feet
25

Risk of Developing TB
Disease
 The risk of developing TB disease is much
higher for persons with weakened immune
systems.
 For example, for people with an untreated TB
infection and untreated HIV infection, the risk is
about 7% to 10% PER YEAR -- a very high risk
over a lifetime.
 HIV infection is the strongest known risk factor
for progressing to TB disease. Worldwide, TB is
the leading cause of death among PLWH.
26

Additional Risk Factors for
TB
Of persons diagnosed with TB in 2016:
 16.4% reported having diabetes
 10.0% reported excessive alcohol use
 5.6% were co-infected with HIV (of TB cases with HIV test
results reported)
 6.8% reported using non-injectable drugs (1.3% reported
using injecting drugs)
 4.9% reported being homeless in the past year
 4.0% were residents of correctional settings at time of
diagnosis
27

Last updated 1/8/2018Infectious Disease Prevention and Health Services Bureau 28

TB Disease Reporting Requirements
 TB is one of the so-called “notifiable/reportable
diseases”.
 Currently reported electronically to CDC.
 Labs required to report all positive TB tests.
 If you have been found to have TB disease, your
doctor is bound by law to notify a local health
officer.
29

Is there a TB vaccine?
 BCG* is a vaccine for TB disease. It is used in
many countries, but not generally recommended
here in the U.S.
 It does not completely prevent people from
getting TB and may cause a false-positive test.
 If it does work, it only gives about 10 yrs
protection.
30
* Bacillus Calmette-Guerin vaccine named after Albert Calmette and Camille
Guérin. First used in humans in 1921.

Good News, Everyone!
 TB disease can be prevented and
cured.
 The first step is to find out if you
are infected with the TB
bacterium.
 You can do this by getting a TB
skin test (TST).
31

Who Should be Tested?
 Tuberculin skin-testing screening is
recommended for:
 Persons with signs or symptoms
 Persons at highest risk for infection
 Immuno-compromised
 Health care workers
 Corrections workers
32

What is a TB skin test?
 A health care worker uses a small needle to put
some testing material called tuberculin just
under your skin. (called a “Heaf” or “PPD”)
 You must return in 2-3 days to see if there is a
reaction. If there is a reaction, the size of the
reaction is measured.
33
HCW administering Mantoux TST. 0.1 ml
of 5 tuberculin units of liquid tuberculin
are injected between the layers of skin on
forearm.

Mantoux Tuberculin Skin Test
 An induration of 15mm or more is considered
positive in anyone, including persons with no
known risk factors for TB.
34

Blood Tests for TB
 TB blood tests (also called interferon-gamma release
assays or IGRAs) measure how the immune system reacts
to the bacteria that cause TB. An IGRA measures how
strong a person’s immune system reacts to TB bacteria by
testing the person’s blood in a laboratory.
 Two IGRAs are approved by the U.S. Food and Drug
Administration (FDA) and are available in the United
States:
 QuantiFERON®–TB Gold In-Tube test (QFT-GIT)
 T-SPOT®.TB test (T-Spot)
35

Blood Tests for TB
 Positive IGRA: This means that the person has been infected with TB
bacteria. Additional tests are needed to determine if the person has
latent TB infection or TB disease. A health care worker will then
provide treatment as needed.
 Negative IGRA: This means that the person’s blood did not react to
the test and that latent TB infection or TB disease is not likely.
 IGRAs are the preferred method of TB infection testing for the
following:
 People who have received bacille Calmette–Guérin (BCG). BCG is a vaccine for
TB disease. It is not commonly used in the U.S.
 People who have a difficult time returning for a second appointment to look for
a reaction to the TST.
 There is no problem with repeated IGRAs.
36

What if I Test Positive for TB
Infection?
 Don’t panic!
 Get the required follow-up tests:
 (chest x-ray), sputum specimen
 Follow your doctor’s advice and
take the medicine as prescribed.
 Today, both TB infection and TB
disease can be treated and cured
with medication.
37

What if I Test Positive for TB
Infection?
A few things to remember:
 After a positive skin test, only 5% will become ill
in 5 years.
 5% of the rest who test positive will progress to
disease.
 Men are more likely to develop disease than
women.
 People with diabetes are more likely to develop
disease.
38

Treatment for TB infection and
disease
 The State provides funding to local health
departments for TB medications.
 The medication must be taken continually
usually for six to twelve months.
 Some people require a year or more for
successful treatment.
39

Treatment for TB infection
 Treatment of latent TB infection is essential to controlling
and eliminating TB in the United States. Latent TB
infection is treated with medication to prevent progression
to TB disease.
 There are three options for the treatment of latent TB
infection:
 Isoniazid (INH) daily for 9 months- (eye-so-nye-ah-zid)
 Isoniazid (INH) and rifapentine (RPT) given in 12 once-weekly
doses under directly observed therapy (DOT)
 Rifampin (RIF) daily for 4 months
(possible side effects: skin rash, upset stomach or liver disease. Avoid alcohol and
acetaminophen/Tylenol)
40

Treatment for TB disease
 Rifapentine- first new drug approved in 25 years
by the FDA in 1998 (brand name: Rifadin)
 Isoniazid (brand name: INH) (1952)
 Ethambutol (brand name: Myambutol) (1962)
 Pyrazinamide (1954)
41
Isoniazid, Rifampin, Pyrazinamide,
and Ethambutol pills
About 2 weeks after
starting treatment, the
person is no longer
infectious to others.

Treatment Standards Update
 Key Changes/Updates from 2003 edition
 Applies only to drug-susceptible TB
HIV/TB Co-infection
 Early initiation of ART in HIV/TB patients
 Extended duration of TB treatment in HIV w/o
ART extended
42
Source: 2016 ATS/CDC/IDSA TB Treatment Guidelines
https://www.cdc.gov/tb/publications/guidelines/pdf/clin-infect-dis.-2016-nahid-cid_ciw376.pdf

Treatment Standards Update
 Evidence base for intermittent therapy reviewed
– Once weekly regimen NOT recommended
 Evidence base for case management (patient
education, incentives, enablers, DOT) reviewed
 TB treatment in pregnancy, language updated
for PZA (Pyrazinamide)
 Steroids not routinely recommended for TB
pericarditis (low benefit, drug interactions)
43
Source: 2016 ATS/CDC/IDSA TB Treatment Guidelines
https://www.cdc.gov/tb/publications/guidelines/pdf/clin-infect-dis.-2016-nahid-cid_ciw376.pdf

Drug-Resistant TB
 For most of human history, TB has been a
widespread disease.
 It was virtually wiped out with the help of
antibiotics developed in the 1950s, but the
disease has resurfaced in potent new forms:
 Multidrug-resistant TB (MDR TB), and;
 Extensively drug-resistant TB (XDR TB)
44

Drug-Resistant TB
 The emergence of drug-resistant TB,
including multidrug-resistant TB (MDR TB)
and extensively drug-resistant TB(XDR TB)
is a major public health threat.
 Drug-resistant TB is very difficult,
complicated, and expensive to treat.
 There were 490,00 new MDR-TB cases
worldwide as of 2016.
45

Drug Resistant TB
46

Drug-Resistant TB
 Resistant means drugs can
no longer kill the bacteria
 Caused by M. tuberculosis
organisms resistant to at
least one TB treatment
drug
 Isoniazid (INH)
 Rifampin (RIF)
 Pyrazinamide (PZA)
 Ethambutol (EMB)
 Bedaquiline *newer*
47
Drug-resistant TB requires a two-
year treatment, but the first six
months are really the worst.

Self Care and Prevention
48
 Get tested yearly.
 Get treated, if necessary.
 Wear a face mask when dealing with clients who
have a TB history or chronic cough.
 Have your area well ventilated (open windows).
 Encourage others to cover their mouths when
they cough.
 Keep tissues at your desk and in common areas.
 Model the behavior that you want others to adopt.

Maryland TB Control Offices
49
Maryland Department of Health
Center for Tuberculosis Control and Prevention
500 North Calvert Street, 5th Floor
Baltimore, MD 21202
Tel: (410) 767-6698
Fax: (410) 383-1762
Nancy Baruch, RN, MBA Chief • nancy.baruch@maryland.gov
https://phpa.health.maryland.gov/OIDPCS/CTBCP/pages/Home.aspx

Continuing Education
 TB 101 for Health Care Workers is designed to
educate health care workers about basic
concepts related to TB prevention and control in
the United States.
 Online, self-study/self-exam
 CEUs (1.0 contact hours)
 80% passing grade on exam
50
https://www.cdc.gov/tb/webcourses/tb101/default.htm

Other TB Resources
51
 CDC Tuberculosis Information
http://www.cdc.gov/tb/default.htm
 TB Facts
http://www.tbfacts.org/
 RESIST-TB : Research Excellence to Stop TB
Resistance
http://www.resisttb.org/
 Stop TB Partnership
http://www.stoptb.org/

Any Questions?
52

And now, this…53
https://www.youtube.com/watch?v=EBdC9H00BHY

Don’t say I didn’t warn you…
Quiz Time!54

Wrap-up
55
 Any other questions?
Thanks and enjoy the rest of the
training! Last updated 1/8/2018Infectious Disease Prevention and Health Services Bureau

Tuberculosis: The Invisible Threat

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