Tools for TB Elimination: Early Case Finding and Prevention Determining Your High-Risk Groups: Using the Universal Risk Assessment Tool Wednesday, d Sacramento, California Mike Carson, MS Program Manager Orange County TB Control Program Why Now? ~2.5 million Californians are infected with tuberculosis but most unaware Current guidelines are - not simple or clear - don t account for combination of exposure and progression risks What evidence supports this change? The best public health and medical evidence suggests that universal TB testing is neither necessary nor costeffective. TST or IGRA should be applied routinely only among high-risk populations. 1
What evidence supports this change? Since 1999, the CDC has discouraged the practice of testing individuals without risk factors for TB exposure, infection and disease due to the potential for false positive tests in persons with a low probability of infection. What was available previously? AAP Red Book 2012 Validated questions to assess LTBI risk Has a family member or contact had TB? Has a family member had a positive TST? Was your child born in a high-risk country? Has your child traveled (had contact with resident population) to a high-risk country for more than 1 week? What was available previously? CDC Latent Tuberculosis Infection: A Guide for Primary Health Care Providers Sample Tool 2013 Persons with any of the following risk factors should be tested for TB infection unless there is written documentation or a previous positive TST or IGRA result 2
CDC Sample Risk Assessment Tool Risk Factors Close contact to infectious TB disease Foreign-born person from or recent traveler to high-prevalence area CXR with fibrosis suggesting past TB HIV infection Organ transplant recipient Immunosuppressive medication CDC Sample Risk Assessment Tool Risk Factors (continued) Injection drug user Resident/employee of congregate setting Medical conditions associated with risk of progressing to TB disease, if infected Signs and symptoms of TB What was available previously? Pre-K & K-12 2015 R l d i l TB t ti f i t Replaced universal TB testing for private, parochial, public K-12 school and nursery school employees and volunteers 3
California Who should use it? Licensed healthcare providers In public health and private settings California Who should it be used for? Adult patients Not previously tested Persons who previously tested negative, and have new risk factors since the last assessment 4
Where did the pieces come from? TB exposure and TB progression risk factors were identified from scientific literature and guidelines Risk factors and risk factor combinations were assigned a testing and treatment priority (high, medium, low) Based on the risk magnitude from available evidence Characteristics of TB Risk Levels High Very high TB progression risk, if infected OR Both exposure with high likelihood of infection and progression risk Characteristics of TB Risk Levels Medium Exposure with high infection likelihood OR Exposure with lower, variable infection risk plus medical risk for progression 5
Characteristics of TB Risk Levels Low Exposure with lower, variable infection risk and no medical risk for progression Priority Level Assignments No risk factors identified, no testing Exposure risk alone Exposure risk + Medical Risk Received a priority level higher Age was not factored into priority level Medical Risks Diabetes mellitus End-stage renal disease Smoker within past one year Leukemia, lymphoma, head/neck cancer Silicosis Intestinal bypass/gastrectomy Chronic malabsorption Body mass index < 20 6
Summary What is the purpose? Provide a simple tool for assessing TB risk in individualsid Provide priority levels for testing and treatment based on risk magnitude for TB disease Who will use it? Summary Licensed healthcare providers Public and private providers 7
Questions? Mike Carson Program Manager TB Control Program County of Orange Health Care Agency (714) 834-8406 mcarson@ochca.com 8