TB CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE NOVEMBER 1-4, 2016 TB BASICS: PRIORITIES AND CLASSIFICATIONS LEARNING OBJECTIVES Upon completion of this session, participants will be able to: 1. List the four strategies that the Centers for Disease Control and Prevention recommends for public health agencies to implement in order to control and prevent tuberculosis 2. Identify several characteristics that distinguish active TB disease from latent TB infection (LTBI) 3. Appropriately apply the American Thoracic Society TB classifications INDEX OF MATERIALS 1. TB basics: priorities and classifications-slide outline Presented by: Ann Raftery, RN, BSN, PHN, MSc PAGES 1-7 SUPPLEMENTAL MATERIALS 1. CDC. Table 2.8: TB Classification System. In: Chapter 2: transmission and pathogenesis of tuberculosis. Core Curriculum on Tuberculosis: What the Clinician Should Know. Atlanta, GA: 2011:40 2. Resources on Tuberculosis 3. Acronyms and Abbreviations, UCSF 300 Frank H. Ogawa Plaza, Suite 520 Oakland, CA; Office (510) 238-5100
TB CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE NOVEMBER 1-4, 2016 ADDITIONAL REFERENCES ATS/CDC/IDSA. Controlling Tuberculosis in the United States Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR. 2005; 54(RR-12):15. Gideon HP, Flynn JL. Latent tuberculosis: what the host sees? Immunol Res. 2011; 50:202-12. ATS/CDC. Diagnostic Standards and Classification of Tuberculosis in Adults and Children. Am J Respir Crit Care Med. 2000; 161(4):1376-1395. doi: 10.1164/ajrccm.161.4.16141 CDC/NCEZID. CDC immigration requirements: technical instructions for tuberculosis screening and treatment using cultures and directly observed therapy. October 1, 2009: 1-37. http://www.cdc.gov/ncidod/dq/panel_2007.htm, UCSF 300 Frank H. Ogawa Plaza, Suite 520 Oakland, CA; Office (510) 238-5100
TB Case Management and Contact Investigation Intensive November 1-4, 2016 TB BASICS: Priorities and Classifications Ann Raftery, RN, PHN, MSc Case Management and Contact Investigation Intensive November 1, 2016 Overview 1. Priority strategies for TB prevention and control 2. Tuberculosis Classifications 3. Latent TB Infection (LTBI) and Active TB Disease 2 TB Basics 1
TB Case Management and Contact Investigation Intensive November 1-4, 2016 What are the priority strategies in public health for TB prevention and control? 3 Priority Strategies for TB Prevention & Control 1. Early and accurate detection, diagnosis, and reporting of TB cases leading to initiation and completion of treatment 2. Identification of contacts of patients with infectious TB and treatment of those at risk with an effective drug regimen 3. Identification of other persons with latent TB infection at risk for progression to TB disease and treatment of those persons with an effective drug regimen 4. Identification of settings in which a high risk exists for transmission of Mycobacterium tuberculosis and application of effective infection control measures Source: ATS/CDC/IDSA. Controlling Tuberculosis in the United States Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR 2005; 54 (No. RR 12):15. 4 TB Basics 2
TB Case Management and Contact Investigation Intensive November 1-4, 2016 Latent TB infection or active TB disease? What features distinguish one from the other? 5 TB Transmission and Pathogenesis No infection (70%) E X P O S U R E Adequate Immunity Non-specific immunity Inadequate Immunity Infection (30%) Not everyone who is exposed to TB will become infected 6 TB Basics 3
TB Case Management and Contact Investigation Intensive November 1-4, 2016 TB Pathogenesis No infection (70%) E X P O S U R E Adequate Immunity Non-specific immunity Inadequate Immunity Infection (30%) Containment (90-95%) Adequate Defenses Immunologic defenses Inadequate Defenses Early progression TB disease (5-10%) 7 TB Pathogenesis (2) No infection (70%) Continued containment E X P O S U R E Adequate Immunity Non-specific immunity Inadequate Immunity Infection (30%) Containment (90-95%) Adequate Defenses Immunologic defenses Adequate Defenses Immunologic defenses Inadequate Defenses Inadequate Defenses Early progression TB disease (5-10%) Late progression TB disease (5-10%) 8 TB Basics 4
TB Case Management and Contact Investigation Intensive November 1-4, 2016 Latent TB Infection (LTBI) Inactive tubercle bacilli in the body Tuberculin skin test or interferon gamma release assay (IGRA) test results usually positive Chest x ray usually normal Sputum smears and cultures negative No symptoms Not infectious Not a case of TB Active TB Disease Active tubercle bacilli in the body Tuberculin skin test or interferon gamma release assay (IGRA) test results usually positive Chest x ray may be abnormal Sputum smears and cultures may be positive Symptoms such as cough, fever, weight loss May be infectious before treatment A case of TB Source: CDC. Transmission and Pathogenesis of Tuberculosis. Self Study Modules on Tuberculosis. US Department of Health and Human Services. Atlanta, GA; 2008: 14. 9 TB Pathogenesis Gideon and Flynn. Immunol Res. 2011 August ; 50(0): 202 212 10 TB Basics 5
TB Case Management and Contact Investigation Intensive November 1-4, 2016 What are the classifications for TB? 11 TB Classification Scheme & Definitions Class Stage of Disease Description 0 No TB exposure, Not infected No history of TB exposure. Negative tuberculin skin test (or IGRA) 1 Exposure, no evidence History of TB exposure. Negative tuberculin skin test (or of infection IGRA) 2 Latent TB infection, no disease Positive tuberculin skin test (or IGRA). No clinical, bacteriologic, or radiographic evidence of TB 3 TB, clinically active M. tuberculosis cultured (if performed). Clinical, bacteriologic, or radiographic evidence of current TB disease 4 TB, not clinically active History of episode(s) of TB OR Abnormal but stable radiographic findings, positive tuberculin skin test, negative bacteriologic studies (if done) AND no clinical or radiographic evidence of current disease 5 TB suspect Diagnosis pending. TB disease should be ruled in or out within 3 months Adapted from: ATS/CDC. Diagnostic Standards and Classification of Tuberculosis in Adults and Children (2000). http://www.atsjournals.org/doi/full/10.1164/ajrccm.161.4.16141#.wa0auk0zxiu 12 TB Basics 6
TB Case Management and Contact Investigation Intensive November 1-4, 2016 CDC TB Classifications: Immigrants and Refugees Classification No TB Class A TB with waiver Class B1 TB, Pulmonary (PTB) Class B1 TB, Extrapulmonary (EPTB) Class B2 TB, LTBI Evaluation Class B3 TB, Contact Evaluation Description Normal TB screening examinations [Active] TB disease and have been granted a waiver No treatment H/o or findings suggestive of PTB but negative AFB sputum smears and cultures and are not diagnosed with [active TB disease] or can wait to have TB treatment started after immigration. Completed treatment Diagnosed with PTB and completed [treatment by] directly observed therapy prior to immigration. Evidence of EPTB. The anatomic site of infection should be documented. Positive TST (>10mm) but otherwise negative evaluation for TB. Recent contact of a known TB case. Adapted from: CDC Immigration Requirements: Technical instructions for tuberculosis screening and treatment (2009). http://www.cdc.gov/immigrantrefugeehealth/ 13 Questions? 14 TB Basics 7
Classification System for Tuberculosis TB Class Type Description 0 No TB exposure Not infected 1 TB exposure No evidence of infection No history of TB exposure and no evidence of M. tuberculosis infection or disease Negative reaction to TST or IGRA History of exposure to M. tuberculosis Negative reaction to TST or IGRA (given at least 8 to 10 weeks after exposure) 2 TB infection No TB disease Positive reaction to TST or IGRA Negative bacteriological studies (smear and cultures) No bacteriological or radiographic evidence of active TB disease 3 TB clinically active Positive culture for M. tuberculosis OR Positive reaction to TST or IGRA, plus clinical, bacteriological, or radiographic evidence of current active TB 4 Previous TB disease (not clinically active) May have past medical history of TB disease Abnormal but stable radiographic findings Positive reaction to the TST or IGRA Negative bacteriologic studies (smear and cultures) No clinical or radiographic evidence of current active TB disease 5 TB suspected Signs and symptoms of active TB disease, but medical evaluation not complete From Centers for Disease Control and Prevention. Table 2.8: TB Classification System. In: Chapter 2: transmission and pathogenesis of tuberculosis. Core Curriculum on Tuberculosis: What the Clinician Should Know. Atlanta, GA: 2011:40.
Resources on Tuberculosis (TB) Centers for Disease Control and Prevention (CDC) Division of Tuberculosis Elimination (DTBE) Guidelines: http://www.cdc.gov/tb/publications/guidelines/default.htm Online Courses: Self-Study Modules on Tuberculosis: http://www.cdc.gov/tb/education/ssmodules/default.htm Core Curriculum on Tuberculosis: What the Clinician Should Know: http://www.cdc.gov/tb/education/corecurr/index.htm (CITC) Medical Consultation Warmline: http://www.currytbcenter.ucsf.edu/consultation 877-390-6682 (toll-free) Warmline inquiries can also be sent to the CITC email address, currytbcenter@ucsf.edu 8:00 AM to 4:30 PM (Pacific Time), Monday through Friday (excluding holidays). Voicemail is available to record incoming messages 24 hours a day, 7 days a week. Online Products: http://www.currytbcenter.ucsf.edu/products (selected highlights only check the web page for the full list) Drug-Resistant Tuberculosis: A Survival Guide for Clinicians, 3 rd edition Radiographic Manifestations of Tuberculosis: A Primer for Clinicians, 2 nd Edition Tuberculosis Infection Control: A Practical Manual for Preventing TB Websites Checked 10/20/2016
(continued) Online Courses & Presentations: http://www.currytbcenter.ucsf.edu/products (selected highlights only check the web page for the full list) Medical Management of Tuberculosis Pediatric Tuberculosis Practical Solutions for TB Infection Control: Infectiousness and Isolation TB Prevention in the HIV-infected Patient: Screening, Testing, and Treatment of LTBI Tuberculosis Radiology Resource Page Archived Webinars: http://www.currytbcenter.ucsf.edu/trainings/webinar-archive Classroom Trainings: http://www.currytbcenter.ucsf.edu/trainings National Tuberculosis Controllers Association (NTCA) Tuberculosis Nursing, 2 nd Edition: http://www.tbcontrollers.org/resources/tb-nursing- manual/#.vfuw7wf4pws Interjurisdictional Transfers (Form): http://www.tbcontrollers.org/resources/interjurisdictional-transfers/#.vfuw3wf4pws Interjurisdictional Transfers (Contacts): http://www.tbcontrollers.org/community/statecityterritory/#.wamclk0zxiu California Tuberculosis Controllers Association (CTCA) California Department of Public Health/CTCA Joint Guidelines: http://www.ctca.org/ CTCA Directory: http://ctca.org/locations.html Websites Checked 10/20/2016
Tuberculosis (TB) Acronyms and Abbreviations AFB ALT ARPE ART AST AK ATS BCG BSC CBC CDC CHOW CI CNS CM CS CXR DTBE DOT DST EMB (E) EPTB ESRD ETA FQN IA IDSA IGRA HIV HPLC HSC IGRA INH (I) acid-fast bacilli alanine aminotransferase Aggregate Reports for Tuberculosis Program Evaluation antiretroviral therapy aspartate aminotransferase amikacin American Thoracic Society Bacille Calmette-Guérin bio-safety cabinet complete blood count Centers for Disease Control and Prevention community health outreach worker contact investigation central nervous system capreomycin cycloserine chest x-ray Division of Tuberculosis Elimination directly observed therapy drug susceptibility testing ethambutol extra-pulmonary tuberculosis end-stage renal disease ethionamide fluoroquinolone injectable agent Infectious Diseases Society of America interferon gamma release assay human immunodeficiency virus high performance liquid chromatography health & safety code interferon gamma release assay isoniazid
IP infectious period IUATLD International Union Against Tuberculosis and Lung Disease (The Union) LFT liver function test LJ Lowenstein-Jensen (type of TB culture medium) LNZ linezolid LTBI latent tuberculosis infection M. tb Mycobacterium tuberculosis MDDR molecular detection of drug resistance MDR-TB multidrug-resistant tuberculosis MFX moxifloxacin MGIT mycobacteria growth indicator tube (TB culture method) MIRU mycobacterial interspersed repetitive units (genotype method) MMCP MediCal Managed Care Plan MMWR Morbidity and Mortality Weekly Report NAAT nucleic amplification test NNRTI non-nucleoside reverse transcriptase inhibitor NRTI nucleoside reverse transcriptase inhibitor NTCA National Tuberculosis Controllers Association NTIP National Tuberculosis Indicators Project NTM nontuberculous mycobacteria NTNC National Tuberculosis Nurse Coalition PAS Para-aminosalicylate PCR polymerase chain reaction PPD purified protein derivative PTB pulmonary tuberculosis PZA (P) pyrazinamide QFT-GIT QuantiFERON -TB Gold In-Tube RBT rifabutin RFLP restriction fragment length polymorphism (genotype method) RPT rifapentine RIF (R) rifampin RTMCC Regional Training and Medical Consultation Center RVCT Report of Verified Case of Tuberculosis SAT self-administered therapy SM streptomycin TNF-α tumor necrosis factor-alpha TST tuberculin skin test VDOT directly observed therapy performed via video VNTR variable number of tandem repeats (genotype method) XDR-TB extensively drug-resistant tuberculosis ZN Ziehl-Neelson (AFB staining method)