1. TB PREVENTION by Assoc. Prof. Dr. Nik Sherina Haidi Hanafi 1

2. LEARNING OBJECTIVES To learn on who should be screened for TB To learn on the available screening tests To learn on the TB preventive strategies for healthcare workers 2

3. CONTENT Screening of contacts Screening tests Preventive strategies for health care workers 3

4. SCREENING Objectives of screening – Early detection of TB – Reduction of TB transmission Persons to screen – Contacts of index TB patients – Index patients: both smear positive & negative cases 4

5. SCREENING Contact screening: – Risk of acquiring all types of TB is higher amongst contacts compared to non- contacts (OR=4.5, 95% CI 4.3 to 4.8) Morrison J et al., Lancet Infect Dis, 2008 Contacts Close contacts No universal definition 5 5 5

6. SCREENING Variable definition of contacts: – family members living in the same room with the index cases for more than 30 days Noertjojo K et al., Int J Tuberc Lung Dis, 2002 – family members or other people who lived with smear-positive PTB cases for more than half a year Hou SY et al.,Chin J Antituberculosis, 2006 6

7. SCREENING Contacts have varying risks: – Diabetes (OR=10.2, 95% CI 3.0 to 34.8) – Cavitation in index patients (OR=1.6, 95% CI 1.1 to 2.2) – More than 100 AFB/field (OR=1.8, 95% CI 1.2 to 2.8) – Household contact at night (OR=2.1, 95% CI 1.3 to 3.2) – Actively smoking (OR=1.6, 95% CI 1.1 to 2.4) Aissa K et al., Am J Respir Crit Care Med, 2008 7

10. CPG MANAGEMENT OF TUBERCULOSIS (3 RD RDITION) 10

11. SCREENING TESTS FOR CONTACTS & HIGH RISK GROUP Tests for asymptomatic individuals (alone or in combination): – CXR – Tuberculin skin test (TST) – IGRA CXR & symptom screening (CFSW: cough, fever, night sweat & weight loss) increases the specificity of screening compared to symptom screening alone 1 Churchyard GJ et al, AIDS, 2010. 2 den Boon S et al., Int J Tuberc Lung Dis, 2006 11

12. SCREENING TEST A clinical scoring system is useful for the diagnosis of smear negative TB – CXR findings – Clinical features (haemoptysis, age >45 years, loss of weight, expectoration, apical infiltrate & miliary infiltrate) AUC=0.83, 95% CI 0.74 to 0.90 1 Soto A et al., Braz J Infect Dis. 2008 2 Soto A et al., PLoS ONE, 2011 12

13. TUBERCULIN SKIN TEST (TST) Most widely used - Mantoux test Preferred test in children <5 years of age Advantages – Cheap – Relatively easy to perform Disadvantages – Timescale – Defaulters – Reading of induration prone to subjective errors False positives – NTM infection – Previous BCG vaccination False negatives – Compromised immune system – Extensive TB (pulmonary or miliary) (paradoxical) 13

14. PREVENTION OF TB INFECTION AMONG HEALTHCARE WORKERS Process: Risk assessment - done to determine the risk of TB transmission at workplace Risk category Risk control – administrative controls – engineering controls – personal protective equipment 14

15. CPG MANAGEMENT OF TUBERCULOSIS (3 RD RDITION) 15

16. TAKE HOME MESSAGES All TB contacts need to be screened. Certain groups are at higher risk of acquiring TB. Screening involves symptom screening, TST & CXR. 16

17. 17 THANK YOU  niksherina@um.edu.my niksherina@um.edu.my