# Presentation: 746701

## LOCAL TB EPIDEMIOLOGY

-    Knowledge of local TB   epidemiology is needed for  facility strategic planning and patient care decisions

**Notes:**
This is the prompt slide for the Local TB Epidemiology
Note to the Local Presenter:   In order to present information on the local TB (Mycobacterium tuberculosis) epidemiology, it is recommended that the local facility obtain information on the following and where feasible make overheads or slides for data presentation: TB cases in the state (preferably by counties displayed on a map of the state that could be photographed as a slide for ease of presentation), TB cases by race and gender for the state and local city, TB cases by age for the state and local city, TB cases with HIV/AIDS co-infection for the state and local city, TB cases with isoniazid resistance and TB cases with multi-drug resistance (resistance to at least isoniazid and rifampin), and for the facility, consider presenting TB cases over the past 5 years showing non-resistant cases and cases with resistance to isoniazid and those with multi-drug resistance (resistance to at least isoniazid and rifampin).
Local presentation:
One definition of epidemiology is the study of the distribution and determinants of disease and other conditions in human populations.  Epidemiology is used to identify the distribution of TB geographically and in populations.  Through knowing the distribution of disease and its determinants in person, place, and time, strategic planning is facilitated and the evaluation of interventions and preventive measures is more effective.
Knowledge of local TB epidemiology can answer the questions of whether TB is a common problem in the area (endemic or epidemic), are there TB cases in local high risk populations, and is drug resistant TB being seen locally.

## LOCAL TB EPIDEMIOLOGYStrategic Planning

- Component of facility TB risk assessment
- Influences facility’s non-hospital based programs
- Engineering controls
- Employee PPD programs

**Notes:**
The protocol for conducting a tuberculosis (TB) risk assessment in a health-care facility, as presented by the Centers for Disease Control and Prevention (CDC) in the Morbidity and Mortality Weekly Report (MMWR) dated  October 28, 1994 Vol. 43 / No. RR-13, has, as element no. 1, the need to review the community TB profile.  This information is used to assist in determining the facility TB risk level (minimal risk, very low risk, low risk, intermediate risk, and high risk).  

The number of TB cases in the community is to be considered when facility decisions are being made concerning adequacy of engineering controls (are there sufficient rooms capable of negative airflow with adequate air exchanges), the type of administrative  and work practice controls for non-hospital based programs (should outreach workers be trained in signs and symptoms of TB and the types of protective measures they need to take), and the extent and/or frequency for employee PPD testing programs.

## LOCAL TB EPIDEMIOLOGYPatient Care Decisions

- Community TB trends
- Prevalence of TB drug resistance
- Initial therapy decisions
- Patient PPD programs
- DOT

**Notes:**
Local TB epidemiology can play a significant role in patient care decisions.  Local TB trends can identify prevalence of TB in specific populations.  This information can then alert the health-care worker working with patients from those risk populations to consider TB infection/disease, take appropriate precautions and make referrals as needed.  Tuberculin skin test programs could be administered in the identified risk populations.  The prevalence of TB drug resistance should be considered when making drug therapy decisions for both active TB disease and preventive therapy if needed for TB infection.
Since the major determinant of the outcome of TB is adherence to the drug regimen, the role of directly observed therapy (DOT) should be considered using local TB epidemiology in the decision making process.

## LOCAL TUBERCULOSISInformation Sources

- State Department of Health
- County Health Department
- City Health Department
- Centers for Disease Control and Prevention (CDC)
- Morbidity and Mortality Weekly Report (MMWR)

**Notes:**
City, County, and State Health Departments have significant roles in the effort to eliminate TB.  Their role is to identify and treat all persons with TB disease, identify and evaluate individuals who have been in contact with persons having active TB disease, and the screening of high-risk groups for TB infection to identify candidates for preventive therapy.  TB reporting is required by law in every state.  Health Care facilities should know the procedures for reporting TB to the local Health Department and work with the Health Department to meet the challenge of TB elimination.  Many health departments routinely publish TB epidemiologic data as it pertains to their jurisdiction.  These data can be very useful for the Health Care facilities.

The Centers for Disease Control and Prevention (CDC) has a Division of Tuberculosis Elimination.  CDC (under the auspices of the U.S. Department of Health and Human Services)  provides information and assistance in the containment and elimination of TB.  The Morbidity and Mortality Weekly Report (MMWR) is prepared by the CDC, Atlanta, Georgia and uses data as submitted by state health departments to assist in providing up-to-date TB information along with other epidemiologic data.  Yearly TB data by states and nationally are reported in the MMWR.  The MMWR should be available in the local VA library, and it is also available on the Internet WWW.CDC.GOV

## LOCAL TB EPIDEMIOLOGYCongregate Settings

- Nursing Homes
- Rehabilitation facilities
- Correctional facilities
- Home-based care programs
- Acute care facilities
- Substance abuse programs
- Long term psychiatric programs
- Shelters for homeless
- Halfway house programs
- Day care programs

**Notes:**
Note to the Local Presenter: Review each of these settings in terms of the community and your facility.  Identify the relationships of these settings and your facility.  Does your facility have such programs and/or does your facility have involvement with any of them at a community level (i.e. does your facility treat veterans from correctional facilities, does the facility have contracts with local nursing homes or half-way house programs, etc.).  Identify these relationships and point out the need to know the prevalence of TB in these settings so that appropriate strategies can be incorporated in your facility’s overall TB Program. 

Local presentation:
TB programs need to include congregate settings such as nursing homes, rehabilitation facilities, correctional facilities, home-based care programs, acute care facilities, substance abuse programs, long term psychiatric programs, shelters for the homeless, half-way house programs, and day care programs.  

## LOCAL TB EPIDEMIOLOGYData

- Case numbers in the city/county
- Case rates for the city/county
- Trends over the last several years

**Notes:**
Note to the Local Presenter: This slide can be used as a prompt with you stating the TB case numbers, TB case rates and discussing local TB trends over the last several years.  The TB information will need to be obtained from your city, county, or state health department.  You could also consider replacing the slide with an overhead(s) or slide(s) depicting the TB case numbers, TB case rates, and TB trends over several years.

(No provided text) 

## LOCAL TB EPIDEMIOLOGYAge Distribution

- What is the age distribution of tuberculosis in the community?
- Is there evidence of pediatric tuberculosis?

**Notes:**
Note to the Presenter: This slide could be used to just point out the significance of knowing the age distribution of TB in the community for readily identifying community spread of TB or it could lead in to a slide or overhead that actually depicts age distribution of TB in the local community.

Local Presentation:

Pediatric TB is a surrogate marker for spread of TB in the community since children are born without TB disease.

## LOCAL TB EPIDEMIOLOGYTB and HIV

- What are the data on HIV and TB?
- Number of TB cases with HIV/AIDS (city/county)
- Percent of TB cases with HIV/AIDS (city/county)

**Notes:**
Note to the Local Presenter: This slide can be used as a prompt with you stating the number of TB cases with HIV/AIDS for the city, county, and state and what percent of the TB cases are the TB cases with HIV/AIDS.  These data need to be obtained from the city, county, or state health department.  Consideration could be given to replacing the slide with an overhead or slide that actually depicts the number of TB cases with HIV/AIDS and the percent they represent of all the TB cases in the city, county, and state. 

(No provided text)

## LOCAL TB EPIDEMIOLOGYM. tb  Susceptibility

- In this area, what are the antibiotic resistance patterns for *M. tb*?
- What are the trends over the last several years?
- Does this facility care for TB patients from outside the immediate area where resistance patterns may be different?
- Does Multidrug Resistant TB occur here?
- INH resistance?
- Rifampin resistance?

**Notes:**
Note to the Local Presenter: This is a prompt slide.  To answer the questions, obtain information on Mycobacterium tuberculosis susceptibility from local or state health department and your own  facility’s experience.

(No provided text)

## VHA TB DATANational

- 							  FY 1992 - 1996
- 					_1992_	  _1993_	 _1994_    _1995_	_1996_
*M. tb*				     781	    765	   678      591	  521
*M. tb* + HIV			  154	    165	   134	   114	  105
- MDRTB		 	 	    23	      10	       7	       5	      5
- MDRTB + HIV		  _  24_	    _    7_	   _  10_	   _    4_	  _    1_
- Total Cases			  982	    947	   829	   714	  632
- 														      VAHQ

**Notes:**
This is national VHA TB data for Fiscal Years 1992 through 1996 obtained from an annual census (100% response rate) of all VHA facilities.

M. tb =  Mycobacterium tuberculosis cases without HIV infection and without multi-drug (at least isoniazid and rifampin) resistance.  Cases ranged from 781 to 521 over the five years. The decline of these cases was statistically significant (p<0.001 chi square -  linear trend).
M. tb + HIV =  Mycobacterium tuberculosis cases with HIV infection and without multi-drug (at least isoniazid and rifampin) resistance.  Cases ranged from 154 to 105 over the five years.  The decline was statistically significant (p<0.001 chi square - linear trend).
MDRTB =  Mycobacterium tuberculosis with multi-drug (at least isoniazid and rifampin resistance) and without HIV infection.  Cases ranged from 23 to 5 over the five years.  The decline was statistically significant (p<0.001 chi square - linear trend).
MDRTB + HIV = Mycobacterium tuberculosis cases with multi-drug (at least isoniazid and rifampin) resistance  and with HIV infection.  Cases ranged from 24 to 1 over the 5 years.  The decline was statistically significant (p<0.001 chi square - linear trend).

The total cases of Mycobacterium tuberculosis ranged from 982 to 632 over the 5 years.  The decline was statistically significant (p<0.001 chi square - linear trend).

## VHA TB DATALocal Facility

- Number of cases
- Susceptibilities
- INH resistance
- MDRTB (at least INH & RIF resistance)
- TB/HIV
- Trends

**Notes:**
Note to the Local Presenter: This is a prompt slide to be used to address the local VA facility TB data.  The total number of Mycobacterium tuberculosis (TB) cases, number of TB cases with isoniazid resistance, number of TB cases with multi-drug (at least isoniazid [INH] and rifampin) resistance, number of TB cases with HIV co-infection, and TB trends need to be obtained from the facility. 

(No provided text)