XDR TB: Evolving Role of Public Health in Tuberculosis ...

XDR TB: Evolving Role of Public Health in Tuberculosis ...

XDR-TB: Evolving Role of Public Health in Tuberculosis Jayne McGunigale, RN Supervisor, Refugee Health and TB Control Howard County Health Department Columbia, Maryland March 22, 2016 Howard County, Maryland Maryland References: United State Census Map, 2015 Howard County Demographics Howard County is one of the wealthiest counties in the United States. Population of 304,000: 1 out of 6 residents is foreign born.

95 % are High School graduates 60 % are College/Professional graduates Howard County TB cases Angola China Ethiopia India Iran Korea Malaysia

Mexico Nigeria Russia Thailand US Vietnam Total 0 0

0 3 0 1 1 0 0 0 0

0 4 0 9 2014 1 2 0 2

0 0 0 0 1 0 1 0 2

0 9 2015 0 1 2 2 1 1

0 1 1 1 0 1 0 1 12

Myanmar Year 2013 MDR-TB in the U.S. XDR-TB in the U.S. Pediatric XDR TB Case Background Healthy U.S. born two-year-old of foreign-born parents Parents are healthcare professionals experienced with TB Traveled to India from 5/31/13 8/20/13 Healthy household members: mother, father, five-year-old sibling

U.S. daycare attendee before and after India trip Pediatric XDR-TB Timeline 8/13 Sx onset (India) 8/23 PCP eval 8/20 Returned to USA home 8/26 QFT(+) 8/26 Hospital Adm

CXR abnl Chest CT abnl Gastric asp x 4 10/8 LHD Notified of 9/30 MTB 11/27 Rx tolerated XDR-TB New daycare confirmed enrollment 8/30 4 TB-drugs

Rx begins 10/3 Cx + for MTB (1 of 4 gastric asp) Hospital notified parent 11/14 9/4 Hospital DC LHD begins DOT 12/4 Hickman cath placed New drug regimen started

12/2 Hosp Adm Notified of drug resistance, Home isolation begins Pediatric XDR-TB Case XDR-TB Drug Resistance Profile First-line drugs Fluoroquinolone Second-line drugs Isoniazid Moxifloxacin Amikacin Rifampin Kanamycin Pyrazinamide Capreomycin Ethambutol

Pediatric XDR-TB Regimen l Regimen changed during course of treatment based upon patient weight, drug levels, and ongoing consultations Total treatment period was 21 months Pediatric XDR-TB LHD Challenges Care Coordination Family Private provider Local and state health departments and the CDC

Other academic faculty working in TB clinical practice and research Public Health Responsibilities Consultations with local, state, federal, and international TB experts DOT Contact/Source case investigations Pediatric XDR-TB DOT Challenge Small LHD TB Program Special order medications Lack of DOT awareness and acceptance Multiple DOT visits Morning visits 90 minutes Evening visits 30-45 minutes Residence 45 minutes from the LHD Pediatric XDR-TB Investigation Challenge

Strengths Federal, state, local agencies and private provider worked efficiently, collaboratively, and compassionately as a team Customized medications were facilitated Patient had private health insurance Hospital pediatric pharmacy prepared unit dosing and provided guidance for administering meds and for monitoring possible side effects LHD provided DOT twice daily 7 days a week LHD funds used to hire agency nurse for evening and weekend DOT Child responded favorably to treatment Weaknesses

Multiple conference calls Up to 24 people on initial calls Numerous private and public health experts Varying and conflicting opinions expressed by experts Example: Experts stated that child was not infectious LHD was not using respiratory precautions BUT Airborne isolation was in place while patient was in the hospital, AND Respiratory precautions ordered for pediatric home health team Funding was not readily available for specialized medications or staff overtime private insurance and HO approved county funds to assist Opportunities Positive culture allowing for susceptibility testing Family had health insurance

Allowed for purchase / preparation of medications Paid for appointments including labs, vision, audiology and vestibular assessments, and consultations with specialists Private provider was open and willing to collaborate with LHD Medications were tolerated Minimal side effects Threats Toddler with XDR-TB Multiple Voices Notoriety of diagnosis Family priorities versus public health priorities DOT Missed DOT doses extended treatment Identifying funding for extensive DOT coverage

Lessons Learned Collaboration is the key to treatment success Consider effects of long-term intense treatment on child and family Length of treatment DOT Schedule: Initial twice daily visits Length of home visits due to IV therapy and spacing of medications Consider DOT team initially, various LHD nurses provided DOT Adjust work schedules to provide DOT into evening hours and weekends Staff Awareness: Resource packets HD provided respiratory training for additional staff Cultural Competency Navigating the experts

Update on child with XDR Seen by private provider in October, 2015 No symptoms of TB Bronze skin color from Clofazimine slightly improved expect complete resolution to take several years TSH and free T4 is normal off Synthroid Child is enjoying kindergarten, and gaining weight appropriately Next follow up in March, 2016 Acknowledgements Maryland Department of Health and Mental Hygiene Center for Tuberculosis Control Program (CTBCP) Nancy Baruch RN, MBA, Maryland TB Controller

Maureen Donovan RN, MGA, Nurse Consultant Lisa Paulos RN, MPH, Epidemiologist Howard County Health Department Maura Rossman, M.D., Health Officer

Bernard Farrell, M.D., TB Clinician Elizabeth Menachery, M.D., Medical Director Andrea Raid, RN, Director of Communicable Disease Dorothy Bauman, RN, Staff TB Control Nurse Sandra Nicholas, LPN Tial Zawkhai, LPN Susan Bauhaus, RN Wendy Kensie, RN, JPS Fiori Tesfamariam, LPN Marilyn Birkner, Clerical Zakariya Kmir, HCPSS Gifted & Talented Program Student Intern Moving Forward Questions?

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