PUBH621 Epidemiology

Question:

As Public Health Officers in a state/territory Health Department, you will be responsible for conducting appropriate contract tracing and exposure assessments.

Students will apply tuberculosis control protocol from two Australian jurisdictions. They will provide a report by the department on their investigations and appropriate information for the media.

Answer:

Notifiable diseases in Australia

Notifiable diseases are those that must be reported to government under the law.

The government can collect information regarding the occurrence of notifiable illnesses to allow them to monitor the situation and give early warnings in case of an outbreak.

In Australia, avian influenza in humans is, campylobacteriosis in Brucellosis and Dengue virus are some of the most important notifiable diseases.

According to the National Communicable diseases Surveillance Report, infectious syphilis was the most recent notifiable illness. It has been identified in Torres Strait Islander men living in northern and central Australia. The alarming rate of infection has also been observed in men who have had sex in urban areas of Victoria and New South Wales. (Australian government Department of health, 2017).

The indicators for person-to-person transmission of influenza have been increasing since July 2018. This makes it one of the most important notifiable diseases.

Shigellosis rates in Australia are higher among Aboriginals than those of non-aboriginals.

Tuberculosis in Australia is also a very important disease to report.

Tuberculosis notifications over a 365-day surveillance period are around 10% higher than the average five-year mean.

The majority of TB cases in Australia have been reported to be from overseas.

These are links to Australian websites

National Notifiable Diseases Surveillance System — current CDNA fortnightly Report

Contact tracing is the process of identifying and following up on people who might have been in contact with someone with a highly contagious disease.

The associated contacts must be kept informed for 21 days after the last known exposure and should not become ill.

If the sexually transmitted disease is not limited to the partners, but highly contagious diseases such as Ebola and tuberculosis can affect anyone who contacts them casually, it’s possible to limit the monitoring to those involved.

The difficulty of controlling emerging contagious diseases such as SARS, foot-and-mouth disease, or pandemic flu is that we can only focus on those who are symptomatic. Treatment, isolation, and culling may be useful, but they are not always effective.

However, it might be more cost-effective to control the entire population than trying to contain the epidemics.

Contact tracing for symptomatic diseases works at an intermediate level. Treatment or quarantine might be beneficial as unidentified infected are more likely to be among the contacts.

The small pox has been successfully controlled using quarantine and tracing.

It was also successful in fighting the recent SARS epidemic.

There are several models that can be used to evaluate the effectiveness of contract tracing as well as the interventions such random screenings for HIV/TB.

The Saskatchewan district has seen successful contact tracing of Tuberculosis (Tian and co., 2013).

Contact tracing of TB can only be done on two types of cases: one with primary TB and one with infectious TB.

A case of infectious TB can be diagnosed by looking at the symptoms. After that, a list of possible contacts must be determined by interviewing the patient.

If the contacts have a history of positive skin tests (Mantoux test), they will not be reexamined.

Emails are usually sent to the remaining contacts for examination.

It is important to trace contacts in order to decrease the chance of re-infection, the complications and the burden on the population from the contagious disease.

Despite the many control measures, tuberculosis is still a concern for those who live in remote parts of Australia’s northern territory and the neighbouring regions.

The 10 year retrospective case series from Australia shows the widespread effects of multi-drug resistant tuberculosis (World Health Organization).

Victoria is home to multi-drug resistant tuberculosis.

Aboriginals and Torres Strait Islander residents in high-risk regions like Victoria and Northern territory are at risk of contracting tuberculosis.

The guidelines for Northern territory recommend DOTS therapy for tuberculosis patients (Judge & Krause 2016).

The majority of international guidelines recommend DOTS therapy. An intermittent three-week regimen is recommended if the patient has not been diagnosed with HIV.

For patients with compliance issues, DOTs therapy is provided in Victoria on a case-by-case basis.

Ethambutol can be used as a standard treatment until the drug’s susceptibility is confirmed.

The guidelines for the Northern Territory recommend that standard DOTs treatment be continued for three months (Department of Health Northern Territory, 2016).

The guidelines for Northern territory included a detailed account of dosage information according to age and duration.

These details are not included in the Victorian guidelines.

Report on Tuberculosis

I) Disease Burden of Tuberculosis in Australia

Tuberculosis continues to be a public health threat worldwide, and it affects both low- and middle-income countries.

According to the World health Organization, there was a global TB burden of 8.9 million cases (128 cases per 100,00 people) and about 1.5 million deaths. Most of these deaths occurred in the Asian-Africa region (Australian Department of Health, (2017).

Australia’s TB rates have remained stable since 1986. In 2015, 1320 cases were reported for every 100,00 people (World Health Organization).

Despite the fact that the statistics are lower than in other regions, TB rates among those who were born abroad or the native population is still high.

The concern of multi-drug resistant tuberculosis was a matter that has been raised by the Australian population.

Judge and Krause (2016) found that at least 2-5 percent of cases were associated with multi-drug resistant TB.

The bacteria is resistant to at most rifampicin (Australian government Department of health, 2017).

Fluroquinone, as well as other second-line anti-TB drugs such as amikacin, kanamycin and capreomycin have been shown to be effective against drug-resistant bacteria.

Globally, there are approximately 25,000 cases with extensively drug-resistant TB. This is associated with high mortality rates.

The majority of TB notifications are still received by the overseas population of Australia (85%).

The TB rates in the Aboriginal population are still six times higher than those of the non-aboriginal population.

Despite Australia’s efforts to maintain a steady control on TB, it is necessary to continue making sustained efforts to reduce the rate and achieve the goals of World health Organization (Australian government Department of health 2017, 2017).

Transmission of Pulmonary Tuber Disease

TB is caused by Mycobacterium tuberculosis, a bacteria that can be transmitted through the air.

Droplet nuclei, which are small air droplets (1-5 microns in size), carry the bacteria.

Infectious droplets are formed by an individual with pulmonary or laryngeal tuberculosis (Wani, 2013,).

These small droplets remain suspended in the air for many hours.

Remember that transmission occurs through air, not by surface contact.

Tuberculosis can be contracted by inhaling these droplets.

The droplet nuclei travel through the nasal passages, oral cavity, upper respiratory tract, and bronchi.

It eventually reaches the alveoli in the lungs (Wani 2013, 2013).

Transmission can also occur through potentially dangerous procedures like sputum injection, bronchoscopy and treatment with the nebulizer. This includes drainage of any open abscess. Autopsy, or any procedure that involves aerosol containing M. tuberculosis bacteria. (Bragina et. al., 2013,).

Transmission of the bacteria may occur only rarely through the skin or mucous membrane.

It can take between 2-10 weeks for the primary lesion to form from infection.

The progression to active tuberculosis is only possible in 4-5% of those with immune systems (Bragina and al., 2013).

As long as bacteria is being excreted from the sputum, a person can remain infected.

Wani (2013) states that the risk of transmission is highest in the time period immediately before diagnosis and treatment.

If there is no drug-resistant bacteria, the risk of transmission decreases over the next two weeks.

The level of communicability depends on how long the TB has been exposed, how intimate the exposure was, and what the bacteria’s infectivity is.

Tuberculosis can be contagious. It spreads easily by simply speaking, laughing, and singing.

High-Risk Group for Contact Tracing

Contact screening is currently limited to close relatives of a person with smear-positive pulmonary TB. This includes people living in the same household as the person with the disease.

Due to their weak immune system, children exposed to infectious people have a higher chance of contracting TB.

The screening is also open to older people who have been in close contact or had contact with an infected person.

High risk contacts must be screened within seven days of diagnosis. Medium infectivity cases should be screened within two weeks (Duarte and al., 2013).

The high-risk contacts with low levels of infection should only be screened once.

Children with active pulmonary tuberculosis should be screened immediately.

The medium exposure risk contacts will only be screened if there is evidence of transmission among high-risk exposure groups.

If there are more than 10 contacts, and the index case is high or moderately severe, the medium contacts will also be screened.

If there is evidence of transmission within the medium risk group, the low risk contacts should be selected.

Contacts with a history of HIV/cancer or other comorbidities should be screened. These comorbidities can affect their immune-competence, make them susceptible to TB, and also make them more vulnerable.

Even if they live in different households, pregnant women should have their contacts tested for Mantoux.

Management and identification of contacts

Contact screening should begin immediately after a confirmed or suspected case of infectious TB is reported.

The notified case information should be obtained from multiple sources, including the hospital records and laboratory records (Fox and al., 2013,).

Interviewing the patient about the details and history of the illness should follow data collection (Hopewell 2016).

Once the characteristics of the index case have been identified, contacts should be classified into high, medium, and low risk groups.

Unless there is evidence of transmission within the medium risk category, it is not necessary to obtain the contact details for low-risk contacts (Horsburgh, Barry & Lange 2015).

How to Manage Your Contacts

Clinical evaluation – This involves determining the time, duration, and context of exposure. It also includes assessing for clinical manifestations consistent with TB symptoms (Department of Health Northern Territory, 2016).

Tuberculin test and Interferon gamma Release assay (IGRA). Among contacts, the TST or IGRA is the preferred test to screen for TB (Zwerling et. al., 2013).

Interpretation and actions – Contacts with positive IGRA or a history of Bacillus Calmette Guerin (BCG), vaccination, and normal chest xray reports should be referred either to a doctor or to a hospital that has supportive infrastructure for TB patients.

Contacts with positive TST, IGRA, and abnormal chest X-rays should be referred to a hospital for active TB treatment. (Department of Health Northern Territory, 2016).

If the TST reaction in the first round is negative, it should be repeated.

Booster phenomenon – It is not usually considered in routine contact tracing, but it can be used to detect tuberculin conversion among heath care workers.

All contacts should be dismissed from follow-up after they have been cleared of TB infection.

For a period of one to two years, chest x-rays should be taken on all contacts who have been identified as infected by the Index Case.

After the boy is confirmed positive for smear, he should be subject to pre-treatment screening and direct observation therapy.

If the patient has already started treatment and is in isolation, the isolation can be stopped.

If the patient has been receiving effective treatment for at least two weeks, and the patient is understanding and able to tolerate the medication, then the isolation should be stopped.

If the boy has had negative AFB smears three days consecutively, he should be removed.

The case index shows that the boy does not have MDR-TB and should be removed from isolation.

Falzon et. al. (2013) found that very few patients continue to produce non-viable bacteria in their sputum after treatment has ended.

Before the patient can be discharged, they must be notified to the department and made arrangements for a follow-up.

A negative smear test result and a normal chest xray can be used to indicate that the patient is returning to normal life.

Extra precautions should be taken in this instance, as the boy is only in secondary school. Returning home with active infectious agents could put the lives of his brother (8 years old) and other students at his school.

The doctor should confirm the information regarding the boy’s recovery with written testimony from the department health and services.

Each copy can be sent to both the school and the community.

Refer to

Australian government, Department of health (2017). National Notifiable Diseases Surveillance System (CDNA Fortnightly Report). Access date: 13.11.2018.

Analyzing gene networks to gain insight into the pathophysiology and causes of dystropy: An example of bronchial asthma or tuberculosis.

Department of Health & Human Services (Victoria), (2016). Management, control, and prevention of tuberculosis Guidelines to health care providers.

Department of Health, Northern Territory (2016). Guidelines for controlling Tuberculosis in the Northern Territory DEPARTMENT of HEALTH.

Improved tuberculosis contact trace: The role of evaluations at home and work in improving tuberculosis tracing.

International Journal of Tuberculosis and Lung Disease 16(1): 55-59.

World Health Organization 2016 update of treatment guidelines for drug resistant tuberculosis.

European Respiratory Journal, 49(3). 1602308.

A systematic review and meta-analysis of contact investigation for tuberculosis.

European Respiratory Journal, 41(1): 140-156

Tuberculosis treatment.

Tuberculosis (pp.

CRC Press.

Horsburgh Jr., Barry III. C. E., & Lange. C. (2015).

Tuberculosis treatment.

New England Journal of Medicine 373(22), 2149-2160.

Multidrug-resistant tuberculosis (MRT) in the Northern Territory: A retrospective 10-year case series.

Report on Communicable Diseases Intelligence Quarterly, 40(3), E334 – E339.

Individual-based modeling is used to evaluate the impact of contact tracing on tuberculosis outcomes for Saskatchewan.

Health Education and Behavior, 40(1)_suppl. 98S-110S.

Tuberculosis 2 – Pathophysiology, microbiology, and treatment of pulmonary tuberculosis.

South Sudan Medical Journal 6(1), 10-12.

World Health Organization.

(2016).

World Health Organization.

World Health Organization.

Guidelines for treatment of drug-susceptible Tuberculosis.

A systematic review of interferon-gamma releases assays for tuberculosis screening in healthcare workers

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