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Transcript of BCCDC TB ManualRevisedFebruary 2012
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TB ManualFebruary 2012 | For proessionals to help manage tuberculosis
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TABLE OF CONTENTS
INTRODUCTION
PURPOSE OF THE MANUAL
ROLES & RESPONSIBILITIES
SECTION I: SCREENING FOR TUBERCULOSIS7 Screening Programs or Populations at Risk14 Screening & Diagnostic Tools
17 Tuberculin Skin Test TS T
22 Radiology
25 Bacteriological Examination o Sputum
28 Flow Chart: TB Mycobacteriology
SECTION II: ACTIVE TUBERCULOSIS30 Case Management & Active Case Finding
39 Flow Chart: Management o An Active Case o Tuberculosis
SECTION III: CONTACT INVESTIGATION
41 Goals o Contact Investigation 41 Roles & Responsibilities
42 Principles to Guide Contact Investigation
44 Assigning Priority or Investigation o Contacts
46 Conducting a Contact Investigation
48 Contact Examination Procedure
52 Contact Examination in Congregate Settings
SECTION IV: PREVENTION56 Preventative Therapy
60 Riampin Preventative Treatment
62 Medication Reordering Instructions or Latent TB Inection
SECTION V: APPENDIX66 Appendix A: Glossary
71 Appendix B: Basic Facts about Tuberculosis
74 Appendix C: Medications
91 Appendix D: Pediatric TB
95 Appendix E: TB Services or Aboriginal Communities
117 Appendix F: BCG Vaccine
119 Appendix G: Tumour Necrosis Factor
121 Appendix H: Atypical Mycobacteria
124 Appendix I: TB & HIV
126 Appendix J: Multiple Drug Resistent TB
128 Appendix K: Directly Observed Therapy
131 Appendix L: Interim Guidelines or use o IGRA Studies
132 Appendix M: Molecular Diagnostic Tools
134 Appendix N: Immigration
137 Appendix O: Tuberculosis & Chronic Renal Failure
139 Appendix P: Sputum Induction
141 Appendix Q: Forms
3
4
5
6
29
40
55
65
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INTRODUCTION
This manual was developed by the physicians and nurses at TB Control to meet
the needs o those proessionals throughout the province responsible or managing
tuberculosis. It refects the changing policies and practices at TB Control which in
turn are based on current research ndings and new technology. The 6th Edition
o the Canadian Tuberculosis Standards has provided the oundation on which the
manual was organized. While there have not been dramatic shi ts in managementprinciples o tuberculosis there are some important changes that have taken place.
The intention was to create a manual that is userriendly, clear and concise and
one that will approximate any expectations that users o the manual may have.
As a Provincial Manual it provides direction to health proessionals working in
a variety o settings. As such it cannot possibly meet all the needs o each health
unit and their community. It will be incumbent upon the health centres to work
with TB Control in developing strategies to conront the challenges they are
acing, whether it is an outbreak setting or an isolated First Nations community.
It is our desire to have a manual that provides both direction and fexibility. As
tuberculosis inormation and practices are continually evolving an eort will bemade to provide timely updates to the manual and communicate these changes to
the eld accordingly. An important component o this guideline or best practice
in the area o tuberculosis control is comments rom the users. Every eort will
be made to incorporate that eedback in our ongoing upgrading o the manual to
better service health proessionals in BC.
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PURPOSE OF THE MANUAL
Bill 23 2008: The Public Health Act, Communicable Disease Regulation; Part 3
www.leg.bc.ca/38th4th/1st_read/gov231.htm#part3 requires that tuberculosis
TB be reported under schedule A. This tuberculosis manual is designed or the
use o sta designated under the Public Health Act to provide tuberculosis control
and surveillance.
The document is produced by the Division o TB Control at the BC Centre or
Disease Control BCCDC, an agency o Provincial Health Services Authority
PHSA, to act as a guide or nurses and doctors working in public health,
community health, and inection controlas well as a reerence or students,
researchers, and primary care physicians.
The Division o TB Control is responsible or the establishment and maintenance
o policies, standards and procedures or the control o TB in British Columbia. The
Canadian Tuberculosis Standards 2007 are used as guidance and adapted to meet
the specic needs within British Columbia.
The manual contains background inormation regarding the signicant
aspects o tuberculosis, the policies, standards, and guidelines or the control
and surveillance o tuberculosis, as well as the supporting documentation and
data collection tools. This manual is meant to be used in conjunction with the
Canadian TB Standards 2007. Copies o the Canadian Tuberculosis Standards
are available by contacting the BC Lung Association at 604 731LUNG 5864
or 1800665LUNG 5864 outside the Lower Mainland, or on line at
http://www.phacaspc.gc.ca/tbpclatb/pubs/tbstand07eng.php
The manual is organized to guide the reader in TB screening methods or various
high risk populations, diagnosis and treatment o active TB cases, diagnosisand treatment o latent TB, contact tracing, TB prevention and client education.
The appendices provide additional inormation, orms and resources or patient
teaching, as well as a glossary o denitions requently used in TB Control.
Recommendations or revisions may be directed to the Director o TB Control.
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ROLES AND RESPONSIBILITIES
The responsibilit y or the control o communicable diseases, including TB, lies with
the Medical Health O cer. The clinical care o an active case o tuberculosis is the
responsibility o the clients personal physician, requently in consultation with the
physicians at TB Control and with the assistance o local public health nurses and
community health nurses working in Aboriginal communities.
TUBERCULOSIS CONTROL (TB CONTROL)
TB Control provides central coordination o management and control measures
or cases, contacts, and others at risk o developing tuberculosis. This includes the
control and provision o ree medications or treatment o active disease and latent
inection. It also includes coordination o contact investigation, administration
o the provincial TB registr y database, and reporting o cases nationally. TB
Control is committed to supporting regional health authorities and Aboriginal
communities in ensuring the provisions o the Bill 23 2008: Public Health Act
and communicable disease regulations are met.
PUBLIC HEALTH
Public and community health nurses play a central role in the delivery o the
TB program in BC. In collaboration with the primar y care physician, MHO,
and TB Control they are actively involved in surveillance, contact investigation,
supervision o treatment o both active TB and latent TB inection within their
health regions. In most instances, they are the primary contact with clients
and consequently have a signicant infuence on the outcome o the treatment
program. Inormation collected in the eld by public health should be relayed to
TB Control so client care is consistent, sae and epidemiological data can be used
or uture program development.
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SECTION I SCREENING FOR TUBERCULOSIS
Screening Programs or Populations at Risk | 7
Screening & Diagnostic Tools | 14
Tuberculin Skin Test TST | 17
Radiology | 22
Bacteriological Examination o Sputum | 25
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SCREENING PROGRAMS FOR POPULATIONS AT RISK
TB Control recommends that certain groups o the population should be screened
based on relative risk actors. Specic populations and programs selected or
screening are as ollows:
Detox Centres and Residential Alcohol & Drug Treatment Programs
Adult Licensed Residential Community Care Facilities Licensed Child Care Facilities
Correctional Facilities
Other Speciic Populations i.e. Health Care employees and Immigration
1) DETOX AND RESIDENTIAL TREATMENT CENTRES
The goal is to identiy and treat individuals with active TB disease and prevent
transmission to a vulnerable population in group settings.
RATIONALE:
Detox acilities are oten short stay settings. Thus, TB Control does not recommend
TB skin testing as it requires a reading 48 to 72 hours ater initial planting and only
indicates inection as opposed to active disease. Chest Xrays CXR, sputum collection
and symptom assessment are more valuable tools in ruling out active disease which is
the goal in screening or admission to detox and treatment centers.
TABLE 1.1: SC REENING FOR DE TOX CEN TRES AND R ESIDENTIAL T REATMENT PROGR AMS
Clients Tuberculin Skin TestTST
Chest Xray CXR Symptom Inquiry Sputum collectionor AFB 3 samples
Detox Centres
Following entry toacility
NOtypically veryshort stays anddiicult to locateclient ollowingdeparture
YES YES I abnormal CXR orsymptomatic:Collect 1 specimenimmediately, then2 additional on theollowing 2 days
Residential Drug &Alcohol TreatmentPrograms
Complete prior to entryto acility
YESunlessdocumentation oprevious positive TSTor history o active TB
disease treated
I TST is positive, orhistory o positiveTST/active TB o rshowing symptoms
o TB
YES I abnormal CXR,symptomatic, orunwilling to haveCXR: Collect 1
specimen immediately,then 2 additional onthe ollowing 2 days
Note: or employee screening, please reer to Public Service Guidelines page 9.
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2) ADULT LICENSED RESIDENTIAL COMMUNITY CARE FACILITIES
All persons who are entering a care acility, or starting employment in such a
acility, should be screened or TB beore admission by their private physician,
public health, or TB Control. Due to the challenges o screening or TB prior
to admission, a patient or employee may be screened post admission as
recommended below i they are not symptomatic. The Medical Health O icer
may make alternative policy decisions based on local disease incidence andprevalence. The Tuberculosis Screening Program Form HLTH 939 must be used
or the initial screening program. http://www.bccdc.ca/NR/rdonlyres/69DDB0EB
CC6C458C8EEC67C3899C6AD2/0/HLTH939_Feb2011.pd
RATIONALE
To minimize the risk o spreading ac tive TB disease as residents in care aci lities
tend to remain or long periods o time in an environment which would pose a
risk to both the sta and the other residents. Compared to general hospitals, care
acilities tend to have reduced levels o medical sur veillance. As many clients
have reduced mental alertness, it is important to screen the above group withinthe suggested period o time. Preventing a case o TB rom spreading within a
acility reduces the need or ex tensive contact tracing and keeps others healthy.
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TABLE 1.2: SCREENING FOR ADULT LI CENSED R ESIDENTIAL COMMUNITY C ARE FACIL IT IES *
Tuberculin Skin TestTST
Chest Xray CXR Symptom Inquiry Sputum collectionor AFB 3 samples
Resident:Complete prior to
admission or within1 month o admissioni not symptomatic
YESonly orresidents less than
60 years o age andpreviously skin testnegative or unknown
YESor residents 60years o age and older,
or symptomatic, orhave a positive TST orpersons who have riskactors or TB
YES I abnormal CXR orsymptomatic:
Submit 3 sputa or AFB
New Employees:Complete prior toemployment or within2 weeks
YESunlessdocumentationo previous positiveTST or histo ry oactive TB disease ori TST neg in last 6months & no contactwith active case
YESi TST is positiveor symptoms o TB
YES I abnormal CXR orsymptomatic:
Submit 3 sputa or AFB
* All licensed group home screening should be based on contact tracing o active cases. Routine
screening, not required.
EXCLUSIONS FOR RESIDENTS:
Where there is di culty arranging a chest radiograph at the time o
admission, the ollowing are acceptable:
A normal chest radiograph completed within one year preceding admissionor asymptomatic clients.
EXCLUSIONS FOR EM PLOYEES:
Normal CXR in the past 6 months
Pregnant employees should have CXR ollowing delivery. Contact TB Control i symptomatic
EXCLUSION FOR TUBERCULIN SKIN TEST (TST):
Previous TB
History o anaphylaxis or severe reaction to TST
Documented previous positive TST
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3) LICENSED CHILD CARE FACILITIES
Routine screening o employees o licensed child care acil ities is currently not
recommended except in Aboriginal communities as identied by TB Control.
RATIONALE
A review o our cases shows that no child had been inected as a result o exposure
to a child care worker in nonAboriginal communities in BC within the last ten
years. Screening o child care employees is logistically di cult and can be costly
due to the large turnover o employees.
The only exceptions to these recommendations are Aboriginal child care acilities
which will continue to require screening at this time. See Appendix E
NOTE:These recomm endations can be changed at the discretion o the local Medical
Health Oicer depending on local circumstances.
4) CORRECTIONAL FACILITIES
Individuals in the correctional setting are at relatively highrisk o being inected
with tuberculosis or having active disease resulting in the potential or outbreaks
in these institutions.
FEDERAL CORRECTIONAL FACILITIES
In 1994, tuberculin skin test was replaced with twostep testing. Individuals with
a positive tuberculin or symptoms are reerred or chest xray and a medical
evaluation.
PROVINCIAL CORRECTIONAL FACILITIES
There are a high number o admissions per year, with the vast majority o inmates
staying or weeks or months at a time. Inmates are assessed upon admission. No
routine tuberculin skin testing is done on asymptomatic inmates. Symptomatic
inmates are reerred or medical assessment and TB workup TST, sputum and
chest xray. Any inmate with a positive skin test should have a chest xray and i
symptomatic, three sputum specimens should be submitted or AFB.
Correction acility sta should have a baseline TST perormed when hired. Furthertesting should only be done in response to an exposure to an active case.
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TABLE 1.3: S CREENING FOR FED ERAL AND PROV INCIAL CORRECT IONAL FACILIT IES
Tuberculin Skin TestTST
Chest Xray CXR Symptom Inquiry Sputum collectionor AFB 3 samples
Federal Corrections:
Inmates
YESonce or newadmissions
Repeat annually or
inmates with negativeTS T
YESor inmateswith a positive TST orreusing a TST
YES * I abnormal CXR orsymptomatic:
Submit 3 sputa or AFB
Federal Corrections:
Sta
YESbaseline uponemployment andannually i negativeTST
Baseline i previouspositive TST or activeTB
YES I abnormal CXR orsymptomatic:
Submit 3 sputa or AFB
ProvincialCorrections:
Inmates
Not routineonly iclient is s ymptomaticor at risk or TB i.e.HIV positive
Not routine
All symptomaticinmates
YES * I abnormal CXR orsymptomatic:
Submit 3 sputa or AFB
ProvincialCorrections:
Sta
YESbaseline TST,unless documentedexclusions
Baseline i previouspositive TST or historyo active TB
YES
* Symptomatic inmates isolated until TB ruled out
5) OTHER SPECIFIC POPULATIONS
Health Care and Public Service Employees
Volunteers
Post Secondary Institutions
Immigration Surveillance
High Risk Individuals
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HEALTH CARE & PUBLIC SERVICE EMPLOYEES
TB Control recommends that all employees be screened or TB at the time o
hiring. The establishment o baseline data or individuals in the above groups
determines who has been inected with the tubercle bacillus and who has not.
Institutions with the classication o medium to high risk o exposure or sta may
decide to implement routine TB screening as an adjunct or substitution or contact
investigation. Once the baseline has been established, contact screening may be
more easily undertaken when necessar y.
Local conditions may be such that the Medical Health O cer and TB Control
jointly make alternate policy decisions.
It is the responsibility o institution to implement.
TABLE 1.4: SCREENING FOR HEALTH CARE AND PUBLIC SERVICE EMPLOY EES
Tuberculin Skin TestTST Chest Xray CXR Symptom Inquiry Sputum collectionor AFB 3 samples
Health CareEmployeesHospitals:
Responsibilityo institution toimplement
YESbaseline uponemployment andannually i negativeTST
Repeat TST based onexposure to activeTB or in accor dancewith acility InectionControl Committeerecommendations
based on level o riskor exposure.
YES i baselineTST positive attime o hiring, orsymptomatic
Repeat CXR i exposedto active TB
YES I abnormal CXR orsymptomatic:
Submit 3 sputa or AFB
Public ServiceEmployees:
Examples include:Community/PublicHealth nurses, homecare nurses, streetnurses, police, ireighters
YESbaseline TSTupon employment
Repeat TST based onexposure to active TB
YESi TST is positiveor showing symptomso TB
Repeat CXR i exposedto active TB
YES I abnormal CXR orsymptomatic:
Submit 3 sputa or AFB
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VOLUNTEERS
The need or testing is determined locally and on an individual basis.
Volunteers working with high risk populations see page 16 should ollow the
same recommendations as or public service employees.
POST-SECONDARY INSTI TUTIONS
Currently it is not our policy in British Columbia to screen postsecondary students
or tuberculosis. Exceptions to this general policy should only be made at the
discretion o the local Medical Health O cer in consultation with TB Control.
An exception to this policy is or students in health care who require baseline TB
screening prior to direct patient care.
IMMIGRATION SURVEILLANCE
Health and Welare Canada screens all persons applying or immigration to
Canada. Immigrants who have a history o previous tuberculosis, or who have
evidence on chest radiograph o inactive tuberculosis, are reerred to TB Controlupon arrival in Canada. These persons have signed a orm that states they will
comply with surveillance requirements and repor t to TB Control or assessment.
Upon receiving notication rom Health and Citizenship Canada, TB Control wil l
send notication see Appendix N page 136 to the health unit HU in which
this person resides requesting:
A health history orm 939
Chest radiograph
Three sputum specimens.
Health Units HU will locate the persons and advise them o TB Controls request
and will arrange or chest radiograph and the collection o the specimens to be
sent to TB Control. See Appendix N
I the individual is asymptomatic and does not have health coverage, the chest
xray CXR can be delayed until they are eligible or health coverage usually
within three months. I an immigrant is symptomatic requiring a CXR beore
three months they will be requested to cover the cost. In the event there is nancial
hardship TB Control will cover the cost o the CXR or those who are symptomatic.
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TABLE 1.5: SCREENING FOR POST-LANDING IMMIGR ATIO N SURVEILLANCE
Tuberculin Skin TestTST
Chest Xray CXR Symptom Inquiry Sputum collectionor AFB 3 samples
Postlandingsurveillance
NO YES YES YES
HIGH RISK INDIVIDUALS
The ol lowing groups require special considerations or screening relating to
their individual risk actors. TB Control recommends TST, symptom inquiry, and
baseline chest xray or the ollowing individuals:
HIV positive
Organ Transplant
Dialysis
Prior to starting Tumour Necrosis Factor TNF inhibitor Appendix G
Street involved including; alcohol and/or substance users Followup screening based on the exposure to active TB or at the
discretion o local healthcare providers
SCREENING AND DIAGNOSTIC TOOLS
ASSESSMENT COMPLET ING HLTH 939 FORM
Proper assessment o an individual and documentation o the assessment provides
important clinical inormation which assists the clinicians at TB Control to
make a diagnosis and/or recommendations. The HLTH 939 orm is a guideline to
completing the assessment and includes the ollowing points:
Demographics
History
Contact inormation
Risk actors or developing active TB
Symptoms o active TB
The public health nurse PHN and community health nurse CHN must ensure
the ollowing inormation is collected and conveyed to TB Control by way o a
Health HLTH 939 orm or each client screened or TB See orms in Appendix Q.
http://www.bccdc.ca/NR/rdonlyres/69DDB0EBCC6C458C8EEC67C3899C6AD2/0/
HLTH939_Feb2011.pd
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TST
Indication or screening
Contraindication
Tuberculin Skin Test TSTto identiy individuals who have been
inected by tubercle bacilli see Appendix Q Decision Support
Tools TST
Chest xray i history, symptoms, and/or TST indicate necessity
3 sputum specimens submitted or AFB smear and culture i
symptom inquiry, chest radiograph and/or TST indicate necessity
DEMOGRAPHICS
Obtain personal inormatione.g. name, date o birth, sex, address, phone
number, physicians name and address, and Personal Health Number PHN
Ethnic origin
Aboriginal statuslives on or o reserve; community & health centre
Country or Canadian province o birthi patient is rom outside o Canada,
must indicate date o arrival in Canada
HISTORY
Prior exposure to tuberculosis
Previous active TB and treatment
Previous preventive treatment
Previous tuberculin tests, i any, provide results
Previous BCG, presence o BCG scar
Travel to countries which have high incidences o TB length o travel
CONTACT INFORMATION
TB number o source case i TB number not yet assigned may use PHN
Date o contact, length o contact, type o contact, location o contact
Indicate i TST baseline or 8 weeks post contact
TY PE OF CONTACT:
Type 1Household or share the same air space or more than 4 hrs/wk
Type 2Nonhousehold or share the same air space or 24 hrs/wk Type 3Casual or share the same air space or less than 2 hrs/wk
NOTE: Further detailed inormation about contact tracing will be discussed in Section IV: Contact Tracing
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RISK FACTORS FOR DEVELOPING ACTIVE TB
INCREASED RISK
Treatment with glucocorticoids or any other immunosuppressive agent
TNF inhibitors see Appendix G
Diabetes
Underweight less than 90% ideal body weight or BMI less than 20
Young age when inected equal to or less than 5
IV drug use/ crack cocaine
Homelessness
HIGH RISK
HIV/AIDS
Transplantation related to immunosuppressant therapy
Chronic renal ailure requiring hemodialysis
Carcinoma o head & neck
Recent TB inection TB contact within 2 years
TB contact within 2 years
Silicosis
SYMPTOMS OF ACTIVE TUBERCULOSIS
Cough, and/or sputum production greater than 3 weeks Collect 3 sputum on 3 consecutive days
Sputum production
Blood in sputum hemoptysis
Night sweats
Fever
Fatigue
Weight loss Loss o appetite
Chest pain
Other symptoms will depend on the site o disease
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TUBERCULIN SKIN TEST (TST)
PURPOSE: To determine whether an individual has been inected
with the tubercle bacillus as evidenced by a positive tuberculin skin test.
The tuberculin skin test TST is the main test used to diagnoselatent tuberculosis inection LTBI. This test consists o an
intradermal injection o 0.1 ml o puried protein derived rom
Mycobacterium tuberculosis bacteria. In a person with normal
immunity to these tuberculin antigens, a cellmediated, delayed
type hypersensitivity reaction will occur within 4872 hours. The
reaction will cause localized swelling and will be maniest as
induration o the skin at the injection site. It requires 3 to 8 weeks
ater an exposure or the body to mount a response and or the test
to turn positive.
A tuberculin skin test is not diagnostic o active tuberculosisdisease. Other diagnostic tools i.e. sputum or AFB, chest xray,
symptom inquiry are the principle means o screening or active
TB disease. A negative TST does not exclude a diagnosis o ac tive
tuberculosis. I symptomatic, collect 3 sputum specimens or
mycobacteriology, send or chest xray, and call TB Control or
urther advice.
INDICATIONS FOR TST ADMINISTRATION
Contacts o a patient with a recent diagnosis o active inectious TB Household, or close contacts o a patient diagnosed with extrapulmonary TB
Reverse contacts o a child diagnosed with active TB
Screening individuals prior to starting tumour necrosis actor TNF inhibitors.
Screening programs or select groups o persons judged to be at risk
i.e. kidney dialysis patients
HIV positive individuals and individuals at high risk or HIV inection
i.e. Injection Drug Users IDU. TST results may not be reliable in HIV positive
individuals with low CD4 counts less than 200.
International travelers who will be residing in countries where tuberculosis is
endemic. These travelers should have a baseline TST beore leaving Canada and
a TST on return to Canada. A twostep TST is an option in this situation at baseline testing.
Travellers returning rom visits to endemic areas
Mass screening to determine community prevalence o inection only applies to
identiied Aboriginal Communities See Appendix E
Specic populations at risk, or example: Health Care Employees see Screening section
Individuals with signs and/or symptoms o active tuberculosis, remembering that a
negative TST does not rule out TB
NOTE:Reliance should not beplaced on a previous TST thatwas not documented unlessthe person can give you aclear description o extensiveswelling, especially withblistering.
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CONTRAINDICATIONS
Persons who have had an anaphylactic response or severe reaction to a previous
TST using Tubersol, a similar product or components o Tubersol.
Persons who have a documented history o a previous positive reaction to
tuberculin testing.
Persons who have documentation o previous active tuberculosis.
Persons with major viral inections or livevirus vaccinations in the past 4 weeksto avoid alse negative reactions.
Individuals with severe burns or eczema at skin testing sites.
NOTE:
A history o a Bacille CalmetteGuerin BCG vaccine is not acontraindication or a TST.
Pregnancy is not a contraindication or a TST.
TST may be given on the same day as MMR and/or Varicella, andYellow Fever vaccine otherwise wait or at least 4 weeks.
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ADMINISTRATION OF TUBERCULIN SKIN TEST
Tuberculin skin testing is standardized by using Sano Pasteur Tubersol bio
equivalent to 5 TU 0.1 ml o tuberculin o puried protein derivative PPD,
which is supplied by the pharmacy at BC Centre or Disease Control.
Tubersol should be used as soon as it is drawn up in the syringe as the tendency o
tuberculin to adhere to plastic suraces causes marked reduction o the strength o the
solution. Sano Pasteur, maker o the PPD, recommends that the tuberculin be let
drawn up in the syringe or a maximum o 20 minutes. Tubersol should be stored in
a rerigerator 28 C and can be adversely aected by exposure to light.
PREPARATION
Ensure all equipment is readily available, including sharps container
and anaphylaxis kit.
Seat the client comortably and explain the procedure. Ensure that
the client is aware that they must return in 48 72 hours or reading.
Selreading o skin test results by the client is not acceptable.
Wash your hands. Use a tuberculin syringe with a 26 to 27 gauge needle
INJECTION PROCESS
Cleanse the skin with isopropyl alcohol unless allergic and allow to dry.
The skin o the orearm should be held taut with one hand.
Administer test intradermally on the anterior orearm, 2 to 4 inches
below the elbow see picture below.
The syringe should be held at a 5 degree angle, with bevel up.
Insert the needle just underneath the irst layer o skin and slowly
inject 0.1ml o tuberculin. You should be able to see the tip o the
needle underneath the skin and eel resistance when you inject .
A wheal or bleb 6 to 10 mm in diameter should appear.
I an elevated wheal does not appear, repeat the skin test 20mm
below the original site or the other arm. Bandaids are not recommended, but i used should be removed
30 minutes ater the tuberculin is administered.
Instruct client to remain in the clinic area or 15 minutes ater the
injection to ensure they have not had an allergic reaction.
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READING THE TUBERCULIN SKIN TEST
A tuberculin skin test should be read 48 to 72 hours ater administration by a
health care proessional trained in this skill. Selreading o skin test results by the
client is not acceptable.
Results should be recorded in millimetres mm, not as positive
or negative.
Negative skin test reactions show no mark or a small bruise around
the injection site. Some skin test reactions will show an area o
erythema redness around the injection site, but no induration can
be palpable at the site. The reaction should be recorded as 0mm.
Large skin test reactions will show an inner indurated area, which
may be blistered, surrounded by erythema. Only the inner
indurated area should be measured. The presence o blistering at
the site should also be recorded.
READING PROCESS
Support the orearm on a irm surace Mark the borders o induration by moving your inger or the tip
o a pen at a 45 degree angle transversely across the arm towards
the site o injection until there is resistance indicating an edge i
one present. Mark that edge.
Repeat on the other side
Measure the distance between the two marks with a calliper ruler
i available i not a lexible ruler can be used.
INTERPRETATION OF THE T UBERCULIN SKIN TEST
The interpretation o the tuberculin skin test depends on the reasonor testing and can rely heavily on data provided on the HLTH 939.
5 mm or greater skin test reaction is considered positive or the
ollowing groups:
Contacts o an active case o TB
Immunocompromised individuals
Individuals with HIV inection
Individuals with chest xrays compatible with
previous TB disease
IV drug users
10 mm or greater skin test reaction is considered positive or all other groups
Individuals with a positive skin test reaction should be reerred or a
chest xray. The Tuberculosis Screening Program orm, HLTH 939
when completed which acts as the chest xray requisition orm.
NOTE:A Personal HealthNumber PHN is requiredor all TB chest xrays aso April 2009.
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UNINTENDED OUTCOMES
ANAPHYLAXIS is very rare but is possible. Epinephrine Hydrochloride Solution
1:1000 must be readily available when administering a tuberculin skin test.
Follow the BC Centre or Disease Control Immunization Programs Protocol or
Emergency Treatment or Anaphylaxis. See http://www.bccdc.ca/discond/comm
manual/CDManualChap2.htm , Immunization Manual Section 5
Document in clients record
Inorm TB Control and local MHO; have vial lot # & do not throw out.
SEVERE REACTION is one with excessive swelling, pain or discomort, or progression
to the stage o vesiculation and sloughing o tissue. Severe reactions sometimes are
associated with infammation o the lymphatics draining the area red streaks in
the arm and with soreness or swelling o the glands in the axilla. This is almost
always a sensitivity reaction and should not be conused with secondary inection.
Apply sterile, dry dressing to any open or sloughing area. Cortisone ointment has
not been ound to be helpul. Reassure client about early resolution though someredpurple discolouration may persist or several weeks. Certain skin types may scar.
At the discretion o the public health nurse, reer person to personal physician.
Severe reaction should be documented on the HLTH 939 orm and in clients record.
Pain, itchiness, discomort at the site may occur, and should be treated with the use
o cold compresses. Benadryl can be eective in reducing the eect o the sideeects.
TWO-STEP T UBERCULIN SKI N TESTING
The twostep Tuberculin Skin Test identies individuals who had been inected
in the past, but may now have a decreased sensitivity to the TST. It enables oneto distinguish between what could be a booster response and a true conversion
rom a recent contact. It is useul as a baseline or individuals working in high
risk settings who will continue to be ollowed by TSTs. It can be an option in other
settings such as HIV positive in high prevalence communities i resources are
available. It should not be used or screening o contacts and need only be done
once.
Procedure or administering a 2step skin test involves completing the init ial TST
and i the TST is negative, a second TST is administered one to our weeks later.
The second one should be administered on the opposite orearm or 5 cm below
the previous site. The same techniques and principals o skin testing apply to the2step skin test.
Due to sta ng, resources and practicality, 2step testing is not generally
recommended by TB Control. Travellers, those working in corrections, and health
care workers are individuals who might benet rom 2step sk in testing when
resources permit.
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RADIOLOGY
PURPOSE: To evaluate individuals with a positive TST or symptoms
compatible o TB disease.
Although the chest xray is a widely used diagnostic tool, the
ndings are not specic or TB and can be conused with other
diagnoses such as pneumonia or lung cancer. Although treatmentmay be initiated based on chest xray ndings alone, sputum
collection remains mandatory to provide denitive proo o disease.
The chest xray is the only way to ollow individuals who have had
previous abnormal chest xrays suggestive o old TB disease or latent
inection to determine i there are new radiological changes.
The Tuberculosis Screening Form HLTH 939 provides a guideline to
assess a client or a TB screening chest xray.
INDICATIONS FOR CHEST RADIOGRAPH
Tuberculin skin test positive 10 mm or greater on general screening
Contact o an active case o tuberculosis who has a skin test equal to or greater than
5 mm
Children under 5 years o age who are close contacts o an active case o inectious
TB
HIV positive individual who has a tuberculin skin test equal to or greater than
5 mm note: HIV positive clients should have a baseline chest xray
Immunocompromised individual who has a tuberculin skin test equal to or greaterthan 5 mm
Immunocompromised individuals, or IDUs, who are contacts o an active case
regardless o TST results.
Immigration medical surveillance requirements directed by TB Control
Suspect case with signs and/or symptoms o active tuberculosis
Individuals requiring TB screening who have had previous documented positive
tuberculin skin test
Individuals requiring TB screening who have had documented tuberculosis
Prior to starting preventative therapy or latent TB inection
Admissions at or over the age o 60 years to Adult Licensed Residential Community
Care Facilities preerably within one month o admission Urgent admission to Detox/Drug & Alcohol Treatment Programs
Those individuals starting TNF inhibitors
Others at the discretion o the Division o Tuberculosis Control
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A chest xray that has been done within the last six months should satisy any
o the above indications or a chest xray. There are some exceptions to this rule
which include:
Contacts o active TB
Individuals with signs and/or symptoms o active TB
Individuals with high/increased risk actors or developing active TB
and are TST or IGRA positive
NOTE:Contact TB Control or advice or these individuals.
A TB screening chest xray should not be done in place o a tuberculin sk in test
unless there is a contraindication to planting a skin test. Any exceptions should be
discussed with TB Control.
CONTRAINDICATIONS
Pregnant women during the rst two trimesters should avoid chest xrays i
possible. In these situations, tuberculin and sputum testing may be utilized or the
diagnosis o tuberculosis. I chest xrays are essential, appropriate shielding shouldbe used. Consult with TB Control.
X-RAY PROCESS
Eective April 1, 2009 MSP has assumed the nancial responsibility or the cost o
TB CXRs. In areas not serviced by stationary TB Clinics, the revised HLTH 939 orm
still acts as the requisition enabling the individual to obtain a CXR at a private
radiology clinic or hospital. The billing number 99996 is printed on the HLTH 939
orm and there is space or the individuals PHN. Steps o the CXR process include:
STEP 1: The health unit lls out the HLTH 939 and axes a copy to TB Control.
STEP 2: Individual takes white copy to a local radiology department and can keep
the pink copy or their own records.
STEP 3: I the chest xray is normal, the radiology department is instructed to send/
ax copy o the report and HLTH 939 orms to TB Control and the amily physician,
so we get 2 copies. I the screening is done or detox, long term care acility, school
or employment and the report is normal, then the individual may contact their
amily physician or results.
STEP 4: I the CXR is nondigital and abnormal the radiology department isinstructed to send the lm, HLTH 939, and report to TB Control. I the CXR is
digital and abnormal the radiology dept. will ax the report and HLTH 939 to TB
Control. TB Control will then contact them when they need to have the chest xray
transerred to 'the grid' to be read.
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STEP 5: I TB Control does not receive the CXR and/or report within three weeks o receiving
the initial HLTH 939, TB Control will ax the HLTH 939 orm back to the HU or appropriate
ollowup.
STEP 6: The respirologist at TB Control review the CXR, sputum results, and HLTH 939 orm
with recommendations made and sent to the HU and private physician.
Depending on a number o variables the turn around time rom when TB Control
receives an xray to when a report is sent out is unpredictable. Sending the CXR by
mail as opposed to putting it up on the grid delays the process. All reports must
be dictated, typed and then validated by the physician at TB Control. It can then
take up to 2 weeks beore a consult report is sent out. I you have not received any
inormation ater that time please contact TB Control.
For those individuals with signicant symptoms and i urgency o diagnosis is
required, please contact the Field Operations/TBSAC nurse to expedite the process.
For those needing to know at what stage the chest xray process is, they can contactthe appropriate radiology clerk at TB Control. See Organizational Chart.
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BACTERIOLOGICAL EXAMINATION OF SPUTUM
Bacteriological examination o sputum is the only diagnostic tool that
provides denitive proo a client suers rom active pulmonary tuberculosis
and is considered the "gold standard" or the diagnosis o TB disease. Without
bacteriological conrmation, drug sensitivities cannot be obtained making it
di cult to select an appropriate drug regime.
INDICATIONS FOR SPUTUM COLLECTION
Any client with a chronic productive cough greater than 3 weeks or other
symptoms compatible with active tuberculosis
PostLanding Immigration Surveillance clients
Any client with a positive TST and symptoms and/or abnormal CXR
HIV positive clients with a positive TST and/or symptoms
Any household contact with a positive TST and/or are symptomatic
consult with TB Control
For high risk clients who are unlikely to return their sputum containers, onthespot sputum collection is an appropriate strategy. For clients unable to produce a
sputum sample, please reer client to a centre that carries out sputum induction.
See Appendix P
SPUTUM COLLECTION
CLINICAL PRACTICE STANDARDS
Containers and requisitions are available rom the Provincial Laboratory;
Mycobacteriology requisition:http://www.bccdc.ca/NR/rdonlyres/BD6A7EAC8603482A9225FB9D8939657A/0/MycobacteriologyandTBRequisitionForm.pd
Container requisition: http://www.bccdc.ca/NR/rdonlyres/9CDC4B7D6587
4A17ACEEB6344FCA3285/0/RequisitionorSpecimenContainersSputumBottles.
pd
Label containers with the clients name and complete the requisitions. Containers
without labels are discarded.
Please ensure all sputum specimen requisitions or AFB are also sent ccd to
TB Control.
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Instructions to the client or obtaining sputum specimens should include:
Obtaining specimen in the morning upon rising beore eating
Taking a deep breath and cough to raise sputum rom the lungs
mucous or saliva rom the mouth is not useul
Using a hot luid drink to help stimulate sputum production i there
is diiculty in obtaining sputum
Collect the sputum specimen in the bottle supplied, ensuring the lidis tightly secured. Place the bottle in the ziplock bag provided and
ensure the bag is illed with absorbent material, e.g. cotton balls or
tissue
Obtain sputum samples on 3 consecutive mornings
Keep sputum samples in the rerigerator and return them as soon as
possible to the health centre or local public health unit or deliver y
to the Provincial Laboratory
The routine cooler and courier system may be utilized or sending
these specimens to the Provincial Laboratory
The specimens should not be sent during weekends or statutory
holidays In order to avoid remaining or too long a period in an overheated
post oice, sputum samples should be sent to the ollowing
laboratory complying with transport o dangerous goods
regulations:
SPUTUM REPORTING
SMEAR
Results are reported within 24 hours ater specimen is received at the laboratory.
They are not processed on the weekend and thereore specimens received on Friday
aternoon will be processed the ollowing Monday morning.
POSIT IVE SMEARAcid ast bacilli seen. This may indicate Non
tuberculosis Mycobacterium NTM. The majority o positive
smears in BC are NTM. Positive smears undergo PCR testing daily
Monday to Friday.
NEGATIVE SME ARNo acid ast bacilli seen. This does not rule out
active TB, but the likelihood the client has inectious TB is reduced.
Specimen is then cultured but not probed at this point.
Provincial Laboratory
BC Centre For Disease Control
655 W 12TH Avenue
Vancouver, BC, V5Z 4R4
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CULTURE
Cultures are incubated in both liquid and solid media or up to 8 weeks. Both
positive and negative smears are cultured.
POSIT IVE CULTUREGrowth o a mycobacterium. This may indicate
M. tuberculosis or a Nontuberculosis mycobacterium NTM.
Positive cultures will be probed once on either Tuesday or Thursday.
NEGATIVE CULTURENo growth on culture medium.
NOTE: Probes are tests to dierentiate Mycobacterium tuberculosis rom NontuberculosisMycobacterium NTM such as Mycobacterium avium MAC that do not cause inectioustuberculosis.
SENSITIVITIES
One to two weeks ater the culture grows, the sensitivity results will be available
through the provincial lab. The report will indicate which drugs the organism issensitive or resistant to and can infuence drug selection. The ollowing drugs are
initially tested: Isoniazid, Riampin, Ethambutol and Streptomycin. I resistance is
ound to either Isoniazid or Riampin, Pyrazinamide will be tested. I resistance
is ound to both Isoniazid and Riampin, second line drug sensitivities will
automatically be tested. Once the physician at TB Control has seen the results o
the sensitivities, prescription adjustments are made as needed and the appropriate
health care providers are inormed.
NOTE: For inormation on Genotyping please see Appendix M
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TB MYCOBACTERIOLOGYRESPIROLOGY SPECIMEN (SPUTUM/BRONCHOSCOPY)
AFB SMEARProcessed within 24 hours
CULTURE for MYCOBACTERIUMIncubation or up to 8 weeks
(Growth usually is between 36 weeks)
Due to issues ofreliabiity, not routinely
performed onnon-respiratory
specimens
Positive growth o
Mycobacteria to be
identifed
(Culture)
Negative, no growth
Approx. 15% o TB
cases in Canada were
culture negative
POSITIVESMEAR
NEGATIVESMEAR
PCR testing
POSITIVECULTURE
MTB Complex
PROBE RESULTSNon-tuberculosis
Mycobacterium (NTM)
PROBE RESULTS
ACCUPROBE
Results take 23 weeks ater
a positive culture
DRUG SENSITIVITY TESTING
NEGATIVECULTURE
M. TBcomplex NTM
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SECTION II ACTIVE TUBERCULOSIS
Case Management & Active Case Finding | 30
Flowchart: Management o An Active Case o Tuberculosis | 39
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CASE MANAGEMENT / ACTIVE CASE FINDING
DIAGNOSIS OF TB
Tuberculosis is a communicable disease caused by the bacteria Mycobacterium
tuberculosis. Humans are its primary host and it may reside anywhere in the body
although it is primarily a pulmonary disease. TB is a reportable disease under the
Health Act see Appendix B.
A diagnosis o active tuberculosis can be made when the ollowing criteria can be
established:
A positive culture growing Mycobacterium tuberculosis complex. These
specimens can come rom a variety o sources, including sputum, pleural
luid, and urine. A positive PCR result predicts a positive culture or M. TB
In the absence o a positive culture there are a number o indicators
which can lead to a diagnosis o tuberculosis.
Abnormal radiological evidence consistent with active
tuberculosis. Abnormal chest xrays, intravenous pyelogramIVP, and CT scans o chest and joints are useul tools in
arriving at a diagnosis.
Pathology indicating caseating granulomatous disease. Any suspect tissue
that is accessible to biopsy may be employed pleural, skin, lymph nodes,
and kidney biopsies. See Appendix B.
Clinical symptoms consistent with actie tuberculosis cough, night sweats,
ever, weight loss, hemoptysis, chest pain, atigue, decreased appetite.
ROLES AND RESPONSIBILITIES
While the responsibility or the control o communicable diseases lies with theMedical Health O cer, the clinical care o an active case o tuberculosis is
the responsibility o the clients personal physician, oten in consultation with
the physicians at TB Control and in collaboration with the local health units/
community health centres. Treatment is carried out based on the policies and
standards recommended by TB Control, who also supply the medication ree o
charge.
NOTIFICATION
Upon notication o an active case o tuberculosis, TB Control will notiy the
physician and the public health nurse. In consultation with a health care provider,the client will be inormed o the diagnosis. I the physician is unavailable it will
be the responsibility o the nurse to inorm the client. I the client has no amily
physician it will be incumbent upon the nurse to assist the cl ient to nd one who
will take responsibility or care.
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ASSESSMENT/ INFORMATION GATHERING
Ater client has been inormed o diagnosis it will be necessary to gather all
relevant medical inormation to determine the most eective treatment plan.
Included in this should be:
Clients drug allergies and weight.
An assessment o the clients social environment and those elements
which will aect issues o adherence and ability to selisolate. The Request or Inormation Form provided by TB Control should be lled
out and returned. This is inormation required by Health Canada.
Obtaining chest xrays, lab work, medical consultations and
orwarding them to TB Control will be the responsibility o the
Public Health Nurse and/or Community Health Nurse. Please reer
to Baseline Monitoring page 37.
Nurse to have patient sign an Access to Pharmanet Form which can
be downloaded o the website.
Included in the initial assessment should be a discussion o the
importance o contact tracing in reducing transmission and begin
collecting names or contact tracing. Please reer to section onContact Investigation.
EDUCATION
The PHN/CHN will meet with the client and amily to assess their needs and
provide education regarding TB disease and treatment o it. Client needs to be
inormed o common side eects o the medications, such as:
Orange urine, eces, sweat, tears rom Riampin
Peripheral neuropathy rom Isoniazid
Rashes
Hepatotoxic symptoms such as nausea and vomiting, abdominal
pain and yellow eyes or yellowing o the skin.
NOTE:For a more comprehensive list o sideeects reer to medication list in Appendix C.
Education will be necessar y or the duration o treatment and ongoing assessment
is important. When available, written educational material should be given to
the client see BCCDC website: http://www.bccdc.ca/discond/az/_t/Tuberculosis/
educmat/deault.htm.
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SELF-ISOLATION
Selisolation at home is required i a diagnosis o pulmonar y TB is made based on
smear positive or culture positive respiratory specimens.
Negative smear and Positive culture: requires selisolation or at least 2 weeks
Positive smear and Positive culture: requires selisolation or at least 2 weeks
ater the initiation o 1st line TB t reatment and 3 consecutive negative sputum
smears
There are a number o steps that can be taken to reduce transmission:
restrict public activities
no public transportation
restrict visitors to home
wear mask to all medical and lab appointments; surgical mask is
suicient
care givers wear N95 protective masks
respiratory hygiene cover mouth when coughing, spit into tissue,
tissue into garbage
When the client is unable to eectively selisolate based on the nurses assessment
then hospitalization is the preerred option. This decision should include the
amily physician, the client and the PHN/CHN. The MHO and TB Control should
be consulted i any problems arise around selisolation and/or hospitalization.
Sel isolation can be a very di cult time or both the patient and their amily.
Let the client know o things they can dosuch as get out or walks or resh
air. Encouragement, guidance, and reenorcement are oten needed during the
"isolation" period.
TREATMENT
Goals o treatment are to cure individual patients and minimize transmission
to other persons. Treatment is divided into two phases. The initial phase is the
intensive phase three or our drugs given and aims to quickly reduce the number
o rapidly dividing bacteria resulting in:
rapid reduction in symptoms
rapid reduction in inectiousness
reduction o the possibility o drug resistance
The second phase is reerred to as the maintenance or continuation phasetwo or three drugs:
elimination o any persistent bacteria not destroyed in
the initial phase
reduction o the possibility or relapse
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The importance o adherence cannot be overstated, especially in the intensive
phase to eliminate the potential or drug resistance. Exellent adherence limits the
chance o requiring a long and complicated, potentially 2nd line regimen and
promotes a successul outcome.
MEDICATIONS
All tuberculosis medications are provided without charge and distributed throughthe BCCDC Provincial Pharmacy. A TB physician must generate the prescription. Any
prescriptions written by a physician in the community must be orwarded and reviewed
by TB Control in order to obtain medication. Local pharmacies will not provide the
medication. Ater a prescription is written a copy will be axed to the health unit
and medications will be shipped. Most health units are supplied with starter units to
acilitate prompt initiation o therapy. Health units in many areas in the province are
also required to supply the local hospital with starter kits.
PHN/CHNs are required to administer medications to outpatients. I daily sel
administered treatment SAT is elt to be sae and appropriate the nurses will provide
the client with one month o medication only. I the client leaves the province or isaway on holiday, they will be provided with a maximum o two months medication to
take with them. I more medications are required the nurse should contact TB Control.
Clients who are on intermittent Directly Observed Therapy DOT should never be
given doses to seladminister because all doses must be directly observed by the PHN.
See Appendix K.
The decision regarding SAT vs DOT is oten recommended by the physicians at TB
Control in consultation with local healthcare providers.
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TABLE 2.1: TREATMEN T OF MYCOBACT ERIAL DISEASE IN ADULTS FIRST LINE MEDICATIONS
ANTI-TUBERCULOSIS DRUG INFORMATION
Drug Major Adverse Reaction Monitoring Remarks
Isoniazid INH
10 mg/kg up to 300 mg
Twice weekly: 15 mg/kg POusually 900 mg
Hepatotoxicity
Hypersensitivity
Peripheral Neuropathy
Symptoms
AST/SGOT
Phenytoin Dilantintoxicity
Pyridoxine 2550 mgmay be given to preventperipheral neuropathy.
With Disuliram Antabusemay lead to behaviour andcoordination disturbances.
Riampin
1020 mg/kg up to 600 mg
Twice weekly: 10 mg/kgusually 600 mg
Hepatotoxicity
Hypersensitivity
GI Upset
Thro mboc ytopeni a
Symptoms
AST/SGOT
Baseline CBC includingplatelet count
Decreases eectiveness othe contraceptive pill.
Increases ANTICOAGULANT drug requirement.
An orangered
discolouration o sweat,tears, may stain sotcontact lenses, urine,saliva, and eces.
Methadone dose may needto be increased.
Riabutin Rash, atigue, ever & sorethroat.
Visual disturbances such aseye pain.
Nausea, diarrhea, musclesor joint pain
See Riampin May cause tears, sweat,urine & eces to be brownorange and use alternativeorm o contraception iusing birth control pills.
Pyrazinamide
2030 mg/kg up to 2 g
Twice weekly: 5070 mg/kg
Hyperuricemia
Gastric irritation
Arthralgia
Hepatoxicity
Symptoms
AST/SGOT
Uric acid rise isunpredictable and does notrequire monitoring unlesshistory o gout.
Ethambutol
15 to 25 mg/kg
Twice weekly: 50 mg/kg
Retro bulbar neuritisrare at 15 mg/kg
Hypersensitivity
Symptoms
Baseline visual acuity andcolour perception monthly bymedication provider.
I on long term ethambutol,then pt should see anophthalmologist or anoptometrist when the abovenot available
Client should report anyvisual changes to physicianimmediately.
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TABLE 2.2: TRE ATMENT OF MYCO BACTER IAL DISEASE IN ADULTS SECOND LINE MEDICATIONS
ANTI-TUBERCULOSIS DRUG INFORMATION
Drug Major Adverse Reaction Monitoring Remarks
Levaquin Rash, hives, or diicultybreathing
Irregular heartbeats orchest pain
Muscle, tendon or joint pain
Jaundice
Nausea, vomiting, diarrhea
Headache
Drowsiness orlightheadedness
Symptoms Avoid taking the ollowingwhen taking Levaquin:
Antacids containingAluminum, Calciumand/or Magnesium
Sucralate ulcermedication
Vitamins or mineralsupplements containingIron, Zinc or Calcium
Use caution when driving,operating machinery orperorming hazardousactivity.
Avoid excessive exposureto sunlight while takingLevaquin.
Avoid pregnancy andbreasteeding. I pregnancyoccurs, contact GP
Streptomycin
15 mg/kg up to 1 g
Twice weekly: 25 to 30 mg/kg usually 1 g
8th nerve toxicity especiallyvestibular
Hypersensitivity reactions
Paraesthesia, perioral notsigniicant
Mildly nephrotoxic
Symptoms
BUN
Creatinine
Hearing tests
Vestibular damagei.e. check balance and gait
I preexisting renalimpairment, monitorclosely.
Reduce dosage in olderclients
In children less than 14years, ater three weeksdaily therapy, reduce doseor give intermittently.
Not to be used duringpregnancy
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TABLE 2.2: TRE ATMEN T OF MYCO BACTERIAL DISEASE IN ADULTS SECOND LINE MEDICATIONS
(CONT.)
ANTI-TUBERCULOSIS DRUG INFORMATION
Drug Major Adverse Reaction Monitoring Remarks
Ethionamide
15 to 30 mg/kg up to 1 g PO
GI disturbance
Hepatotoxic
Hypersensitivity
Symptoms
AST/SGOT
Bacteriostatic to bothintracellular andextracellular organisms.
Divided dose may help GI sideeects; has a metallic taste.
Avoid use during pregnancy.
Cloazamine Lamprene
100 mg daily
Discolouration o skintissue and body luids redcoloured to brownish blackand diminished sweating
and tear production.
Symptoms Bactericidal eect onMycobacterium bacilli.
Take with meals /ood.
Capreomycin
or dosage see Appendix C
8th nerve damage
Nephrotoxic
Ototoxic
Symptoms
Vestibular unction
Hearing tests
BUN
Creatinine
Bactericidal to bothintracellular andextracellular organismsand in cavities.
Use with caution in olderclients.
Rarely used i renal disease.
NOTE:See Appendix C or more comprehensive medication interaction table.
BASELINE MONITORING
The ollowing baseline measurements are necessary to properly prescribe
appropriate treatment and allow or subsequent monitoring requirements during
treatment:
Weight in kilograms
HIV serology consent, pre & postcounselling required
CBC with dierential, liver enzymes AST. For children under 16,
blood work is not required unless there are pre existing medical
conditions See pediatric appendix D
Visual acuity and red/green color discrimination i Ethambutol is
prescribed Schnelling chart or equivalent
Assess clients knowledge o medication side eects and encourage them
to contact physician or nurse immediately with any adverse events
Hepatitis A, B & C serology: at the discretion o the amily physician
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ONGOING MONITORING
AST ater two weeks o therapy, then monthly i AST is normal. In older patients
or those with underlying liver disease more requent monitoring o bloodwork at
the discretion o the TB physician or GP may be necessary.
Assess patient monthly or signs o adverse eects: liver toxicity, peripheral
neuropathy, or rashes.
Visual acuity or those on Ethambutol. I Ethambutol is continued beyond
2 months, an assessment by an ophthalmologist is required; or optometrist i theormer is not available. Followup should be done according to recommendations
by the ophthalmologist.
For those on Streptomycin, a monthly assessment o hearing and vestibular
unctioning should be undertaken.
Monitor or adherence pill counts; blister packs
For those clients who are smear positive, sputum should be collected every 2 weeks
until 3 negative smears have been reported see sputum algorithm page 28.
Collect three sputums monthly until there are 3 negative cultures
Chest xrays should be repeated every two months or pulmonary cases or as
otherwise recommended by TB Control.
For those clients with cavitary disease, repeat 3 sputums at the end o treatmentalong with the exit chest xray.
Report to TB Control any adverse side eects or abnormal lab values.
ADHERENCE
For those clients on seladministered therapy the PHN/CHN will enquire as to
any doses missed. This should be recorded on the Medication Reorder Form
along with any pertinent inormation such as side eects or any di culties with
treatment.
For those clients on Directly Observed Therapy the 'Record o Supervised TB
Medications' http://www.bccdc.ca/NR/rdonlyres/EBFC07282B364412B415
75AF04CD1ECB/0/HLTH832_RevJuly2010.pd shall be lled out as indicated
in the legend. This serves not only as the adherence record, but also the reorder
orm or more medication. A separate ax should be sent to report any other
inormation concerning treatment and issues. The appropriate TB Control nurse
consultant should be contacted by telephone with any urgent issues arising out
o treatment. I the TB nurse consultant is unavailable, contact the local GP with
concerns.
The initial reorder orm should be lled out ater the rst months medication isprovided so there is always one month supply available to ensure continuity o
treatment See Appendix Q.
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RECALCITRANT CLIENT
There may be clients who pose signicant challenges in complying with TB
treatment. Every eort should be made to establish a respectul trusting
relationship and i obstacles arise, clientspecic strategies can be developed to
resolve them. This relationship building will help determine successul completion
o treatment. Discussions should include all relevant participants including the
amily physician and TB Control. When a resolution is not possible, it is important
to keep the client inormed and educated about uture processes or decisions. The
PHN/CHN will be required to inorm the MHO who will make an assessment as
to the risk or the community at large and will give direction accordingly. The
MHO and TB Control should be inormed i there has been a two week period o
nonadherence. Ongoing eorts between the primary health care provider and the
client should be made to reestablish TB treatment.
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MANAGEMENT OF AN ACTIVE CASE OF TUBERCULOSIS
PULMONARY TB NON-PULMONARY TB
t Clinical evaluationt Sputum x 3 i productive cought Baseline CXR
tSmear or AFB ortCulture or MTB
tEnsure 3 sputum collectedor baseline (3 separate days
i possible)t3 sputums Q 2 weeks until 3consecutive negative smears
tQ monthly until 3consecutive negative cultures. A 2 month sputum collection
provides test o conversion
POSITIVE SPUTUM BASELINE SCREENING
t No isolation i Pulmonary TB
is excludedt Monthly clinical assessment
o symptoms, improvement andside eects o medications
t Radiological ollow-up as
recommended by TB Control
FOLLOW-UP
ABNORMAL X-RAY
t Recommend DOT (Directly Observed Therapy)t Requires prescription rom TB Controlt Standard Regime: Isoniazid, Riampin, Pyrazinamide, Ethambutol, Vit B6
MEDICATION
t Baseline: CBC, Dierential, ASTt AST at 2 weeks then:- - Q monthly or the frst 3 months i normal ollowed by: - Q 2 months or duration o treatment
- Abnormal values contact TB Controlt I on Ethambutol, baseline and monthly assessment
o visual acuity & colour discriminationt Children: bloodwork not routinely required on children
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SECTION III CONTACT INVESTIGATION
Goals o Contact Investigation | 41
Roles & Responsibilities | 41
Principles to Guide Contact Investigation | 42
Assigning Priority or Investigation o Contacts | 44
Conducting a Contact Investigation | 46
Contact Examination Procedure | 48
Contact Examination in Congregate Settings | 52
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GOALS OF CONTACT INVESTIGATION
Identiy any secondary cases o TB disease and initiate treatment as soon
as possible
Identiy newly inected individuals and oer preventative treatment and/or
appropriate ollowup
Identiy the source case when the index case is not the source case
ROLES AND RESPONSIBILITIES
Contact investigation is the responsibility o the Medical Health O cer MHO in
the relevant Provincial Health Authority. TB Control provides consultation and
works collaboratively with the designate o the MHO. The designate may be local
public health nurses, community health nurses or a communicable disease unit
within a regional health authority.
TB Control maintains a central registry o all contacts in order to track and
assist with coordination o contact ollowup. TB Control is responsible orcommunicating contact investigation inormation across health regions and
between provinces. It is important that all contact inormation is reported to
TB Control to ensure accurate and timely inormation is communicated to the
appropriate health care providers.
Public health nurses/community health nurses usually provide the rontline TB
screening o contacts and the ollowing inormation is provided to assist these
nurses in the decisionmaking required when undertaking a contact investigation.
TB Control is available or consultation throughout the contact investigation
process.
The physician at TB Control will review the sk in test and/or chest xray ndings o
all contacts and provide recommendations.
Contact investigation needs to be initiated as soon as possible ater a diagnosis o
active TB. The diagnosis o active TB and the initiation o contact investigation are
usually the result o:
Notiication that a respiratory specimen laboratory result is
smear positive or acid ast bacilli AFB and probe positive or
Mycobacterium tuberculosis MTB.
Notiication that a negative respiratory smear result is now culture
positive and/or probe positive or Mycobacterium tuberculosis.
In this setting the patient needs to submit a urther 3
sputum specimens to determine i they have become
inectious smear positive during the time it took or
the culture to grow.
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Active tuberculosis in young children is rarely inectious, but it is
usually a sign o a recent inection. Reverse contact investigation o
the childs close contacts should be done to identi y the source case.
A clinical diagnosis o active TB in the absence o laboratory
conirmation should be discussed with TB Control to determine the
need or contact investigation.
Nonpulmonary TB cases may require contact tracing and should be
discussed with TB Control.
PRINCIPLES TO GUIDE CONTACT INVESTIGATION
1. INFECTIOUSNESS OF THE SOURCE CASE:
Cases o laryngeal TB and smear positive pulmonary TB are considered most
inectious.
Cavitary pulmonary TB is usually very inectious.
Adults and adolescents are generally more inectious than children under 10 years old.
Duration o symptoms, particularly a cough, increases the risk o inectiousness.
Poor respiratory hygiene i.e. doesnt cover mouth when coughing and/or sneezingincreases the risk o spreading TB.
Forceul exhalation such as shouting or singing increases the risk o spreading TB.
Cases o nonrespiratory nonpulmonary TB are considered noninectious once
pulmonary TB has been ruled out ie. symptom inquiry, 3 sputum samples,
and chest xray with the exception o irrigation o open TB site wounds due to
possible aerosolization o TB bacteria.
Contact investigation o nonrespiratory TB is usually limited to household
contacts only, though investigation may expand depending on results o intial
CI. Children only require skin tests i asymptomatic. A chest xray is not required
in the absence o symptoms. Purpose o this screening is to locate the source
case.
2. PERIOD OF INFECTIOUSNESS
The period o inectiousness is usually considered to start at the time o onset
o cough. Individual clinical ndings may infuence the estimated period o
inectiousness. Consultation with TB Control is recommended i the client does not
report a cough.
The period o inectiousness ends when a client has received at least two weeks
o adequate treatment and has had 3 consecutive negative sputum smears. Thesputum specimens should be collected on 3 separate dayspreerably in the
morning.
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3. AIR SHARING EXPERIENCE
Tuberculosis is an inectious disease transmitted almost exclusively by the
airborne route. The risk o transmission depends on the concentration o inectious
droplet nuclei in the air shared by the case and their contacts. It is unlikely
that transmission o TB can occur outdoors. Indoor environments that are
small, conned and poorly ventilated can lead to an increased concentration o
tubercle bacilli in the air. In a closed circuit heating or air conditioning system,
recirculation o air tends to increase the concentration o tubercle bacilli and
increase the possibility o inection.
Another actor in the air sharing experience is the length o time spent in the same
indoor environment does not have to be home environment with an active TB
case. Contacts should be divided into categories according to the number o hours
spent with the source case per week.
TABLE 3.1: TYPE OF CONTAC T
TYPE OF CONTACT AMOUNT OF TIME WITH SOURCE CASE
Type 1 contactMore than our hours per week. Close household
contacts.
Type 2 contact
Two to our hours per week. Close non household
contacts who share the air space on an ongoing
basis i.e. close riends
Type 3 contactLess than two hours per week. Casual contacts
such as sports teams.
Contacts exposed during highrisk medical procedures are at high risk o becoming
inected. These procedures include:
Bronchoscopy
Sputum Induction
Autopsy
Intubation
4. SUSCEPTIBILITY OF THE CONTACT
Any individual with no prior TB inection is at risk o inection when in contact
with an inectious case o TB. Prior treatment o TB inection or disease is believed
to reduce the risk o reinection in individuals with healthy immune systems
although it does not completely remove the risk o reinection
The most susceptible contacts are those contacts most likely to be inected with
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the TB germ and those who are at a high risk o developing active disease once
inected. They include:
Children under 5 years o age
HIV positive
Immunocompromised
These highrisk contacts require a tuberculin skin test TST and a chest xray in a
contact investigation, regardless o TST result.
ASSIGNING PRIORITY FOR INVESTIGATION OF CONTACTS
The extent and order o contact investigation is based on the inectiousness o
the source case, extent o exposure to the source case, and the vulnerability o
the contact. Consultation with TB Control is advised to help establish a contact
investigation plan.
Highpriority contacts usually include household contacts, contacts 5 years old and
under, those contacts who are immunosuppressed, and contacts with symptoms o
TB disease.
CONCENTRIC CIRCLE APPROACH TO CONTACT INVESTIGATION
The concentric circle see Figure 1/page 45 approach to contact investigation is a
tool used to assist in determining who needs to be screened. Investigation begins
with close contacts o the source case. I close contacts have not been inected, it is
unlikely that casual contacts need to be screened.
I there is evidence o transmission o inection or secondary cases o active TB
in the close contacts o the case, then the next circle o type 2 contacts need to be
assessed and screened. Widening o the circle continues until there is no urther
evidence o transmission o TB inection.
Contacts screening may include; individuals, groups or locations, sports teams,
religious gathering places, a persons hobbies, area o employment, ater hours
activities, where a person sleeps i outside o the home, activities o daily living
pubs/bars/school or classes etc.
Although guidelines or TB contact investigations CI have been based upon
concensus expert opinion, recent studies have documented limitations in the
outcomes o traditional CI, including issues with contact identication, screening
completion and LTBI treatment initiation and completion. The problems with
standard CI are amplied in certain highrisk groups, such as homeless persons
and those struggling with issues o substance use who may be unable to recall
their contacts by name or other pertinent identiers.
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TYPE1TYPE2
TYPE3
Babysitter
Neighbours
ChurchGroups
Parties
Hunting
Clubs
Dances
LocalBar
Cofee
Shop
Bingo
Hall
VacationCamping
Public Transport
Friends
LunchRoom
RegularClients
Business Travel
Co-workers
Work
School
RegularMeetings
Tenants
SOURCE
CASE
RegularOvernight
Visitors
HouseholdMembers
SOCIAL NETWORKING & LOCATION-BASED SCREENING
The concentric circle approach to contact investigation has not been very successul
in homeless and street involved populations. These populations are highly mobile,
oten living unconventional liestyles. Street involved people do not always know
the names o people they socialize with, or only know their "street names".
There is evidence that social networking is a more successul approach with this
population, especially in an outbreak setting. Social networking is an approach
where key individuals and locations that are central to the spread o disease are
screened. In addition to screening close named contacts, locations where the source
case requents such as shelters or dropin centres are screened. This approach better
characterizes relationships with contacts and helps to understand unrecognized
patterns o disease transmission. Screening high risk locations should be indicatedin the contact box on the HLTH 939 orm.
A sample questionnaire is included in the appendix but it is important to realize
that the questionnaire may need to be modied to refect the community being
investigated. Including a person in the process who is knowledgeable about the
community is oten quite eective. TB Control can also provide the guidance in
implementation o network inormed CI.
FIGURE 1: CONTACT SCREENING / SOCIAL NETWORKING
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CONDUCTING A CONTACT INVESTIGATION
1. SOURCE CASE MEDICAL INFORMATION REVIEW
Laboratory results smear status; dates
Chest xray results
Symptoms
Onset o symptoms
2. INTERVIEW SOURCE CASE
The initial interview should occur as soon as possible ater the case is diagnosed
with active TB. This interview should include a review o patients symptoms to
veriy the period o inectiousness to identiy the patients contacts and to nd out
places where the patient spent time. It may take several interviews to obtain this
inormation.
The ollowing inormation should be obtained;
Contact with children and their ages
Contact with anyone who is immunosuppressed
Household contacts
Close nonhousehold contacts
Place o work, school, church and play
Other places where the patient may spend 2 or more hours/week
Social gatherings that may have occurred during the period o
inectiousness, such as weddings, unerals and community events.
Does the source case know anyone with signs and/or symptoms o TB?
Has the index case been traveling during the estimated period, or in
the last 2 years, o inec tion? I yes, obtain details o trip, including
means o transportation.
It is important to gather as much detailed inormation about the contacts as
possible to assist in the screening process. This inormation should include names,
dates o birth, addresses, and phone numbers. It may be useul to ask the patient s
permission to interview amily members or close riends to assist in gathering
contact inormation.
Assure the patient that their diagnosis o TB is conidential and will not be shared
with their contacts. Give the patient the choice o inorming their own contacts.
Inorm the patient that i their contacts have not reported or testing within a week
a public health nurse or community health nurse will ollowup with the named
contacts.
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The interviewer needs to be sensitive to the concerns and belies that a patient may
be experiencing about having been diagnosed with active TB. The interview should
include education and inormation about active tuberculosis and its treatment.
The interview should be done in a respec tul manner that helps to develop a
relationship o open communication. The interview may need to take place over
a period o time. Clients should be advised to contact PHN/CHN with additional
inormation names, locations that become apparent as t ime goes by.
A preliminary list o contacts should be established within 3 days see Time Frame
or Contact Tracing page 54 o the diagnosis o an active case o tuberculosis and
sent to TB Control on a Followup Contact Assessment TB Control HLTH 836 s orm.
I public health wishes, they can develop their own orms to meet their particular
needs but must capture the inormation listed on the HLTH 836 s orm.
3. FIELD INVESTIGATION
A eld visit may be benecial to assess the air sharing environment o the source
case. Environmental characteristics o the congregate setting should be assessed
and may assist in determining appropriate site screening. Size o the space, airfow,number o windows are some o the important components in the assessment. The
visit may also provide additional inormation about potential contacts.
4. PRIORITY OF CONTACT SCREENING
All the inormation gathered in the above three steps should be used to determine
the probable risk o transmission. This assessment should then guide the priority
and initial extent o contact screening.
In almost all cases o active tuberculosis, the high priority contacts or screeninginclude household contacts, children under 5 years o age, immunosuppressed
individuals, and contacts with reported symptoms o TB.
Based on the initial risk assessment o transmission, a plan needs to be established
or priority contact screening. Every attempt should be made to ollow the
established plan in order to use personnel resources where they are most needed
and to evaluate the outcomes o the contact circle that is being screened.
In small communities there can be the potential or "panic" and nurses may be
overwhelmed by the volume o casual contacts, and people who are not sure they
are contacts, wanting to be tested. In these situations, it is sometimes advisableto schedule one or two screening clinics to diminish the anxiety o the casual
contacts, while allowing the nurses to concentrate, on the priority contacts.
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CONTACT EXAMINATION PROCEDURES
INTERPRETATION OF TST RESULTS IN CONTACT SCREENING
TABLE 3.2: INT ERPRETING TS T RESULTS IN CON TACT SCREENING
SIZE OF INDURATION INTERPRETATION ACTION
0 to 4 mm Negative Repeat TST in 8 Weeks
5 mm or more PositiveSend or chest xray
PRIORITY SCENARIOS:
1. CHILDREN UNDER 5 YEARS OF AGE
Children under 5 years o age have an increased risk o developing active TB
primary disease once they have been inected with TB. They are also at risk o
developing miliary TB or TB meningitis. Consequently, it is important to protectthese children with primary prophylaxis during the incubation period o TB
inection.
TB Control should be notied immediately o all children under 5 years o age who
are close contacts o the source case. Initial testing o these children will include
a tuberculin test as well as a chest xray. A HLTH 939 orm should be initiated.
I the TST is negative 0 to 4 mm and the chest xray is normal, the child may
be recommended to start on primary prophylaxisIsoniazid syrup, or crushed
tablet, to be prescribed according to the childs weight. The child will have a repeat
tuberculin skin test in 8 weeks.
Children under six months o age may not be able to mount a TST response;
thereore primary prophylaxis Isoniazid treatment may be continued until a
repeat TST at six months o age. I this repeat skin test is negative, Isoniazid can be
stopped. I this repeat sk in test is positive 5 mm or greater the child will continue
preventative therapy or a total o 9 months.
Guidance rom TB Control should be sought or all children under 5 years o age.
The TB Control physician will decide i a chest xray is required.
Inants will need to be weighed regularly to ensure that Isoniazid dosage is
adjusted to accommodate weight gains.
NOTE:Please see Appendix D or more inormation on Pediatric TB.
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PEDIATRIC PRIMARY PROPHYLAXIS OF CHILDREN
PRIMARY PROPHYLAXISFor Children < 5 years o age who are:
MEDICATION
tClose contact to active case of TBtContact TB Control; initiate HLTH 939
tNegative TST at baselinetNormal chest x-ray
tAsymptomatic
tPrescribed & dispensed by TB ControltStandard regime: Isoniazid x 2 months minimum
tChilds weight required to determine dose
BLOOD WORK
tNot required or children
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2. IMMUNO-SUPPRESSED CONTACTS
HIV positive and other immune suppressed contacts should have TST and a CXR
as soon as possible. I these contacts are symptomatic, 3 sputum specimens or
AFB should be submitted to the laboratory. These contacts may be oered primary
prophylaxis i their initial TST is negative 04mm and chest xray is normal.
A repeat TST should be done in 8 weeks. I the second TST is positive 5 mm or
greater the individual will continue preventative therapy or a total o 9 months.
I the second TST is negative, it is possible the individual may need to continue
preventative therapy or a total o 9 months. The decision to stop or continue
preventative therapy is based on the individuals immune response and i it is
deemed capable o mounting a response to tuberculin. This will be assessed on an
individual basis in consultation with TB Control and oten the clients specialist.
Notiy TB Control o all HIV positive and other immune suppressed contacts. I
CD4 counts are available please ax to TB Control.
EXAMINATION OF ALL CONTACTS
A HLTH 939 orm must be completed or each contact and sent to TB Control. It is
important to ll out all sections o the HLTH 939 to assist the TB physician to make
appropriate individual recommendations or each contact.
Assessment o each contact includes:
Demographics o the contact
Type o contact details can be written on HLTH 939 or axed on a
separate sheet
TB number o source case or PHN is TB # not available
Medical risk actors or developing TB disease
Symp