1. Tuberculosis Update Rachel L. Stricof, Epidemiologist
New York State Department of Health

3. TB & MDR-TB - 2005 1,294 cases in NYS, a 4.9% decrease from 2004
> 72 percent decrease since 1992
> 51 of cases outside NYC are from Nassau, Suffolk and Westchester counties
27 MDR cases: 24 from NYC, 3 in rest of state
Approximately, 70 percent of cases born outside U.S.

4. Key to Control Know the epidemiology of TB in the community you serve
Changes can occur rapidly
HIV epidemic
MDR transmission
Introduction of TB in homeless shelters, prisons, high risk populations, etc.
e.g., Hmong Refugees
Changes can have significant impact

5. What you don’t want to happen…
Time 0 through day 5
45-year-old female admitted through ED
3 month history of productive cough, pleuritic chest pain, low grade temp and night sweats
CXR examination revealed RLL infiltrate
Past medical history – diabetes, smoking and asthma
Discharged on oral Levaquin after clinical improvement on IV Levaquin

6. And the story continues….
Day 23 - ED Visit
Fever, chills, productive cough
CXR examination reveals RLL pneumonia
Given prescription for 10 day course of Levaquin
Day 37 - ED Visit
Fever, chills, productive cough, chest pain
Dx: resolving pneumonia and pleuritis
Plan: Motrin and follow-up with PMD in 3 days

7. And the sad story continues….
Day
Patient admitted from ED
Worsening shortness of breath, chest pain, cough, low grade fever
Blood glucose = 592
CXR exam: RLL pneumonia
Placed on Augmentin and develops pruritis and hives
Switched to Ceclor and develops pruritis
Discharged on Clindamycin and Zithromax

8. Is there no end……… Day 157 (5+ months) –
Patient readmitted from the ED
Blood glucose up to 609
CXR exam: RLL infiltrate, pleural effusion, LUL nodule
CT exam: Cavitary lesions in LUL and RLL
ID consultation obtained on 5th hospital day
Noted weight loss (size 18 to 8)
Orders TST, sputum for AFB, isolation
Sputum: 4+ AFB, M. tuberculosis

9. Early Identification Most critical component
As incidence goes down, so does index of suspicion
As incidence goes down, public health infrastructure in jeopardy
As incidence goes down, more difficult to maintain competency (lab, radiology, clinical acumen, etc.)

10. What’s New? Expanded scope – additional settings
Criteria for moving into/out of isolation
Revised risk assessment recommendations
TB screening frequency modifications
Respiratory fit testing and training wording
Voluntary use of respirators by visitors
QuantiFERON testing
Frequently asked questions section added

11. Other Settings ERs Medical offices Ambulatory care units
Bronchoscopy suites
Autopsy suites
Embalming rooms
Operating suites
Laboratories
TB clinics
Ambulatory care units
Dialysis units
Correctional facilities
EMS
Home healthcare
Hospices
LTCF

12. Frequency of Sputum Collection for TB Suspects
Three consecutive negative sputum smears
Taken hours apart
Previous guideline recommended 24 hour intervals between specimens
At least one specimen obtained AM
In most cases, collection will occur over 2 days

13. NYS NAA Testing *on AFB+ respiratory specimens – Not CDC
Mycobacteriology Standard 8 ( to go into effect later this spring ):
All respiratory specimens which test acid-fast smear positive and are from patients who have not previously been diagnosed with tuberculosis shall have nucleic acid amplification testing performed
Guidance:
Specimens from patients with a past history of NTM infection and without clinical suspicion of tuberculosis (e.g., cystic fibrosis patients) do not need nucleic acid amplification testing performed.
If the laboratory does not have the capability to perform nucleic acid amplification testing, an additional respiratory specimen shall be immediately requested and sent to a New York State permitted laboratory that performs nucleic acid amplification.
*Nucleic Acid Amplification:
Gen-Probe AMPLIFIED Mycobacterium tuberculosis Direct (MTD) or Roche AMPLICOR Mycobacterium tuberculosis (MTB) test

14. Free MTD testing on AFB smear negative specimens: Wadsworth*
All of the following criteria should be met:
High clinical suspicion of TB, previously untreated or <7 days of treatment
Respiratory specimen, or
Non-respiratory specimens (request from the lab on a case by case basis if clinical suspicion is high)
*For NYC specimens, Wadsworth or NYCPHL
*not CDC

15. Discontinuing Isolation for Suspect or Rule-out TB Patients
Infectious TB disease is unlikely
AND
Another etiology is identified OR
Three consecutive negative sputum smears taken hours apart
Smear +, NAA-negative for M. tb

16. Discontinuing Isolation for Suspected/Confirmed TB Patients
Remain in airborne isolation until:
Three consecutive negative AFB sputum smear results collected hours apart, with at least one being an early morning specimen
On appropriate anti-TB treatment
Usually a 4 drug regimen to start
Usually for at least 2 weeks prior to discontinuing isolation
Demonstrated clinical improvement

17. Airborne Infection Isolation Rooms (AIIRs)
6 ACH (existing); 12 ACH (new)
Minimum of 2 outdoor air exchanges per hour
Recommended minimum pressure differential has been increased from to 0.01 w.g. (AIA Guidelines 2001)
Monitoring is essential
Direct exhaust to outside
If must recirculate air to other areas, HEPA
Proper installation and maintenance

18. High Efficiency Particulate Air HEPA Filter 99.97% @ 0.3 micron
high air resistance
may lose airflow
leakage at seals
special maintenance

19. Proper
Installation and
Maintenance
Are Essential

20. Continuous Monitors vs. Smoke
189 New York State hospitals
172 (91%) had at least one AII room
117 rooms had a continuous-pressure monitoring device
25% had a discrepancy between smoke testing and continuous monitor
Not associated with any particular type of device or manufacturer
Discrepancies increased with increased verification w/smoke
Recommend daily smoke test when room in use
Pavelchak N, Cummings K, Stricof R et al. Infect Control Hosp Epidemiol 2001; 22(8):518–19

21. Smoke
testing

22. Disruption of Ventilation
Opening/closing windows or doors
Movement of elevators
Blocked air diffusers or exhaust grills
Outdoor wind direction and speed
Dirty filters
Variable air volume (VAV) systems
Changes in one area affect other areas

24. Ultraviolet Germicidal Irradiation (UVGI)
Can be used as a supplement to ventilation
Not a substitute for negative pressure
Can substitute for HEPA filtration when recirculated into same AIIR
Guidelines provide new emphasis on safety and maintenance
Provide guidance on occupational exposure limits

25. CDC Guidelines - Respiratory Protection for Workers
Determining need for a respiratory protection program for TB
Suspect or confirmed TB patients
Selection of respirators
Fit testing
Initial
Periodic
Annual training

26. Selection of Respirators
Certified by CDC/NIOSH as a non-powered particulate filter respirator, including disposable respirators, or PAPRs with high efficiency filters
Have the ability to adequately fit respirator wearers who are included in a respiratory-protection program
Have the ability to fit the different facial sizes and characteristics of HCWs (This criterion can usually be met by making respirators available in different sizes and models.)
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27. Fit Testing (Cut and Pasted)
A fit test is used to determine which respirator fits the user
adequately and to ensure that the user knows when the respirator
fits properly. After a risk assessment is conducted to validate
the need for respiratory protection, perform fit testing
during the initial respiratory-protection program training and
periodically thereafter in accordance with federal, state, and
local regulations (
protection/index.html).
Fit testing provides a means to determine which respirator
model and size fits the wearer best and to confirm that the
wearer can don the respirator properly to achieve a good fit.
Periodic fit testing for respirators used in TB environments
can serve as an effective training tool in conjunction with the
content included in employee training and retraining. The
frequency of periodic fit testing should be supplemented by
the occurrence of 1) risk for transmission of M. tuberculosis,
2) facial features of the wearer, 3) medical condition that would
affect respiratory function, 4) physical characteristics of respirator
(despite the same model number), or 5) model or size of
the assigned respirator (281).
Page 39

28. Respiratory Protection for Visitors
Visitors can use N-95’s – Why?
Visitors may have much more intense and prolonged contact
Minimizes confusion for employees and visitors
No medical assessment or fit-testing is required for visitors
Only necessary when mandated for workers
OSHA standard
Selecting a respirator with inherently good fit characteristics will benefit all

29. Note the Senator has his respirator on . . .
They all have them around their necks
The Senator also has his upside down!!!
That’s why training is SO important!!!!

30. Depends on Facility Type And Specific Regulations
Worker Screening
Depends on Facility Type
And
Specific Regulations

31. TB Screening Prior to Employment
Clinical signs and symptoms
History of previous exposure, disease or treatment
History of BCG, especially if born outside of the US
Perform TB screening
Evaluate based on results

32. Tuberculin Skin Test (TST)
Intradermal (Mantoux) method
5 TU of PPD tuberculin
Read by designated, trained personnel at hours
Read transverse diameter of induration
Record mm of induration, not redness

33. Boosting
Some people with TB infection may have a negative skin test when tested many years after infection
The initial skin test may boost (stimulate) their ability to react to tuberculin
Positive reactions on subsequent tests may be misinterpreted as new infection

34. Two-step Testing
All newly employed HCWs with negative initial TST should be retested within 1-3 weeks
Second reading should be recorded in mm induration
This reading should serve as baseline

35. Tuberculin Screening: CDC vs. NYS
CDC no longer recommends routine, periodic tuberculin skin testing ( or QFT) in low risk settings. [12/30/2005]
NYSDOH still requires annual tuberculin screening in licensed healthcare facilities.
May use Mantoux method tuberculin skin test or QuantiFERON TB Gold

36. QuantiFERON-TB Gold (QFT-G)
December, 2004
FDA approval announced
Whole blood assay
Detects M. tuberculosis infection
Detects immune responses to specific M. tb proteins

37. Advantages of QFT-G Higher specificity
Not affected by prior exposure to BCG or most nontuberculous mycobacteria (exceptions: M. kansasii, M. marinum and M. szulgai )
Eliminates issues surrounding appropriate placement, tuberculin product, reading and interpretation
Requires one visit, not multiple visits
Results within 24 hours
No need for 2-step baseline, does not induce boosting
Can target follow-up resources on positives

38. Disadvantages of QFT-G
Specimen must reach lab within 12 hours
Reagents are more costly
But, other costs need to be considered
Results not directly comparable with TST
HCWs move between different facilities
Some may use QFT-G, others TST
Implementation strategies may need to be developed
Most labs are not offering QFT-G
Not every laboratory will be able to reliably perform this test in a cost-effective manner

39. Disadvantages of TST Placement issues Reading issues
Interpretation issues
Elicits boosting
Reagent issues
Reproducibility issues
Specificity poor

40. For more information on QuantiFERON-TB Gold….
Review CDC Guidelines on QuantiFERON-TB Gold
Review literature as it evolves
Definitely more specific, may be more sensitive
Although NYS regulations specify Mantoux method, QFT is acceptable alternative.

41. TB Prevention and Control in LTC
Letter has been sent to long term care facilities
Employee screening
Baseline and annual
Resident screening
Baseline only
No longer recommend routine, annual testing

42. Chest x-ray Examination
After baseline chest radiograph, no need to repeat CXR unless signs or symptoms of TB disease develop or a clinician recommends a repeat chest radiograph.

43. CDC TB Guideline Reference
CDC Guidelines for Preventing the Transmission of M. tb in Health-Care Settings, 2005