Primary Care Management of Latent Tuberculosis Infection in the Foreign-Born. Investigators Carey Jackson MD, MPH University of Washington Jenny Pang MD, MPH, Seattle-King County Department of Public Health Nick DeLuca PhD, Centers for Disease Control and Prevention (CDC)
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Public HealthSeattle & King County
Granuloma breaks down and tubercle escape and multiply
LTBI is the presence of M. tuberculosis organisms (tubercle bacilli) without symptoms or radiographic evidence of active TB disease
2 billion infected with LTBI!
(Active TB all forms [per 100,000 population per year])
Source: WHO Stop TB Department,
< 3.5 (year 2000 target)
15 million infected with LTBI!
> 4.6 (national average)
*Cases per 100,000.
No. of Cases
57% of cases in 2006 were foreign-born
*Updated as of April 6, 2007.
DC 1986–2006*Percentage of TB Cases Among Foreign-born Persons, United States*
*Updated as of April 6, 2007.
Source: World Health Organization
Cases per 100,000
Highest Incidence is in 65+
Over HALF of active TB cases in the Foreign-Born have been in the US more than 5 years!
*Data exclude foreign-born TB patients for when length of residence in the U.S. prior to diagnosis was unknown.
Patient with risk factors for LTBI
Note: Evaluate patient for LTBI testing and treatment regardless of BCG status
Rule out active TB disease before treatment for LTBI is started
No treatment; Document status in medical record
History/HIV risk,physical exam,chest x-ray
Refer to TB clinic for evaluation of active TB
Treatment ofactive TB by TB clinic
Know the TB status of your at risk patients.
A positive TST (PPD) is determined by
Interpreting Tuberculin Skin Test Reactions Prior to Diagnosis,* 2006
(Note: the CDC discourages testing of people at low risk for infection.)
In Country of Origin
In the US
The Immigration Process does not take care of Latent TB Infection (LTBI) for you!
Should persons who have been vaccinatedwith BCG (Bacille Calmette-Guerin) be tested for LTBI
How should the results be interpreted?
Source: CDC TB Fact Sheet “BCG Vaccine” 2006.
Source: Joos, TJ et al. 2006. “Tuberculin reactivity in bacille Calmette-Guerin vaccinated populations: a compilation
of international data.” The International Journal of Tuberculosis and Lung Disease, Volume 10, Number 8, August 2006.
Anyone who has been diagnosed with latent TB infection is a candidate for treatment, if they also fulfill the following criteria:
(Note: careful assessment to rule out the possibility of active TB disease is always necessary before treatment for LTBI is started.)
Your patient’s TB infection may be latent now, but many factors could increase the risk of progression
Risk Factors for Progression from Latent TB Infection (LTBI) to Active TB Disease (cont.)
* Brassard, P. 2006. Antirheumatics Drugs and the Risk of Tuberculosis. CID 2006:43 (15 September).
Case Example of Progression from to Active TB Disease (cont.)LTBI to Active TB
Source: from practice of PI, Carey Jackson, MD. Internal Medicine. International Clinic, Harborview Medical Center, Seattle, Washington.
A minimum of 270 doses must be administered
within 12 months
Rifampin plus pyrazinamide x 2 months
This regimen has been associated with increased risk of severe hepatic injuryand death
Source: “Update: Adverse Event Data and Revised American Thoracic Society/CDC Recommendations Against the Use of Rifampin and Pyrazinamide for Treatment of Latent Tuberculosis Infection---United States, 2003”; MMWR, August 8, 2003 / 52(31);735-739.
*CDC/ATS Guidelines: Morbidity and Mortality Weekly Report (MMWR), “Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection.” June 9, 2000
Large Scale Study:
(Nolan CM, Goldberg SV, Buskin SE. JAMA. 1999 Mar 17;281(11):1014-8.)
Yes, they can receive treatment for LTBI
Why get treated?
For every patient
Physicians Caring for to Active TB Disease (cont.)
At Risk Populations
The following individuals provided consultation and review of this presentation:
Without the help of the following individuals, this project would not have been possible: