Update on the New Technical Instructions for Panel Physicians Tuberculosis Sundari Mase, MD, MPH November 13, 2008

Transcription

1 Tuberculosis Updates for Clinicians San Antonio, Texas November 13, 2008 Update on the New Technical Instructions for Panel Physicians Tuberculosis Sundari Mase, MD, MPH November 13, 2008 TB Update for the Clinician November 13, 2008 San Antonio, Texas Update on New Technical Instructions for Overseas Screening of Refugee and Immigrant Populations Sundari Mase MD, MPH Medical Team Lead CDC/DTBE/FSEB 1

2 Objectives Describe the new CDC technical instructions for panel physicians/civil surgeons Background Each year, approximately 400,000 immigrants and 50,000 refugees enter the United States Approximately 140,000 Burmese refugees are being resettled over the next 5-10 years The Division of Global Migration and Quarantine (DGMQ) has regulatory authority to stipulate the requirements of the overseas medical examination via Technical Instructions The Bureau of Populations, Refugees, and Migration (BPRM) is the State Department bureau responsible for refugee resettlements BPRM has contracted the International Organization for Migration (IOM) to perform the medical screening for approximately 80% of the refugees. The initial Technical Instructions for Tuberculosis (TB TI) was issued in

3 Overseas TB Screening of Immigrants and Refugees, 1991 Algorithm Inactive TB Chest radiograph > 15 years old No TB Class B2 Active TB AFB sputum smears (3) All (-) (at least one +) Noninfectious TB Class B1 Infectious TB Class A 1991 Tuberculosis Technical Instructions: for applicants 15 years of age Inactive TB Chest radiograph No TB Class B2 Active TB No Class Valid for travel within 6 months Valid for travel within 12 months Valid for travel within 6 months Noninfectious Class B1 AFB sputum smears (3) All (-) (at least one +) Infectious Class A Treat until smear negative 3

4 Rationale for Overseas Screening and Domestic Follow-up Overseas Panel Physicians screen TB suspects using DGMQ TIs Restrict entry of infectious TB cases Facilitate entry of the rest to allow U.S.entry, evaluation and treatment per ATS/CDC standards US Health Department follow-up evaluation and treatment of noninfectious cases is costeffective Background Hmong Outbreak December 2003, the U.S. Department of State approved resettlement of over 15,000 Laotian Hmong refugees to the United States. Medical screening started in February 2004 and refugees began arriving June 2004 January 2005 CDC notified of 31 active TB cases in CA out of 5837 refugees (case rate = 700/100,000) ; 50% of culture confirmed cases (7) MDR-TB Resettlement halted Investigations Thailand and California 4

5 Panel Physician Technical Instructions Revision CDC began revising Technical Instructions in 2005 Scientific literature reviewed Input from U.S. Tuberculosis Community (TB TI Working Group): Advisory Council for the Elimination of Tuberculosis (ACET) National Tuberculosis Controllers Association (NTCA) STOP TB USA 5

6 Vietnam Immigrant Study 1,179 abnormal CXR 82 (7%) positive sputum smears 183 (15.5%) positive sputum cultures Sensitivity of 1991 Technical Instructions 34% Maloney SM, et al. Arch Intern Med 2006;166: Latest Technical Instructions Major additions to previous TIs Addition of AFB culture and DST, in addition to AFB smear, to requirements for evaluation of patients with abnormal CXR CXR for those > age 15 Addition of TST for selected populations (ages 2-15) Requirement that persons with pulmonary TB complete treatment prior to emigration using ATS/CDC guidelines and with DOT LTBI treatment for highest risk contacts, i.e., child < 5, HIV + 6

7 2007 Technical Instructions WHO Incidence 20/100, years of age 15 years of age TST TST <5 mm TST 5 mm CXR No TB Classification Travel within 6 months Normal History, exam, or CXR suggestive of TB or HIV infection If TST<10mm or not required: No TB Classification Travel within 6 months If TST 10 mm: Class B2 LTBI Evaluation Travel within 6 months 1 positive smear or culture Class A TB DST on positive culture DOT according to ATS/CDC/IDSA guidelines until therapy complete Three sputum smears and cultures for Mycobacterium tuberculosis All negative * Class B1 TB Travel within 3 months Class B1 TB Travel within 3 months * Applicants with HIV infection who have a negative evaluation are Class A for HIV and No TB Classification for tuberculosis and must travel within 3 months 2007 Technical Instructions: Classifications Class 1991 Technical 2007 Technical Instructions Instructions No Classification Normal evaluation Normal evaluation Class A Tuberculosis disease Tuberculosis disease Class B1 - Pulmonary Abnormal CXR, sputum Abnormal CXR, sputum smears negative smears and cultures negative Class B1 Extrapulmonary Extrapulmonary tuberculosis Extrapulmonary tuberculosis Class B2 Inactive tuberculosis on LTBI Evaluation CXR Class B3 Old or healed tuberculosis Contact Evaluation 7

8 2007 Technical Instructions for Tuberculosis Screening and Treatment MMWR Notice to Readers Website: Implementation Implementation began in April, 2007 with Burmese refugees screened in Thailand As of May 31, 2008, Populations from 14 countries on three continents are being screening according to the 2007 TB TI 8

9 2007 Technical Instructions Implementation Mae La Camp 9

10 Tuberculosis Indicators Mae La, Thailand Burmese Resettlement April 1 September 30, 2007, 9,899 Screened Indicator N (%) Number with pulmonary 103* disease (100) diagnosed through screening Smear + / Culture + 19 (17) Smear / Culture + 71 (62) Smear + / Culture 1 (1) Smear / Culture *Rate: 1,040 per 100, (11) Stateside Impact Arrivals to the United States Mexico Philippines Fiscal B1 B2 Total B1 B2 Total quarter 1, ,163 2, ,177 3, ,443 4, ,436 1, ,193 2, ,441 10

11 New Refugee Populations Since November 27, 2007 Country (population) Nepal (Bhutanese) Kenya (Ethiopian, Somali, Sudanese) Tanzania (Burundian) Start Date December 13, 2008 January 1, 2008 January 1, 2008 Expected Volume * 3,000 7,000 3,000 Turkey (Iranians, Iraqis) February 4, ,500 * Preliminary targets. Department of State plans to resettle 50-70,000 refugees during fiscal year New Immigrant Populations November 27, 2007 Country Start Date Volume * Botswana March 3, Lesotho March 3, Mozambique March 3, Namibia March 3, South Africa March 3, Swaziland March 3, Turkey February 4, 1,543 Vietnam February , 19, * Fiscal year 2006 immigrant visa entrants. Source: Office of Immigration Statistics, Department of Homeland Security. Applicants receive their medical examination in South Africa. 11

12 Current Populations for 2007 TB TI Implementation Country Immigrant Population * Refugee Population China 37,359 NA Dominican Republic 23,151 NA Egypt 5, Ethiopia 6,550 3,000 Hong Kong SAR 1,923 NA Iraq 1, Jordan 2,403 4,000 Kenya 2,309 7,000 Implemented Malaysia 485 7,000 Syria 1,542 4,000 Thailand 1,663 12,000 - Implemented * Fiscal year 2006 immigrant visa entrants. Source: Office of Immigration Statistics, Department of Homeland Security. Preliminary targets. Department of State plans to resettle 50-70,000 refugees during fiscal year Philippines Evaluation May 26 through June 2, 2008 Saint Luke s Extension Clinic Largest panel site in the world 43,684 immigrant visa entrants during FY ,205 (47%) Class B TB arrivals Began screening according to 2007 TB TI October 1, 2007 Goals of review Thorough evaluation of tuberculosis program Inform DGMQ and DTBE on implementation activities Tuberculosis community representatives: Dr. Charles Nolan, Washington, Dr. Gisela Schecter, California 12

13 Lessons Learned Implementation of TB TI is doable Interest among panel physicians and US tuberculosis community Requires patience, determination, and creativity Building culture and DST capacity easier than developing DOT programs Implementation can contribute to global TB control DOT Biggest challenge for TB TI implementation Not all DOT is the same Some countries have DOT only for initial 2 months National Tuberculosis Programs (NTP) use of WHO regimens Limited drug availability Lack of opportunity for public-private collaboration Developing DOT sites can stretch DGMQ resources and delay implementation 13

14 Future Directions Continue working to implement 2007 TB TI in high priority countries Upcoming site visits Middle East: Egypt, Jordan, Lebanon Africa: Ethiopia, Kenya Asia: Nepal Electronic Disease Notification (EDN) Regulatory responsibility for DGMQ to provide information to receiving health departments (HD) of arriving aliens with a notifiable condition An electronic system to fulfill this DGMQ regulatory responsibility Replaces paper-based Immigrant and Migrant Populations (IMP) system Provide HD access to recorded DS Form information and all scanned overseas DS Forms Provide HD with an electronic system to record and evaluate outcome of domestic follow up evaluations 14

15 EDN In production since March, 2006 Rolled out to all states Data entry function is centralized at the DGMQ headquarters Interface with IOM Electronic transmission of refugee data Deployed in January, 2008 Honolulu EDN States as of June 13, 2008 AK Anchorage San Francisco Seattle CA Los Angeles OR San Diego HI WA NV ID UT AZ Q.S. using IMP MT WY El Paso Quarantine Stations CO NM CDC Data Entry Center/Atlanta ND SD Dallas NE KS TX OK Minneapolis MN IA MO AR WI LA Chicago IL Houston MS IN MI EDN States TN AL OH EDN State Users Not on EDN Detroit KY WV GA ME VT NH MA Boston NY CT RI New York PA NJ Newark MD DE Philadelphia SC VA FL NC Atlanta Miami Washington San Juan (not shown) 15

16 EDN Summit Upcoming meeting on EDN Joint DGMQ-DTBE activity with funding from DTBE Attendees: Lead EDN user from each state DTBE DGMQ Goal Discuss EDN Establish consensus on moving forward Civil Surgeon Technical Instructions Dr. Mary Naughton led effort to revise Input from Division of Tuberculosis Elimination (DTBE) Input from U.S. tuberculosis community Important changes Requirement for mycobacterial cultures Updated guidance regarding latent Mycobacterium tuberculosis infection (LTBI) Delays implementing from United States Customs and Immigration Services (USCIS) resolved New civil surgeon technical instructions become effective May 1, 2008 Notification to states has occurred 16

17 Acknowledgments Drew Posey Medical Officer Division of Global Migration and Quarantine 17