Primary Care Management of Primary Care Management of Latent Tuberculosis InfectionLatent Tuberculosis Infection

in the Foreign-Bornin the Foreign-Born

InvestigatorsInvestigators • Carey Jackson MD, MPH University of WashingtonCarey Jackson MD, MPH University of Washington• Jenny Pang MD, MPH, Seattle-King County Jenny Pang MD, MPH, Seattle-King County

Department of Public HealthDepartment of Public Health• Nick DeLuca PhD, Centers for Disease Control and Nick DeLuca PhD, Centers for Disease Control and

Prevention (CDC)Prevention (CDC)• Stacey Bryant RN, Research CoordinatorStacey Bryant RN, Research Coordinator

Public HealthSeattle & King

County

Active TB DiseaseActive TB Disease• Tubercle bacilli in the bodyTubercle bacilli in the body• Usually positive skin testUsually positive skin test• Infectious (before Infectious (before

treatment)treatment)• Symptoms of TBSymptoms of TB• Chest x-ray usually Chest x-ray usually

abnormalabnormal• Sputum smears and Sputum smears and

cultures usually positivecultures usually positive• An active “case” of TBAn active “case” of TBGranuloma breaks

down and tubercle escape and multiply

Symptoms of Active TB DiseaseSymptoms of Active TB Disease

Systemic Systemic SymptomsSymptoms

PulmonaryPulmonarySymptomsSymptoms

• Weight lossWeight loss

• FatigueFatigue

• FeverFever

• Night sweatsNight sweats

• ChillsChills

• Coughing (duration of Coughing (duration of ≥ ≥ 3 weeks)3 weeks)

• Chest pain (when Chest pain (when breathing or coughing)breathing or coughing)

• HemoptysisHemoptysis

Latent TB Infection (LTBI)Latent TB Infection (LTBI)

LTBI is the presence of LTBI is the presence of M. tuberculosisM. tuberculosis organisms organisms (tubercle bacilli) (tubercle bacilli) without symptoms or without symptoms or radiographic evidence of radiographic evidence of active TB diseaseactive TB disease

Latent TB Infection (LTBI)Latent TB Infection (LTBI)

• Tubercle bacilli in the Tubercle bacilli in the bodybody

• Usually positive skin testUsually positive skin test• NOT infectiousNOT infectious• No symptomsNo symptoms• Normal chest X-rayNormal chest X-ray• Sputum smears and Sputum smears and

cultures are negativecultures are negative• Not a “case” of TBNot a “case” of TB

EpidemiologyEpidemiology

Source: WHO Stop TB Department, website: http://www.who.int/globalatlas/interactiveMapping/MainFrame2.asp

(Active TB all forms [per 100,000 population per year])

Active TB Incidence Worldwide, 2005

2 billion infected with LTBI!

TB Case Rates,* United States, 2006TB Case Rates,* United States, 2006

< 3.5 (year 2000 target)

3.6–4.6

> 4.6 (national average)

D.C.

*Cases per 100,000.

15 million infected 15 million infected with LTBI!with LTBI!

Trends in TB Cases in Foreign-born Trends in TB Cases in Foreign-born Persons, United States, 1986–2006*Persons, United States, 1986–2006*

0

2,000

4,000

6,000

8,000

10,000

86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 060

10

20

30

40

50

60

No. of Cases Percentage of Total Cases

No. of Cases Percentage

*Updated as of April 6, 2007.

57% of cases in 2006 were foreign-born

Percentage of TB Cases Among Foreign-Percentage of TB Cases Among Foreign-born Persons, United States*born Persons, United States*

>50%25%–49%<25%

1996 2006

DC DC

*Updated as of April 6, 2007.

TB Rates in Countries of BirthTB Rates in Countries of Birth20052005

4.6 23100

168 175

291 305344

506

119

0

100

200

300

400

500

600

USA

Mex

ico

China

Russia

Indi

a

Vietn

am

Philippin

esHai

ti

Ethio

pia

Cambo

dia

Per

100

,000

Source: World Health Organization

TB Case Rates by Age Group TB Case Rates by Age Group and Sex, United States, 2006and Sex, United States, 2006

02468

1012

<15 yrs 15–24 yrs 25–44 yrs 45–64 yrs >65 yrs

Male Female

Cases per 100,000

Highest Incidence is in 65+Highest Incidence is in 65+

Percent of Foreign-born with TB by Time of Percent of Foreign-born with TB by Time of Residence in U.S. Prior to Diagnosis,* 2006Residence in U.S. Prior to Diagnosis,* 2006

0%

20%

40%

60%

80%

100%

All Mexico Philippines Viet Nam

<1 yr 1–4 yrs >5 yrs

*Data exclude foreign-born TB patients for when length of residence in the U.S. prior to diagnosis was unknown.

Over HALF of active TB cases in the Foreign-Born Over HALF of active TB cases in the Foreign-Born have been in the US have been in the US moremore than 5 years! than 5 years!

Countries of Birth of Foreign-born Countries of Birth of Foreign-born Persons Reported with TB Persons Reported with TB

United States, 2006United States, 2006

Mexico(25%)

Philippines(11%)

Viet Nam(8%)India

(7%)China(5%)

Haiti(3%)

Guatemala(3%)

OtherCountries

(38%)

Latent TB Infection TestingLatent TB Infection Testing

Flow Chart for Latent TB Infection (LTBI) in Primary CareFlow Chart for Latent TB Infection (LTBI) in Primary CarePatient with risk factors

for LTBI

Negative

No treatment; Document status in

medical record

Candidate for LTBI Treatment

Treatment ofactive TB

by TB clinic

Refer to TB clinic for evaluation

of active TB

Abnormal

Positive

Negative

Positive

Normal

TST (PPD)

History/HIV risk,physical exam,

chest x-ray

Note: Evaluate patient for LTBI testing and treatment regardless of BCG status

Rule out active TB disease before treatment for LTBI is started

Who Should Be TestedWho Should Be TestedKnowKnow the TB status of your the TB status of your at riskat risk patients. patients.

Who is considered Who is considered at risk?at risk?

What countries are What countries are considered TB endemic?considered TB endemic?

Foreign born Foreign born patients from patients from

TB endemicTB endemic countries, countries, where prior TB where prior TB exposure is exposure is almost certainalmost certain

• All All of Asia except Japanof Asia except Japan• AllAll of Central and South of Central and South

AmericaAmerica• AllAll of Africa of Africa • AllAll of Eastern Europe of Eastern Europe

(Yes, that is practically (Yes, that is practically the whole world)the whole world)

Other Groups At High Risk for TBOther Groups At High Risk for TBGroupsGroups

• Close contacts of Active TB casesClose contacts of Active TB cases• Usually taken care of by TB clinicUsually taken care of by TB clinic

• Healthcare workers who serve high risk Healthcare workers who serve high risk clientsclients

• Residents & employees of congregate Residents & employees of congregate settingssettings

• Medically underserved/low-income groups:Medically underserved/low-income groups:• HomelessHomeless• Migrant workersMigrant workers• Street drug usersStreet drug users• Children with parents who have risk factorsChildren with parents who have risk factors

Medical Conditions that Medical Conditions that Put People at High Risk for TBPut People at High Risk for TB

Medical ConditionsMedical Conditions

• HIV +• Renal dialysis• Immunocompromised

(>15 mg prednisone qd for 1 month or more)• Diabetes mellitus• Silicosis• Cancer of the head and neck• Hematologic and reticuloendothelial diseases• Intestinal bypass or gastrectomy• Chronic malabsorption syndromes• Low body weight• Organ Transplant

Who needs repeat LTBI testing?Who needs repeat LTBI testing?

1)1) Healthcare workersHealthcare workers2)2) Close contacts to infectious TB casesClose contacts to infectious TB cases3)3) Frequent travelers to abroadFrequent travelers to abroad

• If baseline TST is negative, consider If baseline TST is negative, consider rretestetestinging your patients that have your patients that have extended travel to high risk areasextended travel to high risk areas..

• Do symptom review upon return and Do symptom review upon return and possibly retesting 8-10 week after return.possibly retesting 8-10 week after return.

Reading the Tuberculin Skin Test Reading the Tuberculin Skin Test (TST)(TST)

• Measure reaction in 48 to 72 Measure reaction in 48 to 72 hourshours

• Measure induration, Measure induration, not erythema (redness)not erythema (redness)

• Record reaction in Record reaction in millimeters, not “negative” millimeters, not “negative” or “positive”or “positive”

• Ensure trained health care Ensure trained health care professional measures and professional measures and interprets the TST (PPD)interprets the TST (PPD)

Interpreting the TST (PPD)Interpreting the TST (PPD)

A positive TST (PPD) is determined byA positive TST (PPD) is determined by

• The size of the indurationThe size of the induration

• The patient’s risk factorsThe patient’s risk factors

(Note: the CDC discourages testing of people at low risk for infection.)(Note: the CDC discourages testing of people at low risk for infection.)

Interpreting Tuberculin Skin Test ReactionsInterpreting Tuberculin Skin Test Reactions

5 mm 5 mm or greateror greater

10 mm 10 mm or greateror greater

15 mm 15 mm or greateror greater

• HIV positive persons HIV positive persons • Recent contacts of Recent contacts of

persons with active persons with active tuberculosis tuberculosis

• Fibrotic changes on Fibrotic changes on chest radiograph, chest radiograph, consistent with consistent with tuberculosis tuberculosis

• Patients with organ Patients with organ transplants and other transplants and other immunosuppressed immunosuppressed patientspatients

• Immigrants from high-Immigrants from high-prevalence areasprevalence areas

• Injection drug users Injection drug users • Residents and employees* of Residents and employees* of

high-risk congregate settingshigh-risk congregate settings• Personnel in Personnel in

mycobacteriology laboratories mycobacteriology laboratories • Persons with clinical Persons with clinical

conditions that place them at conditions that place them at high riskhigh risk

• Children: <4 years of age; all Children: <4 years of age; all exposed to adults at high-riskexposed to adults at high-risk

No known No known risk factorsrisk factors

Interpreting IGRA’sInterpreting IGRA’s• 1) Not entirely sensitive to detect TB--1) Not entirely sensitive to detect TB--

about 70% sensitive and >90% specific about 70% sensitive and >90% specific

• 2) Cannot distinguish latent TB from 2) Cannot distinguish latent TB from active TB active TB

• 3)For LTBI---Useful because of 3)For LTBI---Useful because of specificity of assay to distinguish a specificity of assay to distinguish a false positive TST from a true positive false positive TST from a true positive in testing a foreign-born population in testing a foreign-born population where BCG vaccination is routinely where BCG vaccination is routinely used.  used. 

Interpreting IGRA’sInterpreting IGRA’s•     • 4)In low prevalence LTBI populations, 4)In low prevalence LTBI populations,

such has health care workers born in such has health care workers born in the US--the jury is still out to whether the US--the jury is still out to whether using these assay is feasible and cost using these assay is feasible and cost effectiveeffective

•         a) CDC is studying this question a) CDC is studying this question currently through TBESC currently through TBESC     b)  preliminary data shows that there     b)  preliminary data shows that there could be a reversion from QFN positive could be a reversion from QFN positive to QFN negative and vice versa with to QFN negative and vice versa with serial testing over timeserial testing over time

Interpreting IGRA’sInterpreting IGRA’s

•   5) ? MAI distinction--maybe, but not well 5) ? MAI distinction--maybe, but not well studied. studied.

•   6) Discordance in testing someone for LTBI----   6) Discordance in testing someone for LTBI----   TST negative and QFN positive-- No one knows TST negative and QFN positive-- No one knows what will happen to these patients.  A long term what will happen to these patients.  A long term follow-up study needs to see if TB develops in follow-up study needs to see if TB develops in these patients.these patients.

• 7) Elispot is labor intensive and require 7) Elispot is labor intensive and require processing the same day.  Current processing the same day.  Current QuantiFERON -TB In Tube does not.  It requires QuantiFERON -TB In Tube does not.  It requires an incubator, if specimen is not processed the an incubator, if specimen is not processed the same day.same day.

TB screening for those coming to USTB screening for those coming to US

1)1) Refugees and ImmigrantsRefugees and ImmigrantsIn Country of OriginIn Country of Origin

• Evaluated for Evaluated for active TB ONLYactive TB ONLY

In the USIn the US • Those applying for anThose applying for an a adjustment of status are djustment of status are

evaluated for LTBI butevaluated for LTBI but treatment is NOT mandatedtreatment is NOT mandated

2)2) Visitors, students, temporary workers, Visitors, students, temporary workers, undocumentedundocumented

• Not evaluated

The Immigration Process does not take care of The Immigration Process does not take care of Latent TB Infection (LTBI) for you!Latent TB Infection (LTBI) for you!

BCGBCG

Should persons who have been vaccinatedShould persons who have been vaccinated with BCG with BCG (Bacille Calmette-Guerin) (Bacille Calmette-Guerin) be tested for LTBIbe tested for LTBI

• According to CDC guidelines, persons who have According to CDC guidelines, persons who have received BCG should be tested for LTBI as received BCG should be tested for LTBI as otherwise indicatedotherwise indicated

How How should the results be interpreted?should the results be interpreted?

• Positive TSTPositive TST should be assumed to be due to TB should be assumed to be due to TB infection, not BCG, and treatment should be infection, not BCG, and treatment should be recommended, unless contraindicatedrecommended, unless contraindicated

Source: CDC TB Fact Sheet “BCG Vaccine” 2006.Source: CDC TB Fact Sheet “BCG Vaccine” 2006.

Literature Review on BCGLiterature Review on BCG20062006

• 1500 papers reviewed from 1980-20051500 papers reviewed from 1980-2005

• Data demonstrate that the TST (PPD) Data demonstrate that the TST (PPD) performs well on BCG vaccinated adult performs well on BCG vaccinated adult (15+) patients and on patients from (15+) patients and on patients from high and intermediate incidence high and intermediate incidence countriescountries

• The effect of the BCG vaccine on TST The effect of the BCG vaccine on TST (PPD) reaction decreases with (PPD) reaction decreases with increasing time since vaccinationincreasing time since vaccination..

Conclusion:Conclusion:

• ““Adults (15+) from intermediate and Adults (15+) from intermediate and high-incidence countries are at high high-incidence countries are at high risk for LTBI and the results of risk for LTBI and the results of tuberculin testing can be interpreted in tuberculin testing can be interpreted in the same manner, regardless of the same manner, regardless of vaccination status.”vaccination status.”

Source: Joos, TJ et al. 2006. “Tuberculin reactivity in bacille Calmette-Guerin vaccinated populations: a compilationof international data.” The International Journal of Tuberculosis and Lung Disease, Volume 10, Number 8, August 2006 .

Literature Review on BCGLiterature Review on BCG2006 (cont.)2006 (cont.)

Treatment for Treatment for Latent Tuberculosis Latent Tuberculosis

Infection (LTBI)Infection (LTBI)

Who Should be Treated for Who Should be Treated for Latent TB Infection (LTBI)?Latent TB Infection (LTBI)?

Anyone who has been diagnosed with latent Anyone who has been diagnosed with latent TB infection is a candidate for treatment, if TB infection is a candidate for treatment, if they also fulfill the following criteria:they also fulfill the following criteria:

• Willing and able to complete a full course of Willing and able to complete a full course of therapytherapy

• Available to be monitored during the full Available to be monitored during the full course of treatmentcourse of treatment

• No medical contraindications such as active No medical contraindications such as active liver diseaseliver disease

(Note: careful assessment to rule out the possibility of (Note: careful assessment to rule out the possibility of active TB disease is active TB disease is always always necessary before necessary before treatment for LTBI is started.)treatment for LTBI is started.)

Risk Factors for Progression from Latent Risk Factors for Progression from Latent TB Infection (LTBI) to Active TB DiseaseTB Infection (LTBI) to Active TB Disease

• ImmunosuppressionImmunosuppression• Lymphoma, leukemiaLymphoma, leukemia• DiabetesDiabetes• Renal dialysisRenal dialysis• MalnutritionMalnutrition

• SilicosisSilicosis• Gastrectomy/ Gastrectomy/

jejunoileal bypassjejunoileal bypass• Head and neck cancerHead and neck cancer• HIV +HIV +

Medical Conditions

Your patient’s TB infection may be latent Your patient’s TB infection may be latent nownow, , but many factors could increase the risk of progressionbut many factors could increase the risk of progression

Immunosuppressive agentsImmunosuppressive agents• Steroids (not inhaled) (prednisoneSteroids (not inhaled) (prednisone

>15 mg/day for 1 month or more) >15 mg/day for 1 month or more)• Cancer chemotherapyCancer chemotherapy• CyclosporineCyclosporine• Anti-Rheumatics*Anti-Rheumatics*

• Etanercept (Enbrel)Etanercept (Enbrel)• Infliximab (Remicade)Infliximab (Remicade)• Adalimumab (Humira TM)Adalimumab (Humira TM)• Anakinra (Kineret)Anakinra (Kineret)

Risk Factors for Progression from Latent TB Risk Factors for Progression from Latent TB Infection (LTBI) to Active TB Disease (cont.)Infection (LTBI) to Active TB Disease (cont.)

* * Brassard, P. 2006. Brassard, P. 2006. Antirheumatics Drugs and the Risk of TuberculosisAntirheumatics Drugs and the Risk of Tuberculosis. CID 2006:43 (15 . CID 2006:43 (15 September).September).

Drugs

Case Example of Progression from Case Example of Progression from LTBI to Active TBLTBI to Active TB

Case #1:Case #1: • 68 yo Chinese man with latent 68 yo Chinese man with latent

TB untreatedTB untreated• Hx of Hepatitis B with low level Hx of Hepatitis B with low level

activity activity • Family history of colon cancerFamily history of colon cancer• Developed adenocarcinoma Developed adenocarcinoma

of the colon and was receiving of the colon and was receiving chemotherapy chemotherapy

• Developed hemoptysis and was thought Developed hemoptysis and was thought to have a lung metastasisto have a lung metastasis

• Bronchoscopy aspirate grew TBBronchoscopy aspirate grew TB

Case #2Case #2• 66 yo Vietnamese female 66 yo Vietnamese female

with latent TB (untreated), with latent TB (untreated), diabetes inflammatory diabetes inflammatory arthritis, and depression/arthritis, and depression/PTSD PTSD

• Developed idiopathic thrombocytopenic purpura Developed idiopathic thrombocytopenic purpura and began to have bleedingand began to have bleeding

• Treated with systemic high dose steroids in the Treated with systemic high dose steroids in the hospital and developed milliary TB hospital and developed milliary TB

• Died of complicationsDied of complications

Source: from practice of PI, Carey Jackson, MD. Internal Medicine. International Clinic, Source: from practice of PI, Carey Jackson, MD. Internal Medicine. International Clinic, Harborview Medical Center, Seattle, Washington.Harborview Medical Center, Seattle, Washington.

Case Example of Progression from LTBI to Active TB

Current Treatment for LTBICurrent Treatment for LTBI Preferred RegimenPreferred Regimen

DrugDrug DoseDose FrequencyFrequency DurationDuration

Isoniazid Isoniazid (INH)(INH)

300 mg300 mg DailyDaily 9 months9 months

A minimum of 270 doses A minimum of 270 doses must be administeredmust be administered

within 12 monthswithin 12 months

Alternative Regimens for LTBIAlternative Regimens for LTBI

DrugDrug DoseDose FrequencyFrequency DurationDuration OtherOther

IsoniazidIsoniazid 900 mg900 mg Twice weeklyTwice weekly 9 months9 months DOTDOT

IsoniazidIsoniazid 300 mg300 mg DailyDaily 6 months6 months

IsoniazidIsoniazid 900 mg900 mg Twice weeklyTwice weekly 6 months6 months DOTDOT

RifampinRifampin 600 mg600 mg DailyDaily 4 months4 months

No Longer Recommended No Longer Recommended Regimen for LTBIRegimen for LTBI

Rifampin plus pyrazinamide x 2 Rifampin plus pyrazinamide x 2 monthsmonths

This regimen has been associated with This regimen has been associated with increased risk of severe hepatic injuryincreased risk of severe hepatic injury

and deathand death

Source: “Update: Adverse Event Data and Revised American Thoracic Society/CDC Source: “Update: Adverse Event Data and Revised American Thoracic Society/CDC Recommendations Against the Use of Rifampin and Pyrazinamide for Treatment of Latent Recommendations Against the Use of Rifampin and Pyrazinamide for Treatment of Latent Tuberculosis Infection---United States, 2003”; MMWR, August 8, 2003 / 52(31);735-739.Tuberculosis Infection---United States, 2003”; MMWR, August 8, 2003 / 52(31);735-739.

Monitoring of Patients on Monitoring of Patients on Treatment for LTBITreatment for LTBI

• Baseline and monthly laboratory testing Baseline and monthly laboratory testing not not neededneeded except for patients with except for patients with• HIV infectionHIV infection• Pregnancy or within 3 months post-partumPregnancy or within 3 months post-partum• History of liver disease/heavy alcohol useHistory of liver disease/heavy alcohol use• Patient on chemotherapyPatient on chemotherapy

• Evaluate patients monthly forEvaluate patients monthly for• Adherence to treatmentAdherence to treatment• Symptoms of hepatitis (fatigue, weight loss, Symptoms of hepatitis (fatigue, weight loss,

nausea, vomiting, jaundice)nausea, vomiting, jaundice)

Treatment of PatientsTreatment of Patients35 Years of Age and Older35 Years of Age and Older

• The CDC changed its guideline in 2000 The CDC changed its guideline in 2000 and now encourages treatment of LTBI and now encourages treatment of LTBI in all age groupsin all age groups

• Use clinical judgment in treating older Use clinical judgment in treating older patientspatients

**CDC/ATS Guidelines: Morbidity and Mortality Weekly Report CDC/ATS Guidelines: Morbidity and Mortality Weekly Report (MMWR),(MMWR), “Targeted Tuberculin Testing and Treatment of Latent “Targeted Tuberculin Testing and Treatment of Latent Tuberculosis InfectionTuberculosis Infection.” June 9, 2000.” June 9, 2000

Hepatic Adverse Drug Effects of Hepatic Adverse Drug Effects of Isoniazid (INH)Isoniazid (INH)

• Frequent Frequent (~5%):(~5%): Liver Enzyme Elevations Liver Enzyme Elevations

• InfrequentInfrequent (~0.1%):(~0.1%): Hepatitis Hepatitis

Large Scale Study:Large Scale Study:• 11,141 treated with INH from 1989-199511,141 treated with INH from 1989-1995• 11 had hepatitis, no deaths11 had hepatitis, no deaths• Overall rate was 1 per 1000 (or 0.1%) Overall rate was 1 per 1000 (or 0.1%)

((Nolan CM, Goldberg SV, Buskin SE. JAMA. 1999 Mar 17;281(11):1014-8.) Nolan CM, Goldberg SV, Buskin SE. JAMA. 1999 Mar 17;281(11):1014-8.)

Patients with Chronic Hepatitis B Patients with Chronic Hepatitis B But No Active Liver DiseaseBut No Active Liver Disease

Yes, they can receive treatment for LTBIYes, they can receive treatment for LTBI

• Baseline liver function tests and at 1 month Baseline liver function tests and at 1 month • If the tests are normal at 1 month, no further If the tests are normal at 1 month, no further

testing is necessary unless symptoms testing is necessary unless symptoms developdevelop

• If the tests are elevated at 1 month, continue If the tests are elevated at 1 month, continue monthly testing as long as levels are monthly testing as long as levels are abnormalabnormal

• If any one of the liver function tests exceeds If any one of the liver function tests exceeds 3-5 times the upper limit of normal at any 3-5 times the upper limit of normal at any time, strongly consider stopping therapytime, strongly consider stopping therapy

Counseling a Patient with LTBICounseling a Patient with LTBI

Don’t Say:Don’t Say:• ““You’ve been You’ve been

“exposed” to TB “exposed” to TB so you need to beso you need to betreated.”treated.”

Say Instead:Say Instead:• ““You have been exposed AND infected You have been exposed AND infected

with the TB bacteria. But don’t worry…”with the TB bacteria. But don’t worry…”

Good news:Good news:• ““You do not have You do not have

the disease and youthe disease and youare not contagious are not contagious to anyone.”to anyone.”

Bad news:Bad news: • ““However, it is sleeping in your body and if However, it is sleeping in your body and if

you don’t treat it now it can wake up later you don’t treat it now it can wake up later and make you very ill and contagious to and make you very ill and contagious to others.”others.”

Counseling a Patient with LTBI (cont.)Counseling a Patient with LTBI (cont.)

Why get treated?Why get treated?• ““Treatment will prevent Treatment will prevent

future disease and future disease and protect you and those protect you and those close to you.”close to you.”

WarningWarning• ““Taking medication for 9 months is a long Taking medication for 9 months is a long

time but it takes that long to kill all the TB time but it takes that long to kill all the TB germs.”germs.”

• “ “ TB germs are ‘TOUGH bugs’ … so take TB germs are ‘TOUGH bugs’ … so take your medicine correctly and completely.”your medicine correctly and completely.”

Counseling a Patient with LTBI (cont.)Counseling a Patient with LTBI (cont.)

SummarySummary

Meeting the Challenge of LTBIMeeting the Challenge of LTBI

For every patientFor every patient• Assess TB risk factorsAssess TB risk factors• If risk is present, perform TST (PPD)If risk is present, perform TST (PPD)• If TST (PPD) is positive, rule out active TB If TST (PPD) is positive, rule out active TB

diseasedisease• If active TB disease is ruled out, evaluate If active TB disease is ruled out, evaluate

as candidate for LTBI treatmentas candidate for LTBI treatment• If good candidate, initiate treatment for If good candidate, initiate treatment for

LTBILTBI• If treatment is initiated, ensure completionIf treatment is initiated, ensure completion

• Latent TB Infection should be treated as a condition Latent TB Infection should be treated as a condition in itself which is a precursor to a serious and in itself which is a precursor to a serious and potentially fatal disease potentially fatal disease

• Much the same way we treat hypertension as a Much the same way we treat hypertension as a condition in itself because it significantly heightens condition in itself because it significantly heightens risk of heart disease, renal failure, and stroke or risk of heart disease, renal failure, and stroke or place infants in car seats because of the significant place infants in car seats because of the significant risk of injury without them, so should we approach risk of injury without them, so should we approach latent TB infectionlatent TB infection

• While the condition in itself is asymptomatic, the While the condition in itself is asymptomatic, the risks assumed by ignoring it are substantialrisks assumed by ignoring it are substantial

Meeting the Challenge of LTBI (cont.)Meeting the Challenge of LTBI (cont.)

• Always include TB in the DDXAlways include TB in the DDX

• ““THINK TB” and “TB RISK”THINK TB” and “TB RISK”

Physicians Caring for Physicians Caring for At Risk PopulationsAt Risk Populations

AcknowledgementsAcknowledgements

The following individuals provided consultation and The following individuals provided consultation and review of this presentation:review of this presentation:

• Masa Narita MD, TB Controller for Seattle-King Masa Narita MD, TB Controller for Seattle-King County Public HealthCounty Public Health

• John Bernardo, MD – Tuberculosis Control Officer, John Bernardo, MD – Tuberculosis Control Officer, Massachusetts Department of Public HealthMassachusetts Department of Public Health

• L. Masae Kawamura - MD, Director TB Control L. Masae Kawamura - MD, Director TB Control Section, San Francisco Department of Public HealthSection, San Francisco Department of Public Health

• Stephen Weis, DO –Director of Tuberculosis and Stephen Weis, DO –Director of Tuberculosis and Refugee Services for Tarrant County Health Refugee Services for Tarrant County Health Department, TexasDepartment, Texas

Without the help of the following Without the help of the following individuals, this project would not have individuals, this project would not have been possible:been possible:

• Lan NguyenLan Nguyen

• Ed ChowEd Chow

• Jessie WingJessie Wing

• Ximena Urrutia-RojasXimena Urrutia-Rojas

• Jeff CaballeroJeff Caballero

• Sharon SharnprapaiSharon Sharnprapai

ReferencesReferences

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2.2. DSHS/Public Health Service/CDC. 2006. “TB 101 for DSHS/Public Health Service/CDC. 2006. “TB 101 for Healthcare Providers.” PPT.Healthcare Providers.” PPT.

3.3. DTBE/CDC. 2005. “Targeted Tuberculin Testing DTBE/CDC. 2005. “Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection”. In and Treatment of Latent Tuberculosis Infection”. In Division of Tuberculosis Elimination.Division of Tuberculosis Elimination. Retrieved 9-16-06 Retrieved 9-16-06 from: from: www.cdc.gov/nchstp/tb/pubs/slidesets/slides.htmwww.cdc.gov/nchstp/tb/pubs/slidesets/slides.htm

4.4. DTBE/CDC. 2005. “Tuberculosis in the United States: DTBE/CDC. 2005. “Tuberculosis in the United States: National Surveillance System Highlights from 2004”. In National Surveillance System Highlights from 2004”. In Division of Tuberculosis Elimination.Division of Tuberculosis Elimination. Retrieved 9-16-06 Retrieved 9-16-06 from: from: www.cdc.gov/nchstp/tb/pubs/slidesets/surv/surv2004/dwww.cdc.gov/nchstp/tb/pubs/slidesets/surv/surv2004/default.htmefault.htm

5.5. Hong, SW. 2001. “Preventing Nosocomial Hong, SW. 2001. “Preventing Nosocomial Mycobacterium tuberculosis Transmission in Mycobacterium tuberculosis Transmission in International Settings”. Emerging Infectious International Settings”. Emerging Infectious Diseases. Vol. 7, No. 2, March-April 2001Diseases. Vol. 7, No. 2, March-April 2001

6.6. Joos, TJ; Miller WC; Murdoch, DM. 2006. Joos, TJ; Miller WC; Murdoch, DM. 2006. “Tuberculin reactivity in bacille Calmette-Guerin “Tuberculin reactivity in bacille Calmette-Guerin vaccinated populations: a compilation of vaccinated populations: a compilation of international data.” The International Journal of international data.” The International Journal of Tuberculosis and Lung Disease, Volume 10, Tuberculosis and Lung Disease, Volume 10, Number 8, August 2006, pp. 883-891.Number 8, August 2006, pp. 883-891.

7.7. Kawamura, L. Masae. 2006. “Targeted Testing and Kawamura, L. Masae. 2006. “Targeted Testing and Treatment of Tuberculosis”. In Treatment of Tuberculosis”. In Francis J. Curry Francis J. Curry National Tuberculosis Center.National Tuberculosis Center. Retrieved 9-16-06 Retrieved 9-16-06 from: from: www.nationaltbcenter.edu/testing_ltbi/presentationwww.nationaltbcenter.edu/testing_ltbi/presentation.cfm.cfm

References (cont.)References (cont.)

8.8. World Health Organization. 2005. Global Health World Health Organization. 2005. Global Health Atlas. Accessed 10-2-06 from: Atlas. Accessed 10-2-06 from: www.who.int/globalatlas/dataQuery/default.aspwww.who.int/globalatlas/dataQuery/default.asp

9.9. Update: Adverse Event Data and Revised American Update: Adverse Event Data and Revised American Thoracic Society/CDC Recommendations Against Thoracic Society/CDC Recommendations Against the Use of Rifampin and Pyrazinamide for the Use of Rifampin and Pyrazinamide for Treatment of Latent Tuberculosis Infection---Treatment of Latent Tuberculosis Infection---United States, 2003 MMWR, August 8, 2003 / United States, 2003 MMWR, August 8, 2003 / 52(31);735-739. Assessed 2-2-07 from 52(31);735-739. Assessed 2-2-07 from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5231a4.htm231a4.htm

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