TB CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE MARCH 27-30, 2017

Curry International Tuberculosis Center, UCSF 300 Frank H. Ogawa Plaza, Suite 520 Oakland, CA; Office (510) 238-5100

TB BASICS: PRIORITIES AND CLASSIFICATIONS

LEARNING OBJECTIVES

Upon completion of this session, participants will be able to:

1. List the four strategies that the Centers for Disease Control and Prevention recommends for public health agencies to implement in order to control and prevent tuberculosis

2. Identify several characteristics that distinguish active TB disease from latent TB infection (LTBI)

3. Appropriately apply the American Thoracic Society TB classifications

INDEX OF MATERIALS PAGES

1. TB basics: priorities and classifications-slide outline Presented by: Ann Raftery, RN, BSN, PHN, MSc

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SUPPLEMENTAL MATERIALS

1. CDC. Table 2.8: TB Classification System. In: Chapter 2: transmission and pathogenesis of tuberculosis. Core Curriculum on Tuberculosis: What the Clinician Should Know. Atlanta, GA: 2011:40

2. Resources on Tuberculosis

3. Acronyms and Abbreviations

TB CASE MANAGEMENT AND CONTACT INVESTIGATION INTENSIVE MARCH 27-30, 2017

Curry International Tuberculosis Center, UCSF 300 Frank H. Ogawa Plaza, Suite 520 Oakland, CA; Office (510) 238-5100

ADDITIONAL REFERENCES

• ATS/CDC/IDSA. Controlling Tuberculosis in the United States Recommendations from the

American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR. 2005; 54(RR-12):15.

• Gideon HP, Flynn JL. Latent tuberculosis: what the host “sees”? Immunol Res. 2011; 50:202-12.

• ATS/CDC. Diagnostic Standards and Classification of Tuberculosis in Adults and Children. Am J Respir Crit Care Med. 2000; 161(4):1376-1395. doi: 10.1164/ajrccm.161.4.16141

• CDC/NCEZID. CDC immigration requirements: technical instructions for tuberculosis screening and treatment using cultures and directly observed therapy. October 1, 2009: 1-37. http://www.cdc.gov/ncidod/dq/panel_2007.htm

Basic TB Concepts1

TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center

TB BASICS

Ann Raftery, RN, PHN, MScCurry International Tuberculosis Center

Case Management and Contact Investigation Intensive March 27, 2017

Overview

1. Priority strategies for TB prevention and control

2. TB Transmission and Pathogenesis

• Latent TB infection (LTBI)

• Active TB disease

3. Tuberculosis Classifications

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Basic TB Concepts2

TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center

What are the priority strategies in public health 

for TB prevention and control?

3

Priority Strategies for TB Prevention & Control

1. Early and accurate detection, diagnosis, and reporting of TB cases leading to initiation and completion of treatment

2. Identification of contacts of patients with infectious TB and treatment of those at risk with an effective drug regimen

3. Identification of other persons with latent TB infection at risk for progression to TB disease and treatment of those persons with an effective drug regimen

4. Identification of settings in which a high risk exists for transmission of Mycobacterium tuberculosis and application of effective infection‐control measures

Source: ATS/CDC/IDSA. Controlling Tuberculosis in the United States Recommendations from the American 

Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR 2005; 54 (No. RR‐12):15. 4

Basic TB Concepts3

TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center

Latent TB infection or active TB disease?

What features distinguish one from the other?

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TB Transmission and Pathogenesis

Not everyone who is exposed to TB will become infected

Adequate Immunity

No infection (70%)

Infection (30%)

Inadequate Immunity

Non-specific immunity

EXPOSURE

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TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center

Risk Factors for TB Infection

The chance of INFECTION Increases when… 

• The concentration of TB bacteria circulating in the air is greater

– Coughing; smear‐positive; cavitary disease

– Poor ventilation; small enclosed space

• More time is spent with the infectious person (frequency and duration)

• Exposure occurs in an area where the bacteria can easily survive (no UV light)

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TB Pathogenesis

Immunologic defenses

Inadequate Defenses

Early progressionTB disease (5-10%)

Adequate Defenses

Containment(90-95%)

No infection (70%)

Adequate Immunity

Non-specific immunity

Inadequate Immunity

EXPOSURE

Infection (30%)

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Basic TB Concepts5

TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center

DISSEMINATION: Spread of TB to Other Parts of the Body

1. Lungs (85% all cases)

2. Pleura

3. Central nervous system

(spine, brain, meninges)

4. Lymph nodes

5. Genitourinary system

6. Bones and joints

7. Disseminated (miliary)

© ITECH, 2006

TB Pathogenesis (3)

Immunologic defenses

Inadequate Defenses

Early progressionTB disease (5-10%)

Adequate Defenses

Containment(90-95%)

No infection (70%)

Adequate Immunity

Non-specific immunity

Inadequate Immunity

Infection (30%)

EXPOSURE

Immunologic defenses

Continued containment

Adequate Defenses

Inadequate Defenses

Late progression TB disease

(5-10%)

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Basic TB Concepts6

TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center

Risk Factors for Progression of Infection to TB Disease

• 10% of persons with normal immune systems develop TB at some point in their lifetime

• Recent infection (within 1‐2 years of infection)

• Medical risk factors:– HIV  (7‐10% each year)

– Silicosis

– Diabetes mellitus

– Chronic renal failure or hemodialysis

– Solid organ transplantation

– Carcinoma of head or neck

– Gastrectomy or jejunoileal bypass

– Underweight or malnourished

– Immunosuppressive treatment (e.g., TNF‐alpha blocking agents, cancer chemotherapy, etc.) 11

Latent TB Infection (LTBI)• Inactive tubercle bacilli in the body 

• Tuberculin skin test or interferon‐gamma release assay (IGRA) test results usually positive 

• Chest x‐ray usually normal

• Sputum smears and cultures negative

• No symptoms 

• Not infectious

• Not a case of TB

Active TB Disease• Active tubercle bacilli in the body 

• Tuberculin skin test or interferon‐gamma release assay (IGRA) test results usually positive 

• Chest x‐ray may be abnormal

• Sputum smears and cultures may be positive

• Symptoms such as cough, fever, weight loss 

• May be infectious before treatment 

• A case of TB 

Source: CDC. Transmission and Pathogenesis of Tuberculosis. Self‐Study Modules on Tuberculosis. US Department of Health and Human Services. Atlanta, GA; 2008: 14. 12

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TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center

TB Pathogenesis

Gideon and Flynn. Immunol Res. 2011 August ; 50(0): 202–21213

What are the classifications for TB?

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TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center

TB Classification Scheme & Definitions

Class Stage of Disease Description

0 No TB exposure, 

Not infected

No history of TB exposure.  Negative  tuberculin skin test (or IGRA)

1 Exposure,  no evidence 

of infection

History of TB exposure. Negative  tuberculin skin test (or IGRA)

2 Latent TB infection, no 

disease

Positive tuberculin skin test (or IGRA).  No clinical, bacteriologic, or radiographic evidence of TB

3 TB, clinically active M. tuberculosis  cultured (if performed). Clinical, bacteriologic, or radiographic evidence of current TB disease

4 TB,  not clinically 

active

History of episode(s) of TB  OR Abnormal but stable radiographic findings , positive tuberculin skin test, negative bacteriologic studies (if done) AND no clinical or radiographic evidence of current disease

5 TB suspect

(aka presumptive TB)

Diagnosis pending.  TB disease should be ruled in or out within 3 months

Adapted from: ATS/CDC. Diagnostic Standards and Classification of Tuberculosis in Adults and 

Children (2000). http://www.atsjournals.org/doi/full/10.1164/ajrccm.161.4.16141#.WA0Auk0zXIU15

CDC TB Classifications:Immigrants and Refugees

Classification Description

No TB Normal TB screening examinations 

Class A TB with waiver [Active] TB disease and have been granted a waiver 

Class B1 TB, Pulmonary  (PTB)

No treatment  ‐ H/o or findings suggestive of PTB but negative AFB sputum smears and cultures and are not diagnosed with [active TB disease] or can wait to have TB treatment started after immigration. 

Completed treatment ‐ Diagnosed with PTB and completed [treatment by] directly observed therapy prior to immigration. 

Class B1 TB, Extra‐pulmonary (EPTB)

Evidence of EPTB. The anatomic site of infection should be documented. 

Class B2 TB, LTBI Evaluation

Positive TST (>10mm) but otherwise negative evaluation for TB. 

Class B3 TB, Contact Evaluation

Recent contact of a known TB case.  

Adapted from: CDC Immigration Requirements: Technical instructions for tuberculosis screening and treatment (2009). http://www.cdc.gov/immigrantrefugeehealth/ 16

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TB Case Management and Contact Investigation IntensiveMarch 27-30, 2017Curry International Tuberculosis Center

Questions?

17

Classification System for Tuberculosis

TB Class

Type

Description

0 No TB exposure

Not infected • No history of TB exposure and no evidence of M. tuberculosis infection or disease

• Negative reaction to TST or IGRA

1 TB exposure

No evidence of infection • History of exposure to M. tuberculosis

• Negative reaction to TST or IGRA (given at least 8 to 10 weeks after exposure)

2 TB infection No TB disease

• Positive reaction to TST or IGRA

• Negative bacteriological studies (smear and cultures)

• No bacteriological or radiographic evidence of active TB disease

3 TB clinically active

• Positive culture for M. tuberculosis OR

• Positive reaction to TST or IGRA, plus clinical, bacteriological, or radiographic evidence of current active TB

4 Previous TB disease (not clinically active)

• May have past medical history of TB disease

• Abnormal but stable radiographic findings

• Positive reaction to the TST or IGRA

• Negative bacteriologic studies (smear and cultures)

• No clinical or radiographic evidence of current active TB disease

5 TB suspected • Signs and symptoms of active TB disease, but medical evaluation not complete

From Centers for Disease Control and Prevention. Table 2.8: TB Classification System. In: Chapter 2: transmission and pathogenesis of tuberculosis. Core Curriculum on Tuberculosis: What the Clinician Should Know. Atlanta, GA: 2011:40.

Websites Checked 10/20/2016

Resources on Tuberculosis (TB) Centers for Disease Control and Prevention (CDC) Division of Tuberculosis Elimination (DTBE)

Guidelines: http://www.cdc.gov/tb/publications/guidelines/default.htm

Online Courses:

Self-Study Modules on Tuberculosis: http://www.cdc.gov/tb/education/ssmodules/default.htm

Core Curriculum on Tuberculosis: What the Clinician Should Know: http://www.cdc.gov/tb/education/corecurr/index.htm

Curry International Tuberculosis Center (CITC)

Medical Consultation Warmline: http://www.currytbcenter.ucsf.edu/consultation

877-390-6682 (toll-free)

Warmline inquiries can also be sent to the CITC email address, currytbcenter@ucsf.edu

8:00 AM to 4:30 PM (Pacific Time), Monday through Friday (excluding holidays). Voicemail is available to record incoming messages 24 hours a day, 7 days a week.

Online Products: http://www.currytbcenter.ucsf.edu/products

(selected highlights only—check the web page for the full list)

Drug-Resistant Tuberculosis: A Survival Guide for Clinicians, 3rd edition

Radiographic Manifestations of Tuberculosis: A Primer for Clinicians, 2nd Edition

Tuberculosis Infection Control: A Practical Manual for Preventing TB

Websites Checked 10/20/2016

Curry International Tuberculosis Center (continued) Online Courses & Presentations: http://www.currytbcenter.ucsf.edu/products

(selected highlights only—check the web page for the full list)

Medical Management of Tuberculosis

Pediatric Tuberculosis

Practical Solutions for TB Infection Control: Infectiousness and Isolation

TB Prevention in the HIV-infected Patient: Screening, Testing, and Treatment of LTBI

Tuberculosis Radiology Resource Page

Archived Webinars: http://www.currytbcenter.ucsf.edu/trainings/webinar-archive Classroom Trainings: http://www.currytbcenter.ucsf.edu/trainings National Tuberculosis Controllers Association (NTCA)

Tuberculosis Nursing, 2nd Edition: http://www.tbcontrollers.org/resources/tb-nursing- manual/#.VFuW7Wf4pws

Interjurisdictional Transfers (Form): http://www.tbcontrollers.org/resources/interjurisdictional-transfers/#.VFuW3Wf4pws

Interjurisdictional Transfers (Contacts): http://www.tbcontrollers.org/community/statecityterritory/#.WAmCLk0zXIU California Tuberculosis Controllers Association (CTCA)

California Department of Public Health/CTCA Joint Guidelines: http://www.ctca.org/

CTCA Directory: http://ctca.org/locations.html

Tuberculosis (TB) Acronyms and Abbreviations

AFB acid-fast bacilli ALT alanine aminotransferase ARPE Aggregate Reports for Tuberculosis Program Evaluation ART antiretroviral therapy AST aspartate aminotransferase AK amikacin ATS American Thoracic Society BCG Bacille Calmette-Guérin BSC bio-safety cabinet CBC complete blood count CDC Centers for Disease Control and Prevention CHOW community health outreach worker CI contact investigation CNS central nervous system CM capreomycin CS cycloserine CXR chest x-ray DTBE Division of Tuberculosis Elimination DOT directly observed therapy DST drug susceptibility testing EMB (E) ethambutol EPTB extra-pulmonary tuberculosis ESRD end-stage renal disease ETA ethionamide FQN fluoroquinolone IA injectable agent IDSA Infectious Diseases Society of America IGRA interferon gamma release assay HIV human immunodeficiency virus HPLC high performance liquid chromatography HSC health & safety code IGRA interferon gamma release assay INH (I) isoniazid

IP infectious period IUATLD International Union Against Tuberculosis and Lung Disease (The Union) LFT liver function test LJ Lowenstein-Jensen (type of TB culture medium) LNZ linezolid LTBI latent tuberculosis infection M. tb Mycobacterium tuberculosis MDDR molecular detection of drug resistance MDR-TB multidrug-resistant tuberculosis MFX moxifloxacin MGIT mycobacteria growth indicator tube (TB culture method) MIRU mycobacterial interspersed repetitive units (genotype method) MMCP MediCal Managed Care Plan MMWR Morbidity and Mortality Weekly Report NAAT nucleic amplification test NNRTI non-nucleoside reverse transcriptase inhibitor NRTI nucleoside reverse transcriptase inhibitor NTCA National Tuberculosis Controllers Association NTIP National Tuberculosis Indicators Project NTM nontuberculous mycobacteria NTNC National Tuberculosis Nurse Coalition PAS Para-aminosalicylate PCR polymerase chain reaction PPD purified protein derivative PTB pulmonary tuberculosis PZA (P) pyrazinamide QFT-GIT QuantiFERON®-TB Gold In-Tube RBT rifabutin RFLP restriction fragment length polymorphism (genotype method) RPT rifapentine RIF (R) rifampin RTMCC Regional Training and Medical Consultation Center RVCT Report of Verified Case of Tuberculosis SAT self-administered therapy SM streptomycin TNF-α tumor necrosis factor-alpha TST tuberculin skin test VDOT directly observed therapy performed via video VNTR variable number of tandem repeats (genotype method) XDR-TB extensively drug-resistant tuberculosis ZN Ziehl-Neelson (AFB staining method)