Michael J. Huey, MD. NYSCHA Annual Meeting WE-2, October 19, 2016
|
|
- Della Boone
- 5 years ago
- Views:
Transcription
1 Michael J. Huey, MD Assistant Vice President and Executive Director Emory University Student Health Services Associate Professor, Family and Preventive Medicine Emory University School of Medicine President-elect American College Health Association NYSCHA Annual Meeting WE-2, October 19, 2016
2
3 At the conclusion of this presentation, attendees should be able to: Describe the pathophysiology of latent tuberculosis infection. Describe the strengths and weaknesses of available testing options for latent TB infection (LTBI). List the four current treatment options for prophylaxis of latent tuberculosis and describe their pros and cons, including Directly Observed Therapy (DOT). Leave slightly less confused...
4 Neither I nor my spouse have a financial interest, arrangement or affiliation with any organization or business entity (including self-employment or sole proprietorship) that could be perceived as a conflict of interest or source of bias in the context of this presentation. Butchart Gardens Victoria, British Columbia
5 A 27 y/o public health graduate international student is referred by your immunization clinic to your primary care provider with a + PPD. The PPD measures 15 mm of induration. He does not recall ever having had a PPD done before, but he thinks he may have had a blood test for TB at his undergraduate institution last year. He thinks the result may have been negative. He comes from Thailand, a country where 99% of infants receive a BCG dose. He has not returned to Thailand since last year s blood test and he has not been involved in patient care. He is asymptomatic for active TB symptoms.
6 What should your provider do? 1. Order a chest x-ray. 2. Order an IGRA blood test (T-spot or Quantiferon Gold TB). 3. Request the blood test result from the previous institution. 4. Take the patient s word for the negative blood test and clear him. 5. Repeat the PPD. 6. 1, 2 and 3 above. 7. It depends...
7 What should your provider do? 1. Order a chest x-ray. 2. Order an IGRA blood test (T-spot or Quantiferon Gold TB). 3. Request the blood test result from the previous institution. 4. Take the patient s word for the negative blood test and clear him. 5. Repeat the PPD. 6. 1, 2 and 3 above. 7. It depends...
8 What should your provider do? 8. I DON T KNOW! That is why I came to this presentation, for heaven s sake!
9 Therefore, many nurses and providers continue to lack confidence in both the diagnosis and approach to treatment (including me!). Today, we will try to improve our understanding of the strengths and weaknesses of available testing for latent TB, and become familiar with prophylaxis/therapeutic options.
10 Tuberculosis (TB) is a disease caused by the bacillus Mycobacterium tuberculosis. Most commonly affects the lungs, although it can affect other parts of the body (e.g. bones, CNS). Spread by airborne droplets from a person who is ill with active TB that involves the lungs or airways. The contact person does not usually develop active TB immediately, unless significantly immunosuppressed. In some cases, the person's immune system is able to remove the bacteria and he/she does not develop the disease at all. Murphy, C and Bernardo, J, UpToDate 2016
11 Latent TB The person develops an immune response that controls the bacteria by "walling it off" inside the body, causing the bacteria to become dormant. The person does not develop active TB or become ill at this time but is said to have Latent TB Infection (LTBI). During this latent stage of TB, the person is well and cannot spread the infection to others. If the person is treated at this stage, active TB can usually be prevented. Up to 1/3 of the world's population is infected with LTBI. Murphy, C and Bernardo, J, UpToDate 2016
12 Active TB Active TB may develop if latent infection is not fully treated. This reactivation TB occurs in 5 to 10 percent of people with latent infection at a later time in their lives. The greatest risk for developing reactivation TB disease is within the first two years following the initial infection. Cavitary RUL disease with hilar adenopathy Crapo JD, Glassroth J, Karlinsky JB, King TE. Baum's Textbook of Pulmonary Diseases, 7th Edition. Philadelphia: Lippincott Williams & Wilkins, Murphy, C and Bernardo, J, UpToDate 2016
13 No. of Cases 30, : 79,775 cases 25,000 20,000 15,000 10,000 5,000 Why? 0 *Updated as of June 5, Year
14 *Cases per 100,000 Atlanta GA
15 No. of Cases 20,000 15,000 10,000 5,000 0 U.S.-born Foreign-born *Updated as of June 5, 2015.
16 A 27 y/o public health graduate international student from BCG country PPD =15 mm of induration (positive) No previous PPD Asymptomatic for active TB symptoms Patient with no return home and no presumptive exposures Past result arrives from previous school: T-spot = Positive Now your Quantiferon Gold TB returns = Negative NOW WHAT DO YOU DO?
17 What should your provider do? 1. Call him positive and recommend LTBI prophylaxis 2. Call him positive and recommend annual CXRs 3. Call him negative and recommend annual IGRA tests 4. Call him negative and recommend annual CXRs 5. Send him to Infectious Diseases Clinic (or at least consult by phone) and let them decide! 6. Scream!
18 What should your provider do? 1. Call him positive and recommend LTBI prophylaxis 2. Call him positive and recommend annual CXRs 3. Call him negative and recommend annual IGRA tests 4. Call him negative and recommend annual CXRs 5. Send him to Infectious Diseases Clinic (or at least consult by phone) and let them decide! 6. Scream!
19 Treatment of individuals with active tuberculosis (TB) is the first priority for tuberculosis control An important second priority is identification and treatment of individuals with latent tuberculosis infection (LTBI). Two major tests for identification of latent tuberculosis infection: the tuberculin skin test (TST) and the interferon gamma release assay blood tests (IGRA). Both tests evaluate cell-mediated immunity. The goal of testing for LTBI is to identify individuals who are at increased risk for the development of tuberculosis (TB) and therefore would benefit from treatment of LTBI. Pai, M and Menzies, D, UpToDate 2016
20 TST skin test interpretation depends on two factors: Measurement in millimeters of induration Person s risk of being infected with TB and of progression to disease if infected An induration of 5 or more millimeters is considered positive in HIV-infected persons A recent contact of a person with TB disease Persons with fibrotic changes on chest radiograph consistent with prior TB (e.g. Ghon Complex) Patients with organ transplants Persons who are immunosuppressed (e.g. equivalent of >15 mg/day of prednisone for 1 month or longer)
21 An induration of 10 or more millimeters is considered positive in Recent immigrants (< 5 years) from high-prevalence countries Injection drug users Healthcare workers/healthcare students in patient-care settings Mycobacteriology laboratory personnel Persons with clinical conditions that place them at high risk Children < 4 years of age Infants, children, and adolescents exposed to adults in high-risk categories An induration of 15 or more millimeters is considered positive in Any person, including persons with no known risk factors for TB (however, targeted skin testing programs should only be conducted among high-risk groups)
22 Some persons may react to the TST even though they are not infected with M. tuberculosis. The causes of these false-positive reactions may include, but are not limited to, the following: Infection with non-tuberculosis mycobacteria (e.g. MAC and M kansasii) Previous BCG vaccination Incorrect method of TST administration Incorrect interpretation of reaction Incorrect bottle of antigen used
23 Cutaneous anergy (anergy is the inability to react to skin tests because of a weakened immune system) Recent TB infection (within 8-10 weeks of exposure) Very old TB infection (many years) Very young age (less than 6 months old) Recent live-virus vaccination (e.g., measles and smallpox) Overwhelming TB disease Some viral illnesses (e.g., measles and chicken pox) Incorrect method of TST administration Incorrect interpretation of reaction NOW WHAT?!?
24 Why does a nurse who reads 10 PPDs a day bring a patient to a physician to make the final call on a questionable PPD reading, when the physician reads one PPD every 6 months?!?
25 Interferon Gamma Release Assays (IGRAs) Blood test that can be used in all circumstances where the TST is used Currently QuantiFERON-TB Gold and T-spot Do not cross-react with BCG or non-tuberculous mycobacteria MMWR 2010; 59 (RR-5), 1-25.
26 Measure a cell-mediated immune response. The tests are based on the principle that the T cells of an individual who carries an active infection will respond to the antigens and secrete interferon-gamma, which is measured using ELISA technology Sensitivities and specificities are similar to each other and to the TST/PPD. Information from manufacturers websites
27 When the student comes from a BCG country: The initial TST test is negative, and the person is at high risk for progression to TB disease and bad outcomes (e.g. HIV). TST test is positive, the patient is at low risk, and patient/clinician are hesitant to proceed with prophylaxis. Ill patient has evidence of active TB (sputums pending) and TST is negative. When a single visit is all you have available. When cost is no barrier...
28 BCG WORLD ATLAS
29 A US-born third-year (M3) medical student is referred to your SHS primary care with a 12 mm + PPD done last week and a negative CXR. She had three previous negative PPDs: one while volunteering in the university hospital as a senior undergraduate student; a negative two-step PPD as an M1; and a negative PPD as an M2. She has been in several clinical settings, both inpatient and out-patient, and went to Haiti this summer to work in a healthcare clinic. What would you do?
30 What should your provider do? 1. Do a Quantiferon TB Gold or a T-spot to confirm the (+) PPD. 2. Treat for LTBI with no further testing. 3. Refer to Infectious Diseases. 4. None of the above/other.
31 What should your provider do? 1. Do an IGRA test (Quantiferon TB Gold or a T-spot) to confirm the (+) PPD. 2. Treat for LTBI with no further testing. 3. Refer to Infectious Diseases. 4. None of the above/other
32 There are several treatment regimens available for the treatment of latent TB infection (LTBI) Providers should choose the appropriate regimen based on the following: Drug-susceptibility results of the presumed source case (if known) Coexisting medical illness Potential for drug-drug interactions
33 Drugs Duration Interval Minimum doses Isoniazid (INH) 9 months Daily 270 Twice weekly* 76 Isoniazid (INH) 6 months Daily 180 Isoniazid (INH) and Rifapentine Twice weekly* 52 3 months Once weekly* 12 Rifampin 4 months Daily 120 * Use Directly Observed Therapy (DOT)
34 Drugs Duration Interval Minimum doses Isoniazid (INH) 9 months Daily 270 Twice weekly* 76 Isoniazid (INH) 6 months Daily 180 Isoniazid (INH) and Rifapentine Twice weekly* 52 3 months Once weekly* 12 Rifampin 4 months Daily 120 * Use Directly Observed Therapy (DOT)
35 Immunocompromised students should receive INH daily for 9 months. Immunocompetent students have a choice of: INH daily for 9 months (or 6 months) INH/Rifapentine once a week by DOT for 12 weeks Rifampin daily for 4 months In three clinical trials, completion rates for INH for 9 months was 69%; completion rate for INH/Rifapentine for 12 weeks was 82% and was equally effective in preventing re-activated TB. Rifampin daily for 4 months is recommended when the M. tuberculosis is presumed to be INH-resistant and RIF-susceptible or when INH is contraindicated or is not tolerated by the patient. Rifampin/Rifapentine reduce effectiveness of hormonal contraceptives MMWR December 9, 2011 / 60(48);
36 Asymptomatic elevation of liver enzyme concentrations occurs in 10% 20% of people taking INH LFTs usually return to normal even when treatment is continued. Withhold INH be if LFTs exceeds 3 times the upper limit of normal if associated with symptoms or 5 times the upper limit of normal if the patient is asymptomatic. Clinical hepatitis in about 0.1% of people taking INH; more common when INH combined with other hepatotoxic agents. Factors that may increase severity of hepatitis include daily alcohol consumption, underlying liver disease and concurrent use of other medications which are metabolized in the liver.
37 Peripheral neuropathy occurs in less than 0.2% of people taking INH at conventional doses. More likely in the presence of other conditions associated with neuropathy such as diabetes, HIV, renal failure, and alcoholism. Pyridoxine (vitamin B6) supplementation is recommended only in such conditions or to prevent neuropathy in pregnant or breastfeeding women.
38 INH 300mg daily for 9 months (270 doses), but for at least 6 months (180 doses) CDC: The 9-month regimen is preferred because it is more efficacious. Treatment for LTBI for 6 months rather than 9 months may be more cost-effective and result in greater adherence by patients; therefore, health care providers may prefer to implement the 6-month regimen rather than the 9-month regimen. Every effort should be made to ensure that patients adhere to LTBI treatment for at least 6 months. The preferred regimen for children aged 2 to 11 years is 9 months of daily INH.
39 Patients should visit the health care provider who is managing their treatment on a monthly basis to be assessed for the following: Signs of hepatitis Adherence to medication regimen Symptoms of possible adverse drug reactions or interactions Patients being treated for LTBI who experience possible adverse reactions should be advised to stop medication and consult their health care provider immediately. Do you need lab testing? Well, we do it... At least baseline LFTs (How do you know they are elevated if you don t check!?)
40 INH (50 kg +) 900 mg (3 X 300 mg tablets) + Rifapentine 900 mg (6 X 150 mg tablets) weekly for 12 weeks At Emory SHS, student fills the 12 week Rx and brings the meds to Student Health, where we hold the meds for the 12 weeks We aim for 5-9 day intervals; CDC data is based upon a completion of the 12 doses within 16 weeks. Screen for side effects at each visit. If symptoms, do labs before giving the dose. We contact our Infectious Diseases colleagues if questions or concerns
41 A 24 y/o NP student is diagnosed with LTBI. He has a negative CXR and he is asymptomatic for active TB symptoms. He starts Directly Observed Therapy (DOT) at your Student Health Service. At his week #2 visit, he notes that his urine is dark like tea, which has him concerned. He otherwise feels well, and specifically denies weakness, decreased appetite, abdominal pain, or pale stools. He is tanned from a summer in South America, but you do not think he has scleral icterus (yellow sclera). What do you do?
42 What should you do? 1. Immediately stop treatment for LTBI. 2. Immediately stop treatment for LTBI and order Hepatic Function Tests (LFTs). 3. Reassure patient and give this week s dose of DOT medications. 4. Immediately stop treatment for LTBI and refer to Infectious Diseases. 5. None of the above/other.
43 What should you do? 1. Immediately stop treatment for LTBI. 2. Immediately stop treatment for LTBI and order Hepatic Function Tests (LFTs). 3. Reassure patient and give this week s dose of DOT medications. 4. Immediately stop treatment for LTBI and refer to Infectious Diseases. 5. None of the above/other.
44 Transient hepatitis, sometimes with increased bilirubin; same rules as with INH. Cutaneous reactions, such as pruritis (with or without a rash), may occur in 6% of persons, generally self-limited. Rare hypersensitivity reactions associated with rash, fever, myalgia, and sometimes nephritis and thrombocytopenia. Change in urine color to orange/red, staining of contact lenses. Women using hormonal contraceptives should be advised to consider an alternative method (e.g. a barrier method).
45 Since your last visit, have you had any of the following? Fever Weakness Decreased appetite Nausea Vomiting Stomach pain Yellowing of skin Pale stools Dark urine (like tea) Burning pain in feet Chills Fever Muscle aches Rash PROBLEMS: NON-SPECIFIC QUESTIONS! Rifapentine turns urine orange/red!
46 LTBI DOT 12 week regimen Reason for Treatment: Weight (<50kg adjust dosage) Week Zero, 4 and 8: Hepatic Function Isoniazid (INH) 300mg; 3 tabs PO Rifapentine (RPT) 150mg; 6 tabs PO Labs at 4 & 8 wks Observed DOT Panel (LFTs); CBC Week 1 We use a flow sheet 2 3 template in our EMR (PnC) 4 Labs Due 5 6 Problem: Vacations 7 8 Labs Due and Breaks!
47 A 26 y/o public health/mph student and Registered Nurse had a positive PPD conversion 2 years ago following a medical missionary trip to Central Africa. She had a normal CXR. She was treated for 9 months with INH for LTBI and did well. She has applied to work part-time at a local nursing home while she completes her MPH studies. The employee health nurse told her that she needs a CXR now for TB clearance and that she will need a CXR every year in perpetuity. She has come to Student Health for the CXR and will need a report to take back to the nursing home. She is asymptomatic.
48 What should your provider do? 1. Do the CXR and send the report with the student. 2. Tell the student that she does not need a CXR now or in the future and that she should only be screened annually for TB symptoms. 3. Call the Employee Health Nurse and try to intercede for the student. 4. Refer the student to Infectious Diseases and 2 or 2 and 3 or 1, 2 and 3 6. None of the above/other.
49 What should your provider do? 1. Do the CXR and send the report with the student. 2. Tell the student that she does not need a CXR now or in the future and that she should only be screened annually for TB symptoms. 3. Call the Employee Health Nurse and try to intercede for the student. 4. Refer the student to Infectious Diseases and 2 or 2 and 3 or 1, 2 and 3 6. None of the above/other.
50 A first year nursing student from the US had an 11 mm (+) PPD (prior to a 2-step). He had never been in a clinical setting and had no known prior exposures to TB, including no foreign travel. He needed to start clinicals the next day, so your provider did a CXR (negative) and cleared the student based upon a negative CXR. The provider also ordered a Quantiferon Gold-TB test, which returned negative 5 days later. The student returned 1 year later for a nurse visit for annual TB screening.
51 What should your nurse do? 1. Do a CXR and send the report with the student. 2. Tell the student that she does not need a CXR now or in the future and that she should only be screened annually for TB symptoms. 3. Order a Quantiferon Gold-TB and tell the student that he needs annual IGRA testing for screening, but no CXR. 4. Order a Quantiferon Gold-TB and a CXR. 5. None of the above/other.
52 What should your nurse do? 1. Do a CXR and send the report with the student. 2. Tell the student that she does not need a CXR now or in the future and that she should only be screened annually for TB symptoms. 3. Order a Quantiferon Gold-TB and tell the student that he needs annual IGRA testing for screening, but no CXR. 4. Order a Quantiferon Gold-TB and a CXR. 5. None of the above/other. This student does not have LTBI, and he is working in a clinical setting, so he needs annual screening for LTBI, not for TB reactivation.
53 CDC no longer recommends annual chest x-rays for patients diagnosed with LTBI and given a prophylaxis regimen (actually, hasn t recommended CXRs for many years), including healthcare workers Patients should be screened with an annual questionnaire regarding symptoms of active/re-activated TB Unfortunately, many of our hospitals and healthcare organizations refuse to change their annual CXR policies, and our students get caught in the middle!
54 In the past year have you experienced any of the following for greater than three weeks? Excessive sweating at night? Excessive weight loss? Coughing up blood? Excessive fatigue? Hoarseness? Persistent coughing? Persistent fever? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
55 A student originally from India (a country where 99% of infants receive a BCG dose) is referred to your SHS primary care with a 15 mm + PPD done last month (elsewhere), and a negative CXR. She will be in a health sciences setting. She had a follow-up T-spot done last week in your SHS immunization clinic that is Borderline.
56 What should your provider do? 1. Do a Quantiferon Gold TB. 2. Repeat the T-spot. If Negative or borderline again, continue doing periodic T-spots and consider her negative for now. 3. Treat for LTBI with no further testing. 4. None of the above/other 5. I STILL DON T KNOW, DESPITE YOUR TALK! AND THAT WAS WHY I CAME TO THIS PRESENTATION, FOR HEAVEN S SAKE!
57 What should your provider do? 1. Do a Quantiferon Gold TB. 2. Repeat the T-spot. If Negative or borderline again, continue doing periodic T-spots and consider her negative for now. 3. Treat for LTBI with no further testing. 4. None of the above/other 5. I STILL DON T KNOW, DESPITE YOUR TALK! AND THAT WAS WHY I CAME TO THIS PRESENTATION, FOR HEAVEN S SAKE!
58 The additional LTBI testing modalities can make life confusing! It is extremely common for results to be discordant. The only situation in which one test is considered more accurate than the other is for persons with BCG, in whom the IGRA tests are more specific than the TST. If a patient has a (+) PPD but has a history of BCG vaccine, do an IGRA. You do not need a CXR if the IGRA is (-). If a patient with occupational exposure (e.g. healthcare student) has one or more previous, documented (-) PPDs, and then has a (+) PPD, diagnose them with LTBI, get a CXR and treat. Do not do an IGRA.
59 None of the tests have adequate specificity in a population with a low likelihood of TB exposure (and that would be virtually all of our HCWs who get annual screening without any known exposures). Most positives are false positives when testing low risk people. CDC no longer recommends annual chest x-rays for patients diagnosed with LTBI and given a prophylaxis regimen, including healthcare workers. These patients should be screened with an annual questionnaire regarding symptoms of active/reactivated TB.
60 Michael J. Huey, MD Assistant Vice President & Executive Director Emory University Student Health Services President-elect, ACHA
LTBI Videos-Treatment
LTBI Videos-Treatment This program is presented by the Global Tuberculosis Institute and is based on recommendations from the Centers for Disease Control and Prevention. This is the third in a series of
More informationTuberculosis Tools: A Clinical Update
Tuberculosis Tools: A Clinical Update CAPA Conference 2014 JoAnn Deasy, PA-C. MPH, DFAAPA jadeasy@sbcglobal.net Adjunct Faculty Touro PA Program Learning Objectives Outline the pathogenesis of active pulmonary
More informationDiagnosis Latent Tuberculosis. Disclosures. Case
Diagnosis Latent Tuberculosis Neha Shah MD MPH Field Medical Officer Tuberculosis Control Branch California Department of Public Health Centers for Disease Control and Prevention September 2016 1 Disclosures
More informationLATENT TUBERCULOSIS. Robert F. Tyree, MD
LATENT TUBERCULOSIS Robert F. Tyree, MD 1 YK TB OFFICERS Ron Bowerman Elizabeth Roll Mien Chyi (Pediatrics) Cindi Mondesir (Pediatrics) The new guys: Philip Johnson Robert Tyree 2009 CDC TB CASE DEFINITION
More informationFundamentals of Tuberculosis (TB)
TB in the United States Fundamentals of Tuberculosis (TB) From 1953 to 1984, reported cases decreased by approximately 5.6% each year From 1985 to 1992, reported cases increased by 20% 25,313 cases reported
More informationDiagnosis and Medical Management of TB Infection Lisa Y. Armitige, MD, PhD September 12, TB Nurse Case Management September 12 14, 2017
Diagnosis and Medical Management of TB Infection Lisa Y. Armitige, MD, PhD September 12, 2017 TB Nurse Case Management September 12 14, 2017 EXCELLENCE EXPERTISE INNOVATION Lisa Y. Armitige, MD, PhD has
More informationTreatment of TB Infection Lisa Y. Armitige, MD, PhD April 7, 2015
Treatment of TB Infection Lisa Y. Armitige, MD, PhD April 7, 2015 Tuberculosis Infection Diagnosis and Treatment April 7, 2015 El Paso, TX EXCELLENCE EXPERTISE INNOVATION Lisa Y. Armitige, MD, PhD has
More informationLatent Tuberculosis Best Practices
Latent Tuberculosis Best Practices Last Updated September 7, 2016 LTBI Demographics in the US o 13million people in the US with LTBI (estimate) o In 2014, approximately 66% of TB cases in the United States
More informationContact Investigation and Prevention in the USA
Contact Investigation and Prevention in the USA George D. McSherry, MD Division of Infectious Disease Penn State Children s Hospital Pediatric Section TB Center of Excellence Rutgers Global Tuberculosis
More informationNorthwestern Polytechnic University
Clinical Tuberculosis Assessment by Health Care Provider Clinicians should review and verify the information in the Tuberculosis (TB) Screening Questionnaire (attached). Persons answering YES to any questions
More informationEvaluation and Management of the Patient with Latent Tuberculosis Infection (LTBI)
Evaluation and Management of the Patient with Latent Tuberculosis Infection (LTBI) CURTIS FOWLER MPT,PA C ASSISTANT CLINICAL PROFESSOR UNIVERSITY OF THE PACIFIC Learning objectives Recognize the appropriate
More informationTB in Corrections Phoenix, Arizona
TB in Corrections Phoenix, Arizona March 24, 2011 Treatment of Latent TB Infection Renuka Khurana MD, MPH March 24, 2011 Renuka Khurana, MD, MPH has the following disclosures to make: No conflict of interests
More informationCHILDHOOD TUBERCULOSIS: NEW WRINKLES IN AN OLD DISEASE [FOR THE NON-TB EXPERT]
CHILDHOOD TUBERCULOSIS: NEW WRINKLES IN AN OLD DISEASE [FOR THE NON-TB EXPERT] QUESTION: : Which children in the United States should get a tuberculin skin test? Do questionnaires really work? Jeffrey
More informationTuberculosis Populations at Risk
Tuberculosis Populations at Risk One-third of the world is infected with TB, an average of one new infection per second Two million people died from tuberculosis in 2010, 1 every 20 seconds TB is the leading
More informationUnderstanding and Managing Latent TB Infection Arnold, Missouri October 5, 2010
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
More informationTreatment of Latent TB Infection (LTBI)
Treatment of Latent TB Infection (LTBI) Mahesh C. Patel, MD June 14, 2017 2014 MFMER slide-1 Mahesh C. Patel, MD Associate Professor Treatment of LTBI Department of Internal Medicine, Division of Infectious
More informationChapter 5 Treatment for Latent Tuberculosis Infection
Chapter 5 Treatment for Latent Tuberculosis Infection Table of Contents Chapter Objectives.... 109 Introduction.... 111 Candidates for the Treatment of LTBI... 112 LTBI Treatment Regimens.... 118 LTBI
More informationWhy need to havetb Clearance. To Control and Prevent Tuberculosis
Why need to havetb Clearance To Control and Prevent Tuberculosis How to ID Tuberculosis There are two kinds of tests that are used to determine if a person has been infected with TB bacteria: the tuberculin
More informationDiagnosis and Medical Management of Latent TB Infection
Diagnosis and Medical Management of Latent TB Infection Marsha Majors, RN September 7, 2017 TB Contact Investigation 101 September 6 7, 2017 Little Rock, AR EXCELLENCE EXPERTISE INNOVATION Marsha Majors,
More informationTuberculosis Screening and Targeted Testing of College and University Students: Developing a Best Practice Approach:
Tuberculosis Screening and Targeted Testing of College and University Students: Developing a Best Practice Approach: Lori A. Soos MA, BSN, RN, Niagara University Deborah Penoyer, MS, RN, SUNY Geneseo Learning
More informationTUBERCULOSIS. Presented By: Public Health Madison & Dane County
TUBERCULOSIS Presented By: Public Health Madison & Dane County What is Tuberculosis? Tuberculosis, or TB, is a disease caused by a bacteria called Mycobacterium tuberculosis. The bacteria can attack any
More informationTargeted Testing and the Diagnosis of. Latent Tuberculosis. Infection and Tuberculosis Disease
Self-Study Study Modules on Tuberculosis Targeted Testing and the Diagnosis of Latent Tuberculosis Infection and Tuberculosis Disease 1 Module 3: Objectives At completion of this module, learners will
More informationTB Update: March 2012
TB Update: March 2012 David Schlossberg, MD, FACP Medical Director, TB Control Program Philadelphia Department of Public Health 1 TB Update: March 2012 IGRAs vs TST LTBI A New Regimen NAATs What is Their
More informationSanta Clara County Tuberculosis Screening Requirement for School Entrance Effective June 1, 2014
Guidelines to Revisions to the School Mandate and Requirements 1) What are the tuberculosis (TB) screening requirements for school entrance in Santa Clara County? Students must undergo a TB risk assessment
More informationSharing the Care: Working Together on LTBI Treatment and Management Webinar. September 24, Curry International Tuberculosis Center
TB Infection Diagnostics and Treatment Neha Shah MD MPH Field Medical Officer Tuberculosis Control Branch California Department of Public Health Centers for Disease Control and Prevention 1 Curry International
More information10/3/2017. Updates in Tuberculosis. Global Tuberculosis, WHO 2015 report. Objectives. Disclosures. I have nothing to disclose
Disclosures Updates in Tuberculosis I have nothing to disclose Chris Keh, MD Assistant Clinical Professor, Division of Infectious Diseases, UCSF TB Controller, TB Prevention and Control Program, Population
More informationInterferon Gamma Release Assay Testing for Latent Tuberculosis Infection: Physician Guidelines
Interferon Gamma Release Assay Testing for Latent Tuberculosis Infection: Physician Guidelines Historically, Latent Tuberculosis Infection (LTBI) diagnosis was based on risk assessment, chest x-ray (CXR)
More informationPeggy Leslie-Smith, RN
Peggy Leslie-Smith, RN EMPLOYEE HEALTH DIRECTOR - AVERA TRAINING CONTENT 1. South Dakota Regulations 2. Iowa Regulations 3. Minnesota Regulations 4. Interferon Gamma Release Assay (IGRA)Testing 1 SOUTH
More informationBarbara J Seaworth MD Medical Director, Heartland National TB Center Professor, Internal Medicine and Infectious Disease UT Health Northeast
Practical Aspects for Using the Interferon Gamma Release Assay (IGRA) Test Live Webinar July 14, 2017 Barbara J Seaworth MD Medical Director, Heartland National TB Center Professor, Internal Medicine and
More informationMycobacterial Infections: What the Primary Provider Should Know about Tuberculosis
Mycobacterial Infections: What the Primary Provider Should Know about Tuberculosis Henry F. Chambers, M.D Professor of Medicine, UCSF Topics for Discussion Epidemiology Diagnosis of active TB Screening
More informationTB Skin Test Practicum Houston, Texas Region 6/5 South September 23, 2014
TB Skin Test Practicum Houston, Texas Region 6/5 South September 23, 2014 Catalina Navarro, BSN, RN has the following disclosures to make: No conflict of interests No relevant financial relationships with
More informationAdvanced Management of Patients with Tuberculosis Little Rock, Arkansas August 13 14, 2014
Advanced Management of Patients with Tuberculosis Little Rock, Arkansas August 13 14, 2014 Tuberculosis Pathogenesis and Treatment of Latent TB Infection Lisa Armitige, MD, PhD August 13, 2014 Lisa Armitige,
More informationTUBERCULOSIS IN HEALTHCARE SETTINGS Diana M. Nilsen, MD, FCCP Director of Medical Affairs, Bureau of Tuberculosis Control New York City Department of
TUBERCULOSIS IN HEALTHCARE SETTINGS Diana M. Nilsen, MD, FCCP Director of Medical Affairs, Bureau of Tuberculosis Control New York City Department of Health and Mental Hygiene TODAY S PRESENTATION Epidemiology
More informationMoving Past the Basics of Tuberculosis Phoenix, Arizona May 8-10, 2012
Moving Past the Basics of Tuberculosis Phoenix, Arizona May 8-10, 2012 LTBI and TB Disease Treatment Cara Christ, MD, MS May 8, 2012 Cara Christ, MD, MS has the following disclosures to make: No conflict
More information5. HIV-positive individuals treated with INH should receive Pyridoxine (B6) 25 mg daily or 50 mg twice/thrice weekly on the same schedule as INH
V. TB and HIV/AIDS A. Standards of Treatment and Management The majority of TB treatment principles apply to persons with HIV/AIDS who require treatment for TB disease. The following points are either
More informationLATENT TUBERCULOSIS SCREENING AND TREATMENT:
LATENT TUBERCULOSIS SCREENING AND TREATMENT: TB or not TB Christopher Kwong, MD and William Rifkin, MD Week 14 Educational Objectives: 1. Understand who should be screened for latent TB infection and why
More informationDisclosures. Updates in TB for the PCP: Opportunities for Prevention. Objectives PART 1: WHY TEST? 4/14/2016. None
Disclosures Updates in TB for the PCP: Opportunities for Prevention None Pennan Barry, MD, MPH Chief, Surveillance and Epidemiology, California TB Control Branch Assistant Clinical Professor, Division
More informationPediatric Tuberculosis Lisa Y. Armitige, MD, PhD September 14, 2017
Pediatric Tuberculosis Lisa Y. Armitige, MD, PhD September 14, 2017 TB Nurse Case Management September 12 14, 2017 EXCELLENCE EXPERTISE INNOVATION Lisa Y. Armitige, MD, PhD has the following disclosures
More informationLet s Talk TB A Series on Tuberculosis, A Disease That Affects Over 2 Million Indians Every Year
A Series on Tuberculosis, A Disease That Affects Over 2 Million Indians Every Year Madhukar Pai, MD, PhD Author and Series Editor Camilla Rodrigues, MD co-author Abstract Most individuals who get exposed
More informationTB: Management in an era of multiple drug resistance. Bob Belknap M.D. Denver Public Health November 2012
TB: Management in an era of multiple drug resistance Bob Belknap M.D. Denver Public Health November 2012 Objectives: 1. Explain the steps for diagnosing latent and active TB role of interferon-gamma release
More informationTuberculosis (TB) Fundamentals for School Nurses
Tuberculosis (TB) Fundamentals for School Nurses June 9, 2015 Kristin Gall, RN, MSN/Pat Infield, RN-TB Program Manager Marsha Carlson, RN, BSN Two Rivers Public Health Department Nebraska Department of
More informationLatent tuberculosis infection
EXECUTIVE SUMMARY Latent tuberculosis infection Updated and consolidated guidelines for programmatic management Executive summary Latent tuberculosis infection (LTBI) is defined as a state of persistent
More information11/1/2017. Disclosures. Update In Tuberculosis, Indiana Outline/Objectives. Pathogenesis of M.tb Global/U.S. TB Burden, 2016
Disclosures Update In Tuberculosis, Indiana 2017 Bradley Allen, MD, PhD, FACP, FIDSA Indiana University School of Medicine Division of Infectious Diseases Roudebush VAMC Indianapolis Medical Consultant,
More informationTuberculosis Facts. TB is not spread by: Sharing food and drink Shaking someone s hand Touching bed lines or toilet seats
Tuberculosis Facts Below are frequently asked questions about TB, and their answers. If you have additional questions you may contact the City of Ennis Department of Health Services at 972-875-1234 or
More informationTargeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection (LTBI) Lloyd Friedman, M.D. Milford Hospital Yale University
Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection (LTBI) Lloyd Friedman, M.D. Milford Hospital Yale University Tuberculosis Estimates USA World Infection 15,000,000 2,000,000,000
More informationLatent TB Infection (LTBI) Strategies for Detection and Management
Latent TB Infection (LTBI) Strategies for Detection and Management Patrick T. Dowling MD,MPH Professor and Chair Dept of Family Medicine David Geffen School of Medicine at UCLA Pri-Med March 29 2014 Pdowling@mednet.ucla.edu
More informationHEALTH SERVICES POLICY & PROCEDURE MANUAL
PAGE 1 of 7 References Related ACA Standards 4 th Edition Standards for Adult Correctional Institutions 4-4350, 4-4355 These guidelines are based on the recommendations of the American Thoracic Society
More informationApproaches to LTBI Diagnosis
Approaches to LTBI Diagnosis Focus on LTBI October 8 th, 2018 Michelle Haas, M.D. Associate Director Denver Metro Tuberculosis Program Denver Public Health DISCLOSURES I have no disclosures or conflicts
More informationContact Investigation
Tuberculosis Ann Raftery, RN, PHN, MSc GHS Learning Objectives Upon completion of this session, participants will be able to: Describe the criteria used and method for determining the infectious period
More informationNew Approaches to the Diagnosis and Management of Tuberculosis Infection in Children and Adolescents
New Approaches to the Diagnosis and Management of Tuberculosis Infection in Children and Adolescents Jeffrey R. Starke, M.D. Professor of Pediatrics Baylor College of Medicine [With great thanks to Andrea
More informationLatent TB Infection (LTBI)
Latent TB Infection (LTBI) Diagnosis & Treatment of Latent TB Infection (LTBI) Amee Patrawalla MD MPH Assistant Professor UMDNJ-New Jersey Medical School Infection with Mycobacterium tuberculosis without
More informationESCMID Online Lecture Library. by author
Tuberculosis prevention in immunodepressed patients M. Carmen Fariñas Álvarez Infectious Diseases.H.U.Marqués de Valdecilla University of Cantabria, Spain DISCLOSURES I have no potential conflicts with
More informationLatent Tuberculosis Infection (LTBI) Questions and Answers for Health Care Providers
Latent Tuberculosis Infection (LTBI) Questions and Answers for Health Care Providers Who Should Be Screened for Latent Tuberculosis Infection (LTBI)?... 2 What tests are used to screen for LTBI?... 2 How
More informationPlease distribute a copy of this information to each provider in your organization.
HEALTH ADVISORY TO: Physicians and other Healthcare Providers Please distribute a copy of this information to each provider in your organization. Questions regarding this information may be directed to
More informationManagement of Patients with TB Infection Catalina Navarro, RN, BSN April 7, 2015
Management of Patients with TB Infection Catalina Navarro, RN, BSN April 7, 2015 Tuberculosis Infection Diagnosis and Treatment April 7, 2015 El Paso, TX EXCELLENCE EXPERTISE INNOVATION Catalina Navarro,
More informationLatent TB Infection Treatment
Latent TB Infection Treatment Douglas B. Hornick, MD Pulmonologist w/ Infectious Attitude Division of Pulmonary/Critical Care/Occ Med UI Carver College of Medicine 2014 MFMER slide-1 Disclosures: None
More informationTuberculosis What you need to know. James Zoretic M.D., M.P.H. Regions 2 and 3 Director
Tuberculosis What you need to know James Zoretic M.D., M.P.H. Regions 2 and 3 Director What is Tuberculosis? Tuberculosis, (TB) is a communicable disease caused by the Mycobacterium tuberculosis bacillus
More informationTuberculosis in Primary Care COC GTA Spring Symposium Dr Elizabeth Rea April 2013
Tuberculosis in Primary Care COC GTA Spring Symposium Dr Elizabeth Rea April 2013 1 TB in Toronto - risk groups Diagnosis of active TB LTBI diagnosis and management Infection control 2 TB in Toronto Case
More informationDidactic Series. Latent TB Infection in HIV Infection
Didactic Series Latent TB Infection in HIV Infection Jacqueline Peterson Tulsky, MD UCSF Positive Health Program at SFGH Medical Director, SF and North Coast AETC March 13, 2014 ACCREDITATION STATEMENT:
More informationTuberculosis: Where Are We Now?
Tuberculosis: Where Are We Now? Amee Patrawalla MD MPH Rutgers - NJ Medical School Global TB Institute Rutgers, The State University of New Jersey Learning Objectives Understand the current epidemiologic
More informationTB is Global. Latent TB Infection (LTBI) Sharing the Care: Working Together. September 24, 2014
Sharing the Care: Working Together to Meet the Challenge of TB Presented by: Barbara Cole, RN, PHN, MSN Director, Disease Control County of Riverside Department of Public Health Curry International TB
More informationLatent Tuberculosis Infections Controversies in Diagnosis and Management Update 2016
Latent Tuberculosis Infections Controversies in Diagnosis and Management Update 2016 Randy Culpepper, MD, MPH Deputy Heath Officer/Medical Director Frederick County Health Department March 16, 2016 2 No
More informationPre-Treatment Evaluation. Treatment of Latent TB Infection (LTBI) Initiating Treatment: Patient Education. Before initiating treatment for LTBI:
Pre-Treatment Evaluation Before initiating treatment for LTBI: Treatment of Latent TB Infection (LTBI) Amee Patrawalla, MD Associate Professor, New Jersey Medical School Attending Physician, NJMS Global
More informationTUBERCULOSIS. Pathogenesis and Transmission
TUBERCULOSIS Pathogenesis and Transmission TUBERCULOSIS Pathogenesis and Transmission Infection to Disease Diagnostic & Isolation Updates Treatment Updates Pathogenesis Droplet nuclei of 5µm or less are
More informationDiagnosis & Management of Latent TB Infection
Diagnosis & Management of Latent TB Infection Prof. Ashok Rattan, MD, MAMS, INSA DFG, WHO Lab Director Academics, Industry: Research, Diagnosis, Public Health, Academics Adviser: Laboratory Operations,
More informationDidactic Series. Latent TB Infection in HIV Infection
Didactic Series Latent TB Infection in HIV Infection Jacqueline Peterson Tulsky, MD UCSF Positive Health Program at SFGH Medical Director SF, North Coast and East Bay AETC January 8, 2015 ACCREDITATION
More informationDiagnosis and Management of Latent TB Infection Douglas Hornick, MD September 27, 2011
TB Nurse Case Management Davenport, Iowa September 27 28, 2011 Diagnosis and Management of Latent TB Infection Douglas Hornick, MD September 27, 2011 Douglas Hornick, MD has the following disclosures to
More informationATTACHMENT 2. New Jersey Department of Health Tuberculosis Program FREQUENTLY ASKED QUESTIONS
1. QUESTION Is it required to submit the Annual Report of TB Testing in Schools Form (TB-57) to the New Jersey Department of Health,? NO. The TB-57 form is completed by the school nurse and kept on-site
More informationDiagnosis and Treatment of Tuberculosis, 2011
Diagnosis of TB Diagnosis and Treatment of Tuberculosis, 2011 Alfred Lardizabal, MD NJMS Global Tuberculosis Institute Diagnosis of TB, 2011 Diagnosis follows Suspicion When should we Think TB? Who is
More informationTB Prevention Who and How to Screen
TB Prevention Who and How to Screen 4.8.07. IUATLD 1st Asia Pacific Region Conference 2007 Dr Cynthia Chee Dept of Respiratory Medicine / TB Control Unit Tan Tock Seng Hospital, Singapore Cycle of Infection
More informationSelf-Study Modules on Tuberculosis
Self-Study Modules on Tuberculosis Targe te d Te s ting and the Diagnosis of Latent Tuberculosis Infection and Tuberculosis Disease U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control
More informationManagement of Pediatric Tuberculosis in New Jersey
Management of Pediatric Tuberculosis in New Jersey Helen Aguila, MD NJMS Global TB Institute December 15, 2011 This presentation is in part adapted from Pediatric Tuberculosis by Ann Loeffler, MD : Francis
More informationTuberculosis: A Provider s Guide to
Tuberculosis: A Provider s Guide to Diagnosis and Treatment of Active Tuberculosis (TB) Disease and Screening and Treatment of Latent Tuberculosis Infection (LTBI) Alameda County Health Care Services Agency
More informationPREVENTION OF TUBERCULOSIS. Dr Amitesh Aggarwal
PREVENTION OF TUBERCULOSIS Dr Amitesh Aggarwal 25 to 50 % of persons exposed to intimate contact with active PTB - latent infection with TB. Exposure to index case for 12 hours - high risk of infection.
More informationRevised Technical Instructions for Civil Surgeons. October 9, 2018
Revised Technical Instructions for Civil Surgeons October 9, 2018 Speakers Joanna Regan Centers for Disease Control and Prevention Shereen Katrak California Department of Public Health Pennan Barry California
More informationCommunity pharmacy-based tuberculosis skin testing
Community pharmacy-based tuberculosis skin testing Shanna K. O Connor, PharmD ISU KDHS Spring CE Seminar 2018 In support of improving patient care, Idaho State University Kasiska Division of Health Sciences
More informationAdvanced Concepts in Pediatric Tuberculosis
Advanced Concepts in Pediatric Tuberculosis: Nizar F. Maraqa, MD, FPIDS Division of Pediatric Infectious Diseases & Immunology University of Florida College of Medicine - Jacksonville Advanced Concepts
More informationLatent TB, TB and the Role of the Health Department
Latent TB, TB and the Role of the Health Department Elaine Darnall, RN, BSN, CIC TB Nurse Consultant Illinois Dept of Public Health March 21, 2018 Elaine Darnall has disclosed that there is no actual or
More informationINDEX CASE INFORMATION
Instructions for Completing the MDH Tuberculosis Contact Investigation Report Form Please provide as much information as possible. Each field represents information that is important to the contact investigation.
More informationTuberculosis 6/7/2018. Objectives. What is Tuberculosis?
Tuberculosis Understanding, Investigating, Eliminating Jeff Maupin, RN Tuberculosis Control Nurse Sedgwick County Division of Health Objectives At the conclusion of this presentation, you will be able
More informationTB PREVENTION: TREATMENT OF LATENT TB INFECTION AND BCG VACCINATION
TB PREVENTION: TREATMENT OF LATENT TB INFECTION AND BCG VACCINATION Michelle Haas, M.D. Denver Metro Tuberculosis Program Denver Public Health DISCLOSURES No relevant financial relationships OBJECTIVES
More informationPediatric TB Lisa Armitige, MD, PhD September 28, 2011
TB Nurse Case Management Davenport, Iowa September 27 28, 2011 Pediatric TB Lisa Armitige, MD, PhD September 28, 2011 Lisa Armitige, MD, PhD has the following disclosures to make: No conflict of interest.
More informationTB Intensive Tyler, Texas December 2-4, 2008
TB Intensive Tyler, Texas December 2-4, 2008 Interferon Gamma Releasing Assays: Diagnosing TB in the 21 st Century Peter Barnes, MD December 2, 2008 TOPICS Use of interferon-gamma release assays (IGRAs)
More informationMaking the Diagnosis of Tuberculosis
Making the Diagnosis of Tuberculosis Alfred Lardizabal, MD NJMS Global Tuberculosis Institute Testing for TB Infection Targeted Testing: Key Points Test only if plan for ensuring treatment De-emphasizes
More informationTB Nurse Case Management San Antonio, Texas March 7 9, Clinical Diagnosis and
TB Nurse Case Management San Antonio, Texas March 7 9, 2012 Clinical Diagnosis and Management of LTBI Lynn Horvath, MD March 7, 2012 Lynn Horvath, MD has the following disclosures to make: No conflict
More informationDiagnosis and Medical Case Management of Latent TB. Bryan Rock, MD April 27, 2010
TB Nurse Case Management Lisle, Illinois April 27-28, 28 2010 Diagnosis and Medical Case Management of Latent TB Infection Bryan Rock, MD April 27, 2010 DIAGNOSIS AND MANAGEMENT OF LATENT TUBERCULOSIS
More informationThese recommendations will remain in effect until the national shortage of PPD solution has abated.
Maryland Recommendations Regarding the National Shortage of Purified Protein Derivative (PPD) Solution; Attachment to Health Officer Memorandum National Shortages of Tubersol and Aplisol for TB Skin Testing;
More informationWhat the Primary Physician Should Know about Tuberculosis. Topics for Discussion. Global Impact of TB
What the Primary Physician Should Know about Tuberculosis Henry F. Chambers, M.D Professor of Medicine, UCSF Topics for Discussion Epidemiology Common disease presentations Diagnosis of active TB Screening
More informationCore Curriculum on Tuberculosis: What the Clinician Should Know
Core Curriculum on Tuberculosis: What the Clinician Should Know Sixth Edition 2013 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of Tuberculosis Elimination 1 Chapters
More informationLatent Tuberculosis in Adults: From Testing TO Treatment
Latent Tuberculosis in Adults: From Testing TO Treatment Sergio M. Borgia, MD, MSc., FRCP(C) Infectious Diseases Consultant, WOHS Medical Director, WOHS Tuberculosis Clinic Assistant Clinical Professor,
More informationCoordinating with Public Health on Tuberculosis Testing & Treatment
Coordinating with Public Health on Tuberculosis Testing & Treatment Bernadette Jakeman, PharmD, PhC, BCPS, AAHIVP Associate Professor University of New Mexico College of Pharmacy Objectives 1. Identify
More informationTUBERCULOSIS CONTACT INVESTIGATION
TB CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE TUBERCULOSIS CONTACT INVESTIGATION LEARNING OBJECTIVES Upon completion of this session, participants will be able to: 1. Describe the criteria used
More informationThe Most Widely Misunderstood Test of All
The Most Widely Misunderstood Test of All Lee B. Reichman, MD, MPH NJMS Global Tuberculosis Institute History of Treatment of Latent Tuberculosis Infection For more than 4 decades, treatment of persons
More informationManaging the Patients Response to TB Treatment
Managing the Patients Response to TB Treatment Barbarah Martinez, RN, BSN September 13, 2017 TB Nurse Case Management September 12 14, 2017 EXCELLENCE EXPERTISE INNOVATION Barbarah Martinez, RN, BSN has
More informationStudent Health Requirements Master of Arts, Biomedical Sciences Program
Student Health Requirements Master of Arts, Biomedical Sciences Program All students in medically related programs, just as physicians in practice, are required to be current with required immunizations
More informationLatent Tuberculosis Infection Reporting Instructions for Civil Surgeons Using CalREDIE Provider Portal
Latent Tuberculosis Infection Reporting Instructions for Civil Surgeons Using CalREDIE Provider Portal Civil surgeons are required to report tuberculosis (TB) screening outcomes that result in latent TB
More informationTB Intensive San Antonio, Texas November 11 14, 2014
TB Intensive San Antonio, Texas November 11 14, 2014 Tuberculosis Pathogenesis and Treatment of Latent TB Infection Lynn Horvath, MD November 11, 2014 Lynn Horvath, MD has the following disclosures to
More informationCase Management of the TB/HIV Infected Patient
TB Nurse Case Management San Antonio, Texas December 8-10, 2009 Case Management of the TB/HIV Infected Patient Sarah Hoffman, MPH, MSN, ACRN December 9, 2009 TB/HIV: Considerations in the Care of the Coinfected
More information