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AIDS CLINICAL ROUNDS

TUBERCULOSIS AND HIV SCREENING IN HEALTHCARE WORKERS AT MAPUTO CENTRAL HOSPITAL, MOZAMBIQUE

Francesca Torriani, MD Susannah Graves, MD

University of California, San Diego May 17, 2013

AIDS Clinical Rounds – AVRC - UC San Diego

Estimated number of

cases

Estimated number of

deaths

1.4 million Range: 1.0 – 1

8.7 million (range: 8.3 –9.0 million)

All forms of TB

HIV-associated TB

1.1 million (13%) 430,000 (31%)

Why is TB still important in 2013?

Women Children

2.9 million (range: 2.6–3.2 million)

0.5 million

25% of TB cases are in Africa Highest rates of cases & deaths relative to population

0.5 million

HIV prevalence and TB incidence in Africa

Source: UNAIDS and WHO Source: WHO

HIV prevalence: 11.5% in Mozambique

TB incidence

Question 1

What is the HIV prevalence in Mozambique? A. 1-4.99% B. 5-9% C. 10-20% D. >20%

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

TB Infection Control Measures

Administrative Measures Risk assessment Infection prevention and control plan Administrative support for the program implementation,

including quality assurance Environmental Controls

Separate room Negative pressure room Natural ventilation Filtration UV lights

Personal Protection N95 respirators

TB Infection Control Measures: Administrative Measures

Screen regularly for TB Respiratory hygiene/cough etiquette Educate/Training of patients and staff Triage/Isolate suspect clients Rule out TB without delay Better coordination between TB and HIV services When identified Decrease time patients are hospitalized Defer admission of patients Rapid drug susceptibility assays Involuntary detention if resistance HIV testing

TB Control at Maputo General Hospital

Infection control committee chartered Sept 2011 TB control program chartered in late 2011 National TB reference laboratory acquired capacity

for mycobacterial culture and DST in early 2012 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.

TB Control Team, MCH

Pilot Study Methods - 1

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.

Pilot Study Methods – 2

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 pulmonary 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)

Pilot Study 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%

HIV Screening Results

N = 148/156 (95%) HIV tested

Pilot Study: Active TB

TB in 1/156 (0.6%) of HCW Screened • Asymptomatic at screening • Xray: mediastinal adenopathy • Developed diffuse adenopathy • Diagnosed via LN aspiration • Hospitalized: TB lymphadenitis

TB Symptom Screen Results

Pilot Study Radiographic Findings

Abnormal Xray in12 HCW Lymphadenopathy Diffuse opacities Nodular opacities “Bronchiectasis” Cavitary lesion

2/12 had prior Hx of TB 42% were HIV+ 25% had symptoms

Abnormal Chest Xrays by HIV Status and Symptoms

Microbiologic Data

19 HCW reported productive cough

Only 9 sputum samples obtained: AFB smear – negative in all 9 Mycobacterial culture – 8 negative, 1 contaminated

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

CT findings

Cases Diagnosed 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

Among 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

Pilot Study 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

Pilot Study 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

Question 2

Which clinical symptom is the best to screen for TB? 1. Fever 2. Loss of weight 3. Chronic cough 4. Night sweats 5. ≥2 symptoms

Reid et al Lancet ID 2009

Reid et al Lancet ID 2009

Sensitivity and Specificity of Cough as a Symptom of TB Assess for signs and symptoms suspicious for tuberculosis

The Importance of Early Diagnosis

Prevent new infections: Suspect TB when Weight loss >1.5 kg in last month Cough more than 2 weeks Night sweats more than 2 weeks Fever more than 2 weeks Other: anorexia, hemoptysis, pleuritic chest pain

A diagnosis of TB should fast track patients to ARVs <200 Initiate TB treatment and ARVs <50 Initiate TB treatment and ARVs immediately

Screen and identify TB suspects Assess for signs and symptoms suspicious for tuberculosis

Not all patients will spontaneously report cough! Therefore you should ask: Do you have a cough? If yes, then ask:

How long have you been coughing for? Ask for additional signs or symptoms compatible with TB

Do you cough up blood? Have you had night sweats? Have you had a fever?

Measure current temperature Have you lost weight? How much? Measure weight Ask about previous history of TB in the patient, family or work contacts

Impact of Administrative Measures

Alone prevent < 10% of future XDR TB Early discharge after 5 days avert 6% Admission deferral of 25% clients prevented 7% Rapid drug susceptibility assays prevented 3% Involuntary detention without separate facilities build up

lead to an INCREASE 3%

Basu et al, Lancet 2007;370:1500-7

Question 3

How many sputum samples are sufficient to exclude active contagious TB?

A. 1 B. 2 C. 3

Diagnose TB Promptly

Collect sputum samples (OUTSIDE!) Two sputum samples from every TB suspect (one on

the spot, the second one day after) Two sputum samples identify 95% of smear positive

cases!

Give instructions to patients on Purpose of the sputum collection How to cough up How to handle the container Instruct them to collect 2nd sputum outside

Nelson, JCM, 1998;36:467; Wilmer, Can J Infect Dis Med Microbiol , 2011;22:e1

TB Diagnosis

When the above symptoms exist – send patient for AFB examination of the sputum x 2

In this setting a positive AFB is sufficient to provide a diagnosis of TB If sputum AFB is positive = patient is contagious

Handful of patients who are sputum negative, if there is a high enough suspicion for TB, may consider empiric treating

Key Points to Prevent TB Transmission

Screen regularly Isolate suspect patients and educate about cough hygiene Provide HIV and TB diagnostic and treatment services Promote mask compliance (protects you and your patients) Ensure good natural ventilation

Alert clients ahead of time that windows will be open and encourage them to bring a jacket and/or blanket

Know your status

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

Environmental controls

Natural and/or mechanical ventilation Open windows and

doors Fans to dilute/direct

the flow to outside Filtration UV irradiation Isolation facilities for

MDR or XDR patients Basu et al, Lancet 2007;370:1500-7

Hospital Central de Maputo, Mozambique, Sala de Urgencias

Next Steps

The Study (CFAR Grant): 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

Active TB in HCW 2013 Survey

Aim: To assess annual incidence of active tuberculosis in health workers at MCH.

A publicity campaign with posters and departmental trainings advocating early identification, triage, and treatment of TB suspects, cough etiquette and appropriate mask use.

Twelve months after the initial screen, physicians in the medicine department who treat TB were surveyed via phone to report cases of TB in health workers from MCH.

Active TB in HCW 2013 Survey Results

Twenty cases of active TB in HW were reported: 14 pulmonary 5 extrapulmonary 1 pulm and extra pulm

19 new cases and one re-treatment Three new cases (16%) were MDR-TB 13/20 (65%) AFB smear + 3/20 (15%) AFB smear - 4 did not provide samples HIV status

4 (20%) HIV+ 10 (50%) HIV – 6 unknown

Healthcare workers included medical students, orderlies, nurses, and physicians in at least 8 different departments

Discussion

Given the large number of cases and alarmingly high rate of MDR-TB among HW, MCH has moved to expand the TB office to address gaps identified in current screening and treatment practices.

Gaps include: No active case-finding Lack of sputum specimens for those patients without chronic cough Unknown HIV status in 30% of HCW diagnosed with TB

To address these, the TB office was allocated space and equipment for sputum induction.

Outside funding was secured to screen for active and latent TB and HIV in 500 HW with a plan for annual screening in the future.

Furthermore, to curb transmission, hospital allocated funding for phase 1 of a two-phase plan for an ultraviolet germicidal irradiation installation and triage-isolation protocol in Urgent Care.

TB infection control plan - Urgencias

Patients

Consult

Waiting

Add UV fixtures

Operate all ceiling fans

By Anna Levitt

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

Thank you Questions and Suggestions?