In this issue...
Spittoon Winners Announced
TB Drug Resistance in Virginia
Use of Intermittent Therapy with HIV-Infected Patients
Centers for Disease Control and Prevention's Binational Tuberculosis Referral and Case Management System
During the 2003 World TB Day activities in Virginia, the Division of TB Control announced the winners of the Travelling Spittoon Award. Each year, the Virginia health districts compete in their health regions for this award. The award criteria include the number of cases who complete treatment in one year or less, the number of cases on directly observed therapy (DOT), and the number of contacts who complete treatment for LTBI. Congratulations to the following 2003 Traveling Spittoon Award recipients!
Central Region - Henrico Health District
Eastern Region - Peninsula Health District
Northern Region - Arlington Health District
Northwest Region - Rappahannock Health District
Southwest Region - Roanoke City Health District
The 2004 Travelling Spitton Award criteria will also include outcome and process
evaluation indicators developed by Virginia TB nurses at the 2002 TB Nurse Retreat.
Year |
Percent of Cases Resistant to at Least One Drug on the Initial Isolate |
2000 |
14.1% |
2001 |
16.3% |
2002 |
12.2% |
In the last year, although the percentage of cases resistant to at least one anti-tuberculosis drug on the initial isolate has decreased, the high number of TB cases in Virginia with resistance to at least one drug remains a concern. Given the levels of drug resistant organisms seen in Virginia, the current recommendation that all patients be started on at least four drugs remains. The TB regimen can be adjusted if subsequent drug susceptibility results demonstrate that the organism is sensitive to all first-line TB drugs. Once susceptibility to all first line drugs is demonstrated, EMB can be discontinued immediately, and PZA can be discontinued once the patient has completed the initial phase of treatment. This initial phase of treatment should consist of at least eight weeks of treatment and 22-56 doses of medication, depending on the treatment option selected. Actual doses ingested should always be used to determine the adequacy of the patient's treatment.
More information is available in the new CDC/ATS/ISDA statement on the Treatment of Tuberculosis. This document can be found either on the DTC website (www.vdh.virginia.gov/epidemiology/DiseasePrevention/Programs/Tuberculosis/treatment.htm) or on the Centers for Disease Control and Prevention's website (www.cdc.gov/nchstp/TB).
The new CDC/ATS/ISDA Statement on the Treatment of Tuberculosis makes some specific recommendations for individuals with HIV infection and under treatment for active TB disease. While the treatment of active TB disease in persons with HIV infection is essentially the same as for non-HIV infected individuals, there are several important considerations to remember.
1. The once-weekly regimen of INH-rifapentine should not be used in any HIV infected patient.
2. Twice-weekly treatment with INH-RIF or INH-rifabutin should be not be used in HIV-infected patients with CD4 lymphocyte counts less than 100. In clinical trials, there has been an unacceptable rate of relapse in these patients, usually associated with the development of acquired rifamycin resistance. The recommendation for patients with low CD4 counts is that they remain on either daily or thrice-weekly (3x) treatment regimen. In using any intermittent regimen, regardless of CD4 count, the patient should not have diarrhea or any other symptoms suggestive of malabsorption.
All anti-tuberculosis drugs have potential interactions with medications that HIV-infected individuals may be taking for many other health issues. It is strongly encouraged that DTC be contacted for assistance in the management of co-infected active TB cases. Of particular concern is the interaction of the rifamycins with many of the antiretroviral agents and other anti-infective drugs.
Since new drugs are frequently added to regimens and recommendations are revised, the most up-to-date TB treatment information is on the Centers for Disease Control and Prevention's website (www.cdc.gov/nchstp/tb/). The Johns Hopkins AIDS Service website (http://www.hopkins-aids.edu) is also a useful source for current information. Specifically, the "publications" section in the Hopkins website provides the current edition of Medical Management of HIV Infection by John Bartlett and Joel Gallant, as well as updates for the management of AIDS related tuberculosis and other diseases.
The Centers for Disease Control and Prevention (CDC) and the Mexico National TB program are cosponsoring a new initiative to establish a comprehensive binational tuberculosis (TB) referral and case management system in the US and Mexico. The goals of the initiative are to ensure continuity of care and completion of treatment for TB patients who migrate between the two countries, and to coordinate the referral of patients between the health systems of both countries.
CDC surveillance data for 2002 indicate that almost a quarter of all foreign-born TB patients in the US were from Mexico. Two programs, CureTB and TBNet have been working with this population for several years. The new initiative will integrate the efforts of CureTB and TBNet for the first time and link their referral services with a similar effort of the Mexico National TB Program. The US-Mexico Binational TB Referral and Case management Project began in March 2003, and this system will be piloted in seven states in Mexico, and in sister-cities along the US-Mexican border.
Starting in March 2003, you may see patients from Mexico who have a Binational Health Card. This card does not specifically mention the word "tuberculosis", as agreed upon by consensus in the extensive binational planning effort. The card has US and Mexican toll-free telephone numbers, a unique identification number, the site where the patient first received TB care, treatment start date, treatment regimen, and whether the patient received directly observed therapy.
Virginia is not a project pilot site. Therefore, if you become aware of a patient with a Binational Health Card, please notify the Division of TB Control (DTC) so that the appropriate interjurisdictional notifications can be made. This same notification process can be used for patients who plan to move to Mexico prior to completion of TB treatment.
In addition to this binational effort between the United States and Mexico, CDC has a process for International Notification of TB cases for other areas of the world. If you become aware of a case either moving to or arriving from another country (other than refugees or Class B immigrants), please notify DTC so that the proper notification can be made.