1. Tuberculosis in the Hospital J Rush Pierce Jr, MD, MPH Associate Professor, Texas Tech University HSC Health Authority, Amarillo Bi-City-County health District Texas Society of Infection Control Practitioners Intermediate Course, Amarillo, Texas October 20, 2006

2. Disclosures Salaried by TTUHSC City of Amarillo Department of Public Health provides approximately 30% salary support Consultant for Texas Dept. of Health and AIG Annuity Insurance Company Some of Slides form CDC Teaching Library Received no financial compensation for today’s talk

3. Objectives of today's’ talk List the major symptoms of active tuberculosis. Define latent tuberculosis and explain how it is different than active tuberculosis. List conditions which facilitate the transmission of tuberculosis. List activities which minimize transmission of tuberculosis in hospitals. Explain the role of the Health Department in the management of tuberculosis.

4. An ICP Nightmare

5. A 54 year-old homeless man comes to the ED with cough and fever. He is dirty, unshaven, appears undernourished, and smells of alcohol. After an 8 hour stay in the ED, he is discharged with amoxicillin for bronchitis. Social service arranges stay in a homeless shelter. He returns one week later. He says he has been sick for several weeks with night sweats and cough that has at times produced bloody sputum. He has lost 20 pounds in two months. The ED physician orders a CXR and the patient is admitted to the floor to the on-call physician.

6. The patient is admitted to a semi-private room. The on-call physician orders a regular diet, oxygen, ceftriaxone and azithromycin. The next day (hospital day 2), the radiologist reads the CXR and identifies a right upper lobe cavity. He dictates a report that goes to transcription. The transcribed report arrives on the floor the following day (hospital day 3) and is filed by the clerk in the chart after the physician makes rounds. The report is noted by the physician on hospital day 4. The physician orders sputum for AFB and a TB skin test, but fails to communicate concerns about the possibility of TB to the nursing staff.

7. On hospital day 6, positive AFB smears are reported by the lab. The patient is placed in respiratory isolation and the ICP is contacted.

8. Pertinent questions What is tuberculosis? How is tuberculosis transmitted? What conditions facilitate the transmission of tuberculosis? How is tuberculosis diagnosed? How is transmission of tuberculosis prevented in hospitals?

9. 25 - 49 50 - 99 100 - 300 0 - 9 10 - 24 300 or more No estimate Rate per 100 000 Estimated TB incidence rates, 2000 The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. Global Tuberculosis Control. WHO Report 2002. WHO/CDS/TB/2002.295

10. Unusual qualities of Mycobacterium Slow growing (division time ~ once/day)  Symptoms subacute  Laboratory isolation slow  Long treatment necessary Resistant to ordinary antibiotics Resistant to cellular enzymatic defense mechanisms Unusual staining characteristics

11. Sequencing the genome of M. tuberculosis

13. Transmission of tuberculosis Spread by droplet nuclei Expelled when person with infectious TB coughs, sneezes, speaks, or sings Close contacts at highest risk of becoming infected Transmission occurs from person with infectious TB disease (not latent TB infection)

14. Transmission and Pathogenesis

15. Conditions that facilitate the transmission of tuberculosis Small closed spaces Lack of air movement Lack of light

16. Consequences of infection with M. tuberculosis 95% 5% Infection Immunity Reactivation disease 5% Primary disease

17. Types of Active Tuberculosis Lung Infections PRIMARY  Recent infection  Favors lower lobes  Non-cavitary  Less contagious  Children > Adults REACTIVATION  Remote infection  Upper lobes  Tends to cavitation  More contagious  Almost exclusively adults, occasionally adolescents

18. Active tuberculosis ling infection - History and physical examination Weight loss Night sweats Hemoptysis Signs of weight loss +/- fever Lung exam is usually normal HISTORYEXAM

19. TB Skin Testing

21. AFB smear AFB (shown in red) are tubercle bacilli

22. Chest Radiograph in Active TB Lung Infection Abnormalities often seen in upper lobe or superior segments of lower lobe May have unusual appearance in HIV- positive persons Cannot confirm diagnosis of TB

23. Baseline Diagnostic Examinations for TB Tuberculin skin test Chest x-ray Sputum specimens (= 3 obtained 8-24 hours apart) for AFB microscopy and mycobacterial cultures Routine drug-susceptibility testing for INH, RIF, and EMB on initial positive culture Counseling and testing for HIV infection

24. Contact Investigation in the hospital Enlist the help of the Health Department Identify those at highest risk of transmission Test for acquisition of TB infection Consider preventive therapy (treatment of latent infection) for those who have recently acquired TB infection CQI review

25. Factors to consider when deciding who is at highest risk Duration of exposure Place of exposure (closed room worse than open area) Type of exposure (aerosol-inducing procedures like HHN and bronchoscopy highest risk) Immune system of exposed persons

26. Who was exposed? Staff (nursing, physician, respiratory therapy, physicians, social service, dietary, admitting office, housekeeping, etc.) Patients Visitors

27. How do you know who was exposed? Review of duty hours and work days of staff Post notices to staff Review patient room assignments With help of Health Department, interview patient Letters to visitors, public notices

28. Contact investigation Baseline testing  Rationale  How to do this Repeat testing Assess positive reactors for active disease Offer positive reactors preventive therapy (treatment of latent tuberculosis

29. Testing for TB Infection

30. The Tuberculin Skin Test Inject intradermally 0.1 ml of 5TU PPD tuberculin Produce wheal 6 mm to 10 mm in diameter Follow universal precautions for infection control No contraindication in pregnancy

31. Reading the Tuberculin Skin Test Read reaction 48-72 hours after injection Measure only induration Record reaction in millimeters

32. What is the booster phenomena and what is a two step tuberculin test?

33. Boosting Some people with LTBI may have negative skin test reaction when tested years after infection Initial skin test may stimulate (boost) ability to react to tuberculin Positive reactions to subsequent tests may be misinterpreted as a new infection

35. Two-Step Testing Use two-step testing for initial skin testing of adults who will be retested periodically If first test positive, consider the person infected If first test negative, give second test 1-3 weeks later If second test positive, consider person previously infected If second test negative, consider person uninfected

36. How does BCG vaccine affect the tuberculin test?

38. BCG Vaccination and Tuberculin Skin Testing TST not contraindicated for BCG-vaccinated persons DX and RX for LTBI considered for any BCG- vaccinated person whose skin test reaction is >10 mm, if any of these circumstances are present: -contact with another person with infectious TB - Was born or has resided in a high TB prevalence country - Is continually exposed to populations where TB prevalence is high

39. Consequences of infection with M. tuberculosis 95% 5% Infection Immunity Reactivation disease 5% Primary disease

40. Persons at Higher Risk of Developing TB Disease once Infected HIV infected Recently infected Persons with certain medical conditions Persons who inject illicit drugs History of inadequately treated TB

41. Conditions That Increase the Risk of Progression to TB Disease HIV infection Substance abuse Recent infection Chest x-ray findings suggestive of previous TB Diabetes mellitus Silicosis Prolonged corticosteriod therapy Other immunosuppressive therapy

42. Conditions That Increase the Risk of Progression to TB Disease (cont.) Cancer of the head and neck Hematologic and reticuloendothelial diseases End-stage renal disease Intestinal bypass or gastrectomy Chronic malabsorption syndromes Low body weight (10% or more below the ideal)

43. Candidates for Treatment of LTBI Positive skin test result at least 5 mm HIV-positive persons Recent contacts of a TB case Persons with fibrotic changes on chest radiograph consistent with old TB Patients with organ transplants and other immunosuppressed patients

44. Candidates for Rx of LTBI (cont.) Positive skin test result at least 10 mm Recent arrivals from high-prevalence countries Injection drug users Residents/employees of congregate settings Mycobacteriology laboratory personnel Persons with certain clinical conditions Children < 4 years of age, or children and adolescents exposed to adults in high-risk categories

45. Candidates for Rx of LTBI (cont.) Positive skin test result at least 15 mm Persons with no known risk factors for TB may be considered Targeted skin testing programs should only be conducted among high-risk groups

46. Decreasing transmission in hospitals High index of suspicion  ED staff  Nursing staff  Physicians Early reporting of suspicions Early isolation Get to know your Health Dept Policies

47. Questions and/or comments