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Safety
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TB Facts for
Healthcare Workers
Source:
California Department of Social Services / California Health &
Safety Code 1596
Excerpted
from the
U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers
for Disease Control and Prevention
National
Center for HIV, STD, and TB Prevention
Division
of Tuberculosis Elimination
Atlanta,
Georgia 30333
TUBERCULOSIS
YES! IT'S STILL A PROBLEM!
• Eight million new tuberculosis (TB) cases occur each year in
the world and 3 million people die of the disease.
• In the United States, after several decades of decline, TB
cases increased 20 percent between 1985 and 1992.
Some of the reasons for the increase included: the HIV epidemic,
immigration of persons from areas with a high prevalence
of TB, outbreaks of multidrug-resistant TB occurred in hospitals and
prisons - resulting in high death rates and transmission
to health care workers.
• The 21,337 TB cases reported in 1996 represent the fourth
consecutive year of decline, suggesting the successful use of new
resources in different areas of the U.S. to better detect and treat
persons with active TB and latent infection.
• While the decrease in TB cases is encouraging, there are
several areas of concern which will require expanded efforts:
—
TB cases continue to increase in many areas.
—
Outbreaks of drug-resistant TB continue in many areas.
—
An estimated 10 to 15 million persons in the U.S. are infected with
Mycobacterium tuberculosis.Without intervention,
about
10 percent of these persons will develop TB disease at some point in
life.
—
An increasing proportion of TB cases in the U.S. are among
individuals
born in areas with a high prevalence of TB, and international
collaboration needs to be strengthened to prevent
and
control TB in these persons.
POPULATIONS
AT RISK FOR TUBERCULOSIS
Persons
at risk for TB include anyone who has ever had contact with a person
with infectious TB. Some persons are considered
to be at high risk for TB disease because they belong to groups in
which the prevalence of TB infection is higher
than it is in the general population. These groups include foreign-born
persons from areas with a high prevalence of TB; residents
and employees of long term institutional settings (such as nursing
homes and correctional facilities); and medically underserved
populations, including the poor, the homeless, high risk racial and
ethnic minority groups, and injecting drug
users (IDUs). Other persons are at high risk for developing active TB
disease if they become infected with Mycobacterium tuberculosis.
They include immuno compromised persons (especially those with HIV
infection), persons with other medical
risk factors (such as diabetes, end-stage renal disease, and being 10
percent or more below ideal body weight), and IDUs.
HIV infection is one of the strongest known risk factors associated
with the progression from TB infection to active TB disease.
Studies suggest that the risk of developing TB disease is 7% to 10%
each year for persons who are infected with both M.
tuberculosis and HIV, whereas it is 10% over a lifetime for persons
infected only with M. tuberculosis.
MODE
OF TRANSMISSION
Mycobacterium
tuberculosis is spread by airborne particles, known as droplet nuclei,
that can be generated when persons with
pulmonary or laryngeal TB sneeze, cough, speak, or sing. Persons who
share the same airspace with persons with infectious
TB disease are at greatest risk for infection. Infection occurs when a
susceptible person inhales droplet nuclei
containing tubercle bacilli and these bacilli become established in the
alveoli of the lungs and spread throughout the body.
IDENTIFICATION
OF PERSONS WITH TB INFECTION AND DISEASE: TB SKIN TEST
A
person exposed to an individual with infectious TB or who has other
risk factors for TB as noted above should be given a tuberculin
skin test. The Mantoux tuberculin skin test is the preferred method of
skin testing. The Mantoux tuberculin skin test
is the intradermal injection of purified protein derivative (PPD) of
killed tubercle bacilli, usually on the inner forearm. The
site is examined by a trained health care worker 48 to 72 hours after
injection for induration (palpable swelling). The diameter
of induration is measured and recorded; erythema or bruising is
disregarded. The criteria endorsed by the American Thoracic
Society and CDC for a positive tuberculin skin-test result are intended
to increase the likelihood that persons at high
risk for TB will be candidates for preventive therapy and that persons
having tuberculin reactions not caused by M. tuberculosis
will not receive unnecessary diagnostic evaluation or treatment.
INTEPRETATION
OF TB SKIN TEST RESULTS
• An induration
of ³5 mm is classified as positive in
the following: --- Persons who have had recent close contact with
persons who have active TB; --- Persons who have human immunodeficiency
virus (HIV) infection or risk factors for HIV infection but unknownHIV
status (e.g., injecting drug users); — Persons who have fibrotic
chest radiographs consistent with
healed TB.
• An induration
of ³10 mm is classified as positive
in all persons who do not meet any of the above criteria, but who
belong to one or more of the following groups having high risk for TB:
— Injecting-drug users known
to be HIV seronegative;
— Persons who have other
medical conditions that have been
reported to increase the risk for progressing from latent TB infection
to active TB. These medical conditions include diabetes
mellitus, conditions requiring prolonged high-dose corticosteroid
therapy and other immuno- suppressive therapy (including
bone marrow and organ transplantation), chronic renal failure, some
hematologic disorders (e.g., leukemias and lymphomas), other specific
malignancies (e.g., carcinoma of the head or neck), weight loss of
³10% below ideal body weight, silicosis, gastrectomy,
jejunoileal bypass;
— Residents and employees of
high-risk congregate settings:
prisons and jails, nursing homes and other long-term facilities for the
elderly, health-care facilities (including some resi-dential mental
health facilities), and homeless shelters;
— Foreign-born persons
recently arrived (i.e., within the
last 5 years) from countries W/high prevalence or incidence of TB;
— Some medically underserved,
low-income populations,
including migrant farm workers and homeless persons;
— High-risk racial or ethnic
minority populations, as defined
locally;
— Children <4 years of age
or infants, children, and
adolescents exposed to adults in high-risk categories.
• An induration
of ³15 mm is classified as positive
in persons who do not meet any of the above criteria. Many foreign
countries still use BCG as part of their TB control programs,
especially for infants. In persons vaccinated with BCG, sensitivity to
tuberculin is highly variable, depending upon the strain of BCG used
and the group vaccinated. There is no reliable method of distinguishing
tuberculin reactions caused by BCG from those caused by natural
infections. A reaction to tuberculin in a person with a history of BCG
vaccination is more likely to be due to infection with M. tuberculosis
if:
• the
induration is
large
• the
person was
vaccinated a long time ago
• the
person is a
recent contact of a person with
infectious TB
•
there is a family
history of TB
• the
person comes
from an area where TB is common
•
chest radiograph
findings show evidence of previous
TB
In a BCG-vaccinated person who has
any of the preceding risk factors, a
positive tuberculin reaction probably indicates infection with M.
tuberculosis. Such persons should be evaluated for isoniazid preventive
therapy after disease has been ruled out.
IDENTIFYING
TB DISEASE
If the skin test result is positive
or if symptoms suggestive of TB are
present (e.g., productive and prolonged cough, fever, chills, loss of
appetite, weight loss, fatigue, or night sweats), a chest radiograph
should be obtained to help rule out active pulmonary TB. The chest
radiograph may also be used to detect the presence of fibrotic lesions
suggestive of old, healed TB or silicosis. Acid-fast bacilli (AFB)
smears and cultures should be
per-formed on sputum specimens of all persons who have symptoms of TB
or whose chest radiograph suggests TB. A positive
AFB smear is an indication for beginning treatment for TB. However, a
positive AFB smear may also indicate the presence of
nontuberculous mycobacteria. A positive culture for Myco-bacterium
tuberculosis is the only definitive proof of TB
disease. Health care providers of HIV-infected persons should be aware
of atypical patterns of TB disease in these persons. Extra-pulmonary TB
is more common. Also, pulmonary TB may present in an unusual manner
(e.g., in the lymph nodes or in the lower part of the lungs). All
persons with TB infection or TB disease should be offered counseling
and HIV-antibody testing, because medical management may be altered in
the presence of HIV infection. Maintain a high index of suspicion for
TB in persons with undiagnosed pulmonary disease, especially in persons
who are HIV seropositive.
PREVENTION
OF TUBERCULOSIS
The main purpose of preventive
therapy is to prevent latent infection
from progressing to clinically active TB disease.Therefore, persons with positive tuberculin skin
test results who do
not have clinically active disease should be evaluated for preventive therapy.
CANDIDATES
FOR PREVENTIVE THERAPY
Preventive therapy is recommended
for the following persons with a
positive tuberculin test result regardless of age: Note: this listing
is not all-inclusive – but rather contains some
of the more common cases:
• Persons w/
known or suspected HIV
infection, including
persons
who inject drugs
and whose HIV status is
unknown
³5mm)
• Close contacts
of persons with
infectious, clinically active
TB ³5mm)*
• Persons who
have chest radiograph
findings suggestive
of previous TB
and who have
received inadequate or no
treatment.
• Persons who
inject drugs and who are
known to be HIV
negative
³10mm)
• Persons with
certain medical conditions
that have been
reported to
increase the risk of TB
* Persons who are immunosuppressed,
especially HIV-infected persons may
have a negative tuberculin skin test reaction because they are anergic.
All HIV-infected persons who are close contacts of persons who have
infectious tuberculosis should be administered a full course of
preventive therapy regardless of tuberculin skin test results or prior
courses of chemoprophylaxis after the diagnosis of active tuberculosis
has been excluded.
• Foreign-born
persons from
high-prevalence areas (e.g.,
Latin America,
Asia, and Africa)
• Medically
underserved, low-income
populations,including
high-risk
racial or ethnic groups
(e.g., Asians and Pacific
Islanders, blacks,
Hispanics, and Native Americans)
• Residents of
long-term care facilities
(e.g., correctional
institutions,
nursing homes, and
mental institutions)
• Children
younger than 4 years of age
• Other groups
identified locally as
having an increased
prevalence of
TB (e.g., migrant farm
workers or
homeless
persons)
PREVENTIVE
THERAPY REGIMENS
The usual preventive therapy
regimen is isoniazid (INH) (for
children—10 mg/kg daily, for adults—5 mg/kg daily
up to a
maximum of 300 mg daily) for a
minimum of 6 continuous months for
adults and 6-9 continuous months for children. Twelve months is
recommended for persons with HIV infection or other forms of
immunosuppression. (Note: Persons with fibrotic infiltrates on a chest
radiograph that are thought to represent old, healed TB and those with
silicosis who were formerly considered candidates for preventive
therapy should receive 4 months of multi-drug chemotherapy.) To ensure
that persons in high-risk groups adhere to therapy, INH can be given
twice weekly at a dosage of 15 mg/kg, up to a maximum of 900 mg, using
directly observed preventive therapy(DOPT). DOPT refers to the
observation by a health care provider of patients as they ingest
anti-TB medications. Situations in which patients not receiving DOPT
miss appointments or demonstrate other nonadherent behavior should be
brought to the attention of the appropriate publichealth officials.
These patients should be considered for DOPT.
TREATMENT
REGIMENS
TB is usually curable if effective
treatment is instituted without
delay. Because of the increase in multidrug-resistant TB
(MDR-TB), nearly all persons with
TB should be started on a four-drug
regimen of INH, rifampin (RIF), pyrazinamide (PZA), and ethambutol
(EMB) or streptomycin (SM) until the drug susceptibility results are
known. A less than four-drug initial regimen should only be considered
if there is little possibility of drug resistance (i.e., less than 4%
primary resistance to isoniazid in the community and the patient has
had no previous treatment with TB drugs, is not from a country with a
high prevalence of drug resistance, and has no known exposure to a
patient with drug-resistant disease). If the drugs are given daily at
the start of therapy and susceptibility results show no drug
resistance, EMB or SM can be discontinued and the other drugs continued
until PZA has been given for 2 months. INH and RIF should then be
continued for another 4 months, including at least 3 months of therapy
after the culture has converted to negative. Several options for daily
and intermittent therapy have been published. Persons given anti-TB
therapy should be monitored monthly for drug side effects. The
recommendations for the duration of TB treatment for HIV-infected
persons are generally the same as for persons not infected with HIV.
However, in HIV-infected patients, it is critically important to assess
the clinical and bacteriologic response to therapy. Treatment should be
prolonged if the response is slow or otherwise suboptimal.
REPORTING
TB reporting is required by law in
every state. All new TB cases and
suspect cases should be reported promptly to the health department by
the clinician. Cases may also be reported by infection control nurses
or by pharmacies when TB drugs are dispensed. In addition, all positive
TB smears and cultures should be reported promptly by laboratories.
Early reporting is important for the control of TB and it gives
clinicians access to the
resources of the health department for assistance in case management
(e.g., DOT) and contact investigation.
MULTIDRUG-RESISTANT
TUBERCULOSIS (MDR-TB)
An extremely serious aspect of the
TB problem in the United States is
MDR-TB (i.e., TB resistant to at least isoniazid and
rifampin). MDR-TB can usually be
prevented by initially treating TB
patients with four drugs and by administering TB
medications on a directly observed
basis. Persons at high risk for
MDR-TB include persons who have been recently exposed to MDR-TB,
especially if they are immuno- compromised; TB patients who
failed to take medications as prescribed; TB patients who were
prescribed an ineffective treatment regimen; and
persons previously treated for TB. MDR-TB presents difficult treatment
problems. Treatment must be individualized and based on the
patient’s medication history and drug susceptibility study
results. Clinicians who are not familiar with the management of
patients with MDR-TB disease or with patients infected with multi drug
resistant organisms should seek expert consultation.For
persons likely to have been infected with M. tuberculosis resistant to
both isoniazid and rifampin, observation without preventive therapy is
usually recommended because only isoniazid and rifampin have been
evaluated for preventive therapy. How-ever, for persons at an
especially high risk for TB disease once infected (e.g., persons with
HIV infection), preventive therapy with an alternative regimen should
be strongly considered.
INFECTION
CONTROL MEASURES
The spread of TB in health care
settings can be minimized by
implementing CDC recommendations for preventing TB
transmission in these settings. The
early detection, isolation, and
treatment of disease in persons with infectious TB are essential to
controlling transmission. TB should be suspected in all
persons with symptoms consistent with TB (for example, cough, fever,
night sweats, chills, fatigue, weight loss or loss of
appetite), especially those with confirmed or suspected HIV infection
and undiagnosed pulmonary disease. Precautions should be
taken to prevent airborne transmission of infection until TB is
diagnosed and treated or ruled out. Effective AFB isolation should be
initiated for persons with confirmed or suspected TB to reduce the risk
that they will expose others. Precautions should be taken during and
immediately after procedures that may induce coughing, such as
bronchoscopy, sputum collection, the aerosol induction of sputum, and
the administration of aerosolized medication, such as pentamidine.
Antituberculosis drug treatment should be promptly initiated for
persons with active disease to render them noninfectious. Persons at
high risk for TB infection should be screened and, if
infected, evaluated for preventive therapy. Ongoing TB screening should
be provided to health care workers who have regular
contact with persons with TB or HIV infection.
SELECTED
BIBLIOGRAPHY
American Thoracic Society/CDC.
Treatment of tuberculosis and
tuberculosis infection in adults and children. Am J Respir Critical
Care Med 1994;149:1359-74.
Centers for Disease Control.
Screening for tuberculosis and
tuberculosis infection in high-risk populations. MMWR 1995;
44(No. RR-11).
Centers for Disease Control.
Management of persons exposed to
multidrug-resistant tuberculosis. MMWR 1992;41(No. RR-11).
Centers for Disease Control.
Guidelines for preventing the
trans-mission of Mycobacterium tuberculosis in health-care facilities,
1994. MMWR 1994;43(No. RR-13).
Centers for Disease Control
and Prevention. 1997 USPHS/IDSA Guidelines
for the prevention of opportunistic infections in persons infected with
human immunodeficiency virus. MMWR 1997;46(No. RR-12).
Centers for Disease Control
and Prevention. Anergy testing and
preventive therapy for HIV-infected persons: Revised recom-mendations.
MMWR 1997;46 (No. RR-15).
Selwyn PA, Hartel D, Lewis
VA, et al. A prospective study of the risk
of tuberculosis among intravenous drug users with
human immunodeficiency virus
infection. N Engl J Med 1989;320:545-50.
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