Understanding and Managing Latent TB Infection Arnold, Missouri October 5, 2010

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1 Understanding and Managing Latent TB Infection Arnold, Missouri October 5, 2010 What is Latent TB Infection (LTBI)? Traci Hadley, RN October 5, 2010 LTBI or TB Disease? Presented by : Traci Hadley, RN BSN Missouri Department of Health and Senior Services Bureau of Communicable Disease Control and Prevention/TB Control

2 LATENT TB INFECTION Indicates the presence of tuberculosis bacteria Infection Must breathe the organism deep into lungs They multiply there. Begin as a tiny invisible speck until they multiply as a clump. 5 million can fit into a space the size of the head of a pin. Visualize a rot on a tomato. Sometimes the rotten place heals over and goes no further, TB is the same way. --Other times it continues until it effects the entire tomato

3 In healthy individuals, the body usually regains the upper hand and stops the bacteria from multiplying and encapsulates them (this is what happens about 95% of the time). These spots are reduced to scars or sometimes entirely disappear. Sometimes leave a white chalky appearance called calcium (calcified granulomas) Diagnosing LTBI Positive TST IGRAs(Interferon Gamma Release Assay): Positive Quantiferon Positive T-Spot

4 TB Disease Disease caused by bacteria called Mycobacterium tuberculosis. It can attack any part of your body, such as the kidneys, spine, and brain. (extrapulmonary) Most commonly occurs in the lungs. How is TB Spread Spread from one person to another through droplet nuclei in the air. When someone with TB coughs, sings, speaks, or laughs they expel the bacteria in the air. People who spend significant time with this person may become infected with TB.

5 Transmission and Pathogenesis Higher Risk for TB disease once infected Persons with HIV infection Persons recently infected with M. tuberculosis (within the last 2 years, particularly infants and young children) Persons with certain medical conditions (e.g. diabetes, ESRD) Persons who inject illicit drugs Persons with a history of inadequately treated TB

6 Symptoms of TB Pulmonary TB a productive cough that last longer than 3 weeks Loss of appetite usually resulting in weight loss Night sweats Fatigue/weakness Chills/Fever Chest Pains Abnormal chest x-ray Extra pulmonary pain at location or other symptoms at that site Diagnosing TB Disease Medical exam/history Assess for signs and symptoms TST/IGRA Chest radiograph Sputum collection three sputum collections, (at least one early morning specimen, other 2 collected 8 hours apart)

7 TST Interpretation (High risk for progression from LTBI to TB Disease 5mm induration is interpreted as positive in: HIV-infected persons Close contacts to an infectious TB case Persons with chest radiographs consistent with prior untreated TB Persons with organ transplants and other immunosuppressed patients TST Interpretation 10 mm induration is interpreted as positive in: Recent immigrants from high-prevalence countries Injection drug users Residents or employees of high-risk congregate settings Mycobacteriology laboratory personnel

8 TST Interpretation(con t) Persons with clinical conditions that place them at high risk, such as diabetes, end stage renal disease, cancer of the head and neck, etc. Children < 4 years of age, or children and adolescents exposed to adults in high-risk categories TST Interpretation 15mm induration is interpreted as positive in: Persons with no known risk factors for TB.

9 Quantiferon Whole-blood test used to detect M. tuberculosis infection Approved by the U.S. Food and Drug Administration (FDA) Entails mixing blood samples with antigens from M. tuberculosis, M. Avium complex, and controls and incubating for 16 to 24 hours

10 Two Blood Tests Available: Interferon Gamma Release Assays (IGRAs) The Test QuantiFERON-TB Gold In-Tube IGRAS versus TST IGRAs TST Increase the importance of labs in TB Control IGRAs will be done in quality controlled laboratories Not affected by BCG Done by nurses subject to interpretation TST is not quality control BCG may cause false positive TSTs

11 Specificity IGRAs TSTs More specific Quantiferon ESAT-6 and CFP-10 TB. Spot 3 antigens Highly specific to MTB complex Used to identify LTBI not TB disease Less specific PPD >500 antigens Used to identify LTBI not TB disease IGRAs IGRAs Use fresh blood Stimulates the patient s T-cells Using specific antigens Interferon gamma is released in previously sensitized individuals Allowing for detection of LTBI Must get to lab within specific amount of time : varies 8 16 hours

12 IGRAs Both IGRAs more sensitive than TST Especially in the immunocompromised and children less than two who are more likely to break down to active TB disease This finding more clearly demonstrated with T Spot IGRA Availability Until we can use IGRAs for everyone, we need to maintain the ability to do TB skin testing Dr. Daley

13 Chest x-ray Obtain CXR for all +TST May be indicated in some TST and IGRA negative patients (symptomatic) Adults at minimum should have AP CXR Person with nodular or fibrotic lesions consistent with old TB are high priority of treatment Persons with calcified granulomas are at low risk for progression to TB disease Baseline & Follow-Up Evaluations Appropriate specimens should be collected for microscopic exams and mycobacterium culture When lungs are the site 3 sputums specimens should be obtained Susceptibility testing for INH, RIF, & EMB & PZA should be done on the initial positive culture HIV test should be done on all cases Sputum specimens should be collected until 2 consecutive specimens are negative on culture

14 Questions????

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