American Lung Association of Washington Firland Foundation Washington State Tuberculosis Advisory Co

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American Lung Association of WashingtonFirland
FoundationWashington State Tuberculosis
Advisory Council
This presentation is brought to you through the
collaborative efforts of
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Diagnosis and Treatment of Latent Tuberculosis
Infection (LTBI)

• Practice Guidance from the Washington State TB
  Advisory Council

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Basic Principles about Latent Tuberculosis
Infection

• Latent tuberculosis infection (LTBI) means that a
  person is infected with Mycobacterium
  tuberculosis (the germ that causes tuberculosis)
  BUT is not chronically ill and has no evidence of
  active tuberculosis disease (TB)
• LTBI is common estimated to affect up to 10 of
  the Washington State population
• Persons with LTBI are at high risk for developing
  active TB 10 lifetime risk, much higher if
  immunocompromised.
• LTBI can be diagnosed using the Tuberculin Skin
  Test (TST) or by using a blood test called the
  Quantiferon Gold test.
• LTBI testing should be targeted to persons at
  high risk for having LTBI and/or developing TB
  (criteria to be shown).
• Treatment of LTBI with Isoniazid can help to
  prevent active TB and prevent the transmission of
  TB to others.
• Patient education and simple clinical monitoring
  can prevent serious complications (such as
  hepatitis) of LTBI treatment.

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TB Control Interventions
Targeted Testing and Treatment of LTBI
LTBI
High Risk Groups
Progression Months-Years
Active TB Disease
Transmission Days-Weeks
New Infection
Case Finding and Treatment of Active Disease
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LTBI MANAGEMENT overall approach
Clinical or Epidemiologic risk factor for
Tuberculosis
Adapted from Jasmer et al. NEJM 20023471860-6
No
Yes
No tuberculin skin test
Tuberculin skin test
Negative
Positive
CXR/clinical evaluation
High-risk exposure within 3 months
TB Symptoms (eg. fever, cough, weight loss) or
Abnormal CXR
No Symptoms Normal CXR
No
Yes
Treatment of LTBI not indicated
Evaluate for treatment of LTBI
Evaluate for Active TB
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Who should be screened for LTBI?

• THOSE AT HIGH RISK FOR LTBI
• Any contacts of active TB cases
• HIV infection
• Persons who inject drugs
• Fibrotic changes on CXR c/w prior TB
• Foreign born in high prevalence country
• Resident or employee of high risk facility
• Health care workers who serve high risk patients
• Medically underserved and low income populations
• Special racial and ethnic minority populations

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Who should be screened for LTBI?

• THOSE AT HIGH RISK FOR ACTIVE TB INFECTION
• 
  (if
  infected)
• Recent infection or contact (within 2 years)
• HIV infection
• Persons who inject drugs
• Fibrotic changes on CXR c/w prior TB
• Recent arrival (within 5 yrs) from high
  prevalence country
• Immunosupression
• Other high risk medical conditions
  immunosuppressive therapy, substance abuse,
  malnutrition, renal failure and other medical
  problems)
• Previous TB with inadequate (or undocumented)
  treatment

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How should LTBI screening be performed?

• The tuberculin skin test (TST) must be performed
  correctly using the Mantoux method to yield
  accurate results.
• In no circumstances should a patient history of
  BCG vaccination lead a health care provider to
  disregard a positive tuberculin skin test (TST).
• In some cases for example a recent patient
  history of BCG vaccination (within the past 10
  years) - the Quantiferon-Gold blood test may
  provide a greater degree of accuracy in LTBI
  screening results.
• Training information is available from local
  public health departments or from the CDC.

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TST Interpretation Criteria
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Recommended LTBI Treatment Approach (no active
TB)

• Prescribe Isoniazid (INH) 300 mg po qd for 9
  months (add Pyridoxine 50 mg po qd if pregnant,
  diabetic, malnourished or alcoholic). Fill one
  months supply at a time. Stress the importance
  of full compliance.
• Instruct patient to stop INH and seek immediate
  evaluation if they experience adverse symptoms
  (e.g. rash, numbness in hands or feet, jaundice,
  abdominal pain, nausea, vomiting, or anorexia).
• Arrange clinical follow-up monthly to question
  and examine for adverse effects, to review
  warning symptoms, and to refill prescription.
• Check baseline liver function tests only if
  hepatitis risk factors are present (pre existing
  liver disease, pregnant or lt3 months post-partum,
  HIV, or regular alcohol use.
• Check liver function tests during treatment only
  if symptoms or signs of hepatitis, abnormal
  baseline tests results, or hepatitis risk
  factors.
• Other LTBI regimens exist. Note that the INH
  dose must be weight-adjusted in children.
  Contact your local TB control program if your
  patient is a young child, is unable to take INH,
  or has been exposed to a known INH-resistant case.

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References/Resources

• Find your local Public Health Office
• Directory of Washington State Local Health
  Departments/Districts www.doh.wa.gov/LHJMap/LHJMap
  .htm
• Local and State TB Control Resources
• Seattle King County TB Control Program
  206-731-4579 http//www.metrokc.gov/health/tb/pro
  viders.htm
• Washington State DOH TB Control Program
  360-236-3443 http//www.doh.wa.gov/cfh/TB/default
  .htm
• American Lung Association of Washington
  206-442-5100 http//www.alaw.org/lung_disease/tub
  erculosis/
• CDC Training and TB Control Resources
• TST instructin kit available from CDC
  www.cdcnpin.org/scripts/tb/kit.asp
• CDC TB Education and Training Materials
  http//www.cdc.gov/nchstp/tb/pubs.pem.htm
• Interactive Core Curriculum on Tuberculosis
  What the Clinician Should Know. Web-based
  manual from CDC www.cdc.gov/nchstp/tb/webcourses/
  corecurr/index.htm
• Targeted tuberculin testing and treatment of
  latent TB infection. MMWR 2000 49 (No. RR-6)
  www.cdc.gov/mmwr/preview/mmwrhtml/rr4906a1.htm
• Treatment of Tuberculosis. MMWR 2003 52 (No.
  RR-11) www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1
  .htm
• Billing and Coding Information for LTBI
• ICD-9 code for LTBI (positive PPD, without active
  TB) 795.5
• CPT code for TST (tuberculin skin test
  intradermal) 86580