amp Lots of Time World TB Day in a Pandemic 2021 Dana G Kissner MD Professor Wayne State University Medical Director Detroit TB Michigan Department Health amp Human Services TB Control Program ID: 933014
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TB Treatment: It Takes a Village, Experts,& Lots of Time
World TB Day in a Pandemic 2021Dana G Kissner, MDProfessor, Wayne State UniversityMedical Director, Detroit TB
Slide2Michigan Department Health & Human Services TB Control Program
Tuberculosis Clinical Consultation Program4 physicians, rotate every 2 weekshttps://www.surveymonkey.com/r/TBConsultRequest
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Slide3MDHH TB Consult Request
Mother was 30 weeks pregnantOn INH, Rifampin, and EthambutolThe consult was from a pediatric infectious disease physician at Michigan Medicine.She, in turn, was consulted by the only neonatologist at the local hospital
The neonatologist was concerned about the babies
My 1
st
recommendation was to transfer the mother to the U of M Hospital
My impression was that this was a very complex case that could go very bad very fast
Mortality of congenital TB: ~40%3 patients were involved
Slide4Congenital TB:
Fetus is infected by mother in 2 ways
TB is spread from mother’s blood to the fetus
Hematogenous spread
In miliary TB, the dissemination is hematogenous
TB focus in infant is in liver or lung
Miliary TB
Millet Seeds
Slide5Fetal Circulation:
Hematogenous spread
Slide6Congenital TB: Fetus is infected by mother in 2 ways
TB is spread by aspiration or swallowing of amniotic fluid contaminated by placental or genital infectionFemale genital TB90-100% fallopian tubes => infertility
50-60% endometrium
Mother likely had genital TB => infertility
TB focus in infant is in GI tract or lung
Baby A had significant constipation
Baby A had + PCR in the gastric washings
Risk for both?
Slide7Indian Council for Medical Research
Slide8Consulting:Common impediments
Incomplete knowledgeI am not a pediatrician, obstetrician, or neonatologistBut I know some good pediatric TB docsDr. Jeffrey Starke’s name came to mind as a consultant’s consultant
Specific questions for Dr. Starke
When is it appropriate to do C-section?
Won’t the fetuses get sicker from TB if they are not delivered soon?
Should a vaginal delivery be avoided?
We should assume pelvic TB in the mother
How do we manage the babies after birth?
Slide9Consulting:Other common impediments
Resistance to adviceMultiple specialtists & they don’t talk to each other, let alone to consultants
Internists
Internal medicine and pediatric infectious disease physicians
Obstetricians
Neonatologists
Pediatricians
Local health departmentWhat you suggest does not get passed on
No follow-up
Hospital push-back in obtaining records
It is time consuming and frustrating
Slide10Targeted Testing and Treating for LTBI
Slide11Slide12The BIG ?
Why wasn’t mom’s risk for TB recognized?In India, the evaluation for TB could not have been adequateHere in the USA, why did her obstetricians fail to recognize her risks for TB?India – accounts for 26% of the world’s TB, has highest incidence at 2,640/100,000
Infertile – 50% presenting for IVF in India have TB
Cough since August
Fevers
How do we move toward adherence to the USPSTF recommendations?
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