Talking All Things Cardiopulm
This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences.The goal is to learn, inspire and bring Cardiopulm to the forefront of conversation.
Talking All Things Cardiopulm
Episode 94: TB Outbreak – What you need to know
We currently have a tuberculosis (TB) outbreak across the US and Kansas recently made national news in this regard. I’m here to break down the pathology of TB, and review the incidence to give some assurance, as well as, real concerns with this diagnosis.
In this episode:
- Incidence of TB in the US over the last 5 years
- Current KC TB outbreak
- Active vs. Latent TB
- Signs and symptoms of TB
- Transmission of TB
- Airborne Precautions
- PT exam findings
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Welcome to Talking All Things Cardiopulm. I am your host, Dr. Rachele Burriesci, physical therapist and board-certified cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions treatment interventions, research, current trends, expert opinions and patient experiences. The goal is to learn, inspire and bring cardiopulm to the forefront of conversation. Thanks for joining me today, and let's get after it.
Rachele Burriesci:Today's episode is sponsored by Jane, a clinic management software and EMR. The Jane team knows that when your workday is spent providing care to your patients, it can feel like there aren't enough hours in the day for the rest of your administrative tasks. That's why Jane has designed user-friendly online booking so you can give your patients the freedom to book their appointments at their own convenience. They can also fill out intake forms and enable SMS and email reminders from their secure online portal, which saves you from having to manually do it. To see how Jane can help you reclaim your nights and weekends, head to the show notes, click that link and book a personalized demo. Or, if you're ready to get started, you can use code CARDIOPULM1MO at the time of sign up for a one-month grace period applied to your new account. Thanks again, Jane. All right, welcome.
Rachele Burriesci:Today is I think it's the last day of January, january 31st, it has felt like a chaotic month. There's a lot of chaos, uncertainty, fear and extreme tragedy just happening on so many different levels that and I think that I may have said this last week it feels really hard to sometimes talk about cardiopulmonary right, but I feel like I do have a due diligence to speak about my specialty and keep people informed, and that's what I'm going to continue to do. So a big topic that I wanted to talk about today has made national news. We have a TB outbreak and it has been specifically noted to be in Kansas. So 67 active cases, 79 latent cases, and I think it was 60 of those, 67 were reported to be in Wyandotte County, which is not very far from here, and two active current are in Johnson County, which is where I reside. So you know, obviously you hear this and there's immediate. You know what do we need to be doing, what do we need to be thinking about, what is the overall concern? And so I really did a deep dive into the incidence of TB over the course of the last five years and further back.
Rachele Burriesci:First of all, surveillance only started in the 50s 1953. And I think the earliest date of information that I saw was from 1957. And just for numbers purposes and to give information that we know, in 1957, there were 64,149 active cases of TB, resulting in 13,390 deaths. So in 1953, the US made it a priority to start surveying and having surveillance for TB because it was the number one cause of death globally. For numbers, number, number of years, and there are still millions of people affected by TB worldwide. And so in 1987, an advisory committee was created in the US and we speak very closely and have a big part of being in the WHO right, the World Health Organization. And I think part of understanding pandemics which we just literally came out of, is that germs, bacteria, viruses don't know country boundaries and with technology of things like air travel, it makes it much easier to spread disease globally. So the US has done a really great job of lowering the incidence of TB period.
Rachele Burriesci:Since 1950s it has been on a steady decline down, with a significant downtrend. There was an uptick in the 80s and that was due to the emergence of HIV and HIV is a risk factor of TB. So if you have HIV you are more likely to contract TB and that is really due to the immunocompromised nature. There was also an uptick in the 70s of multidrug resistance, and we'll talk about that a little bit later. But multidrug resistance to TB is a problem because we actually have a cure for TB.
Rachele Burriesci:So first thing to be said is that TB should be taken very seriously in the hospital. Setting is probably the number one diagnosis that you know that is going to put you in airborne precautions prior to COVID, right Like we have negative pressure rooms in hospitals to deal with patients that have TB, and that was always a big concern. You got fit tested every year in the hospital to make sure that you could appropriately wear an N95. And if you didn't fit test well for an N95, you would wear a PAPR in the event that you had to enter airborne precautions. And when there were airborne precautions it's very likely that it would be a TB patient, although those numbers are always have always been low since I have been in healthcare. With that being said, we have to be aware of what that means and we'll go into it being airborne precautions. But I'll hit incidents a little bit more. So we've been on a pretty steady decline period since the 1950s.
Rachele Burriesci:Just to give some more recent numbers in 2000, the incidence of active TB was 16,305, with the result in 776 deaths. In 2019, that was cut in half. So by 2019, it was 8,895 active TB cases, with the result in 526 deaths. We had the lowest incidence of TB in 2020. Well, what happened in 2020? We had a pandemic, we had more people isolating, we had shutdowns right. So in 2020, the active incidence of TB was 7,170, with still a resultant of 600 deaths. 2021, slight uptick from there 7,866. 2022, 8,332. So we're still not past 2019. But in 2023, we started to see an increase of 9,633 active TB cases, so there's a little bit of an uptick. The official numbers for 2024 have not been released yet. On the CDC website the most updated information is of 2023, and the number of deaths reported are not listed yet, so there's obviously delay in collecting data.
Rachele Burriesci:The Kansas outbreak of the 67 active cases is over an entire year, so I think that's important to note. That takes a little bit of the fear out of it. So there have been 67 active TB cases in Kansas over the entire 2024. And I believe August was where there was a higher uptick and 79 latent cases, which we'll talk about in a minute what that means. But Kansas isn't the highest number of active cases in the US. As I said before, we've had somewhere between 8,000 and 9,000 active cases in the United States since 2019. So 67 of that is still a small percent.
Rachele Burriesci:I'm not sure what qualifies the outbreak. Is it the percent per capita, in how much time in a specific area, which might be the case, because 60 of those cases were in Wyandotte County. But just for some information, missouri is right next door, so we share a state line. Missouri is a big state as well. They have active cases of 71 in 2022 and 74 in 2023. So they didn't have a change, but their numbers are technically still higher than Kansas. You go into some of the bigger cities, like New York. New York City in 2023 had 654 active cases,242 cases. California in 2023 was 2,112 cases. So there is an uptick across the US. There has been a surge in a specific county in Kansas and I think that's where some of that concern comes in. But we need to remember that we can travel here and there, right, so these people aren't stationed only here, and I think that's where the concern comes from, and this is why we need to have conversation about what is happening so that we can help prevent spread, and so how has the US been able to really mitigate these numbers?
Rachele Burriesci:And two things. One is surveillance. So we do active TB testing, especially on higher risk people higher risk people, including myself. So health care workers are at higher risk because they have higher likelihood of coming in contact with someone who has latent and or active TB Just to be clear, because I said that latent is not contagious, so just a heads up on that. But because you are working in these areas, it is possible that you can contract TB and you yourself be latent, and so it would be important to do testing. I have remembered pretty much every year since I have been in healthcare I think until I moved here that we TB tested every year.
Rachele Burriesci:It's a skin test. You go in, they do this like little needle under the skin and then you have to wait three days and after three days you have to get it checked. You have to have a medical professional look at it and determine if it's positive or negative and so if it becomes inflamed and things like that, you're positive and then they're going to go further with testing because there are other blood tests that can be done. This is something that is commonly done Surveillance, surveying people who are at higher risk to make sure that they don't have active and or latent disease. So I'll get into a little bit about what TB is. But it's a bacterial infection. So it's myomycobacterium tuberculosis is basically the bacteria that causes tuberculosis.
Rachele Burriesci:And if you were to have active TB and you are symptomatic and you get tested and they confirm that you are active, they are going to start you on a six month regimen medication to combat that diagnosis. Six months, that's a long time and it's a multi-drug cocktail, so to speak. And it's a multi-drug cocktail, so to speak, and they've actually done something called DOT where they do direct observation of, and so that is the concern is that we have increased the number of cases that have resistance to the medication and so basically you go in weekly to be monitored while you take your medication to ensure that A it's being done and to also make sure that there aren't any side effects. So it's a six month course. The other piece of it is if you have latent TB, you don't show symptoms, so they find out if you have latent TB via testing. If you have latent TB they will also treat. And so treating latent TB is important, because latent TB they will also treat, and so treating latent TB is important, because latent TB literally becomes active or can become active months, years later. So I think that's part of the concern too right. If there are 67 known active cases now, there are likely more latent cases later available, which will then spike that number again.
Rachele Burriesci:So just to kind of go through a little bit of the how right, the pathogenesis of this how does this thing contract? What do we need to know? So, like I said before, it is a bacterial infection Mycobacterium tuberculosis, also known as tubercle bacillus and it is transmitted from respiratory to respiratory system. It is considered an airborne infection, meaning I'm going to breathe in air that has this infectious bacteria in it and it's going to enter my body via the lungs. So I'm going to breathe it in, it's going to get pulled into my lungs, basically go into my alveoli, and then three things can happen. One is nothing right. It's not enough bacilli in the air that you have breathed in and your immune system shuts it down. That's option one. Option two is that your body starts to create an immune response against said bacilli, and essentially this does not happen quickly. So one thing I want to kind of just point out is that TB does not spread quickly.
Rachele Burriesci:There is a delay in symptoms which can become problematic. If you think about that right, you get infected. You don't know you're infected. It could take two to 12 weeks for your symptoms to appear. In that time your immune system is basically trying to ward this thing off and so it sends macrophages to the area to basically wall off the bacilli from the rest of the body. And so if it does that and it's effective in walling it off, then you have latent TB. You never develop symptoms, but you have this pocket of basically controlled bacilli.
Rachele Burriesci:Latent TB has no symptoms. Latent TB is not contagious. Latent TB can reactivate itself years later. So there's a percent I believe it was. You have a 10% risk of your latent TB to become active, and it's most high in the first two years. And here's another set 5% to 10% will develop TB in their lifetime.
Rachele Burriesci:Who have latent TB? What they basically said was your likelihood of your latent TB to become active is usually happening in times of low immunity. You're immunocompromised. So a couple of risk factors here are HIV is probably the number one risk factor, diabetes being diabetic end-stage renal disease. If you're an organ, if you received an organ transplant, you're on immunocompromising medications and you're at higher risk. So those things play a role in that kind of coming to fruition. Also, age older age has a higher risk and you can, you know, think about just lower immune system in general, as well as children. So under five years old is at highest risk if they were to become in contact with someone who has TB.
Rachele Burriesci:So then the question is well, what about exposure? And I think this was something that I didn't know until I really did a deep dive on this how long do you have to be exposed to someone with TB in order to likely contract said TB? And it's again, it's like the long game. Tb is playing the long game. There are a few studies that say as little as four hours. Those are older studies. The most recent study I found was in 2019. Let's see if I can pull up the results so I give you correct stats here. Stats here In 2019, they did a study basically monitoring people who had TB and looking at all their contacts.
Rachele Burriesci:It was literally a study on transmission, and so there were 718 patients in this study with active TB. So in general, a lower end, but a decent N Of those contacts. There were 4,490 reported close contacts to those 718 patients. Of those close contacts, 158 became active. And they became active. Their diagnosis was confirmed one to three months after exposure.
Rachele Burriesci:And I think that's where the concern really lies. You can be exposed, but your symptoms might not appear immediately, and so there's a delay. And I think the delay is where there is concern From a from a. What is close contact Like? What is that description? I've seen a couple of vague definitions, something along the lines of being in a confined space for a prolonged period of time, for many hours in a week. That's probably the most vague one I saw. It's not hours or days, it's like weeks that you're exposed. And so in this specific study I like that it actually gave a time frame it said close contact is defined as someone who shared a space with an individual with pulmonary tuberculosis in the household, in an indoor setting, for greater than 15 hours per week or greater than 180 hours total during their infectious period. So this is a long exposure, I think and I'm not sure if it was this study or another study basically said the likelihood that you contract TB with, like, random passing of someone is very low and the rate of exposure, like if you're outside in contracting, very low.
Rachele Burriesci:So it really comes down to enclosed spaces, prolonged time likely someone that you live with, so outside of your own household, thinking about different areas that could be at risk. You're thinking about places that could be overcrowded, places like shelters. So homeless population could be at higher risk if they're in a shelter environment with overcrowding. Another possible population is prisons. Again same thing. Long exposure inside prolonged periods concern if there's overcrowding. Other places could be things like nursing homes where you have prolonged time in enclosed spaces with other residents. And then of course there's healthcare workers who have a higher exposure from the likelihood of TB actually being in your workplace. So I think that can give a little bit of ease and I think that's why it's important to understand pathogenesis so that we can understand how things are transmitted.
Rachele Burriesci:So if someone had active TB and they cough, sneeze, they're talking, they're singing and you're in an enclosed space with them where that respiratory droplet goes out into the air, those aerosols is what you're inhaling, and there has to be a good amount of inhalation of said tubercle bacilli for that activation or infection to occur. So just to kind of give some background on how that happens, then it starts to multiply, right, and that's where the problem becomes. So most commonly TB has pulmonary presentation, pulmonary tuberculosis. Essentially we breathe in the particulate aerosols. We have this proliferation of the epithelial cells that basically try to encapsulate it, to wall it off. It tries to do its job. That walling off actually causes something called a tubercle, which you would then see on chest x-ray Two to 10 weeks after. That initial infection is where the immune response starts to really kick in, multiplication, spread and then potentially, this is where you have the break off into latent versus active. And so it says organisms grow for two to 12 weeks until they reach a number sufficient to elicit a cellular immune response. So there is delay in this infection occurring.
Rachele Burriesci:Once it gets into your alveoli, that is where it's either going to stay and be harbored in the lung or it has the potential to spread via the bloodstream, hyalur lymph nodes. It could happen because there's erosion of blood vessels based on these tubercle lesions in the lungs and then that leaks into the bloodstream and then essentially, once it's in the bloodstream, it could affect other areas of the body and they call this extrapulmonary tuberculosis. So some common areas are the lymph node. You can get TB in your lymph nodes and that would cause redness and swelling. It can affect the kidneys, where you might see blood in the urine. It could affect the meninges, and so urine has some cranial nerve involvement headache, confusion. It can affect the spine, causing back pain, and it can affect the larynx, causing hoarseness, back pain and it can affect the larynx, causing hoarseness.
Rachele Burriesci:So the most infectious seems to be the pulmonary TB, as well as the effect of the larynx, because it's going to affect the droplet. Basically, primary symptoms of TB are cough, so like that's the first thing that people might notice, and specifically that the cough is going to last. So you might have a cough for greater than three weeks right, there's a time component to this one, and what is significant about the cough is that you might have hemoptysis. So blood in the sputum is a big factor in TB, like if you have a patient who has blood in the sputum, this is one of those things to really pay attention to, because this could be a sign that it is TB. It could also have just regular mucus that's non-purulent. And then there's the non-pulmonary symptoms weakness, fatigue, weight loss, no appetite, chills, fever and night sweats. So always looking at the big picture. Always thinking about exposure helps physicians make these decisions right. There was a term that was used for quite some time is like think TB first, so that they would be testing for that, and so some things that they would do from a medical perspective is a skin test. If the skin test is positive, they might do a blood test, chest x-ray and sputum culture. So those are the big pieces to help get the diagnosis outside of signs and symptoms. But the big one is cough for greater than three weeks. They might also have chest pain, which is another kind of vague symptom in regards to the whole picture, so from a you know how do we prevent spread sort of thing In the hospital setting, these patients are placed on airborne precautions, and so what that means is that they're going to be placed in a negative pressure room, and in that negative pressure room they're going to do a lot of cycle change of that HEPA filter somewhere between six and 12 times an hour.
Rachele Burriesci:That room, that negative pressure room, has an exhaust to the outside. So essentially and this makes sense especially in a hospital setting that there's no risk of that stagnant air kind of seeping out into other places. That door always has to be closed For anyone entering that room. They need to be in an N95 and or a PAPR and other standard precautions. So this is N95, papr negative pressure room. That is mainstay in the hospital setting.
Rachele Burriesci:So if this person is in your home, like what things can we talk about doing? They need to be isolated, right. That would be the main goal. They need to go in their own room, door closed, and keep that window open if possible to help move those germs out. If the person has to transport outside of their room in the house or if they're in the hospital, they need to be wearing a mask and you should be teaching them good cough sneeze etiquette. Where they're coughing and sneezing into a tissue and they made that a really big point is coughing and sneezing into a tissue. That's catching the main amount, right. What I didn't say yet is that this diagnosis is not transmitted via fomite, meaning if I cough on the doorknob and I touch the doorknob that I can contract TB. This is airborne, specific. You have to breathe in the particulate. So it's not transmitted via sharing utensils, kissing and handshaking or like touching surfaces. This is an airborne spread. This is an airborne spread disease.
Rachele Burriesci:Confined spaces, long periods of time In the hospital setting. They also try to decrease pregnant women patients or health sorry, health staff, health care workers, who are immunocompromised from entering those rooms. So just you know things to consider. But the big one is N95. N95 PAPR, negative pressure room that's exhausted out to the outdoors. That person is not leaving their room. If they have to for some sort of testing, then that person would be wearing a mask to transport and then you're again teaching them good cough hygiene. Once medication treatment is started, it's somewhere around two to three weeks where they will no longer be contagious and in order to be considered not contagious you have to have three negative sputum cultures. So this is someone who's going to be closely monitored throughout their course. From a PT perspective, like what things could we be looking out for from a examination perspective, from a cardiopulmonary perspective? Right, this is someone who you're definitely going to be auscultating.
Rachele Burriesci:Number one you will have that possible tubercle area and that tubercle area, if it becomes active, basically becomes necrotic and they describe it as they keep, describing it, like cheese. And I kid you not. I read this in multiple articles where they described it as cheese, because basically the area that is warded off becomes necrotic and fibrosed and hard. The tissue essentially looks like cheese and there was a term that was used that I had to look up and now I have to see if I can find it on my notes, kind of sticking out it was. I want to say caseus. I might be pronouncing that wrong but if I come across it it's probably going to be a wordy Wednesday next week. If I come across it it's probably going to be a wordy Wednesday next week. That will definitely be utilized. But basically you're going to have fibrosis in the lung. So you're likely going to hear things like crackles and or bronchial breath sounds in the area where you have these granulomas, where you have this tubercle, where you have this necrotic tissue.
Rachele Burriesci:From a chest wall perspective, because we have fibrosis, we can expect decreased expansion in that area. You might also have tracheal deviation in this patient. So this is a person who could have spontaneous pneumothorax, significant atelectasis from the pressure of the necrotic tissue of surrounding area. So there's a lot of different pulmonary manifestations that can occur. So definitely want to make sure that we're assessing auscultation chest vulnerability. In theory they will have a cough. If they have a cough, you want to look at their sputum. You are obviously in an N95 appropriate PPE when you're assessing this patient and they would likely be in a negative pressure room if you're in the hospital setting.
Rachele Burriesci:Another thing to consider in the post-TB world is the effect on the body. So weight loss is a big thing. Atrophy from overall disuse is really important. So make sure that we're assessing MMT, that we're assessing posture, with potential changes in coughing, that we are maybe even assessing gait pending age and how long they've been down, because there's likely going to be a significant change there.
Rachele Burriesci:So, really important that we understand how disease is transmitted. This is via airborne and what that means, right? So, and also understanding time frame and I think that's an important piece and I'll keep digging to see if I find anything different but it seems to be that prolonged, extended exposure, potentially greater than 15 hours a week, that really puts you at risk. But with this diagnosis, the delay is really problematic, right, the delay in symptoms, the delay in diagnosis, and so that could be a potential issue, right. You don't know the true impact at a certain point because you might have a ton of latent cases based on that new active case that has come up. I don't know if I mentioned numbers earlier, but globally this is still a pretty big concern. There are still 2 billion people with latent infection worldwide and 2 million deaths per year.
Rachele Burriesci:So this isn't something to you know take lightly. It's not something to ignore, it's something to definitely understand. Multi-drug resistance adds another component to it and also the long timeframe for treatment can play a really big role in that. I do not know the cost of these types of meds or how easy it is to access if you have positive TB. That would be another piece of this to really look into, but I did not dig into that piece of it, anything else that I'm missing.
Rachele Burriesci:So prevention is really, you know, in the big picture preventing overcrowding, practicing good cough hygiene period right off. Let's not ignore those things. Let's go get tested right. There are a number of different respiratory things going on in this world right now that we need to pay attention to. Flu A is very prominent right now. That's probably going to be my next conversation. That's probably the most common patient that I have seen this season.
Rachele Burriesci:RSV and COVID and potential TB, right Like those, are big diagnoses to not ignore. So don't ignore. If you have a fever, if you have an active cough, go get checked out. I think we have a personal responsibility to not only keep ourselves safe, responsibility to not only keep ourselves safe but to keep other people safe, right? So just you know, just good cough hygiene, make sure that you're getting tested if you're actively sick, I think. I think it's the little things that really help. And if you are in a healthcare situation, if you work in healthcare, that you are actually getting tested for TB. On my next primary care visit I think I'm going to actually ask them, just to be like a quick screening. So I don't think I've had one in a few years, to be quite honest.
Rachele Burriesci:There are side effects to the meds for the TB. So they are, you know, big medications with side effects. Things like peripheral neuritis homoptysis is possibly on there, optic neuritis, liver injury, and so that's the other piece of the observation, the direct observation during taking this medication. That is really important to help keep you safe. Another piece I don't know if I said is, if you are taking these meds and you miss two weeks of medications, they actually restart you on the whole regimen to help prevent that multi-drug resistance, because that is just a big problem in bacterial infections across the board. All right.
Rachele Burriesci:So I think we covered everything right. We have our precautions, we're airborne, which means we're in a negative pressure room, we are wearing an N95 or a PAPR. We went over signs and symptoms, which include cough for greater than three weeks, cough with blood in it, hemoptysis, potentially sputum, and then some other symptoms, including weight loss, lack of appetite, fever, chills, night sweats, chest pain right, those are things that we should just not be ignoring. In general, we have two forms of TB. We have active and latent. Active is where you're going to have symptoms. Active is where you're going to be contagious and be able to transmit said disease, and latent is basically a time, a period where this diagnosis stays dormant in your system and it can reemerge years later, usually within one to two years, but it could be longer in theory.
Rachele Burriesci:In order to get tested for this or to find out if you are positive for TB, you're going to do a possible skin test. They have specific blood work that they can do. They can do a sputum culture and they can check a chest x-ray. So a couple of testing opportunities there. There is higher risk for patients with HIV diabetes children of young age, less than five years old. If you're in a high-risk environment with overcrowding, shelters, prisons, nursing homes, potential hospital workers.
Rachele Burriesci:This is spread via the air, via respiratory droplet aerosols, so it's a smaller particulate and it is not spread via shaking hands, kissing, sharing utensils, sharing food, things like that. I think that's all I have. Oh, last piece, there is technically a vaccine for TB. This is used in other countries. It is not commonly used here, from my understanding, and the reason is is because it doesn't have great effect on preventing disease and if you have the vaccine you will test positive for skin tests. So it can't determine if you're active, latent or have the vaccine. So the US has done a good job with decreasing the spread of TB via surveillance, via treatment of active TB and treatment of latent TB. So really kind of nipping that in the bud because it has this delayed response and can sort of re-emerge later on.
Rachele Burriesci:All right, if you have any questions, reach out to me. I think I hit everything I wanted to hit. I probably missed something, but not quite sure. A couple of announcements before I sign off with you. I'm going to be doing a presentation in the KCMO area. It's called the KC Metro Therapy Happy Hour and CEU. We are going to. I'm going to be presenting on Wednesday, february 26th, at 4.30 PM, and I will be discussing respiratory muscle training. I will link that link to sign up for registration.
Rachele Burriesci:Another thing that I wanted to mention that I did not mention at the start. Another thing that I wanted to mention that I did not mention at the start is email list. As we have recently seen, social media can just kind of go away right. So we had a TikTok thing. I'm mostly on Instagram.
Rachele Burriesci:There is risk across any platform. In theory, someone could hack an account and it could just be deleted. There is all sorts of possibilities. One thing that can be a true, steady way to contact me is email and being a part of my email list. I send out one to two emails per month giving updates on potentially lectures and anything that I have posted on, as well as podcast links. So hit that link below. Add yourself to that mailing list just in case you know you can stay in contact with me. I can stay in contact with you. Just a little fail safe, if you may. All right, I think that is all I have for you today. I hope everyone is safe. I wish you all well. Thank you for listening. Thank you for sending me comments and questions. It is very much appreciated. I appreciate that you spend time listening to these podcasts. It means more than you know, so I hope you all have a wonderful day, and whatever you have to do, I get after it.
