1. Contact Assessment Contact Assessment and Tuberculosis Skin Testing (TST)

2. Disclosure of Potential for Conflict of Interest M. Ruth Deane RN BN Communicable Disease Coordinator FINANCIAL DISCLOSURE Grants/Research Support: none Speakers Bureau/Honoraria: none Consulting Fees: none

3. Tuberculosis (TB) contact investigations are undertaken to evaluate and follow-up close contacts of active cases, in order to identify secondary cases with active disease, and to identify and treat those with latent tuberculosis infection (LTBI). Purpose of the TB Investigations

4. Assessment of a Contact Symptom review The following questions should be asked: -Do you have a cough right now? Has this cough lasted longer than three weeks? -Have you coughed up any blood? -Have you lost any weight? Were you trying to loose weight? -Do you have any fever?

5. Assessment of a contact con’t -Do you have night sweats? If yes, is there a known cause? (I.e. menopause, note as a symptom and also note the attributable cause) -Do you have any pain with breathing? -Are you fatigued? If any symptom was present, but has since completely resolved, mark as ‘absent’ but with a brief note regarding when they occurred and how long they lasted.

6. Referral for Sputum Any contact with a cough lasting three weeks or longer Should advise those without a cough, but with other symptoms of TB, that we may send for induced sputum based on CXR results

7. Referral for sputum con’t Need to provide specimen containers and instructions Need three samples, at least one should be early morning Need to be refrigerated until delivered to the laboratory

8. TB History Have you ever had TB? Need documented history of fully treated disease Have you ever had a Tuberculin Skin Test? Need documented result, if not documented, repeat

9. High risk conditions when associated with TB contact HIV*** AIDS*** Transplantation (related to immunosuppressant therapy) Silicosis Chronic renal failure requiring hemodialysis

10. Hi Risk Conditions Cont Carcinoma of the head and neck Recent TB infection (< 2 years) Abnormal chest x-ray fibronodular disease Treatment with glucocoriticoids

11. Increased risk conditions Tumor necrosis factor alpha (TNF) antagonists infliximab (Remicade) etanercept (Enbrel) adalimumab (Humira)

12. Increased risk conditions Diabetes mellitus Underweight <90% ideal body weight Young age when infected(0-4yrs) Cigarette smoker Abnormal chest x-ray - granuloma

13. The tuberculin skin test Different types of tuberculin tests are available The Mantoux (intradermal) tuberculin skin test is the preferred type because it is the most accurate The tuberculin used in the skin test is also known a s Purified protein derivative or “PPD”

15. Storage and handling of Tuberculin Date and initial when vial is opened Discard 30 days after opening It is sensitive to light, keep out of light Draw up just prior to injection Store at 2 to 8 degrees C° in a refrigerator or cooler with ice packs

16. Contraindications Do not test people who: Have a documented TST result > 10 mm Have had TB disease in the past, confirmed Have had severe blistering TST reactions in the past Have severe eczema Have a history of anaphylactic reaction to past TST

17. Common Side Effects Pain itchiness discomfort at the test site may occur Treat with cool cloths or ice. Do not scratch.

18. Severe side effects Blistering Ulcers Necrosis Scarring from strongly positive reactions Anaphylactic reaction

19. Dosage and Administration Site: Left inner aspect of the forearm 2-4 inches below the elbow. Avoid areas with abrasions, swelling, visible veins or lesions that will make TST results difficult to interpret. Cleanse skin with alcohol swab and allow to dry

20. Dosage and Administration Dose: 0.1 ml of 5 TU (Tuberculin Units) of Tuberculin Purified Protein Derivative (Mantoux) Manufactured by Aventis Pasteur, trade name Tubersol Supplied by Manitoba TB Control Program for contact testing and select screening programs only

22. Dosage and Administration Route: Intradermally with a 27 gauge, ½ inch needle and 1ml syringe. Hold skin of the forearm tautly. Insert needle with bevel up at a 10-15 degree angle just until the bevel disappears under the skin.

24. Dosage and Administration Slowly inject 0.1 ml Tubersol until activation of safety mechanism Look for a discrete, pale elevation of the skin (wheal) Wheal should measure 6-10 mm in diameter Do not massage the site or cover site with a bandage

26. Dosage and Administration If solution leaks from the site or no wheal appears: TST will be inaccurate Repeat injection at least two inches from the first TST or on the other forearm

29. Timing of administration “TST conversion occurs within 8 weeks of exposure and infection. The traditional concept was that conversion occurred in up to 12 weeks. However, all available experimental and epidemiologic evidence consistently shows that this interval is less than 8 weeks.” CTS p 67

30. How is the skin test read? Test is read by a trained health worker 48 - 72 hours after the tuberculin injection Read the TST in good light (may want to bring a pen light) with the forearm supported on a firm surface and the elbow slightly flexed. Reposition as necessary if interpretation is difficult

31. How is the skin test read? Diameter of the indurated (swelling) area is measured across the forearm Erythema (redness) is not measured Test result is measured in millimeters (mm)

32. How is the skin test read? Find induration by looking at site from the side and then by direct palpation. Mark edges of induration with a pen Also, using a ballpoint pen, draw a line from the outer edge of the arm inward toward the induration, and stop when the pen comes against the border, repeat from the other side

36. Only the induration is being measured. This is CORRECT.

37. The erythema is being measured. This is INCORRECT.

38. Routine Practices for TST reading Wash hands with waterless hand gel or water between clients Cleanse ruler with alcohol swab between readings Ensure ‘cover your cough’ policy is enforced

40. What makes the reaction significant? Whether a reaction to the TST is classified as significant, depends on the size of the induration (swelling) and the person’s risk factors for TB

41. Definition of a significant (positive)TST 0-4 mm HIV infection with immune suppression and the expected likelihood of TB infection is high (e.g. close contact; abnormal x- ray)

42. Definition of a significant (positive)TST >5 or more millimeters (mm) Contact to an infectious case of TB Immunocompromised persons including HIV infection Person with an abnormal chest radiograph, but no evidence of active TB

43. Definition of a significant (positive)TST > 10 or more millimeters (mm) All other persons

44. Recording TST results Record the size of the induration in millimeters Don’t write ‘negative’ or ‘neg’ but record as 0 mm Don’t write ‘positive’ or ‘pos’, but record the actual measurement

45. Factors that can cause a false positive reading Infection with non-tuberculosis mycobacterium Vaccination with BCG Allergic reaction to bandage/tape used to cover TST Improper administration of TST Failure to measure induration correctly

48. BCG can be ignored as cause of false positive if: Was given in infancy and the person tested is now 10 years or older There is a high probability of TB infection (close contact; high risk community or country of origin) There is a high risk of progression from infection to disease

49. BCG should be considered likely cause of a positive TST if: Was given after 12 months of age AND the person is either Canadian – born non Aboriginal OR an immigrant /visitor from a low TB incidence country.

50. BCG Scar Presence of scar indicates that the vaccination ‘took’ or was effective and should be documented. BCG is administered on the left (usually) shoulder in Manitoba Other sites include the leg and back Smallpox vaccination last given in 1970 in Manitoba. No documentation found for other countries

52. Factors that can cause a false negative reading Immune suppression due to: Advanced age Treatment with corticosteroids Cancer therapy agents HIV infection Possible tumor necrosis alfa inhibitors Malnutrition Severe illness, including active TB Major viral illness or immunization within 4 weeks with MMR, varicella or yellow fever vaccine Very young age (less than six months)

53. False negative continued Technique: Improper storage Adsorption Poor injection technique Failure to detect/interpret induration

54. What is a “boosted” reaction to a TST Some persons infected with TB in the past lose their ability to react quickly to TST A first TB test may be (falsely) negative Another test, one week or more later (up to one year) will show a (true) positive reaction.

55. Why do we not do a ‘two-step” in contact investigations? In contact investigations, the ‘contact’ (I.e. breathing in the TB bacilli) is the ‘first step’. Therefore only one TST is needed to identify past infection.

56. Why do we not do a ‘two-step” in contact investigations? Two TSTs are done in some investigations based on time since last contact, ie need at least 8 weeks to develop a reaction. Some of the contacts who are positive on the second test, will be due to a boosted reaction. Referral for assessment and treatment of LTBI is necessary regardless

57. So what does a ‘significant’ reaction mean? We must assume, in the absence of a more definitive test, that a significant reaction indicates tuberculosis infection. In the absence of a documented <10mm two step baseline with in the last year, we will not know when this infection occurred.

58. So what does a ‘significant’ reaction mean? Approximately 5% of immunocompetent newly infected persons will develop primary or progressive primary disease within 18 – 24 months. Those who do not develop primary disease have a 5% chance of reactivation or post primary TB at some time in their lives.

61. Referral for CXR Contacts with significant reactions Contacts with symptoms consistent with TB regardless of reaction Contacts <5 years of age Immuno-suppressed/HIV contacts

62. Where, how, who makes the referral? CXR requisition given Sputum collected as necessary Results are sent directly to 496 Hargrave Contacts are referred to either Klinic, Health Action Centre, Childrens Hospital or Respiratory Outpatients Clinic for assessment and treatment of LBTI

63. References Curry International Tuberculosis Center Canadian Tuberculosis Standards 6 th edition Canadian Immunization Guide 7 th edition Manitoba Health Tuberculosis Protocol December 2009