TB CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE NOVEMBER 1-4, 2016
Curry International Tuberculosis Center, UCSF 300 Frank H. Ogawa Plaza, Suite 520 Oakland, CA; Office (510) 238-5100
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 PAGES
1. TB basics: priorities and classifications-slide outline Presented by: Ann Raftery, RN, BSN, PHN, MSc
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
TB CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE NOVEMBER 1-4, 2016
Curry International Tuberculosis Center, UCSF 300 Frank H. Ogawa Plaza, Suite 520 Oakland, CA; Office (510) 238-5100
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
TB Basics1
TB Case Management and Contact Investigation IntensiveNovember 1-4, 2016Curry International Tuberculosis Center
TB BASICS: Priorities and Classifications
Ann Raftery, RN, PHN, MScCurry International Tuberculosis Center
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 Basics2
TB Case Management and Contact Investigation IntensiveNovember 1-4, 2016Curry International Tuberculosis Center
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 Basics3
TB Case Management and Contact Investigation IntensiveNovember 1-4, 2016Curry International Tuberculosis Center
Latent TB infection or active TB disease?
What features distinguish one from the other?
5
TB Transmission and Pathogenesis
Not everyone who is exposed to TB will become infected
Adequate Immunity
No infection (70%)
Infection (30%)
Inadequate Immunity
Non-specific immunity
EXPOSURE
6
TB Basics4
TB Case Management and Contact Investigation IntensiveNovember 1-4, 2016Curry International Tuberculosis Center
TB Pathogenesis
Immunologic defenses
Inadequate Defenses
Early progressionTB disease (5-10%)
Adequate Defenses
Containment(90-95%)
No infection (70%)
Adequate Immunity
Non-specific immunity
Inadequate Immunity
EXPOSURE
Infection (30%)
7
TB Pathogenesis (2)
Immunologic defenses
Inadequate Defenses
Early progressionTB disease (5-10%)
Adequate Defenses
Containment(90-95%)
No infection (70%)
Adequate Immunity
Non-specific immunity
Inadequate Immunity
Infection (30%)
EXPOSURE
Immunologic defenses
Continued containment
Adequate Defenses
Inadequate Defenses
Late progression TB disease
(5-10%)
8
TB Basics5
TB Case Management and Contact Investigation IntensiveNovember 1-4, 2016Curry International Tuberculosis Center
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): 202–21210
TB Basics6
TB Case Management and Contact Investigation IntensiveNovember 1-4, 2016Curry International Tuberculosis Center
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
of infection
History of TB exposure. Negative tuberculin skin test (or 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#.WA0Auk0zXIU12
TB Basics7
TB Case Management and Contact Investigation IntensiveNovember 1-4, 2016Curry International Tuberculosis Center
CDC TB Classifications:Immigrants and Refugees
Classification Description
No TB Normal TB screening examinations
Class A TB with waiver [Active] TB disease and have been granted a waiver
Class B1 TB, Pulmonary (PTB)
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.
Class B1 TB, Extra‐pulmonary (EPTB)
Evidence of EPTB. The anatomic site of infection should be documented.
Class B2 TB, LTBI Evaluation
Positive TST (>10mm) but otherwise negative evaluation for TB.
Class B3 TB, Contact Evaluation
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
Classification System for Tuberculosis
TB Class
Type
Description
0 No TB exposure
Not infected • No history of TB exposure and no evidence of M. tuberculosis infection or disease
• Negative reaction to TST or IGRA
1 TB exposure
No evidence of infection • 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.
Websites Checked 10/20/2016
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
Curry International Tuberculosis Center (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, [email protected]
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, 3rd edition
Radiographic Manifestations of Tuberculosis: A Primer for Clinicians, 2nd Edition
Tuberculosis Infection Control: A Practical Manual for Preventing TB
Websites Checked 10/20/2016
Curry International Tuberculosis Center (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, 2nd 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
Tuberculosis (TB) Acronyms and Abbreviations
AFB acid-fast bacilli ALT alanine aminotransferase ARPE Aggregate Reports for Tuberculosis Program Evaluation ART antiretroviral therapy AST aspartate aminotransferase AK amikacin ATS American Thoracic Society BCG Bacille Calmette-Guérin BSC bio-safety cabinet CBC complete blood count CDC Centers for Disease Control and Prevention CHOW community health outreach worker CI contact investigation CNS central nervous system CM capreomycin CS cycloserine CXR chest x-ray DTBE Division of Tuberculosis Elimination DOT directly observed therapy DST drug susceptibility testing EMB (E) ethambutol EPTB extra-pulmonary tuberculosis ESRD end-stage renal disease ETA ethionamide FQN fluoroquinolone IA injectable agent IDSA Infectious Diseases Society of America IGRA interferon gamma release assay HIV human immunodeficiency virus HPLC high performance liquid chromatography HSC health & safety code IGRA interferon gamma release assay INH (I) 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)