Practical Applications of ACHA TB Guidelines ACHA 2010 Annual Meeting, Philadelphia June 4, 2010

1. Practical Applications of ACHA TB GuidelinesACHA 2010 Annual Meeting, Philadelphia June 4, 2010 Susan Even, MD (University of Missouri) Sharon McMullen, RN, BSN (University of Pennsylvania) Brenda Johnston, RN, MSN (Oklahoma City University) Tim Crump, RN, MSN, FNP (University of Portland)

2. Introduction • Guidelines released June 2008 -1 year of work by task force • Update needed to strengthen public health measures on campuses to prevent TB and to include IGRAs • TB Subcommittee - part of Coalition of Emerging Public Health Threats and Emergencies • Request -present program to illustrate application of guidelines

3. Presentation Goals • Review guidelines • Describe implementation at a large private university in east (University of Pennsylvania) • Describe implementation at a small, private university in southern midwest (Oklahoma City University) • Q & A (providing input for a FAQ document for ACHA)

4. ACHA Guidelines for Tuberculosis Screening and Targeted Testing of College and University Students

5. Purpose • Highlight screening and testing as key strategy for controlling and preventing infection on campuses • Target population – incoming students who are at increased risk for TB • Review appropriate follow up care for students diagnosed with latent tuberculosis infection (LTBI) or TB disease

6. Definitions • Screening – identification of high risk students who need testing, commonly by a questionnaire • Testing – procedure for diagnosing LTBI; using Mantoux tuberculin skin test (TST) or blood tests using interferon gamma release assay (IGRA)

7. Definitions • Population risks vs Medical risks

8. Definitions • Population risks – epidemiological and population-based risk factors of incoming students that increase their likelihood having LTBI, therefore targeting these for testing • Medical risks – factors placing an individual who is already infected with TB (LTBI) at high risk for progressing to active disease

12. Whom to Screen All incoming students using screening questionnaire • Highest risk group – international students from countries with increased incidence of TB • High- incidence – countries with annual TB disease greater or equal to 20 cases per 100,000 • Close contacts to known or suspected TB disease • Workers in high risk congregate settings (healthcare facilities, nursing homes, homeless shelters, corrections institutions, etc) • Persons who inject illicit drugs, etc • Travelers to areas of high incidence of TB (no evidence-based data regarding length of time) -consider provider visit to assess significance of potential exposure

13. Whom to Screen Continuing students – usually a program rather than an institutional requirement • When specific activities place them at risk (study abroad, research, volunteering, etc.) • Health professions students -annual requirement usually monitored by specific program

14. Whom to screen Medical Clinic setting As part of routine evaluation, clinicians should • screen for both risk of LTBI and risk of LTBI progressing to TB disease AND • conduct appropriate testing

15. When to Screen and Test • Prior to arrival on campus, give questionnaire • Review with verification of prematricuation immunization requirements • Test high risk students only – no sooner than 3 – 6 mos before arrival • Complete by second semester/quarter registration

16. How to Test - TST • Tuberculin Skin Test (TST) • Mantoux Test – intradermal injection of 0.1 ml PPD (5 tuberculin units) • History of BCG doesn’t preclude TST • Delay 4 – 6 weeks after a live virus vaccine (usually MMR) • May give concurrently with live virus vaccine without compromising results

17. How to Test - TST Two-step testing: • Initial testing for persons retested periodically (health professions students, volunteers) • TST #2 is performed 1 to 3 weeks after TST #1 is negative • If TST #2 is positive, LTBI is diagnosed (identifying a childhood infection)

18. Interferon Gamma Release Assays (IGRAs) • May be used in all circumstances where TST is used • Use with caution in immunocompromised individuals • Has greater specificity than TST – no reaction to BCG or most non-tuberculousmycobacteria • Usually single test is adequate making compliance easier • Cost and availability are limitations • CDC does not support use of IGRA as a confirmatory test after positive TST however, this practice is prevalent in the US (following international use)

19. How to Interpret the TST • Read 48-72 hours after injection; measure induration in transverse diameter; record in mm of induration (0 mm if no indiration) • Interpretation – based on induration and risk factors

20. How to Interpret the TST >5 mm is positive in the following: • Recent contacts of individuals with infectious TB disease • Chest x-ray with fibrotic changes consistent with past TB disease • Organ transplant recipients and other immunosuppressed persons • Persons with HIV/AIDS

21. How to Interpret the TST >10 mm is positive in the following: • Persons born or residing in high prevalence country • History of illicit drug use • Mycobacteriology lab personnel • Workers, volunteers of high risk congregate settings, including health care facilities • Persons with clinical conditions including diabetes, silicosis, chronic renal disease, leukemia, lymphoma, cancers of head, neck or lungs, body weight >10% below ideal, gastrointestional conditions such as gastrectomy, intestinal bypass, malabsorption syndromes

22. How to Interpret the TST >15 mm is positive in the following: • Persons with no known risk factors for TB disease

23. What to do When the TST or IGRA is Positive Chest x-ray and medical evaluation (review signs and symptoms) If abnormal x-ray OR any signs and symptoms of TB • Must exclude active TB disease • Sputum smears and cultures, chest CT, bronchoscopy If normal x-ray and medical evaluation • Diagnose LTBI • Recommend treatment for LTBI • Contact with public health officials (reportable in some states)

24. What to do When the TST or IGRA is Positive Reasons to treat LTBI • Reduce risk for progression to TB disease (90%) • Reduce burden of TB in US Highest risk of progression from LTBI to TB disease • TST or IGRA conversion within 2 year • HIV/AIDS or other clinical conditions with increased risk due to impaired immunity

25. What to do When the TST or IGRA is Positive • LTBI Treatment Options • INH daily for 9 months–preferred, 6 months minimum • Directly Observed Therapy (DOT) – two times per week at higher dose • Rifampin in exposures to known INH-resistant disease

26. What to do When the TST or IGRA is Positive  Completion of treatment high priority • Provide education in primary language when possible (refer to translated chart) • Insure confidentiality • Consider incentives • Gain trust by case management with culturally competent provider

27. What to do When the TST or IGRA is Positive Monitoring of treatment • Monthly symptom checks • If symptoms suggest adverse reactions - laboratory testing • Routine testing only if increased risk of complications

28. What to do When the TST or IGRA is Positive Conditions requiring routing laboratory monitoring • Regular use of alcohol • History of liver disorder, risk of hepatic disease • HIV/AIDS • Pregnancy or up to 3 months post-partum • Medications with risk of liver toxicity

29. What to do When the TST or IGRA is Positive Post-treatment follow up • Provide documentation of TST or IGRA results, chest x-ray results, dosage and duration of medication treatment • Reinforce signs and symptoms of TB disease with instructions to seek medical attention upon developing any

30. Student Health Service

31. Facts and Figures Private, 280-acre urban campus 24,000 students 20,000 full-time (½ undergrad, ½ grad) 3,500 international students 3000 health professional students Student Health Service: 45,000 visits/year Primary Care, Women’s Health, Sports Medicine, Travel, Immunization/Allergy, Podiatry, Lab, Health Ed, Public Health, Massage/Acupuncture

32. Immunization Requirements • Required: • Hepatitis B: 3 doses • MMR: 2 doses • Varicella: 2 doses or hx of disease • Meningococcal • Screening for TB infection • Web-based data entry and faxed records • Student Immunization compliance: ~97%

33. Goals • Screening • Documentation • Testing for TB Infection • +TTBI follow up • Compliance

34. Screening for TB Infection Method: web-based questionnaire Who gets screened? All 8000 matriculating, full-time students per year Who gets tested? Anyone whose answers “yes” to a screening question Health professional students annually Goal: to find LTBI

35. Screening Questions Have you ever : 1. been in close contact with anyone with active TB? 2: worked/volunteered with people in prisons? 3: worked/volunteered with the homeless? 4: worked/volunteered with refugees? 5: worked/volunteered with people in hospitals? 6: been diagnosed with diabetes? 7: been diagnosed with cancer? 8: Do you have a history of prolonged use of corticosteroids and/or immunosuppressive treatment? 9: Are you HIV positive? 10: Country of Origin:

36. Non-TB Endemic Countries

37. Assessment of Volunteers • 4 x 4 x 4 Rule • 4 hours a day • 4 days a week • 4 weeks in a month

38. TTBI Documentation • Acceptable proof of +PPD: • Dates of placement AND reading • Size in mm • Official letterhead or signature of provider • “Positive" on an imm. card is not sufficient • Acceptable proof of a negative IGRA: • Official lab report with reference ranges noted • < 12 months old • Not accepted: • proof of negative PPD

39. Chest XRay Documentation • Acceptable proof of cxr: • Official US radiologist's report • Dated AFTER the positive PPD • Negative reading • Not accepted: • “Negative cxr” on immunization card is not sufficient • International chest xray reports • Cxr films

40. Prior Treatment Documentation • Acceptable proof of treatment completion: • Official letterhead (or signed by the supervising healthcare provider) • Name(s) and dosage(s) of the medications • Initiation and completions dates • Not accepted: • “Treated for TB” on an immunization card is not sufficient

41. Testing for TB Infection • Method: PPD • 5500 PPDs placed annually • 3100 incoming international students, returning travelers • 2400 Health professional, including 1000 2-steps • 1200 SON • 770 SOM • 430 SDM

42. PPD Reading • Within 2-3 days • Nurse reads PPD • No self-readings • If negative, student is compliant • If positive, nurse will: • TB Symptom Check • Order cxr • Review instructions with student • Send links to on LTBI, BCG • Student is not compliant until cxr is done

43. 2 Step PPDs • Required for incoming health prof students • Timing: placed 1-3 weeks apart • Purpose: assess remote TB exposure

44. Follow-up of positive results • 350 positive PPDs (6%) • PHN tracks each +PPD monthly • 100% compliant with TB Symptom Check • 97% compliant with required cxr • Follow-up eval for LTBI treatment (~50%) • Not required but strongly encouraged • 12% accept medications for LTBI • Rifampin vs INH • Monitored via secure message each month • Completion of Therapy Letter

46. Compliance • Registration hold • Students cannot register for the next semester’s classes if there is an SHS hold on their account • Exception • Health professional schools track/enforce their program-specific requirement of annual PPDs

47. STUDENT HEALTH AND DISABILITY SERVICES

48. Introduction • Private, faith-based (Methodist) University on 60 acre urban campus in the lower Midwest • 3,200 students 3,000 full-time 1,800 undergraduate 500 graduate 5 doctoral 600 law • 446 International students – most from China, Taiwan, Korea, West Africa, India, Saudi Arabia. Few from Europe and Canada. • 274 Health professional students (Nursing)

49. Student Health Services • 2,300 visits per year Services: • Primary care • Women’s Health • Immunization and Allergy • Laboratory • Health Education • Disability Services is part of program

50. Staffing • Nurse Director – also serves as Disability Services Coordinator, 12 months • ARNP - full-time, 10 months + 1 day/week in summer • RN – full-time, 10 months • Office manager – full-time, 12 months • Receptionist - full-time, 12 months