Project TypeDevelopment of TB Education

Materials for school Healthcare Staff

Project TitleA Comprehensive Desk- Guide

on TB Protocols and DOT Administration for School

Nurses

INTRODUCTION

Background

Academic InformationDes Moines University- College of Health

SciencesMaster of Public Health (MPH) Candidate 2016

DSHS PlacementDSHS TB Elimination Division

Health Service Region 4/5N- TB Prevention & Immunization Clinic

DSHS Supervisor- Suzanne Fisher, MPA-HCA, BSN-RN

Sub Office- Nacogdoches, TX

Texas TB statistics

A total 1,269 TB cases were reported in Texas in 2014

5 in 100,000 Texans had active TB last year compared to the national average of 3 in every 100,000

55% of reported TB cases in 2014 were among Hispanics, 18% were among African Americans, 9% percent were among Whites, and 18% were among Asians.

On average 57 cases have large contact investigations with more than 50 contacts identified.

TB rates are higher along the Texas-Mexico border and TB/HIV co-infection is more commonly found in urban areas of Texas

TB Demographics in Texas Counties

County Cases

Harris 320

Dallas 167

Bexar 89

Tarrant 77

Hidalgo 70

Cameron 67

El Paso 43

Travis 49

Collin 27

Webb 25

Highest incidence of TB Cases in Texas Counties, 2014

Regional TB statistics in Texas

Health Service Region

Number of Cases

Percentage of Cases (%)

1 52 4.09

2/3 305 24.03

4/5N 43 3.38

6/5S 387 30.5

7 82 6.46

8 132 10.4

9/10 56 4.41

11 189 14.9

Texas 1269 100

Why is there need for a TB Desk-Guide for school Nurses? Situation? Very little formal state literature that addresses the problem of TB on

school campuses and/or is catered towards school nurses

The Texas Health guide for schools has only allocated 2 pages on the topic of TB.

Most of the students diagnosed with TB take their medication on school campuses (DOT), hence a well trained nursing workforce is crucial to eradicate TB in school going children.

The Need!-A need for a state literature based on the CDC/DSHS

guidelines that goes into more detail about the TB Topics such as TST reading/interpretation and DOT administration.

.

What is the purpose of this?The purpose of this desk-guide is to

Educate and train the school nurses on the right protocol handling TB cases on school campuses.

Let’s Begin!!!

Borderline- High Risk Counties of Texas

The rate of tuberculosis in these counties is twice the average of the state

Brooks Calhoun Cameron Cherokee

Collingsworth Edwards Frio Garza

Hansford Jack La Salle Lipscomb

Martin Moore Nacogdoches Parmer

Reagan Terry Val Verde Webb

Zavala

Incidence Rate of TB with various Risk factors

What is Tuberculosis /Transmission and Pathogenesis

Tuberculosis is caused by the

Mycobacterium tuberculosis (M.

tuberculosis) and is spread by airborne

droplet nuclei

The transmission of TB is causes by the prolonged contact with the infected

individual.

Transmission occurs by coughing, sneezing, laughing

or singing

Any untreated person with active

pulmonary TB disease can infect

an estimated 10-14 people in a year

TB is categorized into two-related conditions: latent TB infection and active TB disease.

Latent TB Infection Active TB Disease

Inactive Tubercle Bacilli in the body Active Tubercle bacilli in the body

Tuberculin skin Test (TST) or Interferon-gamma release assay (IGRA) usually

positiveTST or IGRA usually positive

Chest radiograph usually negative/normal Chest Radiograph usually positive/abnormal

Sputum smear and culture negative/normal Sputum smear and culture positive

Lack of symptoms Symptoms such as cough, fever. Weight loss

Not infectious Often infectious before treatment

Difference between TB infection and TB Disease

Symptoms of TBThese symptoms are more common in adults and older children (American Academy of Pediatrics [AAP], 2000). Symptoms of TB include one or more of the following:

Fever

Persistent cough (3 weeks)

Weight loss/failure to gain weight

Lymphadenopathy (LAD)

Fatigue

Night Sweats Chest Pain

Hemoptysis

Chills

How to Test for TB (TB blood test) vs. Skin Test)

TB blood tests

Interferon-gamma release assays or IGRAs- measures how

the immune system reacts to the bacteria that cause TB.

Two IGRAs are approved by the U.S. Food and Drug

Administration (FDA) and are available in the United States

QuantiFERON®–TB Gold In-Tube test (QFT-GIT)

T-SPOT®.TB test (T-Spot)

How to Test for TB (TB Blood Test)

TB Skin Testing

The diagnostic tool for detection of TB infection is

the tuberculin skin test (TST) using the Mantoux

method.

“Target testing” is recommended, and

Routine testing should not be done in low prevalence

areas

As the school nurse, you may be asked to do the testing for a “high-risk

child”

High Risk for TBPeople at High Risk for an LTBI infection People at High Risk for active TB disease

Close contacts of people known or suspected to have TB

People living with HIV

People, including children, who have come to the United States (within the last 5 years) from areas of the worlds where TB is common (for example, Asia, Africa, Russia, Eastern Europe, or Latin America)

People recently infected with M. tuberculosis (within the past 2 years)

Low-income groups with poor access to health care, including homeless people

People with medical conditions known to increase the risk for TBo Silicosiso Diabetes mellituso Severe kidney disease and certain

intestinal conditionso Certain types of cancer & Organ transplanto Immunosuppressive therapy (prolonged

use of corticosteroids and (TNF-alpha)

People at High Risk for an LTBI infection People at High Risk for active TB disease

People who inject illegal drugs People who inject illegal drugs

People who live and work in high-risk residential settings (for example, nursing homes, homeless shelters, or correctional facilities)

Infants and children younger than 4 years

Healthcare workers who serve high risk clients

Low body weight

Healthcare or ethnic minority populations, as locally defined

Infants, children and adolescents exposed to adults in high-risk groups

High Risk for TB Cont’d

What constitutes as Target Testing TB Targeted testing is a TB control strategy that is used to identify and

treat persons who are at high risk for LTBI or at high risk for developing TB disease.

During patient evaluations, healthcare providers should identify and test persons who are at high risk for TB.

Testing activities should only done when there is a plan for follow-up care to evaluate and treat all individuals diagnosed with LTBI or TB disease. “The decision to test is the decision to treat”.

People who are not high risk for LTBI generally should not be tested.

Testing in low-risk populations can take resources away from other important activities.

How to determine if you repeat a TB Skin test on a child?How to perform a TB test? TST using the Mantoux method is the only skin testing method that should be used. Before administration, it is important to obtain the student/ patient’s TST history.

No

Has the child ever tested positive using the Mantoux TST method?

If No IF Yes

Yes No

Yes No

Does the documentation have the dr. signature, date, mm? ?reading?

Child is exempt Is there documented history of treatment?

Ask for written documentation Proceed with the TST

Proceed Wit the Test Child may be exempt; inquire with DSHS

Interpret the TST

TB Treatment Plan

Medicine Dosage and Timings

Isoniazid (INH)

9 months/ *2 every week= 76 dosesThese two doses must be 72 hours apart (at least alternative days). For instance,

(M & Th), (Tu & F) or (M & F)

Latent TB Infection Treatment Plan

Medicine Dosage and Timings

Isoniazid and Rifampin (INH/RIF)

7 days a wk. (14days)

2 days a wk. (60 days)

Total of 40 doses

Isoniazid and Pyrazinamide(INH/PZA)

7 days a wk. (14days)

2 days a wk. ( 6 months)

= Total of 76 doses

Active TB Disease Treatment Plan

Methods of the Project

Literature research on educational TB resources

Annotation of the previously written material for the project.

Proposed modifications to the DSHS and submitted work plan

for approval

Initiate and complete writing phase

References and appendix

Phase I- Project Research & Writing

Methods Continued

Submit for review to DSHS Supervisor

Create an anonymous feedback survey and administer to a sample of school nurses.

Gather the survey results and discuss feedback

Finalize the document.

Submission to DSHS for publication and usage as a future

resource

Phase II- Project Evaluation and Analysis

Results100% of the respondees found it to be a helpful

addition to TB training & related educational

materials.

For 100% of the respondees, it took less

than an hour to read

100% of the respondees indicated that the guide

addressed all the relevant TB related topics for school

nurses

100% of the respondees indicated the guide provides detailed

instructions on Direct Observed Therapy (DOT)

with visual aids

67% of the respondees found the guide “easy to

read” whereas 33% found the guide “very easy to

read”

Recommendations

Officially publish the desk- guide under as a DSHS

resource

Distribution of the guide to all

the school nurses and school

campus DOT providers

Continued Training and CE for school

nurses on TB related topics

ReferencesAdverse Reactions. (2008, April). Retrieved 11 05, 2015, from Curry International Tuberculosis Center: www.currytbcenter.ucsf.edu/drtbArbex, M. A., Varella, M. d., Siqueira, H. R., & Mello, F. A. (2010). Antituberculosis drugs: Drug interactions, adverse effects, and use in special situations. Part 1: First-line drugs. J Bras Pneumol, 626-640.Clinic Locations- Region 4/5 N. (2016, May). Retrieved November 5, 2015, from http://www.dshs.state.tx.us/region4-5/Clinic-Locations.pdfCDC | TB | Basic TB Facts. (2012). Retrieved from Centers of Disease Control and Prevention website: http://www.cdc.gov/tb/topic/basics Diagnostic Standards and Classification of Tuberculosis. (1990). American Review of Respiratory Disease, 142(3), 725-735. doi:10.1164/ajrccm/142.3.725 Direct Observed Therapy [Photograph]. (2014). Retrieved from https://results.usaid.gov/georgia/health/tuberculosis#fy2014 Graham, S. M. (2015). Desk-Guide For Diagnosis and Management of TB in Children. Retrieved from International Union against TB and Lung Disease (The Union) website: http://www.theunion.org/what-we-do/publications/technical/desk-guide-for-diagnosis-and-management-of-tb-in-childrenHealth Service Region 4/5N Tuberculosis Elimination Program. (2015, March). Retrieved from http://www.dshs.state.tx.us/region4-5/tuberculosis.shtmHow To Administer, Read and Interpret TB. (2014). Retrieved from http://www.parsterileproducts.com/products/products/aplisol/administer-read-interpret.phpMantoux- Tuberculin Skin Test [Poster]. (2012). Retrieved from http://www.cdc.gov/tb/publications/Posters/images/Mantoux_wallchart.pdf Self-Study Module on Tuberculosis: Transmission and Pathogenesis of Tuberculosis. (2008). Retrieved from US Department of Health and Human Services & Centers for Disease Control and Prevention- Division of Tuberculosis Elimination website: http://www.cdc.gov/tb/education/ssmodules/pdfs/module1.pdfSelf-Study Module on Tuberculosis: Treatment of Latent Tuberculosis Infection and Tuberculosis Disease. (2008). Retrieved from US Department of Health and Human Services & Centers for Disease Control and Prevention- Division of Tuberculosis Elimination website: http://www.cdc.gov/tb/education/ssmodules/pdfs/module4.pdfSelf-Study Modules on TB: Targeted Testing and the Diagnosis of Latent Tuberculosis Infection and Tuberculosis Disease. (2008). Retrieved from US Department of Health and Human Services & Centers for Disease Control and Prevention- Division of Tuberculosis Elimination website: http://www.cdc.gov/tb/education/ssmodules/pdfs/module3.pdfTexas Department of State Health Services- Health Service Region 4/5N: Tuberculosis Manual ( ). (2015). Tyler, TX: Texas Department of State Health Services.Tuberculosis Control Laws and Policies: A handbook for Public Health and Legal Practioners. (2009). Retrieved from Centers for Disease Control and Prevention website: http://www.cdc.gov/tb/programs/TBLawPolicyHandbook.pdfTuberculosis Day. (2015). Retrieved from http://www.earthtimes.org/newsimage/world-tuberculosis-day_24-3-2013.jpgWorking towards a TB and HIV free community [Photograph]. (2013, February). Retrieved from http://emailblog.graphicmail.com/mobile-marketing-case-study-tbhiv-care-association/

Questions/ Comments?

Thank you very much for you time!