Tuberculosis Screening and Treatment Process

1. Tuberculosis Screening and Treatment Process

2. Why do we test? • 1. We want to prevent an outbreak of Tuberculosis in our campus community • 2. We want to find those that are affected and get them treated so you are able to continue to participate in your schooling. • 3. Countries of Africa, Asia, Eastern Europe, South and Central America have a high incidence of tuberculosis.

3. Tuberculosis • What is it? • Tuberculosis (TB) is a disease caused by germs that are spread from person to person through the air. TB usually affects the lungs, but it can also affect other parts of the body, such as the brain, the kidneys, or the spine. A person with TB can die if they do not get treatment. • About 10-20% of the international students that we screen each semester will be positive for a tuberculosis infection and will need further work up!

4. Tuberculosis Continued • How is it spread? • TB germs are put into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings. These germs can stay in the air for several hours, depending on the environment. Persons who breathe in the air containing these TB germs can become infected; this is called latent TB infection. • http://www.cdc.gov/tb/

5. Active versus Latent Disease The Difference between Latent TB Infection and TB Disease A Person with Latent TB Infection A Person with TB Disease • Has no symptoms • Has symptoms that may include: - a bad cough that lasts 3 weeks or longer - pain in the chest - coughing up blood or sputum - weakness or fatigue - weight loss - no appetite - chills - fever - sweating at night • Does not feel sick • Usually feels sick • Cannot spread TB bacteria to others • May spread TB bacteria to others • Usually has a skin test or blood test result indicating TB infection • Usually has a skin test or blood test result indicating TB infection • Has a normal chest x-ray and a negative sputum smear • May have an abnormal chest x-ray, or positive sputum smear or culture • Needs treatment for latent TB infection to prevent active TB disease • Needs treatment to treat active TB disease

6. Tuberculosis • How do you get tested? • There are two tests that can be used to help detect TB infection: a skin test or a special TB blood test. The Mantoux tuberculin skin test is performed by injecting a small amount of fluid (called tuberculin) into the skin in the lower part of the arm. A person given the tuberculin skin test must return within 48 to 72 hours to have a trained health care worker look for a reaction on the arm. The special TB blood test measures how the patient’s immune system reacts to the germs that cause TB.

7. Tuberculosis • What does a positive test mean? • A positive test for TB infection only tells that a person has been infected with TB germs. It does not tell whether or not the person has progressed to TB disease. Other tests, such as a chest x-ray and a sample of sputum, are needed to see whether the person has TB disease.

8. Tuberculosis • What is BCG? • BCG is a vaccine for TB disease. BCG is used in many countries to prevent TB infections in infants and young children. BCG vaccination does not completely prevent people from getting TB. It may also cause a false positive tuberculin skin test. However, persons who have been vaccinated with BCG can be given a tuberculin skin test or specific TB blood test.

9. QFT • What is it? • The QuantiFERON®-TB Gold test (QFT-G) is a whole-blood test for use as an aid in diagnosing Mycobacterium tuberculosis infection, including latent tuberculosis infection (LTBI) and tuberculosis (TB) disease. This test was approved by the U.S. Food and Drug Administration (FDA) in 2005. • How does it work? • Blood samples are mixed with antigens (substances that can produce an immune response) and controls. For QFT-G, the antigens include mixtures of synthetic peptides representing two M. tuberculosis proteins, ESAT-6 and CFP-10. After incubation of the blood with antigens for 16 to 24 hours, the amount of interferon-gamma (IFN-gamma) is measured. • If the patient is infected with M. tuberculosis, their white blood cells will release IFN-gamma in response to contact with the TB antigens. The QFT-G results are based on the amount of IFN-gamma that is released in response to the antigens. • Clinical evaluation and additional tests (such as a chest radiograph, sputum smear, and culture) are needed to confirm the diagnosis of LTBI or TB disease.

10. QFT • A positive result suggests that M. tuberculosis infection is likely; a negative result suggests that infection is unlikely; and indeterminate result suggests QFT-G results cannot be interpreted as a result of low mitogen response or high background response.

11. Positive Test Results • You will see the TB specialist at Student Health • Sent to the hospital to have a Chest x-ray • You will then come back to Student Health for results • The provider will determine if you have the Latent (inactive) form or the Active form of Tuberculosis

12. Treatment Options • Active TB cases will be sent to Columbia for an infectious disease physician to manage • Latent TB cases (the majority): • Take the treatment • Isoniazid daily treatment for 9 months with Vitamin B-6 • Medication will be provided free of charge • You will have blood taken again after the 1st, 2nd, 3rd and 6th month of treatment • You will come into student health for monthly visits to make sure you are not having any side effects and for medication refills.

13. INH Treatment • Take medication daily along with Vitamin B-6 • Baseline and routine laboratory monitoring during treatment of LTBI are indicated only when there is a history of liver disease, HIV infection, pregnancy (or within 3 months post delivery), or regular alcohol use. Baseline liver measurements of serum AST, ALT, and bilirubin are used in the situations mentioned above and to evaluate symptoms of liver toxicity. • Clinical monitoring, including a brief physical examination, should occur at monthly visits to assess adherence and identify signs or symptoms of adverse drug reactions.

14. INH Treatment • Drug-Drug Interactions • Obtain a list of patient’s current medications to avoid drug interactions. Some interactions to note: • INH increases blood levels of phenytoin (Dilantin) and disulfiram (Antabuse) • Side Effects • Patients on treatment for LTBI should be instructed to report any potential medication side effects to their health care provider, including • Unexplained anorexia, nausea or vomiting, dark urine • Persistent numbness/tingling of hands or feet • Persistent weakness, fatigue, fever, or abdominal tenderness • Easy bruising or bleeding

15. Treatment Options • You have to decide the risk and benefits of treatment versus the latent infection becoming active. • You may decide not to take treatment • If so, you will be asked to come in every 6 months and review signs and symptoms of active disease with the TB specialist at Student Health. • You should be aware of your chances of getting active tuberculosis • The following website will interpret the likely hood of going from latent to active disease: www.tstin3d.com

16. Adherence • Important that once you start treatment that you adhere to the medication regime. • If we need to stop the treatment because of side effects we will discuss options from there. • Drug resistant Tuberculosis has been associated with the incomplete treatment of Latent Tuberculosis.

17. We are here for you • We want to keep you healthy and also keep the campus community healthy. • The goal is to keep you in class so that you are able to complete your degree and move on to your professional life. • It is important that you review this information and then we can answer questions as they arise.

18. References • Center for Disease Control and Prevention, Tuberculosis, http://www.cdc.gov/tb/ • ACHA guidelines: Tuberculosis screening and targeted testing of college and university students (2008). http://www.acha.org/Publications/docs/Tuberculosis%20Screening%20and%20Targeted%20Testing_Jul2008.pdf