tuberculosis a synopsis of information from the centers for disease control and prevention

1. TuberculosisA Synopsis of Information from the Centers for Disease Control and Prevention May 2005 Prepared by: Rosemarie Battaglia, RN, MSN Adapted from: 2005 CDC Division of Tuberculosis Elimination

3. Tuberculosis (TB) Outline the CDC documentation requirements for reading the TB skin test. Discuss interpreting positive results and explain the implications of >5mm, >10mm and >15 mm induration. Explain the meaning of a negative or positive TB skin test result. Describe causes of false –positive reactions. Describe causes of false-negative reactions. Determine which patients should have follow up and where follow up is provided. Explain the implications and follow-up for false-negative reactions related to young age, anergy and recent exposure to known TB infection. List the treatment medications for active TB. Describe how to prevent the spread of TB in vulnerable groups. Correctly place, read, interpret and document a TB skin test.

4. Tuberculosis (TB) Definitions TB is a disease that spreads person to person through the air. When a person with pulmonary or laryngeal TB coughs or sneezes, droplet nuclei containing M. tuberculosis are expelled in the air. These particles (1-5 microns in diameter) can remain suspended in the air for several hours. A person that inhales these droplet nuclei may become infected

5. Tuberculosis (TB) 3 Factors that affect development of TB disease Infectiousness of the person with TB Environment in which the exposure occurred Duration of the exposure

6. Tuberculosis (TB) Active TB - is associated with the following symptoms: Weight loss Fever Night sweats Prolonged cough (3 weeks or more) Chest pain Coughing up blood / productive cough

7. Tuberculosis (TB) TB usually affects the lung, but may also affect other parts of the body. Brain Kidney Spine

8. Tuberculosis (TB) Latent TB: people who have TB infection, but do not have symptoms and cannot spread TB to others. Bacteria are made inactive by the body’s immune system Bacteria can remain inactive for years Usually have a positive reaction to TB skin test 10% will go on to develop the disease at other time, usually when the immune system is impaired or stressed May be given treatment to prevent infection from progressing to disease

9. Tuberculosis (TB) Initial Screening Early assessment and identification of patients with suspected active TB is essential in the Ambulatory Care environment. Staff Check for the following symptoms: Coughing for > 3 weeks Fever, night sweats > 3 weeks Weakness, Lethargy Unexplained weight loss Coughed up blood in past 6 months Previous treatment for TB Someone in the home has been diagnosed with TB

10. Tuberculosis (TB) Initial Screening High Risk Patients include: Homeless families Persons from high endemic areas ( foreign born ) Immune suppressed patients Drug / alcohol abusers HIV patients

11. Tuberculosis (TB) Hospital Policy : Prevention of Transmission of TB, IC #15 TB precautions in the Ambulatory Care setting include: Placing patients with YES answers to the TB screen questions in a separate area from other patients Giving patient / family members a surgical mask to wear Giving patient / family members tissues and instructing them to cover their nose and mouth when coughing or sneezing.

12. Tuberculosis (TB) Mantoux Tuberculosis Skin Test Standard method for detecting latent TB Used in 2 situations Test close contact of people who have TB Targeted testing on groups at risk for TB Healthcare workers Foreign born people from areas that have a high TB risk Residents and employees of correctional facilities

13. Tuberculosis (TB) Who can receive TB skin test All persons, only contraindicated for persons who have had a severe reaction (e.g. necrosis, blistering or anaphylactic shock – all are very rare) NOT contraindicated for infants, children, pregnant women, HIV-infected persons or persons vaccinated with BCG

14. Tuberculosis (TB) How often can TB skin test be repeated Can be given in an interval as short as 1 week since the last TB skin test as long as it is placed 2 inches away from the original site There are no contraindications to repeating the test unless a previous TB skin test was associated with a severe reaction.

15. Tuberculosis (TB) Administering the Mantoux Tuberculin Skin Test Supplies Vial of tuberculin (Aplisol or Tubersol) TB syringe with 27 gauge 1/2 inch needle Ruler with mm measurements 2X2 gauze Alcohol swabs Sharps container Administration record

16. TB Administration Procedure Check order Provide patient education Do not administer any test if patient is not able to return for appropriate reading in 48 – 72 hours 4. Ensure vial has been stored in refrigerator 5. Check vial for expiration date 6. Write date and your initials on any newly opened vial 7. Transport TB solution in the dark and avoid light exposure 8. Wash hands Patient safety Understanding increases compliance 4. Potency of solution is reduced when not refrigerated 5. Discard vial if expiration date is passed 6. Discard vial that has been open more than 30 days Potency of solution is reduced with prolonged exposure to light Maintain infection control .

17. TB Administration Procedure Draw up .1ml Tuberculin solution in a TB syringe with a 27 gauge ½ inch needle Wash hands On a firm surface, expose patient arm and flex it at the elbow, palm facing upward Stretch the skin taut between your thumb and forefinger Place injection on the LEFT forearm, 2 – 4 inches below the elbow Bevel of the needle should face up Insert needle slowly at a 5 – 15 degree angle. Intradermal injection. Be sure to return vial to refrigerator immediately after drawing up dose. Maintain infection control Taut skin ensures medication is delivered intradermally Left is the standard location for 1st placement of TB skin test. Bevel up and angle of insertion ensures intradermal delivery of medication

18. TB Administration Procedure Release the stretched skin and inject the tuberculin solution. Ensure a 6 to 10 mm in diameter wheal has formed Remove the needle without pressing or massaging the area If area is bleeding blot lightly with a 2X2. Do not apply a band aide Discard needle Remind patient of date to return to have test read 10. Allows medication to enter the skin If wheal is less than 6 mm the test MUST be repeated. If the test must be repeated use another site 2 inches form the original site or use the alternate site (right arm) 14. Maintain sharps precautions

19. TB Administration Documentation Document the following: Date + time of TB test Manufacture name of solution Site used Site used if test was repeated Name of person administering the test Reason for test - routine screening - high risk screening - TB symptoms present 16. CDC documentation requirements

20. TB Administration: Education Tips Reinforce date for return appointment Explain that mild itching, swelling and irritation may occur, these are normal reactions Above reactions usually go away within a week Avoid scratching the site, putting on creams, lotions or adhesive bandages. Water may be applied to the site, but area should not be wiped or scrubbed

21. Reading the TB Skin Test Skin test will be read at 48 – 72 hours To locate the site Inspect the skin in good light to check visually for redness, swelling or induration Touch the area lightly with the pads of your fingertips to locate induration that may not be visible Palpate and mark any induration with a pen. Only measure induration, NOT redness or swelling

22. Reading the TB Skin Test Induration Using a light, gentle motion, sweep the fingertips over the surface of the arm in a 2 inch diameter in all 4 directions to locate margins or edges of induration When palpating for margins be careful not to confuse a margin of induration with a margin of muscle on the forearm The margin of induration is measured ACROSS the FOREARM ( like your watchband) Put your fingertip on one edge of the induration, slide your other fingers across the induration and hold your fingertips on the far edge. Mark both edges with a pen. Fingertips should remain in contact with the skin at all times

23. Reading the TB Skin Test Induration continued If the margins are irregular, mark and measure he longest diameter across the forearm Measure using millimeters (mm) Place the zero ruler line on the left marked edge and read the ruler line inside the right marked edge. Record blistering in mm even if there is no induration, describe as blistering, not induration

24. Reading the TB Skin Test: Documentation Date and time test read Name of the person reading the test Exact measurement in millimeters DO NOT RECORD NEGATIVE Any adverse reactions Record measurement in mm for blisters with no induration Positive interpretations with reason ** Remember you are always recording induration. *** Remember to record TB reading in Progress Note Section of the medical record

25. Interpreting the TB Skin Test Skin test interpretation depends on : The measurement in millimeters (mm) of the induration The person’s risk of being infected with TB and / or progression of the disease if infected

26. Interpreting the TB Skin Test Negative TB skin test and No symptoms present No follow up action required unless provider thinks test may be a false negative False negative tests are repeated in a specific time frame or additional testing is done. See slide 15 for details

27. Interpreting the TB Skin Test Negative TB skin test, but symptoms are present Follow up with a health department visit and possible chest x-ray and to determine if there is evidence of active or past infection in the lungs. If the x-ray indicates active infection a sputum sample may also be obtained The health department determines the treatment and follow up protocol for all TB cases

28. Interpreting the TB Skin Test Positive TB skin test (use table to determine which type reactions are considered positive (5mm, 10mm or 15 mm) A positive reaction indicates past exposure to the TB bacteria. If you have no symptoms it indicates your body has been successful in fighting the disease. Positive reactions are followed up with health department visit and possible chest x-ray and to determine if any treatment or follow up is needed. The health department determines the treatment and follow up protocol for all TB cases

29. Interpreting the TB Skin Test Induration > or = 5 mm is considered positive in: HIV positive Patients Patient with recent contact with someone with TB Persons with fibrotic changes on chest X-ray consistent with prior TB Patients with organ transplants Immunosuppressed patients (receiving 15mg/d of prednisone for 1 month or more) Patients being evaluated for anergy (see information on false –negative TB skin tests)

30. Interpreting the TB Skin Test Induration > or = 10 mm is considered positive in: Recent immigrants (within the last 5 years) from high prevalence countries Children < 4 years of age or infants, children and adolescents exposed to high risk adults IV drug users Persons with the following clinical conditions: Diabetes Chronic renal failure Malignancies, carcinomas, leukemia and hematological disorders Weight loss of > 10% of ideal body weight Residents and employees of high risk groups Prisons and jails Nursing homes and long term facilities for the elderly + immunosuppressed patients Hospitals and healthcare facilities

31. Interpreting the TB Skin Test Induration > or = 15 mm is considered positive in: Persons with no known risk factors for TB

32. False-Positive Reactions Factors that may affect the TB skin test Infection with nontuberculous mycobacterium Vaccination with BCG BCG (bacillus Calmette-Guerin) is a vaccine for TB disease used in may countries. Rarely used in the US because it is not completely affective. Incorrect administration of the TB skin test Incorrect interpretation of the reaction Incorrect antigen used for testing

33. False-Positive Reactions There is no reliable way to distinguish a positive tuberculin reaction caused by vaccination with BCG from a reaction caused by true TB. The Reaction is more likely to be due to TB infection if any of the following are true: The reaction is very large The person was vaccinated a long time ago The person comes from an area of the world where TB is common The person has been exposed to someone with infectious TB disease The person’s family has a history of TB

34. Follow up Anyone who has a positive reaction to a TB skin should be further evaluated for TB disease. This is only done through the Health Department. Clinic Staff should refer patients to the following Health Department Offices: Charleston County Health Department Downtown office 579-4500 Dorchester County Health Department Summerville office 832-0041 ext. 6 Berkley County Health Department Moncks Corner office 723-3800 ext. 4612 (?)

35. False-Negative Reactions Some people have a negative reaction to the TB skin test even though they have TB infection. False-negative reactions may be due to Very young age ( younger than 6 months old) Anergy Recent TB infection (within the past 10 weeks) Recent live virus vaccination (Measles) Some viral illnesses (measles, chicken pox) Incorrect administration of the TB skin test Incorrect interpretation of the reaction

36. False-Negative Reactions Very Young Age Children under 6 months of age may have a false-negative reaction because their immune systems are immature ***Close contacts of someone with infectious TB disease who have a negative reaction to the tuberculin skin test should be re-tested 10 weeks after the last time they were in contact with the person who had TB disease or after they are older than 6 months of age

37. False-Negative Reactions Anergy Is the inability to react to skin tests because of a weakened immune system Anergy testing can be done by giving skin tests using 2 substances other than tuberculin. The recommended substances for anergy testing are Candida ( fungus) or tetanus extracts. Healthy people will have a reaction to one or more of these substances

38. False-Negative Reactions Anergy continued: People who have less than 3 mm of induration to all skin tests are considered anergic People who have a reaction >3 mm of induration to any of the substances are NOT anergic If a person being evaluated for anergy has a reaction of 5mm of induration to tuberculin, he or she is considered to have TB infection, regardless of the reaction to other substances.

39. False-Negative Reactions Recent TB infection It takes 2 – 10 weeks after TB infection for the body’s immune system to be able to react to tuberculin ***Close contacts of someone with infectious TB disease who have a negative reaction to the tuberculin skin test should be re-tested 10 weeks after the last time they were in contact with the person who had TB disease.

40. TB Treatment Active TB Treatment with several different medications Isoniazid (INH) Rifampin (RIF) Ethambutol Pyrazinamide * Medication will be administered for 6 months or longer * Cases of active TB will need to be on medication several weeks before being able to return to work or school

41. Preventing the Spread of TB Patient Education to prevent the spread of TB: Take all medication as prescribed Cover mouth with tissue when coughing Dispose of tissues in a closed bag Do not go to work or school until the heath department nurse gives clearance ( approximately 3 weeks) Avoid close contact with others Sleep in a separate room from others Air out rooms often, use a fan to blow air outdoors

42. Tuberculosis (TB) Continue to next page for Post test

43. TB COMPETENCY TEST Name:___________ Induration after TB skin testing means the patient has TB disease True False TB screening questions are asked so patients can be isolated from others to prevent the possible spread of the TB disease. True False TB testing is performed on all clinic patients when they present for their annual screen True False The correct location to administer the TB skin test is 2 - 4 inches below the elbow on the palm side of the left forearm. True False The TB skin test is an intradermal injection. True False 6. When placing the test is NOT necessary for a wheal to be present True False The TB skin test is read in 24 – 48 hours True False

44. TB COMPETENCY TEST Name:___________ Mild itching and swelling are signs of a problem True False When measuring a reaction measure redness and induration True False Induration is not always visible so you need to palpate with you fingertips True False 11. Induration is measured across the forearm True False 12. An induration that measures “3mm” should be documented as “3mm” not as “ negative”. True False 13. All readings greater than “0 mm” will be interpreted as positive True False TB skin tests interpreted as positive may be followed by any provider True False TB skin tests interpreted as negative always indicate no risk of TB infection True False