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Practical Considerations of Latent Tuberculosis Infection

Practical Considerations of Latent Tuberculosis Infection. 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. Disclaimer.

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Practical Considerations of Latent Tuberculosis Infection

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  1. Practical Considerations of Latent Tuberculosis Infection 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. Disclaimer The presenters have NO actual or potential conflict of interest in relation to this educational activity or presentation Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  3. Campus Case • 22 yo Vietnamese female graduate student • Tested during fall orientation • Risk factor – country with high TB incidence • Symptom review – negative • QFT-GIT positive Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

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  5. Case management Partnered with local health department Smears negative Culture positive for M. tuberculosis, pan-sensitive Contact investigation - roommates negative initially and 8 weeks Completed 9 month treatment (3 drugs) May 2011 Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  6. Tuberculosis is a very Ancient Disease Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  7. Evidence of tubercular decay has been found in Egyptian Mummies. • 3000-2400 BCE Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  8. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  9. Recently, discoveries in the submerged village of Atlit-Yam suggest Tuberculosis was present 7000 BCE Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  10. Atlit-Yam was a village that now is submerged just off the coast of Israel. • The village dates from the very dawn of Neolithic times, earliest agricultural settlements. • Both skeletal and DNA evidence demonstrate TB in a woman and an infant buried together. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

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  12. TB already established at dawn of agricultural settlements. • DNA supports that human TB was not from Bovine TB. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

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  14. In the 17th and 18th Centuries, Tuberculosis caused up to 25% of all Deaths in Europe Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  15. In 1854, Herman Brehmer proposed TB was a curable disease. • Established the Sanitorium movement. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  16. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  17. TB Established as Infectious Disease • In 1882, Robert Koch discovered the bacteria that caused TB • In 1900, he isolated tuberculin from tubercle bacilli, which became the basis of the ppd. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  18. Robert Koch Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  19. BCG • In 1921, the BCG Vaccine was first used in humans, though widespread use did not occur till after WWII. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  20. BCG • Most effective against TB Meningitis and Miliary TB. • Most useful in pediatric age group. • Efficacy Varies. Studies in UK consistently have shown protective effect of 60-80%. • Closer to equator, benefit appears less. • Causes false positive TST results. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  21. BCG: Method of Administration • TST administered prior to BCG; positive TST contraindicates BCG administration. • Positive TST does not imply immunity, only that there is high probability of severe local reaction. • Intradermal administration. • BCG Leaves a Characteristic Scar, often used as proof of prior immunization. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

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  24. Effect of BCG on TST • The effect on TST of BCG received in infancy is minimal, especially > 10 years after vaccination • BCG received after infancy produces more frequent, more persistent and larger TST reactions. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  25. Medications to Treat Tuberculosis • In 1946, Streptomycin was introduced as the first antibiotic to be effective against TB. • In 1952, Isoniazid (INH) was introduced. Originally an antidepressant. • While initial results were dramatic, resistance was soon noted to develop. • As other TB antibiotics were discovered, it was noted that combination therapy prevented or slowed the development of resistance. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  26. Selman Waksman Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  27. Burden of Tuberculosis • In 2008, WHO estimated that 1/3 of the global population is infected with TB. • In 2005, 1.6 million people died of TB. • The emergence of drug-resistant organisms threatens to make TB once again an incurable disease. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

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  29. “High Incidence” Countries are defined as areas with reported or estimated incidence of ≥20 cases per 100,000 population Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  30. Afghanistan, Algeria, Angola, Argentina, Armenia, Azerbaijan, Bahrain, Bangladesh, Belarus, Belize, Benin, Bhutan, Bolivia (Plurinational State of), Bosnia and Herzegovina, Botswana, Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, Burundi, Cambodia, Cameroon, Cape Verde, Central African Republic, Chad, China, Colombia, Comoros, Congo, Cook Islands, Côte d'Ivoire, Croatia, Democratic People's Republic of Korea, Democratic Republic of the Congo, Djibouti, Dominican Republic, Ecuador, El Salvador, Equatorial Guinea, Eritrea, Estonia, Ethiopia, French Polynesia, Gabon, Gambia, Georgia, Ghana, Guam, Guatemala, Guinea, Guinea-Bissau, Guyana, Haiti, Honduras, India, Indonesia, Iraq, Japan, Kazakhstan, Kenya, Kiribati, Kuwait, Kyrgyzstan, Lao People's Democratic Republic, Latvia, Lesotho, Liberia, Libyan Arab Jamahiriya, Lithuania, Madagascar, Malawi, Malaysia, Maldives, Mali, Marshall Islands, Mauritania, Mauritius, Micronesia (Federated States of), Mongolia, Montenegro, Morocco, Mozambique, Myanmar, Namibia, Nepal, Nicaragua, Niger, Nigeria, Pakistan, Palau, Panama, Papua New Guinea, Paraguay, Peru, Philippines, Poland, Portugal, Qatar, Republic of Korea, Republic of Moldova, Romania, Russian Federation, Rwanda, Saint Vincent and the Grenadines, Sao Tome and Principe, Senegal, Serbia, Seychelles, Sierra Leone, Singapore, Solomon Islands, Somalia, South Africa, Sri Lanka, Sudan, Suriname, Swaziland, Syrian Arab Republic, Tajikistan, Thailand, The former Yugoslav Republic of Macedonia, Timor-Leste, Togo, Tonga, Trinidad and Tobago, Tunisia, Turkey, Turkmenistan, Tuvalu, Uganda, Ukraine, United Republic of Tanzania, Uruguay, Uzbekistan, Vanuatu, Venezuela (Bolivarian Republic of), Viet Nam, Yemen, Zambia, Zimbabwe Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  31. “Low Incidence” Countries are defined as areas with reported or estimated incidence of <20 cases per 100,000 population Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  32. Albania, Andorra, Antigua and Barbuda, Australia, Austria, Bahamas, Barbados, Belgium, British Virgin Islands, Canada, Chile, Costa Rica, Cuba, Cyprus, Czech Republic, Denmark, Dominica, Egypt, Fiji, Finland, France, Germany, Greece, Grenada, Hungary, Iceland, Iran (Islamic Republic of), Ireland, Israel, Italy, Jamaica, Jordan, Lebanon, Luxembourg, Malta, Mexico, Nauru, Netherlands, New Zealand, Norway, Oman, Puerto Rico, Saint Kitts and Nevis, Saint Lucia, Samoa, Saudi Arabia, Slovakia, Slovenia, Spain, Sweden, Switzerland, United Arab Emirates, United Kingdom, United States of America, West Bank and Gaza Strip Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  33. Screening our Students • ACHA Recommendations • Screening vs. Testing Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  34. Increased Risk For Tuberculosis Infection (Population risks): • Foreign-born persons who have immigrated within the last 5 years from countries with high incidence of TB disease • Persons with a history of travel to/in areas with a high incidence of TB disease • Persons with signs and symptoms of active TB disease • Close contacts of a person known or suspected to have TB disease • Employees, residents, and volunteers of high-risk congregate settings (e.g., correctional facilities, nursing homes, homeless shelters, hospitals, and other health care facilities) • Some medically underserved, low income populations as defined locally • High-risk racial or ethnic minority populations defined locally as having an increased prevalence of TB disease • Persons who inject illicit drugs or other groups of high-risk substance users (e.g., crack cocaine) Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  35. What are Schools Doing? • Informal study via SHS • Some schools following ACHA Guidelines and screening all students and testing appropriately. • Some schools are testing certain higher risk populations who are easily mandated for testing (International, health-care, education students). • Some schools do not require asymptomatic testing. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  36. Why should we care about Tuberculosis Screening? Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  37. Identify, Treat, and Minimize Transmission of Active TB Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  38. Also Important: Identify and Treat Latent TB • 10% of persons with Latent TB will develop Active TB at some point in their life. • 80% of Active TB in the US is from reactivation of previous disease. • Nearly all of those cases could have been prevented by prior administration of prophylactic treatment of latent infection. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

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  40. TUBERCULIN SKIN TEST Also known as PPD (Purified Protein Derivative) Or Mantoux Test Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  41. I’m Preaching to the Choir Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  42. Purpose of the TST • PPD (Mantoux) is indicated for the detection of a delayed hypersensitivity reaction to tuberculin as an aid in the detection of infection with Mycobacterium tuberculosis Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  43. History of the TB Skin Test • Test created in 1907 by Charles Mantoux in France, modified in 1939 in USSR • Used worldwide, largely replacing Tine test • Tuberculin is a glycerol extract of the tubercle bacillus • PPD is precipitate of molecules obtained from filtrates of sterilized concentrated cultures Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  44. Indications for use • Immigrants from countries where prevalence of TB is high • Risk of reactivation due to impaired immunity • Healthcare workers • Travelers at risk from travel in high-endemic countries • Staff members in correctional facilities Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  45. Methodology of TST • 0.1 ml (5 TU) • Injected intradermally with ¼ to ½” needle, usually anterior surface of forearm • Requires producing wheal of 6 to 10 mm • Read at 48-72 hours Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  46. Why and how does this test work? • After initial exposure with M. Tuberculosis, sensitization occurs primarily in regional lymph nodes • T lymphyocytes proliferate in response to the antigenic stimulus • Subsequent re-stimulation by PPD evokes a local reaction mediated by these cells • Incubation of 2 to 12 weeks usually necessary after exposure to TB in order for result to be positive. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  47. Two-Step Testing Not a test of dance skills! 2-step used to detect individuals with past TB infection who now have diminished skin test reactivity • Reduces the likelihood that a boosted reaction is later interpreted as a new infection • 2-step testing is indicated as initial test for persons who will be retested periodically, such has health profession workers. (not indicated if IGRA available) • Method: A second TST is placed 7 days after first • Abbreviated method: first test read 7 days after placing it and 2nd test administered during same visit. Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  48. Interpretation • Read at 48-72 hours • Induration is produced through vasodilatation, edema, fibrin deposition and other inflammatory cells • Measure induration transversely across the forearm Result is positive if: >5mm in immunocompromised persons or those who have had recent close contact with active TB >10 mm if born in countries in Asia, Africa, Caribbean, Latin America or high-risk communities. Also healthcare workers >15 mm if general population with no other risk factors Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  49. False Negatives Can be caused by: • Viral infections such as MMR, chickenpox and HIV • Live virus vaccinations given within 1 month • Active TB • Immunosuppressive agents • Malignancy Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

  50. Documentation • Document: Date, brand, lot number, expiration date, result in mm • Provide patient with documentation of date and result in mm • Do not accept documentation stating “positive” or “negative” • Most Universities do not accept testing beyond 1 year Even-McMullen-Johnston-Crump, ACHA, 6.2.2011

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