Francesca Torriani, MD, of UC San Diego Health System presents, "Tuberculosis Screening in Healthcare Workers at Maputo Central Hospital"

1. The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease clinicians, physicians and
researchers. The goal of these presentations is to provide the most
current research, clinical practices and trends in HIV, HBV, HCV, TB
and other infectious diseases of global significance.
The slides from the AIDS Clinical Rounds presentation that you are
about to view are intended for the educational purposes of our
audience. They may not be used for other purposes without the
presenter’s express permission.
AIDS CLINICAL ROUNDS

2. 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

3. 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

4. HIV prevalence and TB incidence in Africa
Source: UNAIDS and WHO Source: WHO
HIV prevalence:
11.5% in Mozambique
TB incidence

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

6. 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

7. 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

8. 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

9. 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.

10. TB Control Team, MCH

11. 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.

12. 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

13. 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)

14. 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%

15. HIV Screening Results
N = 148/156 (95%) HIV tested

16. 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

17. TB Symptom Screen Results

18. 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

19. Abnormal Chest Xrays by HIV Status and Symptoms

20. Microbiologic Data
 19 HCW reported productive cough
 Only 9 sputum samples obtained:
 AFB smear – negative in all 9
 Mycobacterial culture – 8 negative, 1 contaminated

21. 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

22. CT findings

23. 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

24. 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

25. 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

26. 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

27. Reid et al Lancet ID 2009

28. Reid et al Lancet ID 2009
Sensitivity and Specificity of Cough as a Symptom of TB
Assess for signs and symptoms suspicious for tuberculosis

29. 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

30. 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

31. 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

32. Question 3
How many sputum samples are sufficient to exclude
active contagious TB?
A. 1
B. 2
C. 3

33. 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

34. 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

35. 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

37. 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

38. 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

39. Hospital Central de Maputo, Mozambique, Sala de Urgencias

42. 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

43. 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.

44. 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

45. 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.

46. TB infection control plan - Urgencias
PatientsConsult
Waiting
Add UV fixtures
Operate all ceiling fans
By Anna Levitt

47. 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

48. Thank you
Questions and Suggestions?