Tuberculosis Among Health Care Workers, Researchers, Trainees, and Travelers to Kenya in Association with

AMPATH

Adrian Gardner MD, MPH

Clinical Research Fellow, Infectious Diseases

Miriam Hospital/Alpert School of Medicine at Brown University

4/16/10

TB-infected resident doctor may have exposed hundreds of [Chicago] children!www.digitaljournal.com Apr 12, 2009

More than 3,700 face tests for TB!Boston Globe June, 2005”More than 3,700 hospital patients and workers started receiving notices yesterday that they should be tested for tuberculosis after possibly being exposed to a junior doctor who rotated through four Massachusetts hospitals while she had a contagious form of the disease for six months.”

BackgroundTuberculosis continues to be one of the most common infectious diseases in the world (9.27 million new cases in 2007). Many regions of the world continue to report a rise in the number of cases of drug resistant tuberculosis.

Kenya is #13 on the WHO list of 22 high-TB burden countries and hasan incidence rate of approximately 350 new cases/100,000 population per year

Latent TB infection: no symptoms, inactive bacteria, positive skin test

TB disease: symptoms, usually culture positive, contagious (respiratory tract)

BackgroundGrowing number of students, faculty, physicians-in-training, researchers and other health professionals from the US traveling to work in areas of the world where tuberculosis (TB) and drug-resistant TB are endemic.

Activities in these areas frequently involve exposure to infectious TB patients in settings that lack effective infectioncontrol policies and practices.

Little is known about the risk of TB infection in this population and whether there is a need for specific, targeted education andcounseling of program directors and participants.

MethodsSurvey program participants who traveled to Eldoret, Kenya in association with the AMPATH program between July, 2004 – June, 2009

Administered questionnaire via an online survey tool and by hard copy upon request

MethodsSurvey designed to collect:

Demographic characteristics of participantsExperience with pre-travel TB counseling and testingIn-country activitiesPost-travel TB testing

Results (Preliminary)69% responded (N=418)

Analysis in progress

Results: Demographics

326 (80.5)36 (8.9)

43 (10.6)

TB HistoryNegative test for LTBIHistory of LTBINever tested for LTBI/Unknown

340 (93.4)Medical History

No chronic medical illness

227 (54.8)GenderFemale

N (%)6 (1.4)

167 (40.3)110 (26.6)57 (13.8)53 (12.8)37 (8.9)

Age (years)18-2122-3031-4041-5051-60>60

*Other- PCP, Health center, previous travelers, self

Other includes safari trips, downtown restaurants/dance clubs, classrooms, weddings, operating room, pharmacy,TB clinic

47%

41%

9%

Revealing Comments….“I visited AMPATH, but was not involved in any of the TB work. Just wanted you to know that I will not be completing the survey.”

“I don't think I should be on this list. I took a short mission trip to Kenya but I know nothing about the TB testing. I do not remember any council specific to TB before we left, just generalinformation about immunizations but the discussions focused more on malaria.”

“I work with SMILE providing laboratory support. The survey doesnot really apply to my experience in Eldoret. Therefore, I did not fill in the survey.”

Results: “Ideal care”Definition of “Ideal Care”

Pre-travel counseling on TBPre-travel TST within one year of departurePost-travel TST related to travel

Only 28% of adult participants received “ideal care” (i.e. met all three criteria)

Results: TST conversions10 participants reported a negative or unknown pre-travel TST and + TST post-travel for a conversion rate of 2.7 - 3.8%.

Of those who reported TST conversion or active TB, 8 (73%) reported participation in direct medical care vs. 3 (27%) reported no participation in direct medical care.

One participant reported active TB

66 children under the age of 21 years accompanied survey respondents to Kenya.

Of these, 26 (39%) had a TST upon return and 3 had a conversion for a conversion rate of 4.5% - 11.5%.

Conclusions (Preliminary)HCW, researchers, trainees, and travelers to western Kenya with the AMPATH medical exchange program tend to be young and healthy.

Their in-country activities place them at significant risk for TB infection

Many do not receive adequate pre and post-travel counseling and testing

Further study is needed to more accurately quantify the risk of TB infection and elucidate “higher-risk” in-country activities.

Pre-travel consultation for travelers to TB-endemic countries should include specific TB education and counseling

Operational responseAMPATH

Designing an educational brochure which will be given to programparticipants upon arrival in Kenya

Create a system for reminding participants to have a post-travel TST

Ongoing efforts to develop and implement an infection control plan for the hospital in Eldoret

At Brown, hoping to develop mechanism for educating all students, faculty, trainees who are working internationally in TB-endemic areas

CDC working group: national guidelines for humanitarian and health care providers working in areas where drug-resistant TB is endemic

Asante Sana for your attention!