Download Text Version - Global Tuberculosis Institute

Slide 1: Tuberculosis Update for School Nurses
 June 18, 2015
Slide 2: Tuberculosis in Children and Adolescents
 Peter N. Wenger, MD
 Saint Peter’s University Hospital
Slide 3: Definitions
 Pediatric tuberculosis (TB):
 TB disease in a person <15 years of age
 Latent TB infection (LTBI) – infection with M. tuberculosis without evidence of
active disease in a person <15 years of age
 Infectious TB:
 TB disease in the lungs or larynx in a person who has the potential to transmit
infection to other people
Slide 4: Epidemiology - Global
 Leading cause of infectious disease morbidity and mortality
 Approximately 1/3 of the world’s population (>1.9 billion people) are infected with
M. tuberculosis
 In the 2000s:
 90 million new cases
 30 million deaths
 Among children <15 years of age:
 ~13 million cases
 14% of total cases
 5 million deaths
 17% of total mortality
 Case fatality rate: 39%
 2012 Estimated: 8.6 million new cases
 530,000 in children (<15 yrs of age): 74,000 deaths
Slide 5: Epidemiology: United States
 TB in children and adolescents appears to be declining
 Annual case notifications in persons <18 years of age decreased from 997
(2007) to 818 (2010)
 Between 2008 and 2010 69% of children and adolescents with reported TB were
born in the US
 Of these 66% had at least one foreign-born parent
 4% of pediatric TB patients had parents who were both born in the US
(international adoptees?)
 Between 2008 and 2010 of the 2628 children and adolescents with TB with
known race/ethnicity
 45% - Hispanic
 27% - Black



20% - Asian
7% - White
1% - Native American (including Native Alaskan)
Slide 6: Epidemiology – United States
 TB cases 2013
 9,582 cases reported in total
 485 (5.1%) in the pediatric age group
 297 (61.2%) in those 0-4 years of age
 188 (38.8%) in those 5 – 18 years of age
Slide 7: Transmission of M. tuberculosis to Children
 Children are most commonly exposed in the immediate household by a family
member with active disease
 Casual extra-familial contact is less often the source of infection
 Children rarely infect other children or adults:
 Tubercle bacilli are relatively sparse in secretions
 Paucibacilliary TB (smear negative, culture positive)
 Children with pulmonary TB rarely cough
 Cough, when present, lacks the tussive force needed to aerosolize bacilli
Slide 8: Risk of Tuberculosis Disease by Age
Risk of disseminated
Risk of
tuberculosis/tuberculosis pulmonary
meningitis following
tuberculosis
primary infection
following
primary
infection
<1 years
10-20%
30-40%
Risk of no
disease
following
primary
infection
50%
Comments
High rates of
morbidity and
mortality
1-2 years
2-5%
10-20%
75%
High rates of
morbidity and
mortality
2-5 years
0-5%
5%
95%
..
5-10 years
<0-5%
2%
98%
“Safe school
years”
>10 years
<0-5%
10-20%
80-90%
Effusions or
adult-type
pulmonary
disease
 Table 1: Risk of pulmonary and extrapulmonary disease in children following
infection with Mycobacterium tuberculosis
 Newton S, et al. Lancet ID 2008 after Marais BJ, et al. Int J Tuberc Lung Dis 2004
Slide 9: Increased Risk of Progression of LTBI to TB Disease
 Age groups:
 Infants and young children
 Post pubertal adolescents
 Recent infection:
 Highest risk in first 6 months after infection
 Remains high for 2 years
 Recent immigration
 Immunodeficiency:
 HIV infection, Hodgkin disease, lymphoma, diabetes mellitus, chronic renal
failure, malnutrition
 Immunosuppressive drugs: prolonged or high-dose corticosteroid therapy,
chemotherapy, tumor necrosis factor (TNF-alpha) antagonists used to treat
rheumatoid arthritis and Crohn disease
Slide 10: Clinical Manifestations
 Pulmonary disease and associated intrathoracic adenopathy most common
presentation of TB in children
 Common symptoms are often nonspecific
 Chronic, unremitting cough that is not improving and present for>3
weeks
 Fever >38°C for at least 2 weeks, other common causes excluded
 Weight loss or failure to thrive (based on growth chart)
 Children, 5 – 10 years may present with clinically silent but radiographically
apparent disease
 Infants more likely to present with signs and symptoms of lung disease
 Elucidating the epidemiologic risk factors for TB vital in evaluation for TB
 Adolescents can present with features common in children or adults
Slide 11: Extrapulmonary tuberculosis
 In the context of exposure to TB, presence of any of the following signs should
prompt evaluation for extrapulmonary TB
 Superficial lymph nodes (scrofula)
 Fixed, painless, enlarged superficial nodes (usually cervical)
 TB meningitis
 Meningitis not responding to antibacterial medications, with a subacute onset,
communicating hydrocephalus, stroke, and/or elevated intracranial pressure
 Pleural TB
 Pleural effusion
 Pericardial TB
 Pericardial effusion
 Abdominal TB
 Distended abdomen with ascites, abdominal pain, jaundice, or unexplained
chronic diarrhea
Slide 12: Extrapulmonary TB
 TB of the joint
 Nontender joint effusion
 Vertebral TB (Pott’s disease)
 Back pain, gibbus deformity (a form of structural kyphosis) especially of
recent onset (uncommon)
 Skin
 Warty lesion(s), papulonecrotic lesions, lupus vulgaris, erythema nodosum
may be a sign of tuberculin hypersensitivity
 Renal
 Sterile pyuria, hematuria
 Eye
 Iritis, optic neuritis, phylctenular conjunctivitis
Slide 13: Pediatric TB Cases by Site of Disease, 1993–2012
Percentage of pediatric TB cases
Pulmonary
70.6%
Extrapulmonary
22.2%
Both
7.2%
 Table 2: Types of pediatric TB cases between 1993 and 2012
Percentage of any extrapulmonary
involvement (totaling 29.4%)
Lymphatic
18.8%
Meningeal
3.4%
Miliary
1.4%
Bone & Joint
1.5%
Other
4.3%
 Table 3: Percentage of extrapulmonary sites with any extrapulmonary involvement in
all TB cases, from 1993 to 2012
Slide 14: Tuberculosis in Adolescents
 Adolescents develop tuberculosis in one of two ways:
 Reactivation of infection acquired during childhood
 The closer to puberty at the time of infection the greater the risk of
reactivation
 Chronic pulmonary tuberculosis
 Progression of infection acquired during adolescence to disease:
 Classic primary disease
 Progressive primary pulmonary tuberculosis
 Chronic pulmonary tuberculosis
Slide 15: Adolescents: Reactivation Tuberculosis
 Constitutional symptoms often more prominent than respiratory symptoms
 Weight loss and fever are very common
 Cough, chest pain, hemoptysis

 Drenching night sweats occur several times per week
Cavitary lesions frequently seen
Slide 16: Significance of Tuberculosis in Children
 Public Health: Diagnosis of LTBI or tuberculosis disease in a child is considered a
“sentinel public health event” usually representing recent transmission of TB within a
community
 Personal Health: High rates of morbidity and mortality
Slide 17: Prevention of TB in Children: Potential Missed Opportunities
 Failure to find and appropriately manage adult source cases (case finding)
 Delay in reporting the initial diagnosis of TB
 Contact investigation interview failure
 Delay in evaluation of exposed children
 Failure to completely evaluate exposed children
 Failure to prescribe INH “window prophylaxis”
 LTBI diagnosed; treatment not prescribed
 Failure to complete treatment for LTBI
Slide 18: TB Control: Targeted TB Testing
 What is Targeted TB Testing?
 Identifies persons at high risk of infection with M. tuberculosis
 Identifies persons at high risk of progressing to disease should they be
infected
Slide 19: Why Use Risk-Based Targeted TB Testing?
 Why not use routine, universal, administratively mandated TB testing? Why not use
the Tuberculin Skin Test (TST) or Interferon Gamma Release Assay (IGRA) as a
screening tool?
 Daycare
 Schools
 Colleges
 Summer camps
 Answer: Limitations of the TST/IGRA
 Universal testing means that large numbers of low risk children will be tested:
Inefficient use of healthcare resources
 Even if the specificity of the test approaches 99%, testing of persons in lowprevalence groups would result in mostly false-positives
 IGRA specificity reduces but does not eliminate false positives in low risk
population
Slide 20: Targeted TB Testing
 Risk assessment:
 Signs and symptoms consistent with TB disease
 Contact and source-case investigations


>1 risk factor identified on screening risk-assessment questionnaire
 General pediatric practice
 School-based healthcare
High risk of progression due to underlying conditions:
 HIV infection, Hodgkin disease, lymphoma, diabetes mellitus, chronic
renal failure, malnutrition, prolonged or high-dose corticosteroid therapy,
chemotherapy, tumor necrosis factor (TNF-alpha) antagonists
Slide 21: Control of TB in the United States
 Contact investigations
 The most reliable TB control program is based upon aggressive and expedient
contact investigations, rather than routine screening of large populations
 High priority contact
 Household
 Age <5 years
 Medium risk condition
 Procedure
 Congregate, Time
 Can be complex and may require lots of detective work
Slide 22: Targeted TB Testing Risk-Assessment Questionnaire
 Has a family member or contact had TB disease?
 Has a family member had a positive TB test?
 Was your child born in a high-risk country (i.e. outside US, Canada, Australia, New
Zealand, or Western European countries)
Slide 23: Using the Risk Assessment Questionnaire
 At first contact with child and every 6 months until age 2 years
 After age 2 years, ask risk assessment questions every year if possible
 Anytime a risk factor is identified, a TST or IGRA should be performed
Slide 24: TST and IGRA
 TST preferred, IGRA acceptable
 Children <5 years of age
 Positive result of either test is considered significant
 IGRA preferred, TST acceptable
 Children ≥5 years of age who have received BCG vaccine
 Children ≥5 years of age who are unlikely to return for TST reading
Slide 25: TST and IGRA
 TST and IGRA should be considered:
 The initial and repeat IGRA are indeterminate
 The initial test is negative (TST or IGRA) and:
 Clinical suspicion for TB is moderate to high
 Risk of progression and poor outcome is high

The initial TST is positive and:
 >5 years of age and a history of BCG vaccination
 Additional evidence needed to increase compliance
 Nontuberculosis mycobacterial disease is suspected
Slide 26: Limitations
 TST and IGRA by themselves cannot distinguish between infection and disease
 In circumstances of moderate to high clinical suspicion for TB disease, negative
results in either/or TST and IGRA do not exclude the diagnosis
 The IGRA should not be used in children <2 years of age unless TB disease is
suspected
 In children 2 through 4 years of age, there are limited data about it’s
usefulness in determining TB infection, but can be performed if disease is
suspected
 Children with a positive IGRA result should be considered infected with MTB
complex
 TST results may be confounded by previous BCG administration (agedependent) and infection with nontuberculosis mycobacteria
 Indeterminate IGRA results do not exclude TB infection and may necessitate repeat
testing
 Should not be used to make clinical decisions
Slide 27: Mycobacteriologic Diagnosis of Tuberculosis
 Adults: 70-90% have a sputum that is (+) for M. tuberculosis
 Children:
 Tubercle bacilli are relatively few in number
 Sputum generally cannot be obtained from children
<10 yrs old
 Gastric aspirates in children with PTB
 30-40 % sensitive in children
 60-70% sensitive in infants
 Bronchoalveolar lavage (BAL): Sensitivity may be less than gastric aspirates
Slide 28: Establishing a definitive diagnosis of TB disease in children is often
associated with great difficulty!
Slide 29: Treatment of Latent Tuberculosis Infection
 INH 10-15 mg/kg (max., 300 mg) PO daily for 270 doses
 Efficacy approaches 100%
 Alternative: Twice weekly directly observed (DOT) INH 20-40 mg/kg (max., 900 mg)
PO for 72 doses
 Monitor index case isolate sensitivities
 Hepatotoxicity from INH is rare in children:
 Monthly assessment for clinical evidence of hepatotoxicity should be made:
malaise, loss of appetite or weight, nausea, vomiting, abdominal pain,
jaundice

Routine monitoring of LFTs is not indicated
Slide 30: Treatment of Latent Tuberculosis Infection
 Rifampin 10-15 mg/kg/day (max. 600 mg) po daily for 6 months is an alternative
 INH not tolerated
 Index patient isolate INH-resistant
 Rifapentine/INH
 12 week course
 900mg/900mg maximum taken once a week via Direct Observed Therapy
(DOT)
 MDR-LTBI: TREAT???? NOT TREAT????
 Treatment can reduce risk of disease by up to 2/3
 Regimen based on susceptibilities of index patient isolate
Slide 31: Treatment of TB in Children & Adolescents
 If INH resistance rate >4% or if other risk for resistance include four drugs in initial
regimen:
 Isoniazid (10 mg/kg/day, range 10-20, max. 300)
 Rifampin (15 mg/kg/day, range 10-20, max. 600)
 Pyrazinamide (20-30 mg/kg/day)
 Ethambutol (15-25 mg/kg/day)
 Treatment complicated by child unfriendly preparations of the medications
 Directly observed therapy (DOT)
 Monitor liver transaminases? – Depends on severity of disease
 Follow susceptibility studies of Mtbc isolate (index and/or child isolate)
 Important to be familiar with resistance patterns in the community
Slide 32: Directly Observed Therapy in Schools
 June 18, 2015
 Lillian Pirog, RN
Slide 33: Topics
 Factors that influence adherence to TB medication regimens
 Strategies for overcoming barriers and achieving success
Slide 34: Directly Observed Therapy
 Directly observed therapy (DOT) involves a healthcare or outreach worker watching
as a patient swallows their anti-tuberculosis medications
 DOT is the standard of care for TB disease
 Should be used with any intermittent treatment
Slide 35: Directly Observed Therapy - 2
 DOT can be provided almost anywhere…
 Home or home of babysitter
 Daycare



School
Health department
Workplace
Slide 36: Directly Observed Therapy - 3
 Can be supervised by:
 Physician
 Health Department Nurse
 Trained Outreach Worker
 School Nurse
 Should not be supervised by:
 Parents or other close family member
Slide 37: Factors that May Affect Adherence
 Reactions to medication administration vary depending on:
 Length of medication regimen
 Relationships with caregiver or person administering medication
 Medication side effects – nausea or the bitter taste of the medication
 Reactions of others
 Remember children usually do not feel sick yet are expected to take
medication daily for 6-9 months
Slide 38: Removing Barriers to Adherence - 1
 General tips for medication administration
 Administer medication at same time every day
 Establish a routine-around meal time
 Start off on positive note-praise efforts to cooperate
 Avoid distractions-quiet room
 Ignore behaviors that interfere with administration
 Usually after 2 weeks child will take medications without difficulty
Slide 39: Steps to successfully administer medication
 The most important recommendation is to keep the volume to the smallest amount
possible
 Goal is to administer all 4 TB medications in the total volume of 5-10mL
 Pills should be crushed to a fine powder
Slide 40: Steps to successfully administer medication (2)
 Open capsules of Rifampin and add powder to crush pill
 Then add less than 5mL of very warm water to dissolve the granules
 Finally add a small amount of fruit, yogurt, applesauce, juice or anything the child
likes
Slide 41
 Shows photo of chocolate pops that a nurse made to help a child take their medicine
Slide 42: Assessing for Adverse Reactions
 Report any adverse reactions immediately to the healthcare provider
 Use the following questions to assess:
 Do you have any of the following?
 Abdominal pain
 Nausea or vomiting
 Loss of appetite
 Fatigue
 Rash
 Are you taking any medications other than anti-TB medications?
 Has there been a change in your appetite?
 What color is your urine?
Slide 43: DOT in the School Setting: Some Basics
 Obtain parental consent- signed agreement
 Maintain confidentiality-private area for DOT
 Ensure good communication between school and physician- report to MD problems
such as frequent absences, or adverse reactions
 Use DOT log and monitor adherence rate
Slide 44: DOT in the School: Variables Affecting Adherence - 1
 School nurse may be covering more than one school
 Lack of back-up or coverage
 Poor communication between nurse and attendance office
 Ask parent to call the school nurse directly regarding any absences
 Timing
 Work with the child to find the best time for them (morning, lunch, etc.)
 Extended absences (i.e., suspension)
 Health department will need a copy of the school calendar and to be notified if
the child is absent so DOT can be done at home
 Multiple social problems
 Peer pressure
Slide 45: DOT - Challenges
 Lack of cooperation from parent or school-stigma attached to TB
 Older child who refuses meds
 Try to determine cause, is it due to medication side effects or time given, you
may just need to alter the time of dosing
Slide 46: Resources
 Tuberculosis Handbook for School Nurses
http://globaltb.njms.rutgers.edu/educationalmaterials/productfolder/tbhandbook.html
 Management of Multidrug-Resistant Tuberculosis in Children: A Field Guide
http://sentinel-project.org/2014/07/22/second-edition-of-management-of-multidrugresistant-tuberculosis-in-children-a-field-guide/
Slide 47: Tuberculosis Testing and Reporting Guidelines for New Jersey Schools
 Karen Galanowsky, RN, MPH
 Nurse Consultant
 New Jersey Department of Health
 Tuberculosis Program
Slide 48: Tuberculosis Testing Guidance
 The New Jersey Department of Health, Tuberculosis Program, provides annual
guidance to the New Jersey Department of Education regarding tuberculosis (TB)
testing of students as a condition for admission to NJ schools
 The regulation and enforcement of these recommendations is the responsibility of
the Department of Education, NOT the Department of Health
Slide 49: Purpose of these School Guidelines
 The purpose of these guidelines is to identify new students and employees who are
at the highest risk of latent TB infection (LTBI) so that they can receive treatment
and prevent the development of TB disease at a later time
 These recommendations restrict TB screening in NJ schools to teachers/other
employees and ONLY those students who are at the highest risk for latent TB
infection
Slide 50: Targeted Testing
 The CDC and New Jersey Department of Health, TB Program, do not recommend
TB screening for the general population including school employees and students
 Knowledge of the result of a TB test provides no benefit to the school WITHOUT
treatment for LTBI
 The decision to test is a decision to treat
 Rate of false tuberculin testing increases in proportion to the decreased risk for LTBI
Slide 51: Targeted Testing
 Targeted tuberculosis testing is recommended to:
 Detect persons with LTBI who would benefit from treatment
 De-emphasize testing of groups that are not at high risk for TB
 Reduce the waste of resources and prevent inappropriate treatment
Slide 52: Requirements for TB Testing of Students
 These requirements pertain to TWO GROUPS of students ONLY
 Students born in country where there is a high incidence of TB and entering
school in the US for the first time, regardless of age or grade
 Students transferring into the NJ school system directly from a country with a
high incidence of TB, regardless of age or grade
Slide 53: Exceptions
 TB testing is not required IF the student has attended school in another state prior to
entering the NJ school system
 Students entering grades preschool – five
 TB testing is not required if the student has a documented TB test at the age
of 3 years or older, regardless of the result of that test
 Students entering grades six – twelve
 TB testing is not required if the student has a documented negative TB test in
the last six months, or a positive test, regardless of when the test was done
Slide 54: Religious Exemptions
 Any student with parents claiming religious exemptions cannot be compelled to
submit to TB testing
 Each school district is responsible for obtaining documentation of the religious
exemption
 In lieu of a TB test, an assessment for TB symptoms must be done and documented
 The symptom assessment may be done by the school nurse and complete for
Assessment Form (TB-5) and chest X-ray
 If TB symptoms are identified, a medical evaluation to rule out active disease must
be completed and documented
Slide 55: Requirements for TB Testing of Employees
 A TB test is required prior to employment of all newly hired full and part-time
employees, student teachers, school bus drivers, and other persons who have
contact with the students 20 hours per month or more
Slide 56: Exemptions
 New employees, student teachers and contractors who have a documented negative
TB test result within the last six months or a positive TB test, regardless of when the
test was done
 Employees transferring between school districts or from a non-public school within
NJ with a documented TB test result upon his/her initial employment in a NJ school
 Religious exemptions – same as for students
Slide 57: TB Testing
 An interferon gamma release assay (IGRA) blood test or a Mantoux tuberculin skin
test (TST) is acceptable for TB testing in schools
 The two acceptable IGRA tests are the Quantiferon-TB Gold or T-Spot
 A “positive” IGRA indicates the “likely presence of MTb”
 A 10 mm or greater TST is considered a positive reaction
Slide 58: Positive IGRA/TST Follow-up
 Any student/employee/contractor with a positive IGRA or TST is required to have a
medical evaluation and chest X-ray to rule out active TB disease


Students/employees/contractors with a positive IGRA or TST do not have to be held
out of school/work until the medical evaluation and chest X-ray is done provided
there are no TB symptoms
If the appointment with the MD and chest X-ray cannot be obtained prior to school, a
symptom assessment should be done by the school nurse
 The student/employee should not be excluded from school unless
symptomatic for TB
Slide 59: Positive IGRA/TST Follow-up
 It is the responsibility of the school nurse to obtain the chest X-ray results and
prescribed treatment, and treatment outcomes for LTBI and retain this information
on site
 The school nurse can provide directly observed therapy (DOT) for LTBI treatment
during school hours and monitor for side effects of medication if ordered by the
physician
 Need parental consent
 MD orders
 DOT form medication(s)
Slide 60: Evaluation of Symptoms
 A symptom assessment and documentation is important to do at the time of the TST
administration/reading or IGRA
 Any person with symptoms of pulmonary TB should be medically evaluated
regardless of the result of the IGRA or TST and excluded from school until TB
disease is ruled out
 The Symptom Assessment Form (TB-5) can be found on the NJDOH TB
Website
 If the individual is diagnosed with pulmonary TB disease, he/she must be
excluded from school until determined to be non-infectious as indicated in
writing by the treating physician
Slide 61: Reporting Requirements
 Schools are no longer required to submit the “Annual Report of TB testing in
Schools” (TB-57) to the NJDOH, TB Program
 The TB-57 Report should be kept up-to-date and onsite at each school
 A copy should be sent to the school superintendent and the county TB Program
 The report is for each current calendar year and should only include testing from that
period
Slide 62: Reporting Requirements - 2
 All TB forms can be found on the TB website under the “FORMS” tab:
http://web.doh.state.nj.us/apps2/forms/subforms.aspx?pro-aids#tb
 Tuberculosis Testing Outcomes should be completed as follows:
 If no TB testing is required and no “significant reactors identified - 1/15/16
 TB testing done and “significant” reactors identified - 3/15/16
Slide 63: Question #1
 Can a chest X-ray be substituted for the TB test?
 Yes, provided the physician agrees
 Yes, if the school has written policies relating to this
 Yes, only in the case of religious exemption
 No, a chest X-ray always has to be done
Slide 64: Question #2
 Are students coming in from another US state or US city required to receive a TB
test?
 Yes, they might have lived in a city with a high number of TB cases
 No, the school TB testing program is focused on students born in high TB
incidence countries who are entering school in NJ for the first time
 Yes, they went on a two week vacation to a high incidence county last
summer
 No, they were probably tested in another state/city
Slide 65: Question #3
 Are students returning from vacation/travel out of the country required to have a TB
test before entering school again?
 No, there is no need to re-test these students unless there was known TB
exposure during the travel/vacation or TB symptoms
 Yes, if they traveled or vacationed in a high incidence country
 Yes if the school district writes policies accordingly
Slide 66: Question #4
 A student came from a high incidence country and started school before TST was
done. The child relocated to another school. Should a TST be done by the second
school?
 No, the child was already in school
 Yes, the second school needs to do a TST and follow-up
 No, only a symptom assessment should be done
 No, only chest X-ray should be done
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Slide 69: Medical Consultation
 Information Line
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Slide 70: Thank you for your participation!