SUPPLEMENTAL READING MATERIALS

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1 CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE BASIC CONCEPTS IN TB OBJECTIVES Upon completion of this session, participants will be able to: 1. List three priority 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. Basic concepts in TB-slide outline Presented by: April King-Todd, RN, BSN, MPH PAGES 1-9 SUPPLEMENTAL READING 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)

2 Tuberculosis Case Management and Contact Investigation Intensive May 26 28, 2015 April King Todd, BSN, MPH Nurse Manager Los Angeles County TB Control Program TB Control Priorities in US Pathogenesis Transmission Risk factors associated with transmission TB vs LTBI Drug resistant & MDR TB TB Classification system 1 Objectives Upon completion of this session, participants will be able to: 1. List three priority 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 1

3 Tuberculosis (TB) remains one of the world s deadliest communicable diseases. In 2013, an estimated 9.0 million people developed TB and 1.5 million died from the disease, of whom were HIV-positive. TB National Priorities for TB Control Priority 1: Identify & treat active cases Identify, evaluate & treat contacts Priority 2: Evaluate &treat new immigrants & refugees with Class B TB notifications upon arrival to U.S. Priority 3: Targeted testing and treatment of high risk populations Source: Tuberculosis Elimination and Laboratory Cooperative Agreement, CDC RFA PS National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Introduction Airborne disease caused by the bacterium Mycobacterium tuberculosis (M. tb) M. tb complex (M. tb, M. bovis, M. africanum, M. microti, M. canetti, M. caprae, M. pinnipedii, and M. mungi) can cause TB disease Majority of TB cases caused by M. tb M. tb organisms also called tubercle bacilli 2

4 Transmission of M. tuberculosis M. tb spread via airborne particles called droplet nuclei Expelled when person with infectious TB coughs, sneezes, shouts, or sings Transmission occurs when droplet nuclei inhaled and reach the alveoli of the lungs, via nasal passages, respiratory tract, and bronchi Probability TB will be Transmitted Susceptibility of the exposed person Infectiousness of person with TB (i.e., number of bacilli TB patient expels into the air) Environmental factors that affect the concentration of M. tb organisms Proximity, frequency, and duration of exposure (e.g., close contacts) Can be transmitted from children, though less likely Pathogenesis Droplet nuclei containing tubercle bacilli are inhaled, enter the lungs, and travel to the alveoli. Tubercle bacilli multiply in the alveoli. 3

5 Pathogenesis A small number of tubercle bacilli enter the bloodstream and spread throughout the body. The tubercle bacilli may reach any part of the body, including areas where TB disease is more likely to develop (such as the brain, larynx, lymph node, lung, spine, bone, or kidney). Pathogenesis Within 2 to 8 weeks, special immune cells called macrophages ingest and surround the tubercle bacilli. The cells form a barrier shell, called a granuloma, that keeps the bacilli contained and under control (LTBI). If the immune system cannot keep the tubercle bacilli under control, the bacilli begin to multiply rapidly (TB disease). This process can occur in different areas in the body, such as the lungs, kidneys, brain, or bone. Latent TB Infection (LTBI) Granulomas may persist (LTBI), or may break down to produce TB disease 2 to 8 weeks after infection, LTBI can be detected via TST or interferon gamma release assay (IGRA) The immune system is usually able to stop the multiplication of bacilli Persons with LTBI are not infectious and do not spread organisms to others 4

6 TB Disease In some, the granulomas break down, bacilli escape and multiply, resulting in TB disease Can occur soon after infection, or years later Persons with TB disease are usually infectious and can spread bacteria to others Positive M. tb culture confirms TB diagnosis Sites of Disease Lungs (pulmonary): most common site; usually infectious Miliary: occurs when bacilli spread to all parts of the body; rare, but fatal if untreated Central nervous system: usually occurs as meningitis, but can occur in brain or spine Sites of Disease (cont.) Outside the lungs (extrapulmonary): usually not infectious, unless person has Concomitant pulmonary disease, Extrapulmonary disease in the oral cavity or larynx, or Extrapulmonary disease with open site, especially with aerosolized fluid. 5

7 Risk of Developing Disease Normal Immune System Untreated, 5% of infected persons with normal immunity develop TB in first 1 2 years post infection, another 5% later in life Thus, about 10% of infected persons with normal immunity will develop TB at some point in life if not treated Risk of Developing Disease (cont.) Weak Immune System Persons with weak immunity at increased risk of progressing to TB disease Untreated HIV infection highest risk factor: risk of developing TB disease is 7% 10% each year; Children <5 years of age also at increased risk 6

8 LTBI vs. TB Disease Person with LTBI (Infected) Has a small amount of TB bacteria in his/her body that are alive, but inactive Person with TB Disease (Infectious) Has a large amount of active TB bacteria in his/her body Cannot spread TB bacteria to others May spread TB bacteria to others Does not feel sick, but may become sick if the May feel sick and may have symptoms such as a bacteria become active in his/her body cough, fever, and/or weight loss Usually has a TB skin test or TB blood test reaction indicating TB infection Radiograph is typically normal Sputum smears and cultures are negative Should consider treatment for LTBI to prevent TB disease Does not require respiratory isolation Not a TB case Usually has a TB skin test or TB blood test reaction indicating TB infection Radiograph may be abnormal Sputum smears and cultures may be positive Needs treatment for TB disease May require respiratory isolation A TB case Drug Resistant TB Caused by organisms resistant to one or more TB drugs Transmitted same way as drug susceptible TB, and no more infectious Delay in detecting drug resistance may prolong period of infectiousness because of delay in starting correct treatment Multidrug Resistant (MDR) and Extensively Drug Resistant (XDR) TB MDR TB caused by bacteria resistant to best TB drugs, isoniazid and rifampin XDR TB caused by organisms resistant to isoniazid and rifampin, plus fluoroquinolones and 1 of the 3 injectable second line drugs All TB TB with any drug resistance MDR TB* with drug resistance to at least the firstline drugs isoniazid and rifampin XDR TB** with drug resistance to the first-line drugs isoniazid and rifampin and to specific second-line drugs *Often resistant to additional drugs **Resistant to any fluoroquinolone and at least one of three injectable second line drugs (i.e., amikacin, kanamycin, or capreomycin 7

9 Types of Drug Resistance Drug resistance develops in two ways: Primary resistance develops in persons initially infected with resistant organisms Secondary (acquired) resistance develops during TB therapy Circumstances Increasing the Risk of Drug Resistant TB Risk of drug resistant TB is increased with exposure to a person who Has confirmed drug resistant TB Had prior unsuccessful treatment for TB, and drug susceptibility results not known Originated in a drug resistant TB prevalent country Has positive smear and culture 2 months after treatment start Classification System for TB Based on TB pathogenesis (stage of disease) Helps clinician track the development of TB in patients Persons with class 3 or 5 TB should be reported to health department Patients should not have class 5 classification for more than 3 months 8

10 TB Classification System Class Stage of Disease 0 No exposure, no infection 1 Exposure, no evidence of infection 2 TB infection, no disease 3 TB, clinically active 4 TB, not clinically active 5 TB suspect References CDC Core Curriculum slide set TB Nursing: A Comprehensive Guide to Patient Care v 6/13/11 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 Resources on Tuberculosis Acronyms and Abbreviations 9

11 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.

12 Resources on Tuberculosis (TB) Centers for Disease Control and Prevention (CDC) Division of Tuberculosis Elimination (DTBE) Guidelines: Online Courses: Self-Study Modules on Tuberculosis: Core Curriculum on Tuberculosis: What the Clinician Should Know: (CITC) Medical Consultation Warmline: (toll-free) Warmline inquiries can also be sent to the CITC address, 8:00 AM to 4:30 PM (Pacific Time), Monday through Friday (excluding holidays). Voic is available to record incoming messages 24 hours a day, 7 days a week. Online Products: (selected highlights only check the web page for the full list) Drug-Resistant Tuberculosis: A Survival Guide for Clinicians, 2nd edition Radiographic Manifestations of Tuberculosis: A Primer for Clinicians, Second Edition Tuberculosis Infection Control: A Practical Manual for Preventing TB Websites Checked 5/7/2015

13 (continued) Online Courses & Presentations: (selected highlights only check the web page for the full list) Asking the Right Questions 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: Classroom Trainings: National Tuberculosis Controllers Association (NTCA) Tuberculosis Nursing, 2 nd Edition: manual/#.vfuw7wf4pws Interjurisdictional Transfer Form and Contacts: California Tuberculosis Controllers Association (CTCA) California Department of Public Health/CTCA Joint Guidelines: CTCA Directory: Websites Checked 5/7/2015

14 Tuberculosis (TB) Acronyms and Abbreviations AFB AIDS ALT ARPE ART AST ATBD ATS BCG CBC CC CDC CI CNS CXR DTBE DOT DST EMB ESRD FQN IA IDSA HIV HPLC IGRA INH IP IUATLD acid-fast bacilli acquired immune deficiency syndrome alanine aminotransferase Aggregate Reports for Tuberculosis Program Evaluation antiretroviral therapy aspartate aminotransferase active tuberculosis diease American Thoracic Society bacilli Calmette-Guérin complete blood count cultural competency Centers for Disease Control and Prevention contact investigation central nervous system chest x-ray Division of Tuberculosis Elimination directly observed therapy drug sensitivity testing ethambutol end-stage renal disease fluoroquinolone injectable agent Infectious Diseases Society of America human immunodeficiency virus high performance liquid chromatography interferon gamma release assay isoniazid infectious period International Union Against Tuberculosis and Lung Disease

15 LEP limited English proficiency LFT liver function test LJ Lowenstein-Jensen LTBI latent TB infection M. tb Mycobacterium tuberculosis MDR-TB multidrug-resistant TB MGIT mycobacteria growth indicator tube MIRU mycobacterial interspersed repetitive units MMCP MediCal Managed Care Plan MMWR Morbidity and Mortality Weekly Report MOTT mycobacteria other than tuberculosis 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 OTIS Online Tuberculosis Information System PCR polymerase chain reaction PI protease inhibitor PPD purified protein derivative PZA pyrazinamide QA quality assurance QI quality improvement QFT-GIT QuantiFERON -TB Gold In-Tube test RBT rifabutin RPT rifapentine RIF rifampin RTMCC Regional Training and Medical Consultation Center RVCT Report of Verified Case of Tuberculosis TDR totally drug-resistant tuberculosis TNF-α tumor necrosis factor-alpha TST tuberculin skin test T-Spot T-SPOT.TB test SAT self-administered therapy SM streptomycin WHO World Health Organization XDR-TB extensively drug-resistant tuberculosis