TB_presentationrev2008 - Immunizations Immunizations...

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Unformatted text preview: Immunizations Immunizations Immunization Immunization Schedules Schedules Infant Immunization Schedule Infant Birth to 24 months Hep B DTaP Hib Polio Varicella Varicella Pneumococcal Immunization Schedule Immunization 4 to 6 years old Boosters for Kindergarten: DTaP IPV MMR #2 Understanding Tuberculosis Tuberculosis Adapted presentations from Adapted Mercy Wey RN, PhD Mercy Judy Frey PHN; as well as Yves Reggie Chery; Ana Lisa Lazo; Kishore Tarun Yves Parmar; Shella Ann Simmons and Naomi Yamasaki Parmar; What is TB/Tuberculosis? TB/Tuberculosis? Tuberculosis is one of the oldest known diseases affecting humankind. Tuberculosis (TB) is a disease that can damage a person's lungs or other parts of the body and cause serious illness. TB has claimed more human lives than any other known disease. Tuberculosis (TB) Tuberculosis A disease known as consumption, wasting disease disease, and the white plaque; disease, Has affected humans for centuries; 1/3 of world population is infected Estimated up to 60% of adults in developing Estimated countries are infected countries 10-15 million people in U.S. are infected 900 million women and girls (15-44) infected 900 worldwide worldwide CA highest pediatric cases (25% of US total) TB (continued) TB Before mid-1800s- hereditary; 1882 Robert Koch discovered bacteria that 1882 caused TB; caused 1885-X-rays 1934-Development of PPD 1944-Development of Streptomycin 1950-Development of INH and PZA 1969-Development of EMB and RIF 1969-Development Mid 1970s, TB declined in the US Mid Epidemiology and Statistics of Tuberculosis Statistics In Mid 1980s… TB cases have started increasing again: TB The HIV epidemic Immigration from countries where TB is Immigration common common The spread of TB in certain settings The (correctional facilities and homeless shelters) shelters) Inadequate funding for TB control and Inadequate other public health efforts other Reported TB cases 1948-2002 Reported Epidemiology of TB (1) Epidemiology There is an increased incidence of active TB There among immigrants in the Santa Clara County due to: • llow socioeconomic status, ow • llimited access to healthcare, imited • llanguage and sociocultural differences, anguage • crowded living conditions. Epidemiology of TB (2) Epidemiology 1/3 of world population is infected Estimated up to 60% of adults in Estimated developing countries are infected developing 10-15 million people in U.S. are infected 900 million women and girls (15-44) 900 infected worldwide infected CA highest pediatric cases (25% of US CA total) total) Epidemiology of TB (3) Epidemiology According to the CDC, in 2003… There were 14,874 reported cases in the There United States United There were 3,227 reported cases in California There were 208 cases reported in San Jose Santa Clara County has the 7th highest TB Santa incidence rate in CA, after San Francisco, Imperial, Long Beach, Fresno, Monterey, and Alameda Alameda Impact on foreign-born persons Impact In 2004, minority populations had In rates of TB significantly higher than the overall U.S. average the The TB rates among foreign born The individuals (22.5/100,000) was nearly 9 times the rate among persons born in U.S. (2.6/100,000) in Incidence of TB in Ethnic Populations (1) Populations Out of the 3,227 cases of TB reported in Out California, 2,421 were foreign-born individuals individuals According to The Santa Clara County According Public Health Department, 92.5% of the reported TB cases were from persons born outside of the US born Incidence of TB in Ethnic Populations (2) Populations Top five countries of origin (from Top www.sccphd.org) www.sccphd.org) Mexico The Philippines Vietnam India China Incidence of TB in Ethnic Populations (3) Populations Among all TB cases reported in 2003, Among Asians/Pacific Islanders had highest rate at 32.9 cases per 100,000; Hispanics/Latinos came in second with 9.5 per 100,000 100,000 Of the foreign-born cases in SCC, 24.3% of the Of cases were diagnosed within 1 year of arrival in the US; 27.5% of cases were dx’d 14 years or more after arriving arriving TB Cases Rates and Counts in SCC, 93-03 93-03 TB Case Rates by Race and Ethnicity SCC, 93-03 Ethnicity Proportion of TB Cases by Country of Origin SCC, 93-03 Country Transmission of Tuberculosis Tuberculosis M. Tb Complex M. M. tuberculosis M. bovis M. africanum M. microti Transmission of TB Transmission Caused by an organism called Mycobacterim Caused tuberculosis; and/or the M.Tb. Complex Spread from person to person through the air via Spread droplet nuclei; Droplet nuclei can remain suspended in the air for several hours, depending on the environment; environment; Not everyone who is exposed to an infectious Not TB patient becomes infected; TB Mycobacterium tuberculosis Mycobacterium Probability of transmission Probability Infectivity of person with TB Environment Duration of exposure Environment Agent Host Environment Exposure of active tuberculosis germs spread airborne through day to day contact with infected persons. Agent Mycrobacterium tuberculosis is the organism that is the causative agent of tuberculosis (TB). Host Immigrants of countries where tuberculosis is endemic. Transmission of TB Transmission Person to Person Inhaling droplets of infected material Coughing or exhaling forcefully TB is spread when people who have active untreated TB germs in their lungs or throat cough, sneeze or speak, and send their germs into the air. People who breathe these germs into their lungs can become infected. Transmission of TB Transmission How TB is NOT Spread How Touching objects Touching used by someone with TB with Touching a person TB is spread only by TB breathing particles containing live TB germs germs Disease Process of TB Infection and TB Disease Infection TB and HIV TB People with weakened immune systems are People more likely to develop active TB disease more HIV positive individuals are at least 10 times HIV more likely to develop active TB disease than those who are HIV negative those TB can worsen HIV disease progression Worldwide, TB is the leading cause of death Worldwide, in individuals of HIV positive in HIV positive individuals should be screened HIV regularly with TST and a chest X-ray regularly Common Sites for Tuberculosis Types of Tuberculosis Types Pulmonary Tuberculosis: TB disease that Pulmonary occurs in the lungs (about 85% of all US cases), typically causing a cough and abnormal chest x-ray; pulmonary TB is usually infectious if untreated. usually Extrapulmonary TB: TB disease that Extrapulmonary occurs in places other than the lungs, such as the lymph nodes, the pleura, the brain, the kidney, or the bones; usually not infectious infectious Screening of TB Screening Screening Screening Identify infected Identify persons at high risk for disease and who would benefit from latent TB infection therapy therapy Identify person with Identify TB disease who needs treatment needs Groups to Screen Groups Persons with/or at risk Persons of HIV infection of Close contacts to Close infectious TB infectious Persons with certain Persons medical conditions medical Persons who inject Persons drugs drugs Persons from areas Persons where TB is endemic where More High Risk Groups More Residents of long Residents term care facilities term Health Care Health Workers Workers Staff of long term Staff care and correctional facilities correctional Staff at childcare Staff facilities facilities Staff of AIDS Staff hospices hospices Screening of Tuberculosis The Tuberculin Skin Test (TST) or Mantoux Test/ PPD skin test: inject intradermally and examine the result in 48 to 72 hours. Commonly used for screening. screening. Multiple-Puncture Test: easy to administer Multiple-Puncture and convenient, however; it is not as accurate as the Mantoux skin test. accurate Interpretation of TST Results Interpretation Must be done in 48 to 72 hours after the Must test was administered; test Positive reaction: TB infection or exposure Positive to TB to Reaction: an area of induration or swelling Reaction: around the site of injection around Erythema (redness) around the indurated Erythema area is not measured area 5 or more millimeters or People with HIV infection; Close contacts to TB cases; People who have had TB disease before; People who inject illicit drugs and whose People HIV status is unknown HIV 10 or more millimeters 10 Foreign-born persons; HIV negative persons who inject illicit HIV drugs drugs People who live in residential facilities; People with certain medical conditions; Children younger than 4 years old; People in other groups likely to be People exposed to TB. exposed False-Positive Reactions False-Positive Infection with nontuberculosis Infection mycobacteria mycobacteria Vaccination with BCG BCG is rarely used in the US and is not BCG completely effective completely NO RELIABLE WAY to distinguish a NO positive TST caused by vaccination with BCG from a reaction caused by true TB infection infection False Negative Reaction False Anergy: the inability to react to TB skin Anergy: tests because of a weakened immune system, such as HIV infection, cancer, or severe TB disease itself; severe Recent TB infection- within 10 weeks after Recent exposure; exposure; Very young age- children younger than 6 Very months old. months BCG BCG What is BCG? May cause positive PPD results A history of BCG vaccination is not a history contraindication to giving a TST contraindication Latent TB Infection Latent LTBI Latent TB Infection (LTBI) Latent In the US, 5% of people infected will In develop disease in the first 2 years after infection infection Another 5% will develop disease later in Another life life 90% will stay infected, but free of 90% disease for the rest of their lives disease Latent TB Infection (LTBI) Previous Previous exposure to TB bacteria/tubercle bacilli bacilli The immune system is keeping the The tubercle bacilli contained and under control control No symptoms of TB No infectious Priority for Treatment of Latent TB/TB infection TB/TB Persons with HIV infection Persons recently infected with M. TB Persons with chronic medical conditions Persons or suppressed immune systems or IV drug users Persons with history of inadequately Persons treated TB treated Treatment of TB Infection Treatment Positive reaction of tuberculin skin test INH for 9 months INH Recent contact to a person with TB disease disease Children under age 2 Those who are at high risk for TB disease Health care providers Monitor LTBI Therapy Monitor Adherence Symptoms of Symptoms hepatitis hepatitis Symptoms of Symptoms neurotoxicity neurotoxicity Medical Conditions that Increase Risk Increase HIV infection Substance abuse TB infection within TB the past 2 years the CXR suggestive of CXR previous TB (inadequately treated) treated) Diabetes Mellitus Silicosis Prolonged steroid Prolonged therapy therapy Immunosuppresive Immunosuppresive therapy therapy Cancer of head/neck More Medical Conditions More Leukemia Hodgkin’s End Stage renal End disease disease Intestinal bypass Chronic Chronic malabsorption syndrome syndrome Low body weight Low (more than 10% below ideal) below TB Disease/Active TB TB TB Disease/Active TB TB Individuals with previous TB infection Individuals progress to active TB or TB disease with symptoms of TB symptoms Weak or compromised immune system Tubercle bacilli begin to multiply rapidly Highly contagious- they can spread Highly tubercle bacilli to the others before treatment treatment Requires isolation until infection is Requires contained or under control contained People at Higher Risk for TB Disease Disease People with HIV infection; Certain medical conditions: leukemia, Certain Hodgkin’s disease, cancer of head and neck, diabetes, immunosuppresive therapy, long term use of steriods, and severe kidney disease, etc. severe Recent TB infection; People who inject illicit drugs. Common Sites of TB Disease Common Lungs Pleura Lymphatic System Genitourinary system Bones and joints Disseminated Extrapulmonary TB Extrapulmonary TB disease that occurs in place other than TB the lungs, such as the lymph nodes, the pleura, the brain, the kidneys, or the bones. bones. Most types of extrapulmonary TB are not Most infectious. infectious. Symptoms of Pulmonary TB Disease Disease Coughing: productive and prolonged cough Pain in the chest when breathing or coughing Hemoptysis Chest pain Weight loss Fatigue or malaise Fever Night sweats Symptoms Symptoms Pulmonary and laryngeal (85-90% of Pulmonary cases) cases) Extra pulmonary (10-15% of cases) Symptoms of extrapulmonary TB Symptoms depend on sites depend Diagnosis of TB Disease Diagnosis The Medical history: been exposed to TB, The symptoms of TB disease, had TB infection or TB disease before, and risk factors for developing TB; developing The tuberculin skin test; The chest x-ray; The bacteriologic examinations: smears, The culture, and drug susceptibility culture, Diagnostic Microbiology Diagnostic Obtain 3 sputum specimens for smear Obtain and culture examination and Smear positive acid fast bacillus (AFB) Smear indicates risk of infecting others—mask precautions until 3 negative smears precautions Culture results take 2-6 weeks and Culture confirm TB diagnosis confirm TB Infection TB vs. TB Disease Tuberculosis skin test- positive Chest x-ray usually Chest normal normal Sputum smears and Sputum cultures negative negative No symptoms Not infectious Not a case of TB Not of Chest x-ray usually Chest abnormal abnormal Sputum smears and Sputum culture positive positive Symptoms: cough, Symptoms: fever, weight loss, night sweat Often infectious Often before treatment before A case of TB case of Treatment of TB Disease Isoniazid (INH) and Vitamin B6 Isoniazid Rifampin (RIF) Pyrasinamide (PZA) and either Ethambutol (EMB) OR Ethambutol OR Streptomycin (SM) *TB disease must be treated for at least 6 *TB months; in some cases, treatment lasts months; even longer. even Pulmonary/Extra Pulmonary Pulmonary/Extra FOUR DRUGS, FIRST 2 MONTHS: Isoniazid (INH), Rifampin (RIF), Isoniazid Pyrazinamide (PZA), Ethambutol (EMB) Pyrazinamide TWO DRUGS, NEXT 4 MONTHS: Isoniazid (INH) and Rifampin (RIF) Special Considerations Special Longer treatment may be needed for: Bone and joint TB Miliary TB: tubercle bacilli enter the Miliary bloodstream and are carried to all parts of the body where they grow and cause disease in multiple sites disease TB meningitis Treatment for Pregnant and Lactating Women Lactating Begin therapy ASAP (after first Begin trimester) trimester) PZA and streptomycin should not be PZA used if pregnant used Breastfeeding—TB therapy meds have Breastfeeding—TB no effect on newborns no Drug Side Effect Drug Rifampin reacts with oral Rifampin contraceptives-Decreases effectiveness of oral contraceptives contraceptives Adverse Reactions to Isoniazid (INH) (INH) Nausea Vomiting Abdominal pain Fatigue Dark Urine Abnormal liver function test: age 35 or Abnormal older, black and Hispanic women are at higher risk of developing hepatitis. higher Treatment for Children Treatment Prompt and Prompt aggressive treatment ASAP treatment Same regimen as Same used for adults used Monitoring Adherence to Treatment Monitoring Directly Observed Therapy (DOT) DOT should be considered for all patients Weekly, biweekly, or monthly pill counts Monthly assessment of adverse reactions Monthly to treatment to MDR TB MDR Multi-Drug Resistance TB Resistant to at least INH and RIF Resistant and Uncommon in the U.S. INH resistance: 7-8% of cases Drug Resistance Drug Individualized treatment Clinicians need to seek expert Clinicians consultation consultation Use DOT Treatment costly Patients at Increased Risk for Drug Resistance Drug History of previous tx with TB meds Contact to drug resistant TB Foreign born from area of high Foreign prevalence of drug resistant TB prevalence Smears or cultures remain positive after Smears 2 months of treatment months Response to Treatment Response Culture conversion after 3 months of tx. Negative smear and culture—chest xray and clinical evaluations used as ray indicator of response to treatment indicator Treatment length = minimum of 6 Treatment months months Infection Control Infection • Detect TB disease and start treatment Detect ASAP ASAP • TB patients to wear surgical mask during TB the contagious period the • Cover the mouth and nose with a tissue Cover when coughing or sneezing when • Health care workers to wear N95 Health respirator respirator • Good ventilation Description of CHN Role Description CHNs responsibilities Assess adherence to the prescribed medical regimen. medical Assess signs and symptoms of adverse Assess reactions to the medication. reactions Conduct an appropriate clinical Conduct assessment. assessment. Cultural Implications Implications Cultural Implications for treatment of Asian Americans of Health beliefs and misconceptions of Health illness may impede recognition of early warning signs, and delay access to early medical treatment. early Non-adherence to medical schedule Non-adherence and dosing requirements due to commonly held ‘myths’ commonly Cultural Implications (cont.) Cultural Diagnosis of TB may lead to increased social stigma and social isolation. Implications for the PHN Implications Evaluation of Health Beliefs is key Education of clients about disease process Education and treatments is important and Directly Observed Therapy (DOT) may be the Directly best choice for these clients best Outreach to folk healers may help in providing Outreach earlier treatment earlier Cultural Implications for treatment of Hispanic Americans of Health Care provider’s beliefs must be Health evaluated evaluated Emphasize present time with short term Emphasize goals goals Family involvement is crucial Implications for the PHN Implications It is important to build a relationship with It the client, and client’s family. the Outreach to folk healers may be helpful. Same day appointments may be more Same effective, concentrate on achieving many short term goals. many Nursing Diagnoses Diagnoses 1. Knowledge deficit related to unknown 1. Knowledge implications of disease and complicated drug regimen. complicated 2. Ineffective individual therapeutic Ineffective regimen management related to complex treatment regimen, secondary to unpleasant side effects of TB infection. of 3. Risk for infection related to lowered Risk defense mechanisms secondary to TB infection. infection. Role of the Health Department Role Identify and ensure appropriate Identify treatment of all persons with TB disease treatment Identify and evaluate all contacts to Identify persons with infectious TB persons Offer therapy for LTBI as appropriate Health Department Responsibility Responsibility Surveillance Containment Contact investigation Community policy and planning Mandates Mandates Reporting all patients with confirmed or Reporting suspected TB is mandated by the State of California of Health and Safety Code: Div. 4, Chapt. Health 5 Administrative Codes: Title 17, Chapt. Administrative 4, section 2500 ...
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This note was uploaded on 09/08/2010 for the course HS 104 at San Jose State.

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