HD60 - Comprehensive and Cost-Effective Means of Eliminating Tuberculosis Development Strategic Plan

  • Published: 1994
  • Author: Department of Health
  • Enabling Authority: House Joint Resolution 531 (Regular Session, 1993)

Executive Summary:
This report was written pursuant to House Joint Resolution (HJR) 531, adopted by the1993 General Assembly. The resolution calls for the study of effective methods to arrest the spread of active tuberculosis (TB) and prevent the development of multidrug-resistant tuberculosis (NMR-TB). The report describes the causes for the recent resurgence of TB, and the scope of the TB problem in the United States and Virginia. Strategies for prevention, detection, and treatment of TB, as well as increased funding requirements to carry out proposed recommendations, are presented.

Background

TB is caused by a bacterium called Mycobacterium tuberculosis (M.tb.) which spreads through the air from a person suffering from TB of the lung or larynx to susceptible persons who share the same air. The more frequently a susceptible person breaths air containing M.tb., the more likely will infection occur. TB is not highly communicable. Only 30 percent of household contacts to an active case of pulmonary TB become infected. The percentage can increase with overcrowding in poorly ventilated environments. For this reason, TB is most common among persons living in crowded conditions.

Recent Resurgence of TB

In the last century, TB was the leading cause of death in the United States and it remained so well into the 20th century. Improved housing and living conditions, aggressive public health interventions, and development of effective drug therapy in the late 1940s led to a steady decline in TB cases. However, TB cases in the United States are again reaching epidemic proportions; 26,673 cases were reported nationally in 1992. In Virginia the reported cases of TB remained fairly steady from 1986 to 1991; 415 were reported in 1986, and 379 in 1991. The number reported in 1992 was 456, and as of December 20, 1993, 464 cases have been reported. In Virginia in 1991, 8.4 percent of the TB cases reported had at least partial resistance to one drug; in 1992 it was 5.9 percent.

Basic TB Control Strategies

The majority of active TB cases could be averted if preventive therapy is administered to persons with TB infection; MDR-TB could be prevented if patients complete their course of treatment in accordance with their physicians' instructions. While there is a heightened national interest to look for innovative approaches to contain the problem, the federal Centers for Disease Control and Prevention (CDC) have reiterated that the single most important step for controlling the disease is the effective and appropriate treatment of TB. It is essential that physicians follow the May 1993 treatment recommendations of the national Advisory Council for the Elimination of TB. These recommendations were published in the October 1993 issue of the Virginia Epidemiology Bulletin which is mailed to all licensed physicians in the Commonwealth. Treatment serves three public health purposes:

• Treatment is effective in preventing persons with TB infection (which is non-communicable) from progressing to clinically active disease.

• Treatment of active cases benefits individuals and can eliminate transmission of TB to others.

• Continuation of the full course of treatment can prevent the development of MDR-TB.

Because non-compliance with treatment recommendations has contributed significantly to the resurgence of TB and MDR-TB, the CDC strongly encourages the use of directly observed therapy (DOT) whenever there is concern about non-compliance. The utilization of public health outreach workers is crucial for the success of DOT.

Multidrug-Resistant TB (MDR-TB)

While the prevalence of MDR-TB in Virginia is still low, every case gives concern. The necessary course of treatment increases from approximately 6 months for non-MDR-TB to 18 to 24 months or longer for MDR-TB, and the cure rate decreases from nearly 100 percent to 60percent, respectively. Major outbreaks of MDR-TB have occurred in other states within correctional institutions, shelters, residential facilities, and hospitals. Prompt diagnosis and rigid adherence to the CDC treatment guidelines can greatly minimize outbreaks.

The current Regulations for Disease Reporting and Control require the directors of laboratories to report TB cases identified by culture. However, commercial and hospital laboratories are not required to report the results of drug susceptibility testing. If all laboratories were required by regulations to submit TB isolates to the Division of Consolidated Laboratory Services for drug susceptibility testing, delays in initiating treatment of MDR-TB could be minimized.

Containing Outbreaks in Institutions

Recent reports of the increased transmission of TB in institutional settings such as hospitals, nursing homes, homeless shelters, and jails and prisons in other states indicate that priority should be given to:

• Early identification and treatment of patients with suspected or confirmed TB disease,

• Strict adherence to isolation procedures for such patients,

• Adequate environmental control of TB, i.e., the use of ultraviolet lights and negative pressure ventilation in rooms occupied by TB patients,

• Rapid reporting of cases of TB to the appropriate local health department, and

• Coordination of treatment and follow-up of all cases with the appropriate local health department and the Virginia Department of Health (VDH) Bureau of TB Control.

Populations Especially at Risk for TB

The TB epidemic is occurring primarily among the urban poor, minorities, immigrants and refugees from countries with high TB rates, homeless persons, migrant workers, injecting drug users, residents of correctional facilities, nursing home residents, and persons infected with IRV. The latter have a striking vulnerability to TB; once infected, they are much more likely to develop TB disease than those not FUV-infected. As is currently being done in Virginia, HIV-infected persons should be closely monitored for TB symptoms and screened for TB as part of their routine health care. Another important measure is outreach into medically underserved low-income populations to screen for TB.

The VDH initiated a special incentive program in 1992 to address the problem of treating homeless persons with TB. Such persons, especially those also infected with FHV, need immediate access to housing and services for two primary reasons:

• They are at the greatest risk of continued homelessness, illness, and even death due to their dual diagnoses, and

• They have the greatest likelihood of transmitting TB because they tend to congregate in poorly ventilated settings.

The VDH has made it a priority to identify hospitalized homeless persons with TB who are at risk of treatment non-compliance and to provide for their living needs in a supervised environment before they are discharged from the hospital.

Legal Measures for Controlling TB

On occasion, there is a need to deal with persons who refuse to take medications despite repeated counseling. Such persons are a potential risk to the public and may need to be isolated. An amendment to the Code enacted by the 1993 General Assembly makes rapid isolation possible after all other measures to convince patients to take medications have been exhausted and a significant risk exists that the patient may be lost to treatment. The law provides an appropriate balance between public health needs and the protection of human rights. An order for isolation may be sought by the Commissioner only after an array of incentives, counseling, and support have been provided to the person and DOT has not been successful. A procedure for court review follows within three days.

Last, but not least, the past decade has shown that policies for the prevention of TB must be developed in concert with those for HIV infection. The VDH has been doing this for several years and will continue.

Conclusion/ Recommendations

While cases of TB are increasing in Virginia, the situation is not yet "out of control." Since TB is a major public health concern, individual health care clinics/facilities and health care providers in the private sector must also fully participate to decrease the spread of this disease. The following should be done to prevent the problem from getting worse:

• Screen more persons for TB, especially those at high risk for TB, such as persons with HIV infection and foreign-born persons. Use licensing regulations to require screening of health-care-facility personnel for TB;

• Ensure that the Division of Consolidated Laboratory Services is well equipped to provide rapid diagnostic services;

• Employ 22 more outreach workers to conduct directly observed therapy (DOT); $209,030 in funding, and FTE's have been included in the Governor's budget of December 20, 1993;

• Inform health care providers about the latest recommendations of the Advisory Council for the Elimination of TB;

• Reinforce the Homeless Incentive Program (HIP), including additional incentives and enablers. The cost will be $147,000;

• Urge medical schools to give greater emphasis to courses on TB;

• Reinforce infection control measures in hospitals and other institutions housing TB patients;

Provide for environmental adaptations in local health departments at a one-time cost of $187,000;

• Establish appropriate facilities for isolating persons with, or suspected of having, infectious TB, and treating cases of MDR-TB. The cost will be $276,000;

• Provide for acute care hospitalization and second line anti-TB drugs at a cost of$128,000;

• Reinforce program management and evaluation at the VDH at a cost of $80,000. This is necessary because of the reduction in funding and resources that occurred for several years before the resurgence of TB,

• Provide seven additional public health nurses for local health departments at a cost of $210,000;

• Investigate and control outbreaks of TB promptly, involving both public health and individual health care service systems; and

• Solicit the support of the Medical Society of Virginia for the implementation of these recommendations.

The total cost for implementing the portion of these recommendations that will be the direct responsibility of VDH is $1,237,030 in general funds for the first year. Since the cost for environmental adaptations is a one-time expenditure of $187,000, the continuation budget request is $1,050,030 per annum after the first year.