Mahoning County. TUBERCULOSIS ELIMINATION PLAN Mahoning County General Health District Board of Health Edition

Transcription

1 Mahoning County TUBERCULOSIS ELIMINATION PLAN Mahoning County General Health District Board of Health 1997 Edition

2 CONTENTS Purpose of Document... 3 Background Information... 4 Problems with TB Control in Mahoning County... 5 Mission, Priorities Strategies... 7 Improving Surveillance... 8 Improving Case Prevention Improving Disease Containment Program Assessment Evaluation Mahoning County Tuberculosis Control Advisory Committee Members Appendix

3 PURPOSE OF DOCUMENT The Mahoning County Tuberculosis Elimination Plan is based on strategic plans developed by National Advisory Committee for Elimination of Tuberculosis Ohio Tuberculosis Coalition (OTC). The Plan describes problems of tuberculosis control goals, objectives activities for elimination of tuberculosis from Mahoning County by year In this document statewide goals, objectives strategies of OTC Ohio Tuberculosis Elimination Plan have been adopted local activities proposed for advancing TB control efforts. These local activities will be reviewed revised annually as necessary. The Plan calls for all boards of health, voluntary health human service agencies health care providers in Mahoning County work ger ward goal of eliminating TB in Mahoning County. 3

4 BACKGROUND INFORMATION Tuberculosis is a communicable disease caused by bacteria (Mycobacterium tuberculosis) that are usually spread from person person through air. Airborne infectious particles are produced when a person with TB of respirary tract coughs. When inhaled by anor person, bacteria cause an infection that spreads throughout body. Most individuals who become infected do not develop a clinical illness because body s immune system brings infection under control. Infected persons do, however, develop a positive TB skin test. The infection can persist for years, perhaps for life. Infected persons remain at risk for developing disease, i.e., clinical illness, any time, especially if immune system is impaired. Although disease usually affects lungs, it can occur at virtually any site in body. While prevalence of cases day is lower than in past, TB remains a public health problem in United States, Ohio Mahoning County. Isolated but potentially dangerous enclaves of this preventable curable disease persist. In Ohio, number of TB cases reported annually decreased steadily from 7,300 cases in cases in However, this long-term downward trend has leveled off since 1985 in Ohio Mahoning County as in U.S. as a whole. The recent change in tuberculosis morbidity trend is attributable, in large part, occurrence of current TB disease in persons co-infected with human immunodeficiency virus (HIV). Some of se cases represent reactivation of latent TB infection. However, when HIV-infected persons are newly infected with TB bacterium, as many as 40% may develop current TB disease soon after infection. A second major facr contributing increase in TB is rise in drug-resistant TB outbreaks of multidrug-resistant TB (MDR-TB). The proportion of patients that resist treatment with conventional drugs has more than doubled in last decade. Now that far more patients have MDR-TB, chance of becoming infected with a resistant strain (as opposed developing resistance incomplete rapy or inappropriately prescribed drug regimens) is increasing rapidly. Or groups at high risk for developing disease include persons in group or institutional settings, such as correctional facilities, shelters for homeless, residential care facilities, nursing homes, hospitals. Persons with underlying medical conditions, substance abusers, children are also at high risk. Approximately one-half of cases now occur among African-Americans. TB is also common among immigrants, refugees, migrant workers from countries where disease is prevalent. Among all racial ethnic groups, tuberculosis case rates are highest among elderly. 4

5 PROBLEMS WITH TB CONTROL IN MAHONING COUNTY Problems with TB control in Mahoning County are illustrated by following observations: In 1996, number of confirmed TB cases in Mahoning County increased over previous years. Three of 1993 cases were reported have positive skin tests in previous years. These cases represented a possible failure initiate complete preventive rapy. One of 11 cases reported in 1993 was a person with AIDS. 30% of tal cases in 1996 in Mahoning County were among African-Americans. African-Americans experience a case rate nearly eight times that of whites. Persons in 65--older age group experienced 40% of tal morbidity in 1996, although y comprise only 23% of population. Only 38% of new employees with positive TB skin tests in Mahoning County nursing homes started preventive rapy in Among nursing home residents, 4.1% had positive skin tests in 1993, slightly above state average of 3.2%. Screening of refugee arrivals in Ohio for infection revealed that nearly 50% of those tested had a significant reaction Manux skin test. One of cases reported in 1993 was an immigrant. Drug-resistant TB due noncompliance inappropriately prescribed drug regimens, particularly among foreign-born, is emerging as a problem in Ohio, but not yet in Mahoning County. Obstacles TB elimination include: The number of AIDS/TB cases is increasing. The pool of infected persons is large an estimated 500,000 in Ohio. Drug resistant cases are difficult treat cure. Nonadherent or unmotivated cases, who are often homeless, alcoholics, /or intravenous drug users, present special case management problems. Infected persons in institutions (e.g., jails nursing homes) can rapidly spread infection once disease develops. The lack of access medical care of those most affected by TB promotes spread of infection hinders treatment of infected persons at high risk of developing disease. 5

6 The lack of understing among legislars, public officials, health care providers leads indifference. Available strategies technologies for diagnosis, patient management, prevention, treatment have not been fully utilized. Available strategies technologies need improvement. Newly developed techniques tend be adopted slowly in clinical public health practice. 6

7 MISSION, PRIORITIES AND STRATEGIES The MISSION of Mahoning County Tuberculosis Control Program is achieve elimination of TB from Mahoning County. Prevention is keysne. Three types of prevention must occur: Primary Prevention: People who are not infected with tubercle bacillus must be prevented from ever becoming infected. Secondary Prevention: People who are infected must be identified early treated before y develop disease. Tertiary Prevention: People with active disease must be detected treated promptly decrease risk of transmitting infection. PRIORITIES include adequate appropriate treatment for all persons with TB, identification of high-risk population groups, appropriate use of preventive treatment in members of se groups. Specifically, Program seeks : Reduce incidence of TB fewer than one case per million population by year Achieve an interim rate of 1.5 per 100,000 population in Mahoning County by year 2000 *. If se goals are reached, no more than four cases during year 2000 no cases during year 2010 will be reported in Mahoning County. STRATEGIES that are key reaching se goals are: Improving Surveillance Improving Case Prevention Improving Disease Containment Continuous Program Evaluation Assessment * In 1996, case rate was 3.8 per 100,000 population. 7

8 IMPROVING SURVEILLANCE The Problem The identification reporting of TB cases, suspects contacts is often slow or incomplete, thus delaying treatment preventive intervention. This is more likely occur among poor, elderly, homeless, drug users, prisoners, foreign-born. Objectives All individuals with signs/sympms of TB or TB infection will be reported TB Control Program within one working day of initial diagnosis or positive Manux skin test. Active population-specific casefinding, screening, preventive intervention programs will be established maintained by TB Control Program. Suspects cases are be interviewed by TB Control Program within three working days after notification. Infected persons are be interviewed within fourteen working days after notification Methods 1. Educate health-care professionals high- risk groups in community about TB. 2. Evaluate individuals with signs/sympms of TB within two weeks of initial contact with a health-care provider. 3. Report suspected cases TB Control Program within one working day facilitate contact follow-up. 4. Use a TB Report Form report suspected confirmed cases state TB registry within seven days after receiving case/suspect report. If written laborary confirmation is received, complete forward anor TB Report Form on cases previously reported as suspected. 8 Activitie s Hospital gr rounds, seminars for health care providers, TB update mailings primary care physicians, paid public service announcements. Educate clinicians infection control practitioners.

9 ethods M s Activitie confirmary of results report Complete 5. one Program within TB Control tests confirmation following day working control infection clinicians Educate practitioners TB Control persons infected Refer 6. facilitate day working one Program within follow-up. control infection clinicians Educate practitioners with persons of investigation an Complete 7. notification. of days 14 within TB infection given be will investigation for Priority younger. or old years 15 persons of registry County Mahoning a Maintain 8. allow persons infected contacts cases, indices program performance of extraction information. epidemiological detailed indices. county-specific publish Annually Database Tuberculosis CDC - Install state for developed System (CDC-TDS) programs. TB control local TB that date between time Monir 9. date suspected initially was TB Control reported was case suspected three than more of delays Investigate Program. prevent action corrective take days delays. future control infection clinicians Advise practitioners. (e.g., records review selected Periodically 10. death reports, pharmacy reports, laborary system surveillance validate certificates) cases. report failures any detect which in community in groups Identify 11. occurs. TB transmission in persons of screening conduct Promote facilities, correctional occupations, high-risk treatment abuse substance shelters, homeless long-term or homes nursing centers, facilities. care IMPROVING SURVEILLANCE 9

10 IMPROVING CASE PREVENTION The Problem Preventable TB cases occur in Mahoning County. By definition, preventable cases include those in which one or more of recommended interventions should have been used but were not. These interventions include use of ultraviolet lights in high-risk areas of buildings, contact identification examination, isolation of suspected diagnosed cases, screening for infection, preventive rapy for infection, prompt diagnosis of disease, chemorapy for disease, adequate ventilation, prompt reporting, Directly Observed Therapy (DOT). Some of se interventions (e.g., isolation) are designed prevent transmission of infection among residents staff of high-risk institutions such as correctional institutions, homeless shelters, nursing homes hospitals. Or interventions (e.g., preventive rapy) are designed prevent disease among those already infected. Isoniazid (INH) preventive rapy reduces risk of TB by more than 90 percent among those who complete a full course of treatment. Objectives At least 95 percent of close contacts infectious cases should receive complete medical evaluations including a Manux (PPD) skin test, chest x-ray if indicated, clinical evaluation for preventive treatment (INH) within 30 days following identification. At least 95 percent of infected persons less than 15 years old should be placed on preventive treatment at least 90 percent on treatment should complete a minimum of six continuous months. At least 75 percent of infected persons age 15 older should be placed on preventive treatment. Methods 1. Assess prevalence, incidence socio- demographic characteristics of cases infected persons. Based on se data, initiate tuberculin screening programs targeted at high- risk groups in community 2. At a minimum, ensure such programs are extended persons with sympms compatible with tuberculosis; all foreign-born persons ( ir families) from high-prevalence countries; admissions correctional institutions; HIV- infected persons; admissions nursing homes; migrant workers; homeless. Activitie s Promote conduct screening of persons in high-risk occupations, correctional facilities, homeless shelters, substance abuse treatment centers, nursing homes or long-term care facilities 10

11 IMPROVING CASE PREVENTION Methods 3. Conduct tuberculin skin testing programs annually among staff of substance abuse treatment centers, home health care agencies, schools, mycobacteriology laboraries, correctional institutions, mental institutions, dialysis units, homeless shelters, nursing homes, TB clinics, hospitals, or health care facilities. Staff who are Manux skin test negative frequently exposed patients with TB or who are involved with potentially high-risk procedures (e.g., bronchoscopy, sputum induction, or aerosol treatments given patients who may have TB) should be retested at least every six months. 4. Skin test all HIV-infected persons. Consider preventive rapy for those with positive tuberculin reactions or a hisry of a positive tuberculin reaction (without active disease), regardless of age. Note: Because much of recent increase in TB cases has occurred among persons infected with HIV, HIV infection status should be determined for all persons with TB infection of active disease. Activitie s Assist outreach screening efforts in: - senior citizen programs - Rescue Mission - County jail - schools - community clinics Develop sign a memorum of understing with HIV testing counseling site providing for Manux skin testing of clients. Advise physicians caring for TB- infected persons about current recommendations for preventive rapy. 5. Continuous screening programs for refugees, immigrants, entrants from high-prevalence countries. Isolate infectious cases until y become non-infectious. Unless contraindicated, place those with infection (without disease) on preventive rapy eir before or within two months after ir arrival in Mahoning County. Monir refugee screening data from Ohio Department of Health (ODH). 6. Consider routinely obtaining sputum for mycobacterial smear culture for sympmatic nursing home residents with suspected lower respirary infection Advise nursing home operars medical direcrs. 11

12 IMPROVING CASE PREVENTION Methods 7. Consider tuberculin skin testing all persons, not only those in high-risk groups, at least once establish a baseline or detect undiagnosed cases. Record results in patient's permanent medical record. Activitie s Make recommendations school districts regarding pupil screening. Assist Head Start, Youngswn or school districts in pupil screening. 8. Interview tuberculosis patients suspects within three days after receiving case/suspect report. 9. Assign contacts infected persons TB Clinic Outreach Nurse for follow-up ensure compliance with preventive treatment. 10. Initiate medical examination (at a minimum a Manux skin test) of close contacts within seven days after index case is diagnosed or case/suspect report is received. 11. Place infected contacts with no evidence of clinical disease on preventive rapy no later than 30 days after initial diagnosis or case notification. Ensure that y receive a full course of treatment. 12. Place children on preventive rapy if y are skin test negative but close contacts of infectious cases. Continue rapy until repeat skin testing (three months after contact is broken) documents absence of infection. 13. Consider preventive rapy for all or high-risk infected persons, regardless of age. This includes newly infected people (skin test converters), people with chest radiographic findings consistent with past TB, those with medical risk facrs (e.g., silicosis, below ideal body weight, gastrecmy, immuno-suppressive rapy) known substantially increase risk. 14. Review records of contacts or high- risk infected persons not starting preventive treatment for appropriateness of that decision. 12

13 IMPROVING CASE PREVENTION Methods 15. Offer a system of incentives enhance compliance among high-risk patients on preventive treatment. Activitie s Obtain ODH patient incentive funds for cases at risk for noncompliance. 16. Use DOT two times weekly when necessary ensure compliance. Ongoin g 17. Monir patients on INH preventive rapy monthly for compliance sympms of xicity. Spot testing urine for INH metabolites is highly recommended when compliance cannot be observed directly. Discontinue rapy immediately re-evaluate patient if signs of xicity appear. Do not dispense more than a one month supply of medication at any visit. 18. Consider installing maintaining ultraviolet lights in high-risk facilities, such as prisons homeless shelters. Health care facilities that admit untreated TB patients or TB suspects should have proper facilities procedures for instituting appropriate isolation. This includes private rooms with negative air flow that exhausts outside. Advise assist Youngswn hospitals, county jail authorities Rescue Mission staff. 13

14 IMPROVING DISEASE CONTAINMENT The Problem Some patients with TB do not complete a recommended course of rapy. Objectives All patients with TB should complete treatment with an appropriate regimen. At least 90 percent of all infectious patients should become noninfectious within three months of starting rapy. Methods 1. For each new case of tuberculosis, ensure education of patient about TB its treatment, continuity of rapy, contact follow up. The TB Clinic Outreach Nurse will visit patient within three days of diagnosis identify contacts possible problems related compliance with rapy. Activitie s 2. For each new infectious case, develop a specific treatment moniring plan within four days of diagnosis. This plan should include: drugs be used; dose frequency, duration of administration; methods assess ensure compliance; assessment of xicity. 3. Collect sputum from patients who are clinically ill able produce sputum; urge patients comply with recommendations; document sputum conversion. 4. Monir patient progress document conversion of sputum consult with attending physician when apparent problems preventing documenting sputum conversion arise. TB Control Officer will contact consult with attending physician for each case not in TB Control Program care. 14

15 IMPROVING DISEASE CONTAINMENT Methods 5. Provide appropriate antituberculosis drugs, laborary services, contact examination, or necessary services patients without regard patients' ability pay. Activitie s 6. Provide laborary services using modern rapid-detection methods. 7. Use incentives enhance compliance. To be most effective, tailor se incentives individual needs desires of patient. It may be as simple as a cup of coffee or conversation, or as complex as providing food housing for a homeless patient. Particular attention must be given ensuring patients have transportation clinic. Continue utilize Ohio Department of Health laborary. Obtain ODH patient incentive funds for patients at risk for noncompliance. Assign vehicle TB Clinic Outreach Nurse for home visits patient transportation. 8. Use DOT two times weekly when needed. Ongoin g 9. Encourage funding at federal, state local level for outreach staff. Seek assistance from appropriately instructed home health care workers, public health nurses or health department staff supervise rapy. Apply for state TB Control grants if y become available fund development of a lay outreach worker program. 10. Obtain funding maintain an optimal staff of outreach workers. As above. 11. Review state local laws regulations address all aspects of TB prevention control. 12. Adopt a procol for isolation of infectious TB cases who are not adherent treatment recommendations. 13. Develop a regional consultation network with recognized experts in TB diagnosis treatment provide help with difficult cases identify cases where consultation is indicated. Support Ohio Tuberculosis Coalition efforts enact legislation for improved funding reform of Ohio's TB control laws. Enter in agreements with Rescue Mission Mahoning County jail authorities provide for isolation of nonadherent cases. Include TB Control Officers from nearby Counties infectious disease specialists in membership of Mahoning County TB Control Advisory Committee. Invite Norrn Regional Coordinar of ODH TB Refugee Health Unit join Advisory Committee. 15

16 PROGRAM ASSESSMENT AND EVALUATION The Problem In many areas, assessment of community TB control problems is incomplete, community prevention control efforts are inadequately evaluated. As a result, programs do not function as effectively efficiently as y should. Objective A system should be in place achieve an ongoing, effective assessment of TB problem evaluation of activities at all levels for control elimination of TB. 16

17 PROGRAM ASSESSMENT AND EVALUATION Methods 1. Annually evaluate local progress ward elimination of TB. This should include an analysis of morbidity mortality data, case reporting, case finding, treatment prevention activities. Collaborate with interested constituencies such as American Lung Associations, minority senior citizen organizations, professional societies. 2.Conduct expert assessment annually for TB Control Program. 3. Develop a protype computerized record system for use by TB Control Program for case reporting, patient management, program assessment. 4. Develop publish an annual community TB summary program plan, including objectives, methods, a discussion of program progress or failure, corrective action needed. 5. Using criteria forms developed by CDC, determine wher each new TB case or death could have been prevented had current recommendations from ATS/CDC been followed. Based on se reviews, develop implement new policies reduce number of preventable cases. 6. Develop a "center of excellence" for TB treatment prevention in Mahoning County Board of Health. Activitie s quality assurance review of TB Control Program operations by staff Advisory Committee. through ODH. Advisory Committee Extend Board of Health's computer services Program. Acquire software, provide training pilot test CDC Tuberculosis Database System (CDC-TDS) developed for state local TB control programs. This document updated annually. TB Control Officer will actively encourage physicians referral of all cases, contacts infected persons Board of Health for evaluation treatment. 17

18 MAHONING COUNTY TUBERCULOSIS CONTROL ADVISORY COMMITTEE MEMBERS Neil H. Altman, M.P.H., Youngswn Health Commissioner Virginia Banks, M.D., Southside Medical Center Jan Carpenter, Youngswn City Schools Anthony Cutrona, M.D., St. Elizabeth Hospital Medical Center Robert DeMarco, M.D., Mahoning County Tuberculosis Control Officer James Demidovich, D.O., Nursing Home Medical Direcr David Schaffer, Executive Direcr, Mahoning County Alcohol & Drug Addition Services Board John Dunne, D.O., Occupational Health Physician Suzanne Gomochak, R.N., Mahoning County Board of Health Brian Gordon, M.D., Medical Direcr, Mahoning County Health Department Robert Knight, R.N., Mahoning County Justice Center Robert Morehead, M.S., Columbiana County Health Commissioner Terry Puet, M.D., Trumbull County Tuberculosis Controller Dorothy Shadl, R.N., Ohio Department of Health Rev. David Sherrard, Rescue Mission of Mahoning Valley Matw Stefanak, M.P.H., Mahoning County Health Commissioner Amelia Tunanidas, D.O., Mahoning County Board of Health John Venglarcik, M.D., Tod Children s Hospital David A. Watkins, M.D., Mahoning County Medical Society Sally Wehmer, Direcr, American Lung Association of Ohio, Norastern Branch 18