Medical Management of Contacts to Infectious Pulmonary Tuberculosis

1. Medical Management of Contacts to Infectious Pulmonary Tuberculosis Alfred Lardizabal, MD New Jersey Medical School Global Tuberculosis Institute

2. Continuing Education Statement • The University of Medicine and Dentistry of New Jersey –Center for Continuing and Outreach Education (UMDNJ-CCOE) designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credits.  Physicians should only claim credit commensurate with the extent of their participation in the activity. • UMDNJ-CCOE certifies that this continuing education offering meets the criteria for up to .15 Continuing Education Units, as defined by the National Task Force on the Continuing Education Unit (CEU), provided the activity is completed as designed. One CEU is awarded for 10 contact hours of instruction.

3. Faculty Disclosure • Alfred Lardizabal has expressed that his presentation does not include discussion of commercial products or services, or an unapproved or uninvestigated use of a commercial product. He has no significant financial relationships to disclose. • Lillian Pirog has expressed that her presentation does not include discussion of commercial products or services, or an unapproved or uninvestigated use of a commercial product. She has no significant financial relationships to disclose.

4. Background (1) • 1962: Isoniazid (INH) demonstrated to be effective in preventing tuberculosis (TB) among household contacts of persons with TB disease • Investigation and treatment of contacts with latent TB infection (LTBI) quickly becomes strategy in TB control and elimination in the U.S. • 1976: American Thoracic Society (ATS) published guidelines for investigation, diagnostic evaluation, and medical treatment of TB contacts

5. Background (2) • 2005: National TB Controllers Association (NTCA) and CDC release guidelines on the investigation of contacts of persons with infectious TB • Expanded guidelines on investigation of TB exposure and transmission, and prevention of future TB cases through contact investigations • Standard framework for assembling information and using findings to inform decisions

6. Contact Investigations – A Crucial Prevention Strategy • On average, 10 contacts are identified for each person with infectious TB in the U.S. • 20%–30% of all contacts have LTBI • 1% of contacts have TB disease • Of contacts who will ultimately have TB disease, approximately one-half develop disease in the first year after exposure

7. Decisions to Initiate a Contact Investigation • Public health officials must decide which • Contact investigations should be assigned a higher priority • Contacts to evaluate first • Decision to investigate an index patient depends on presence of factors used to predict likelihood of transmission • Site of disease • Positive sputum bacteriology • Radiographic findings

9. Determining the Infectious Period • Focuses investigation on contacts most likely to be at risk for infection • Sets time frame for testing contacts • Information to assist with determining infectious period • Approximate dates TB symptoms were noticed • Bacteriologic results • Extent of disease

10. Start of Infectious Period • Cannot be determined with precision; estimation is necessary • Start is 3 months before TB diagnosis (recommended) • Earlier start should be used in certain circumstances (e.g., patient aware of illness for longer period of time)

11. Closing the Infectious Period Infectious period closed when all the following criteria are met • Effective treatment for ≥ 2 weeks, • Diminished symptoms, and • Bacteriologic response

12. Assigning Priorities to Contacts

13. Prioritization of Contacts (1)

14. Prioritization of Contacts (2)

15. Diagnostic Evaluation of Contacts

16. Information to Collect During Initial Assessment (1) • Previous M. tuberculosis infection or disease and related treatment • Contact’s verbal report and documentation of previous TST results • Current symptoms of TB illness

17. Information to Collect During Initial Assessment (2) • Medical conditions making TB disease more likely • Mental health disorders • Type, duration, and intensity of TB exposure • Sociodemographic factors

18. Information to Collect During Initial Assessment (3) • HIV status; contacts should be offered HIV counseling and testing if status unknown • Information regarding social, emotional, and practical matters that might hinder participation

19. Reassess Strategy After Initial Information Collected After initial information collected • Priority assignments should be reassessed • Medical plan for diagnostic tests and possible treatment can be formulated for high- and medium-priority contacts

20. Tuberculin Skin Testing • All high or medium priority contacts who do not have a documented previous positive tuberculin skin test (TST) or previous TB disease should receive a TST at the initial encounter. • If not possible, TST should be administered • ≤7 working days of listing high-priority contacts • ≤14 days of listing medium-priority contacts

21. Interpreting Skin Test Reaction • ≥ 5 mm induration is positive for any contact • Two-step procedure should not be used for testing contacts • A contact whose second TST is positive after initial negative result should be classified as recently infected

22. Postexposure Tuberculin Skin Testing • Window period is 8–10 weeks after exposure ends • Contacts who have a positive result after a previous negative result are said to have had a change in tuberculin status from negative to positive

24. Evaluation and Follow-up of Children <5 Years of Age • Always assigned a high priority as contacts • Should receive full diagnostic medical evaluation, including a chest radiograph • If TST ≤5 mm of induration and last exposure <8 weeks, LTBI treatment recommended (after TB disease excluded) • Second TST 8–10 weeks after exposure; decision to treat is reconsidered • Negative TST – treatment discontinued • Positive TST – treatment continued

25. Evaluation and Follow-up of Immunosuppressed Contacts • Should receive full diagnostic medical evaluation, including a chest radiograph • If TST negative ≥ 8 weeks after end of exposure, full course of treatment for LTBI recommended (after TB disease is excluded)

26. Window-Period Prophylaxis Decision to treat contacts with a negative skin test result should take the following factors into consideration • The frequency, duration, and intensity of exposure • Corroborative evidence of transmission from the index patient

27. Prophylactic Treatment Prophylactic treatment (after TB disease is excluded) of presumed M. tuberculosis infection recommended for persons • With HIV infection • Taking immunosuppressive therapy for organ transplant • Taking anti-tumor necrosis factor alpha (TNF-α) agents

28. Treatment After Exposure to Drug-Resistant TB • Consultation with physician with MDR expertise recommended for selecting a LTBI regimen • Contacts should be monitored for 2 years after exposure

29. Selecting Contacts for Directly Observed Therapy • Contacts aged <5 years • Contacts who are HIV infected or otherwise substantially immunocompromised • Contacts with a change in their tuberculin skin test status from negative to positive • Contacts who might not complete treatment because of social or behavior impediments

30. Source-Case Investigations

31. Source-Case Investigations • Seeks the source of recent M.tuberculosis infection • In the absence of cavitary disease, young children usually do not transmit M.tuberculosis to others • Recommended only when TB control program is achieving its objectives when investigating infectious cases

33. Child with LTBI • Search for source of infection for child is unlikely to be productive • Recommended only with infected children <2 years of age, and only if data are monitored to determine the value of the investigation

34. Procedures for Source-Case Investigation • Same procedure as standard contact investigation • Patient or guardians best informants (associates) • Focus on associates who have symptoms of TB disease • Should begin with closest associates

35. Contact Investigations

36. Background – 1 • 6/14/04 39 year-old female admitted to the hospital with complaints for approximately one month of cough, fever, decreased appetite, night sweats and 23 lb weight loss • 6/17 Chest x-ray cavitary disease consistent with TB • 6/17 Bronchial wash AFB smear positive (3+)

38. Background - 2 • 6/19 Treatment (RIPE) initiated • 6/21 Suspected case of tuberculosis verbally reported by hospital infection control to the local health department

39. Background – 3 • 6/21 LHD informed TB Control of suspected case adding the following information • Presenting patient was a volunteer at a daycare center • Director of center is the sister of patient • Name, address and telephone of daycare center provided

40. Background – 4 • 6/21 Telephone call to director of daycare center from TB controller • Purpose to set up a meeting to discuss potential exposure to children and staff • Conduct on-site exposure assessment of center • Provide TB education to the director • Identify high-priority contacts during infectious period established at 2/14–6/14/04

41. Background - 5 • During telephone conversation, the following was indicated by the director: • Index patient was a part-time volunteer a “couple of hours” (2-5) per week • Secretary with little or no exposure to children

42. Background - 6 • Near the conclusion of telephone call the following exchange occurred • Director: So, should my daughter be tested? • TB Control: Tell me about your daughter and how much exposure she had to your sister • Director: Not too much. She doesn’t attend the daycare but we do spend some time socially (maybe 5 hours) together on the weekends going to the mall

43. Background - 7 • TB Control: How old is your daughter? • Director: 6 months • TB Control: I’ll make arrangements for your daughter to be tested tomorrow morning • TB Control: By the way, how is your daughter feeling? • Director: Well, she was diagnosed with bronchitis a few weeks ago and is still coughing

44. Final culture result MTB

45. Contact Investigation • 6/22: First of 4 TB interviews with the patient conducted by HCW in hospital revealed • Infectious period confirmed at 2/14-6/14/04 • Patient may have spent more time in daycare than originally described • Patient indicates not much contact with children at daycare • 8 high priority contacts identified • 2 household • 6 social • 6/23 Initiation of on-site assessment of daycare center

47. Contact Investigation • As a result of on-site assessment 35 high priority contacts identified • 30 children ages 3-4 years • 5 staff members • Notification process begins for testing • Education sessions provided to parents of daycare children • During these sessions it is learned that the 6 month old infant, director’s daughter, was at daycare center on regular basis

48. Contact Investigation • 6/23 6 month old infant (director’s daughter) evaluated at clinic • TST 15 mm • CXR hilar adenopathy with suspected miliary TB • Admitted to hospital with diagnosis of suspected miliary TB

50. Contact Investigation • 6/25 Field visit to social contact residence by HCW identifies a second 6 mo. old infant not named on initial interview • 70 hours exposure per week during infectious period • Diagnosed with pneumonia 3 weeks ago • HCW & TB Controller consult with pediatric nurse practitioner at Lattimore and infant is referred to ED and is admitted with a diagnosis of suspected pulmonary TB