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Introduction
Slide 1 (Title
slide): Core Curriculum on Tuberculosis.
Graphic of a globe.
Slide 2: Core
Curriculum Contents
-
Inroduction
-
Transmission and Pathogenesis
-
Epidemiology of Tuberculosis (TB) in the
US
-
Testing for TB Disease and Infection
-
Diagnosis of TB
-
Treatment of Latent TB Infection
-
Diagnosis of TB
-
Treatment of Latent TB Infection (LTBI)
-
Treatment of TB Disease
-
Infection Control in Health Care Settings
-
BCG Vaccination
-
Community TB Control
Slide 3 (Chapter
title slide): Introduction
Slide 4: Areas
of Concern
-
TB cases continue to be
reported in every state
-
Drug-resistant cases reported
in almost every state
-
Estimated 10-15 million
persons in U.S. infected with M. tuberculosis
Transmission
and Pathogenesis
Slide 5 (Chapter
title slide): Transmission and Pathogenesis
This graphic depicts the transmission of TB. The dots in the air surrounding
two people represent droplet nuclei containing tubercle bacilli.
Slide 6: Transmission
of M. tuberculosis
-
Spread by droplet nuclei
-
Expelled when person with
infectious TB coughs, sneezes, speaks, or sings
-
Close contacts at highest
risk of becoming infected
-
Transmission occurs from
person with infectious TB disease (not latent TB infection)
Slide 7: Probability
TB Will Be Transmitted
-
Infectiousness of person
with TB
-
Environment in which exposure
occurred
-
Duration of exposure
-
Virulence of the organism
Slide 8: Pathogenesis
-
10% of infected persons
with normal immune systems develop TB at some point in life
-
HIV strongest risk factor
for development of TB if infected
-
Certain medical conditions
increase risk that TB infection will progress to TB disease
Slide 9: Conditions
That Increase the Risk of Progression to TB Disease
-
HIV infection
-
Substance abuse
-
Recent infection
-
Chest radiograph findings
suggestive of previous TB
-
Diabetes mellitus
-
Silicosis
-
Prolonged corticosteroid
therapy
-
Other immunosuppressive
therapy
Slide 10: Conditions
That Increase the Risk of Progression to TB Disease (cont.)
-
Cancer of the head and
neck
-
Hematologic and reticuloendothelial
diseases
-
End-stage renal disease
-
Intestinal bypass or gastrectomy
-
Chronic malabsorption syndromes
-
Low body weight (10% or
more below the ideal)
Slide 11: Common
Sites of TB Disease
Slide 12: Drug-Resistant
TB
Slide 13: Classification
System for TB (chart)
Class: 0; Type: No TB exposure. Not infected; Description: No history
of exposure. Negative reaction to tuberculin skin test.
Class: 1; Type: TB exposure. No evidence of infection; Description: History
of exposure. Negative reaction to tuberculin skin test.
Class: 2; Type: TB infection. No disease; Description: Positive reaction
to tuberculin skin test. Negative bacteriologic studies (if done). No
clinical, bacteriological, or radiographic evidence of active TB.
Class: 3; Type: TB, clinically active; Description: M. tuberculosis
cultured (if done). Clinical, bacteriological, or radiographic evidence
of current disease.
Class: 4; Type: TB. Not clinically active; Description: History of episode(s)
of TB or Abnormal but stable radiographic findings. Positive reaction
to the tuberculin skin test. Negative bacteriologic studies (if done)
and No clinical or radiographic evidence of current disease.
Class: 5; Type: TB suspected; Description: Diagnosis pending.
Epidemiology
of TB in the United States
Slide 14 (Chapter
title slide): Epidemiology in the United States
Image of the United States
Slide 15: TB
Morbidity Trends in the United States
-
From 1953 to 1984, reported
cases decreased by an average of 5.6% per year
-
From 1985 to 1992, reported
TB cases increased by 20%
-
Since 1993, reported TB
cases have been declining again
-
18,361 cases reported in
1998
Slide 16: Reported
TB Cases, United States, 1953-1998
This graph shows the total number of TB cases reported annually in the
United States from 1953, the year national TB surveillance officially
began, through 1998. From 1953 through 1985, the number of reported TB
cases declined steadily, from more than 84,000 in 1953 to 22,201 in 1985.
From 1985 through 1992, however, the number of cases increased by 20%
to 26,673.
Slide 17: Factors
Contributing to the Increase in TB Morbidity: 1985-1992
-
Deterioration of the TB
public health infrastructure
-
HIV/AIDS epidemic
-
Immigration from countries
where TB is common
-
Transmission of TB in congregate
settings
Slide 18: Factors
Contributing to the Decrease in TB Morbidity Since 1993
Increased efforts to strengthen
TB control programs that
-
Promptly identify persons
with TB
-
Initiate appropriate treatment
-
Ensure completion of therapy
Slide 19: Reported
Cases of TB by Country of Birth - United States, 1986-1998
In 1986, CDC began collecting information about country of birth on the
individual TB case report. In 1986, 22% of U.S. TB cases were among foreign-born
persons. The proportion of TB cases among foreign-born persons has steadily
increased since 1986 and increased markedly since 1992 (from 27% in 1992
to 42% in 1998).
Slide 20: Multidrug-Resistant
TB (MDR TB) Remains a Serious Public Health Concern
Slide 21: MDR
TB Cases, 1993-1998.
During 1993 through 1998, 45 states and the District of Columbia reported
at least one multidrug-resistant TB (MDR TB) case (i.e., resistance to
at least isoniazid and rifampin)
Slide 22: Persons
at Higher Risk for Exposure to or Infection with TB
-
Close contacts of person
known or suspected to have TB
-
Foreign-born persons from
areas where TB is common
-
Residents and employees
of high-risk congregate settings
-
Health care workers (HCWs)
who serve high-risk clients
Slide 23: Persons
at Higher Risk for Exposure to or Infection with TB (cont.)
-
Medically underserved, low-income
populations
-
High-risk racial or ethnic
minority populations
-
Children exposed to adults
in high-risk categories
-
Persons who inject illicit
drugs
Slide 24: Persons
at Higher Risk of Developing TB Disease once Infected
-
HIV infected
-
Recently infected
-
Persons with certain medical
conditions
-
Persons who inject illicit
drugs
-
History of inadequately
treated TB
Testing for
TB Disease and Infection
Slide 25 (Chapter
title slide): Testing for TB Disease and Infection
This slide shows the administration of the tuberculin skin test.
Slide 26: Purpose
of Targeted Testing
-
Find persons with LTBI who
would benefit from treatment
-
Find persons with TB disease
who would benefit from treatment
-
Groups that are not high
risk for TB should not be tested routinely
Slide 27: All
testing activities should be accompanied by a plan for follow-up care
This slide shows the administration of the tuberculin skin test.
Slide 28: Groups
That Should Be Tested for LTBI
Persons at higher risk for exposure to or infection with TB
-
Close contacts of a person
known or suspected to have TB
-
Foreign-born persons from
areas where TB is common
-
Residents and employees
of high-risk congregate settings
-
Health care workers (HCWs)
who serve high-risk clients
Slide 29: Groups
That Should Be Tested for LTBI (cont.)
Persons at higher risk for exposure to or infection with TB
-
Medically underserved, low-income
populations
-
High-risk racial or ethnic
minority populations
-
Children exposed to adults
in high-risk categories
-
Persons who inject illicit
drugs
Slide 30: Groups
That Should Be Tested for LTBI (Cont.)
Persons at higher risk for TB disease once infected
-
Persons with HIV infection
-
Persons recently infected
with M. tuberculosis
-
Persons with certain medical
conditions
-
Persons who inject illicit
drugs
-
Persons with a history of
inadequately treated TB
Slide 31: Administering
the Tuberculin Skin Test
-
Inject intradermally 0.1
ml of 5 TU PPD tuberculin
-
Produce wheal 6 mm to 10
mm in diameter
-
Do not recap, bend, or break
needles, or remove needles from syringes
-
Follow universal precautions
for infection control
-
This slide includes a picture
of the administration of the tuberculin skin test.
Slide 32: Reading
the Tuberculin Skin Test
-
Read reaction 48-72 hours
after injection
-
Measure only induration
-
Record reaction in millimeters
-
This slide includes a picture
of the reading of the tuberculin skin test.
This slide includes a picture
of the reading of the tuberculin skin test.
Slide 33: Classifying
the Tuberculin Reaction
Greater than or equal to 5 mm is classified as positive in
-
HIV-positive persons
-
Recent contacts of TB case
-
Persons with fibrotic changes
on chest radiograph consistent with old healed TB
-
Patients with organ transplants
and other immunosuppressed patients
Slide 34: Classifying
the Tuberculin Reaction (cont.)
Greater than or equal to 10 mm is classified as positive in
-
Recent arrivals from high-prevalence
countries
-
Injection drug users
-
Residents and employees
of high-risk congregate settings
-
Mycobacteriology laboratory
personnel
-
Persons with clinical conditions
that place them at high risk
-
Children < 4 years of
age, or children and adolescents exposed to adults in high-risk categories
Slide 35: Classifying
the Tuberculin Reaction (cont.)
Greater than or equal to 15 mm is classified as positive in
Slide 36: Occupational
Exposure to TB,
Appropriate Cutoff Depends on
Slide 37: Factors
that May Affect the Skin Test Reaction (Chart)
Type of Reaction: False-positive. Possible Cause: Nontuberculous mycobacteria.
BCG vaccination.
Type of Reaction: False-negative. Possible Cause: Anergy. Recent TB infection.
Very young age (< 6 months old). Live-virus vaccination. Overwhelming
TB disease.
Slide 38: Anergy
-
Do not rule out diagnosis
based on negative skin test result
-
Consider anergy in persons
with no reaction if:
-
Anergy skin testing no
longer routinely recommended
Slide 39: Boosting
-
Some people with LTBI may
have negative skin test reaction when tested years after infection
-
Initial skin test may stimulate
(boost) ability to react to tuberculin
-
Positive reactions to subsequent
tests may be misinterpreted as a new infection
Slide 40: Two-Step
Testing
Use two-step testing for initial skin testing of adults who will be retested
periodically
-
If first test positive,
consider the person infected
-
If first test negative,
give second test 1-3 weeks later
-
If second test positive,
consider person infected
-
If second test negative,
consider person uninfected
Diagnosis
of TB
Slide 41 (Chapter
title slide): Diagnosis of TB
This slide shows a picture of a microscope.
Slide 42: Evaluation
for TB
Slide 43: Symptoms
of Pulmonary TB
Slide 44: Systemic
Symptoms of TB
-
Fever
-
Chills
-
Night sweats
-
Appetite loss
-
Weight loss
-
Easy fatigability
Slide 45: Medical
History
-
Symptoms of disease
-
History of TB exposure,
infection, or disease
-
Past TB treatment
-
Demographic risk factors
for TB
-
Medical conditions that
increase risk for TB disease
Slide 46: Mantoux
Tuberculin Skin Test
Preferred method of testing for TB infection in adults and children
Slide 47: Chest
Radiograph
-
Abnormalities often seen
in apical or posterior segments of upper lobe or superior segments
of lower lobe
-
May have unusual appearance
in HIV-positive persons
-
Cannot confirm diagnosis
of TB
This slide includes a picture
of a chest radiograph with an arrow pointing to cavity in patient's right
upper lobe.
Slide 48: Specimen
Collection
-
Obtain 3 sputum specimens
for smear examination and culture
-
Persons unable to cough
up sputum, induce sputum, bronchoscopy or gastric aspiration
-
Follow infection control
precautions during specimen collection
Slide 49: Smear
Examination
-
Strongly consider TB in
patients with smears containing acid-fast bacilli (AFB)
-
Results should be available
within 24 hours of specimen collection
-
Presumptive diagnosis of
TB
Slide 50: AFB
smear
This slide shows an AFB smear. AFB (shown in red) are tubercle bacilli.
Slide 51: Cultures
-
Use to confirm diagnosis
of TB
-
Culture all specimens, even
if smear negative
-
Results in 4 to 14 days
when liquid medium systems used
This slides includes a picture
of colonies of M. tuberculosis growing on media
Slide 52: Drug
Susceptibility Testing
Drug susceptibility testing on initial M. tuberculosis isolate
Repeat for patients who
-Do not respond to therapy
-Have positive cultures despite 2 months of therapy
Promptly forward results to the health department
Slide 53: Persons
at Increased Risk for Drug Resistance
-
History of treatment with
TB drugs
-
Contacts of persons with
drug-resistant TB
-
Foreign-born persons from
high prevalent drug resistant areas
-
Smears or cultures remain
positive despite 2 months of TB treatment
-
Received inadequate treatment
regimens for greater than or equal to 2 weeks
Treatment
of Latent TB Infection (LTBI)
Slide 54 (Chapter
title slide): Treatment of Latent TB Infection (LTBI)
A picture showing a patient and health care worker. The patient is taking
medication given by the health care worker.
Slide 55: Candidates
for Treatment of LTBI
Positive skin test result greater than or equal to 5 mm
-
HIV-positive persons
-
Recent contacts of a TB
case
-
Persons with fibrotic changes
on chest radiograph consistent with old TB
-
Patients with organ transplants
and other immunosuppressed patients
Slide 56: Candidates
for Treatment of LTBI (cont.)
Positive skin test result greater than or equal to 10 mm
-
Recent arrivals from high-prevalence
countries
-
Injection drug users
-
Residents and employees
of high-risk congregate settings
-
Mycobacteriology laboratory
personnel
-
Persons with clinical conditions
that make them high-risk
-
Children < 4 years of
age, or children and adolescents exposed to adults in high-risk categories
Slide 57: Candidates
for Treatment of LTBI (cont.)
Positive skin test result greater than or equal to 15mm
Slide 58: Treatment
of LTBI with Isoniazid (INH)
-
9-month regimen considered
optimal
-
Children should receive
9 months of therapy
-
Can be given twice-weekly
if directly observed
Slide 59: Treatment
of LTBI with a Rifamycin and Pyrazinamide (PZA)
HIV-Positive Persons
-
A rifamycin and PZA daily
for 2 months
-
May be given twice weekly
-
Administration of rifampin
(RIF) contraindicated with some protease inhibitors (PIs) and nonnucleoside
reverse transcriptase inhibitors (NNRTIs)
HIV-Negative Persons
-
Clinical trials have not
been conducted
-
Daily RIF and PZA for 2
months
-
May be given twice weekly
Slide 60:
Contacts of INH-Resistant TB
-
Treatment with a rifamycin
and PZA
-
If unable to tolerate PZA,
4-month regimen of daily RIF
-
HIV-positive persons: 2
month regimen with a rifamycin and PZA
Contacts of Multidrug-Resistant
TB
-
Use 2 drugs to which the
infecting organism has demonstrated susceptibility
-
Treat for 6 months or observe
without treatment (HIV-negative)
-
Treat HIV-positive persons
for 12 months
-
Follow for 2 years regardless
of treatment
Slide 61:
Fibrotic Lesions
Pregnancy and Breast-feeding
-
INH daily or twice weekly
-
Pyridoxine supplementation
-
Breast-feeding not contraindicated
Slide 62: Monitoring
Patients
Before treatment for LTBI is started, clinicians should
-
Rule out possibility of
TB disease
-
Determine history of treatment
for LTBI or disease
-
Determine contraindications
to treatment
-
Obtain information about
current and previous drug therapy
-
Recommend HIV testing if
risk factors are present
Slide 63: Monitoring
Patients (cont.)
Establish rapport with patient and emphasize
-
Benefits of treatment
-
Importance of adherence
to treatment regimen
-
Possible adverse side effects
of regimen
-
Establishment of optimal
follow-up plan
Slide 64: Monitoring
Patients (cont.)
Baseline laboratory testing
Slide 65: Monitoring
Patients (cont.)
At least monthly, evaluate for
-
Adherence to prescribed
regimen
-
Signs and symptoms of active
TB disease
-
Signs and symptoms of hepatitis
(if receiving isoniazid alone, and at 2, 4, and 8 weeks if receiving
RIF and PZA)
Treatment of TB Disease
Slide 66 (Chapter
title slide): Treatment of TB Disease
A picture showing a patient and health care worker. The patient is taking
medication given by the health care worker.
Slide 67: Basic
Principles of Treatment
-
Provide safest, most effective
therapy in shortest time
-
Multiple drugs to which
the organisms are susceptible
-
Never add single drug to
failing regimen
-
Ensure adherence to therapy
Slide 68: Adherence
Slide 69: Case
Management
-
Assignment of responsibility
-
Systematic regular review
-
Plans to address barriers
to adherence
Slide 70: Directly
Observed Therapy (DOT)
-
Health care worker watches
patient swallow each dose of medication
-
Consider DOT for all patients
-
DOT should be used with
all intermittent regimens
-
DOT can lead to reductions
in relapse and acquired drug resistance
-
Use DOT with other measures
to promote adherence
Slide 71: Treatment
of TB for HIV-Negative Persons
Slide 72: Treatment
of TB for HIV-Positive Persons
Slide 73: Treatment
of TB for HIV-Positive Persons (cont.)
RIF-based regimens generally recommended for persons
Initial treatment phase should
consist of
-
Isoniazid (INH)
-
Rifampin (RIF)
-
Pyrazinzamide (PZA)
-
Ethambutol (EMB)
RIF may be used with some PIs
and NNRTIs
Slide 74: Treatment
of TB for HIV-Positive Persons (cont.)
For patients receiving PIs or NNRTIs, initial treatment phase may consist
of
-
Isoniazid (INH)
-
Rifabutin (RFB)
-
Pyrazinamide (PZA)
-
Ethambutol (EMB)
An alternative nonrifamycin
regimen includes INH, EMB, PZA, and streptomycin (SM)
Slide 75
Extrapulmonary TB
In most cases, treat with same regimens used for pulmonary TB
Bone and Joint TB, Miliary TB, or TB Meningitis in Children
Treat for a minimum of 12 months
Slide 76
Pregnant women
-
9-month regimen of INH,
RIF, and EMB
-
PZA and SM are contraindicated
-
PZA not contraindicated
in HIV-positive pregnant women
Children
Infants
Slide 77: Treatment
Regimens for TB Resistant Only to INH
HIV-Negative Persons
-
Carefully supervise and
manage treatment to avoid development of MDR TB
-
Discontinue INH and continue
RIF, PZA, and EMB or SM for the entire 6 months
-
Or, treat with RIF and EMB
for 12 months
HIV-Positive Persons
Slide 78: Multidrug-Resistant
TB (MDR TB)
-
Presents difficult treatment
problems
-
Treatment must be individualized
-
Clinicians unfamiliar with
treatment of MDR TB should seek expert consultation
-
Always use DOT to ensure
adherence
Slide 79: Monitoring
for Adverse Reactions
-
Baseline measurements
-
Monitor patients at least
monthly
-
Monitoring for adverse reactions
must be individualized
-
Instruct patients to immediately
report adverse reactions
Slide 80: Monitoring
Response to Treatment
-
Monitor patients bacteriologically
monthly until cultures convert to negative
-
After 3 months of therapy,
if cultures are positive or symptoms do not resolve, reevaluate for
-
If cultures do not convert
to negative despite 3 months of therapy, consider initiating DOT
Infection
Control in Health Care Settings
Slide 81 (Chapter
title slide): Infection Control in Health Care Settings
This slide includes a drawing of a man wearing a face mask.
Slide 82: Infectiousness
Patients should be considered infectious if they
-
Are coughing
-
Are undergoing cough-inducing
or aerosol-generating procedures, or
-
Have sputum smears positive
for acid-fast bacilli, and they
-
Are not receiving therapy
-
Have just started therapy,
or
-
Have poor clinical response
to therapy
Slide 83: Infectiousness
(cont.)
Patients no longer considered infectious if they meet all of these criteria:
-
Are on adequate therapy
-
Have had a significant clinical
response to therapy, and
-
Have had 3 consecutive negative
sputum smear results
Slide 84: Infection
Control Measures
-
Administrative controls
to reduce risk of exposure
-
Engineering controls to
prevent spread and reduce concentration of droplet nuclei
-
Personal respiratory protection
in areas where increased risk of exposure
Slide 85: Administrative
Controls
Reduce risk of exposing uninfected persons to infectious disease:
-
Develop and implement written
policies and protocols to ensure
-
Rapid identification
-
Isolation
-
Diagnostic evaluation
-
Treatment
-
Implement effective work
practices among HCWs
-
Educate, train, and counsel
HCWs about TB
-
Test HCWs for TB infection
and disease
Slide 86: Administrative
Controls (cont.)
Perform risk assessment and classification of facility based on
-
Profile of TB in community
-
Number of infectious TB
patients admitted
-
Analysis of HCW skin test
conversions
Slide 87: Engineering
Controls
To prevent spread and reduce concentration of infectious droplet nuclei
Slides 88: Personal
Respiratory Protection
Use in areas where increased risk of exposure:
BCG Vaccination
Slide 89 (Chapter
title slide): BCG Vaccination
This slides shows picture of a needle and medication vial.
Slide 90: Recommendations
for BCG Vaccination
Slide 91: Recommendations
for BCG Vaccination (cont.)
Considered for an infant or child with negative skin-test result who
Slide 92: Recommendations
for BCG Vaccination (cont.)
HCWs considered on individual basis in settings in which
-
High percentage of MDR TB
patients has been found
-
Transmission of drug-resistant
TB strains and subsequent infection are likely, and
-
Comprehensive TB infection-control
precautions implemented and not successful
Slide 93: BCG
Contraindications
Contraindicated in persons with impaired immune response from
-
HIV infection
-
Congenital immunodeficiency
-
Leukemia
-
Lymphoma
-
Generalized malignancy
-
Receiving high-dose steroid
therapy
-
Receiving alkylating agents
-
Receiving antimetabolites
-
Receiving radiation therapy
Slide 94: BCG
Vaccination and Tuberculin Skin Testing
-
Tuberculin skin testing
not contraindicated for BCG-vaccinated persons
-
LTBI diagnosis and treatment
for LTBI considered for any BCG-vaccinated person whose skin test
reaction is greater than or equal to 10 mm, if any of these circumstances
are present:
-
Was contact of another
person with infectious TB
-
Was born or has resided
in a high TB prevalence country
-
Is continually exposed
to populations where TB prevalence is high
Community
TB Control
Slide 95 (Chapter
title slide): Community TB Control
This slide shows a picture of three men on a street corner. The patient
is taking medication administered by an outreach worker.
Slide 96: Preventing
and Controlling TB
Three priority strategies:
-
Identify and treat all persons
with TB disease
-
Identify contacts to persons
with infectious TB; evaluate and offer therapy
-
Test high-risk groups for
LTBI; offer therapy as appropriate
Slide 97: Health
care providers should work with health department in the following areas:
-
Overall planning and policy
development
-
Identification of persons
with clinically active TB
-
Management of persons with
disease or TB suspects
-
Identification and management
of persons with LTBI
-
Laboratory and diagnostic
services
-
Data collection and analysis
-
Training and education
Slide 98: Overall
Planning and Policy
-
Develop overall TB control
strategy
-
Review local laws, regulations,
and policies
-
Guide and oversee TB control
efforts of local institutions and practitioners
-
Provide consultations in
TB treatment, contact investigations, and infection control practices
-
Seek out necessary funding
and resources
-
Educate policymakers
Slide 99:
Identification of Persons Who Have
Clinically Active TB
Contact Investigation
-
Purpose of a contact investigation
is to find persons who
-
Have TB disease so treatment
can be given, and further transmission stopped
-
Have LTBI so treatment can
be given
-
Are at high risk of developing
TB disease and require treatment until LTBI excluded
Slide 100:
Management of Persons Who Have TB Disease or TB Suspects
Management involves range of services, which include
-
Developing a treatment plan
-
Promoting and ensuring adherence
-
Providing a referral system
for other medical problems
-
Providing clinical consultation
services
-
Providing inpatient care
when necessary
-
Providing appropriate facilities
to isolate and treat patients with infectious TB
-
Maintaining an infection
control program
Slide 101:
Identification and Management of Persons with LTBI
-
Establish working relationships
with other health care providers
-
Target testing to well-defined
high-risk groups
-
Flexibility needed in defining
high-priority groups
Slide 102:
Laboratory and Diagnostic Services
-
Readily accessible
-
AFB results within 24 hours
of specimen collection
-
Clinicians promptly report
all TB cases and suspected cases
-
All TB smear and culture
results reported by laboratories
Slide 103:
Data Collection and Analysis
-
TB reporting required in
every state
-
All new cases and suspected
cases promptly reported to health department
-
All drug susceptibility
results sent to health department
Slide 104:
Training and Education
TB control programs should
-
Provide training for program
staff
-
Provide leadership in TB
education to the community
-
Ensure community leaders,
clinicians, and policymakers are knowledgeable about TB
-
Educate the public
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