Louisiana Statistics

According to the State of Louisiana Public Health Office data, there were 139 cases of active TB cases in 1998 with a case rate of 13.5 /100 K population in Region 1 (New Orleans Metropolitan area and surrounding 5 parishes region). This reduced to 110 active cases in 1999, but increased again to 134 active cases in 2000. This data does not include PPD positive LTB cases and PPD negative contact cases. It is estimated that 5 % of the population of Louisiana is PPD positive with latent TB. The LSU-Wetmore TB Clinic scheduled 1717 TB related clinic visits in 1999. Eighty eight percent of the active TB cases are on the DIRECT OBSERVED TREATMENT (DOT) program with 90% of these cases undergoing FIELD DOT conducted by DIS workers reaching these patients at home or at place of work.

Post Katrina Data

View Louisiana Data in MS Excel Spreadsheet

Louisiana Office of Public Health - Tuberculosis Control Program
http://www.dhh.louisiana.gov/offices/?ID=273

TB Update Contemporary Topics in MTB 2010

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The Orleans Parish Triangle of TB

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To Be Informed Newsletter

To Be Informed is a newsletter/brochure in Vietnamese and English based on frequently asked questions by audience and participants of the TEACH Program. It is distributed to community venues and primary care clinics.

Fall/Winter

Discussion Points

Tuberculosis Synopsis Update 2011

• Definition : LTBI, “Chemoprophylaxis”
• Targeted tuberculosis testing in high risk/high prevalence groups and “precision treatment” options
• Three cut-off points for TST (tuberculin skin test) remain
• US Public health Strength of recommendation ABC
• Quality of evidence I II III
• Duration of LTBI Rx: 9 months
• Flexibility based on local public health considerations.

Recent Changes in Emphasis

• Criteria for PPD TST (tuberculin skin test) positivity, by risk stratification
• New definition of PPD TST (tuberculin skin test) converter: increase in 10 mm or more within a 2-year period.
• Clinical monitoring
• Lab monitoring in (a) HIV (b) pregnant (c) postpartum (d) Hx of liver disease
  (e) Those who continue use of alcohol regularly. (f) Other medical conditions. For
  cessation of Rx on the basis of LFTs recommended:
  Rule of “FASTS” 5 times if asymptomatic; 3 times if symptomatic
• Intermittent Rx must be DOPT
• Rifabutin in place of Rifampin in HIV patients where PI’s are used
• In pregnant women with HIV or recent contact history or conversion, treatment should be started even in the first trimester.
• In other lower risk pregnant patients, Rx can be deferred till after delivery
• Options in INH resistant or PZA intolerant patients available
• Immune-competent contacts of MDRTB with LTB, PZA/ETM or PZA/QUIN for
  6 months.
• Immune-compromised contacts of MDRTB…………Rx for 12 months

Teaching Bullets

• Acid-fast
• Obligate aerobe: Involvement of spleen/heart?
• Intracellular
• Replication time 15-20 hours
• New Colonies generally do not appear after 6 weeks
• 99% Niacin-positive
• Flouroscient stain more sensitive than CF stain ( Overall: low sensitivity with 10000 (10 X4) bact/cc. Quantitatively: Rare= 3-9/slide; few =>10/slide; numerous 1/oil
• PCR: false positive
• DNA probe: rapid but expensive for ID
• Other AFB = Nocordia,Legionella Micadei
• 40-70 % of patients with MTB isolated on culture have positive smears
• Culture = egg based or agar based
• CXR: nodular= 10x2 –10x4; Cavitary=10x7-10x9

  With treatment:

• Within 15 days: TB bacilli decrease 2 log i.e. 10x6 to 10x4
• Cough decreases in 40 % in 1 week and 65 % in 2 weeks
• Drug regimens that do not include INH do not render the patient non infectious as rapidly
• Operational implications regarding infectiousness should be modified depending upon living and working conditions.
• Under standard conditions and humidity, 60% survive 3 hours and 30 % survive 9 hours

  Rate of TB:

• 15/1000 close contacts
• 3/1000 - close contacts

  Control:

• BCG reduces the growth of organisms in macrophages
• In low incidence areas---endogeneous infection—Rx LTB
• In high incidence areas—exogeneous infection---TB control measures

  PPD test:

• 48-72 hours –1 week. Plant Day 0 ; if not read in 7 days, replant 48-72 hours later
• Booster/2 step

• Except in children, the size of the PPD TST (tuberculin skin test) reaction bears no relationship to the likelihood of active TB.
• BCG induced reactions are smaller and tend to wane more quickly than reactions caused by naturally occurring infections
• History of BCG generally ignored in the US

  LTB: Treatment (Chemoprophylaxis)

• 80% reduction in incidence of active TB
• 50% less per year
• Overall 60% reduction

  
  PULM TB

• 35-80 % of patients have fever
• 11% have hyponatremia
• Single early morning specimens have higher yield and lower rate of contamination than pooled specimens. Increase in yield between 3-5 specimens is low
• Drug resistant mutants: ETH 10x4; INH/SM 10x6;RIF 10x8
• 8-16 % delinquent rates in 6 month DOT
• INH induced hepatitis: 10/1000 ( 0.1-0.3-3%)
• Retrobulbar neuritis with ETH: 15 % with 50mg/kg; 1-5% with 25mg/kg; <1% with 15mg/kg. Increased with renal dysfunction
• 50% of untreated TB patients die within 5 years
• 25% remain chronically ill with positive sputum cultures and infectious
• 25% resolve spontaneously
• Steroids in TB: Cachexia,shock,ARDS,Pericardial disease
• Lymphnode TB: Medical Rx after aspiration better outcome than surgical excision and Rx
• Pleural TB: 30 % have no evidence of pulm lesions on CXR
• Pl Fluid: 10 % eosinophils and 5 % mesothelial cells rules out TB
• POTTS: Two adjacent vertebrae with IV disk ( lower thoracic and upper lumbar)
• CSF : AFB smear 20% +, Culture 50-80%
• TB peritonitis: Active TB uncommon; 50 % have MTB culture positive
• GU TB: 50-70 % have old TB
• 50% of those with pericardial disease have pleural involvement



• Quantiferon TB Gold/TB Spot Test
• Gamma Interferon necessary for activation of microbicidal mechanism in macrophages
• Nitric Oxide: Microbicidal and bacteriostatic
• Murine macrophages which produce NO both inhibit growth and kill virulent human TB bacilli in vitro when activated by TNF alpha and gamma interferon
• Cytokines and lymphokines have the ability to organize granulomas and wall of infection, decrease bacillary load and restrict the mobility of infected macrophages and hence spread of infection
• In immune-deficiency individuals, decreased TNF causes lack of granuloma formation and hence unrestricted spread.
• Caseation necrosis and cavitation is due to killing of TB bacilli with cytokines and T lymphocytes
• MMWR - TIGRA TB Tests June 2010 Update

  NTM/MOTT

  Who Dat Mott 2011 PowerPoint Presentation

  Of all Mycobacteria isolated in 41state labs

• 65% NTM
• 21% MAC
• 5% Mycobacterium kansasii (MyKS)
• MAC in HIV :serotype 4-8
• Rx of MAC in non immune compromised host: 50 % successful with 20 % relapse

  Mycobacterium kansasii (MyKS)

• Colonization less frequent than MAC
• 53 % of those from whom MyKS isolated truly had invasive disease
• Same criteria of dx
• 35-40% have no significant lung disease

  Rapid growers

• beaded gram positive rods on gram stain
• MyCh/Mfort: Sternal osteomyelitis, mediastinitis,pericarditis,vascular inv, aspiration pneumonitis
• MAC-PD Management Strategy & NTM Summary

For more information regarding NTM/MOTT, please click on the following link: Nontuberculosis Mycobacteria Info & Research

Contemporary Topics in MTB 2010 through the Wemore TB Clinic Tour

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TB & HIV: Quadruple Jeopardy