Primary Care Management of Latent Tuberculosis Infection in the Foreign-Born: Primary Care Management of Latent Tuberculosis Infection in the Foreign-Born Investigators
Carey Jackson MD, MPH University of Washington
Jenny Pang MD, MPH, Seattle-King County Department of Public Health
Nick DeLuca PhD, Centers for Disease Control and Prevention (CDC)
Stacey Bryant RN, Research Coordinator Public Health Seattle & King County
Slide2: Contents
Definitions
Epidemiology
Latent TB Infection Testing (LTBI)
Treatment for Latent TB Infection (LTBI)
Summary
Local Information
Definitions: Definitions
Active TB Disease: Active TB Disease Tubercle bacilli in the body
Usually positive skin test
Infectious (before treatment)
Symptoms of TB
Chest x-ray usually abnormal
Sputum smears and cultures usually positive
An active “case” of TB
Granuloma breaks down and tubercle escape and multiply
Symptoms of Active TB Disease: Symptoms of Active TB Disease
Latent TB Infection (LTBI): Latent TB Infection (LTBI) LTBI is the presence of M. tuberculosis organisms (tubercle bacilli) without symptoms or radiographic evidence of active TB disease
Slide7: Latent TB Infection (LTBI) Tubercle bacilli in the body
Usually positive skin test
NOT infectious
No symptoms
Normal chest X-ray
Sputum smears and cultures are negative
Not a “case” of TB
Epidemiology TB is Global and National: Epidemiology TB is Global and National
Slide9: Source: WHO Stop TB Department, website: www.who.int/tb {Active TB all forms (per 100,000 population per year)} Active TB Incidence Worldwide, 2004
2 billion infected with LTBI!
Active TB Case Rates* United States, 2005: Active TB Case Rates* United States, 2005 < 3.5 (year 2000 target) 3.6 – 4.8 > 4.8 (national average) D.C. * Cases per 100,000 15 million infected with LTBI!
Trends in Active TB Cases in Foreign-born Persons, United States, 1986–2005*: Trends in Active TB Cases in Foreign-born Persons, United States, 1986–2005* No. of Cases Percentage * Updated as of October 16, 2006. 55% of cases in 2005 were foreign-born
Epidemiology TB is Local: Seattle-King County: Epidemiology TB is Local: Seattle-King County
Characteristics of Active TB Cases Seattle-King County, 2005: Characteristics of Active TB Cases Seattle-King County, 2005
Slide14: Foreign Born TB Cases Seattle-King County, 2005 Place of Birth Other 24 % Cambodia 3 % Philippines 14 % Vietnam 13 % Korea 4 % China 5 % Somalia 8 % India 8 % Mexico 10 % Ethiopia 11 %
TB Rates in Countries of Birth 2004: TB Rates in Countries of Birth 2004 Per 100,000 Source: World Health Organization
Time in the US Before Diagnosis of Active TB Among Foreign Born King County, 2005: Almost 2/3 of active TB cases in the Foreign-Born have been in the US more than 5 years! Time in the US Before Diagnosis of Active TB Among Foreign Born King County, 2005 > 5 Years 65 % 1 - 5 Years 23 % < 1 Year 12 %
Time in the US Before Diagnosis of Active TB Foreign Born from Philippines King County, 2005: Over 80% Filipino immigrants diagnosed more than 5 years AFTER arrival! Time in the US Before Diagnosis of Active TB Foreign Born from Philippines King County, 2005 > 5 Years 83% < 1 Year 17%
TB Case Incidence King County, 2005 Age Group: TB Case Incidence King County, 2005 Age Group Highest incidence in over 65 group Incidence per 100,000
TB Cases by Zip Code King County, 2001-2005: TB Cases by Zip Code King County, 2001-2005 Concentration of active TB cases over the West side of King County, especially in the areas of Kent and Rainier Valley. 100,000 infected with LTBI
Latent TB Infection Testing: Latent TB Infection Testing
Flow Chart for Latent TB Infection (LTBI) in Primary Care: Flow Chart for Latent TB Infection (LTBI) in Primary Care Patient with risk factors for LTBI Negative No treatment; Document status in medical record Candidate for
LTBI Treatment 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 Tested: Who Should Be Tested Know the TB status of your at risk patients.
Other Groups At High Risk for TB: Other Groups At High Risk for TB
Medical Conditions that Put People at High Risk for TB: Medical Conditions that Put People at High Risk for TB
Frequency of Testing: Frequency of Testing Dependent on ongoing risk of TB exposure
Retest your patients that have extended travel to high risk areas Who should be retested and how often?
Reading the Tuberculin Skin Test (TST): Reading the Tuberculin Skin Test (TST) Measure reaction in 48 to 72 hours
Measure induration, not erythema (redness)
Record reaction in millimeters, not “negative” or “positive”
Ensure trained health care professional measures and interprets the TST (PPD)
Interpreting the TST (PPD): Interpreting the TST (PPD) A positive TST (PPD) is determined by
The size of the induration
The patient’s risk factors
Slide28: (Note: the CDC discourages testing of people at low risk for infection.) Interpreting Tuberculin Skin Test Reactions
Immigration and TB Refugee and Immigrant Screening: Immigration and TB Refugee and Immigrant Screening In Country of Origin
Evaluated for active TB ONLY
In the US
Those applying for an adjustment of status are evaluated for LTBI but treatment is NOT mandated
Not evaluated
Visitors, students, temporary workers, undocumented The Immigration Process does not take care of Latent TB Infection (LTBI) for you!
BCG: BCG According to CDC guidelines, persons who have received BCG should be tested for LTBI as otherwise indicated
Induration considered positive should be assumed to be due to TB infection, not BCG, and treatment should be recommended, unless contraindicated Source: CDC TB Fact Sheet “BCG Vaccine” 2006. Should persons who have been vaccinated with BCG (Bacille Calmette-Guerin) be tested for LTBI, and if tested, how should the results be interpreted?
BCG (cont.): BCG (cont.) Multiple factors influence TST (PPD) reactions after BCG vaccination
Strain and dose of BCG
Method of vaccination
Health status of those vaccinated
Time interval between vaccination and TST (PPD)
Number of previous TSTs (PPDs)
Presence of atypical environmental mycobacteria
Literature Review on BCG 2006: Literature Review on BCG 2006 1500 papers reviewed from 1980-2005
Data demonstrate that the TST (PPD) performs well on BCG vaccinated adult (15+) patients and on patients from high and intermediate incidence countries
The effect of the BCG vaccine on TST (PPD) reaction decreases with increasing time since vaccination.
Literature Review on BCG 2006 (cont.): “Adults (15+) from intermediate and high-incidence countries are at high risk for LTBI and the results of tuberculin testing can be interpreted in the same manner, regardless of vaccination status.”
Examples of High Incidence: Cambodia, Philippines, Vietnam, China (including Hong Kong), African countries, Haiti
Example of Intermediate Incidence: Mexico Source: Joos, TJ et al. 2006. “Tuberculin reactivity in bacille Calmette-Guerin vaccinated populations: a compilation
of international data.” The International Journal of Tuberculosis and Lung Disease, Volume 10, Number 8, August 2006.
Literature Review on BCG 2006 (cont.)
Treatment for Latent Tuberculosis Infection (LTBI): Treatment for Latent Tuberculosis Infection (LTBI)
Who Should be Treated for Latent TB Infection (LTBI): Who Should be Treated for Latent TB Infection (LTBI) (Note: careful assessment to rule out the possibility of active TB disease is always necessary before treatment for LTBI is started.)
Anyone who has been diagnosed with latent TB infection is a candidate for treatment, if they also fulfill the following criteria:
Willing and able to complete a full course of therapy
Available to be monitored during the full course of treatment
No medical contraindications such as active liver disease
Risk Factors for Progression from Latent TB Infection (LTBI) to Active TB Disease: Risk Factors for Progression from Latent TB Infection (LTBI) to Active TB Disease Immunosuppression
Lymphoma, leukemia
Diabetes
Renal dialysis
Malnutrition
Silicosis
Gastrectomy/ jejunoileal bypass
Head and neck cancer
HIV + Medical Conditions Your patient’s TB infection may be latent now, but many factors could increase the risk of progression
Slide37: Immunosuppressive agents
Steroids (not inhaled) (prednisone >15 mg/day for 1 month or more)
Cancer chemotherapy
Cyclosporine
Anti-Rheumatics*
Etanercept (Enbrel)
Infliximab (Remicade)
Adalimumab (Humira TM)
Anakinra (Kineret) Risk Factors for Progression from Latent TB Infection (LTBI) to Active TB Disease (cont.) * Brassard, P. 2006. Antirheumatics Drugs and the Risk of Tuberculosis. CID 2006:43 (15 September). Drugs
Case Example of Progression from LTBI to Active TB: Case Example of Progression from LTBI to Active TB Case #1:
68 yo Chinese man with latent TB untreated
Hx of Hepatitis B with low level activity
Family history of colon cancer
Developed adenocarcinoma of the colon and was receiving chemotherapy
Developed hemoptysis and was thought to have a lung metastasis
Bronchoscopy aspirate grew TB
Slide39: Case #2
66 yo Vietnamese female with latent TB (untreated), diabetes inflammatory arthritis, and depression/ PTSD
Developed idiopathic thrombocytopenic purpura and began to have bleeding
Treated with systemic high dose steroids in the hospital and developed milliary TB
Died of complications
Source: from practice of PI, Carey Jackson, MD. Internal Medicine. International Clinic, Harborview Medical Center, Seattle, Washington. Case Example of Progression from LTBI to Active TB
Current Treatment for LTBI Preferred Regimen: Current Treatment for LTBI Preferred Regimen A minimum of 270 doses must be administered
within 12 months
Alternative Regimens for LTBI: Alternative Regimens for LTBI
No Longer Recommended Regimen for LTBI: No Longer Recommended Regimen for LTBI Rifampin plus pyrazinamide x 2 months
This regimen has been associated with increased risk of severe hepatic injury and death Source: “Update: Adverse Event Data and Revised American Thoracic Society/CDC 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.
Monitoring of Patients on Treatment for LTBI: Monitoring of Patients on Treatment for LTBI Baseline and monthly laboratory testing not needed except for patients with
HIV infection
Pregnancy
History of liver disease/heavy alcohol use
Patient on chemotherapy
Evaluate patients monthly for
Adherence to treatment
Symptoms of hepatitis (fatigue, weight loss, nausea, vomiting, jaundice)
Treatment of Patients 35 Years of Age and Older: Treatment of Patients 35 Years of Age and Older The CDC changed its guideline in 2000 and now encourages treatment of LTBI in all age groups
Use clinical judgment in treating older patients
*CDC/ATS Guidelines: Morbidity and Mortality Weekly Report (MMWR), “Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection.” June 9, 2000
Hepatic Adverse Drug Effects of Isoniazid (INH): Hepatic Adverse Drug Effects of Isoniazid (INH) Frequent (~5%): Liver Enzyme Elevations
Infrequent (~0.1%): Hepatitis
Large Scale Study:
11,141 treated with INH from 1989-1995
11 had hepatitis, no deaths
Overall rate was 1 per 1000 (or 0.1%)
(Nolan CM, Goldberg SV, Buskin SE. JAMA. 1999 Mar 17;281(11):1014-8.)
Patients with Chronic Hepatitis B But No Active Liver Disease: Patients with Chronic Hepatitis B But No Active Liver Disease Yes, they can receive treatment for LTBI
Baseline liver function tests and at 1 month
If the tests are normal at 1 month, no further testing is necessary unless symptoms develop
If the tests are elevated at 1 month, continue monthly testing as long as levels are abnormal
If any one of the liver function tests exceeds 3-5 times the upper limit of normal at any time, strongly consider stopping therapy
Counseling a Patient with LTBI: Counseling a Patient with LTBI Don’t Say:
“You’ve been “exposed” to TB so you need to be treated.”
Say Instead:
“You have been exposed AND infected with the TB bacteria. But don’t worry…”
Counseling a Patient with LTBI (cont.): Good news:
“You do not have the disease and you are not contagious to anyone.”
Bad news:
“However, it is sleeping in your body and if you don’t treat it now it can wake up later and make you very ill and contagious to others.” Counseling a Patient with LTBI (cont.)
Counseling a Patient with LTBI (cont.): Why get treated?
“Treatment will prevent future disease and protect you and those close to you.”
Warning
“Taking medication for 9 months is a long time but it takes that long to kill all the TB germs.”
“ TB germs are ‘TOUGH bugs’ … so take your medicine correctly and completely.” Counseling a Patient with LTBI (cont.)
Summary : Summary
Meeting the Challenge of LTBI: Meeting the Challenge of LTBI For every patient
Assess TB risk factors
If risk is present, perform TST (PPD)
If TST (PPD) is positive, rule out active TB disease
If active TB disease is ruled out, evaluate as candidate for LTBI treatment
If good candidate, initiate treatment for LTBI
If treatment is initiated, ensure completion
Meeting the Challenge of LTBI (cont.): Latent TB Infection should be treated as a condition in itself which is a precursor to a serious and potentially fatal disease
Much the same way we treat hypertension as a condition in itself because it significantly heightens risk of heart disease, renal failure, and stroke or place infants in car seats because of the significant risk of injury without them, so should we approach latent TB infection
While the condition in itself is asymptomatic, the risks assumed by ignoring it are substantial Meeting the Challenge of LTBI (cont.)
Slide53: Always include TB in the DDX
“THINK TB” and “TB RISK” Physicians Caring for
At Risk Populations
Local Information: Local Information
TB Control Program: TB Control Program Harborview Medical Center 325 – 9th Avenue Seattle, WA 98104
TB Nurse Line: 731-4579
TB Manager: 731-4578
TB Disease Control Officer Seattle-King County Public Health: TB Disease Control Officer Seattle-King County Public Health Masa Narita, M.D. masa.narita@metrokc.gov
731-4579
Pierce County: Pierce County For TB Testing Only: (sliding scale)
Multi Care HealthWorks
502 54th Avenue East
Fife, WA
253-459-7500
Multi Care HealthWorks-Allenmore
1901 S. Union Suite A203
Tacoma, WA
253-459-6811
Good Samaritan Hospital
Mobile Services Pioneer Campus
615 E. Pioneer
Puyallup, WA
253-435-393
Latent TB Infection (LTBI): Latent TB Infection (LTBI) LTBI is reportable in Pierce County within 7 work days
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References (cont.): Massachusetts Department of Public Health.2005. “2004 Tuberculosis Overview”. In Massachusetts Department of Public Health. Retrieved 9-18-06 from: www.mass.gov/dph/cdc/tb/tbstat04.pdf
Public Health Seattle & King County. 2006. “Seattle & King County Annual Tuberculosis Report”. In TB Control Program. Accessed 9-18-06 from: www.metrokc.gov/health/tb/tbfacts.htm
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Tarrant County Public Health. 2005. “Reportable Diseases Trends 2000 – 2004”. In: Health Data and Information. Accessed 9-27-06 from: www.tarrantcounty.com References (cont.)
References (cont.): Tarrant County Public Health. 2005. “Communicable Diseases 2003”. In: Health Data and Information. Accessed 9-27-06 from www.tarrantcounty.com
TB Control Branch (TBCB), California Department of Health Services. 2005. “REPORT ON TUBERCULOSIS IN CALIFORNIA, 2004”. In: TB Control Branch. Accessed 9-26-06 from www.dhs.ca.gov/ps/dcdc/tbcb/index.html
Washington State TB Advisory Council. (nd). Screening and Treatment of (Latent) Tuberculosis.
Weis S, et al. Tuberculosis in the Foreign-Born Population of Tarrant County, Texas by Immigration Status. Am J Respir Crit Care Med Vol 164. pp 953–957, 2001
World Health Organization. 2005. Global Health Atlas. Accessed 10-2-06 from: www.who.int/globalatlas/dataQuery/default.asp
Update: Adverse Event Data and Revised American Thoracic Society/CDC 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. Assessed 2-2-07 from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5231a4.htm References (cont.)