The Children’s Clinic, Serving Children and Their Families Tuberculosis Screening and Treatment at TCC Patricia Bellas, MD Associate Medical Director May 6, 2010

The Children’s Clinic, Serving Children and Their Families Who are We? TCC is an independent not-for-profit 501 (c) (3) community health center with six sites dedicated to providing comprehensive health care, health promotion and disease prevention in a culturally sensitive and linguistically appropriate manner to medically underserved, low income and high-risk populations in the Long Beach area. Our largest site is on the Long Beach Memorial Medical Center/Miller Children’s Hospital campus.

The Children’s Clinic, Serving Children and Their Families Mission Statement To partner with parents and the community to provide quality health care services, health education and promotion to needy children and families

The Children’s Clinic, Serving Children and Their Families Facts Founded in 1939 Six clinic sites In 2009: Provided over 65,746 Health Care Visits to 22,047 children and adults Lion’s Eye Clinic- provided over 1,100 comprehensive ophthalmologic visits Almost 29,000 medication provided through our dispensaries Over 19,000 immunizations provided, and a Walk-In Immunization Clinic No one is denied care due to inability to pay

The Children’s Clinic, Serving Children and Their Families TST Data At Vasek Polak Site in 2009: Total of 584 TSTs done (79% children, 21% adults) 21% did not return for readings Overall 11% positive (22% in adults, 7% in children) 5

The Children’s Clinic, Serving Children and Their Families Clinic Sites

The Children’s Clinic, Serving Children and Their Families Documents to Be Covered Today: Tuberculosis Screening Guidelines from TCC’s Clinical Policies and Procedures Tuberculosis Risk Assessment TB Patient Discharge Status Card TCC TB Patient Education Trifold (English/Spanish)

The Children’s Clinic, Serving Children and Their Families POLICIES AND PROCEDURES   SUBJECT:  TUBERCULOSIS SCREENING GUIDELINES AUTHORITY: Long Beach Department of Health and Human Services, TB Controller; Children’s Health and Disability Program (CHDP) Guidelines; Red Book, 26th Edition (Published by the American Academy of Pediatrics); Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection (Morbidity and Mortality Weekly Report) June, 2000

I. “TUBERCULOSIS RISK ASSESSMENT” The Children’s Clinic, Serving Children and Their Families Policies and Procedures I. “TUBERCULOSIS RISK ASSESSMENT” Perform tuberculosis risk assessment annually with routine physical exam. If risk assessment positive, place TST- unless patient has had a previous positive TST). Notes The TST is not useful in evaluating patients who have previously tested positive for tuberculosis re-exposure or reactivation All patients who have previously tested positive should be screened for symptoms of TB disease.  If present, a chest x-ray should be obtained. Immigrants who have been only screened with a CXR, should be TST tested and treated for LTBI if positive  

The Children’s Clinic, Serving Children and Their Families The Children’s Clinic- Tuberculosis Risk Assessment Date: MD/ NP Initials: Has the patient ever been tested for tuberculosis in the past?        Yes / No Was it Positive? Was it treated with medicine? Has the patient had chronic cough, coughing up blood, unexplained fever, weight loss or sweating at night?       Has the patient had close contact with anyone who is sick with tuberculosis? (e.g. coughing, wt loss, etc) Has the patient lived in Asia, Mexico/Latin America, Africa or the Middle East in the past 3-5 years? Does the patient spend significant time in a household with anyone who has the following: HIV/AIDS        Long term illegal drug use Recently released from prison (past year)        Recently arrived from another country – (past year) Has the patient lived in a homeless shelter in the past year?

Policies and Procedures (cont.) The Children’s Clinic, Serving Children and Their Families Policies and Procedures (cont.) II. When to do Tuberculin Skin Testing (TST): Immediate TST in children and adults: i. displaying symptoms or radiographic findings of TB. ii. contacts of those with confirmed or suspected TB. iii. Children and adults with HIV or living with HIV infected adult (if last TST>1 year ago) Annual TST on children and adults with HIV or living with HIV infected adult. TST every 2 years for children with ongoing potential exposure by risk assessment Routine screening with TST at 1 year of age, repeat TST placed at 4-6 years and 11-16 years for people without additional risk factors. BCG: Place TST no sooner than 1 year after BCG placement.

Policies and Procedures (cont.) The Children’s Clinic, Serving Children and Their Families Policies and Procedures (cont.) II. When to do Tuberculin Skin Testing (TST): Adults: no routine TST; use “TUBERCULOSIS RISK ASSESSMENT” to determine need for TST Adults at higher risk for re-activation of LTBI need to have clear documentation of TST status Diabetes mellitus, silicosis, chronic renal failure/dialysis, gastrectomy, jejunoileal bypass, solid organ transplantation, carcinoma of head or neck, etc.

Policies and Procedures (cont.) The Children’s Clinic, Serving Children and Their Families Policies and Procedures (cont.) III. Interpretation and reporting guidelines: Interpret TST according to standardized guidelines. All patients with a positive TST should be referred for CXR.  TST may be repeated at any time if patient failed TST reading. File “Confidential Morbidity Report” (CMR) for the following i. All children three years and under if positive. ii. Chest X-ray findings suggestive of TB- provider to direct Medical Assistant to file CMR in these cases. Note PPD “converters” no longer need to be reported

Policies and Procedures (cont.) The Children’s Clinic, Serving Children and Their Families Policies and Procedures (cont.) Monitoring Pediatric patients must return to clinic at least every 3 months   Adults have a higher risk of side effects and should be seen monthly or every other month LFT testing (SGOT or SGPT and Bili) is not routinely indicated LFTs are recommended in early postpartum period (within 3 months of delivery) and for HIV. 270 doses (9 months) must be administered within 1 year for treatment to be considered complete. Lapses of <3 months: restart INH where left off to complete course Lapses of >3 months: Consider a repeat chest X-ray if symptomatic or if lapse very long (e.g. 1 year) Restart INH therapy from beginning At end of INH therapy, Tuberculosis Patient Discharge Status card should be given to patient

The Children’s Clinic, Serving Children and Their Families

Policies and Procedures (cont.) The Children’s Clinic, Serving Children and Their Families Policies and Procedures (cont.) Adverse reactions/discontinuing treatment Patients who have allergic reactions to INH Liver function tests are more than 3 times normal limits Noncompliance/patient choice Severe reactions to INH will be reported to the health department for inclusion in national surveillance.

The Children’s Clinic, Serving Children and Their Families

Common Dilemmas in LTBI Treatment To Treat or Not to Treat? The Children’s Clinic, Serving Children and Their Families Common Dilemmas in LTBI Treatment To Treat or Not to Treat? “A decision to test is a decision to treat” does not necessarily apply to low-risk persons tested because mandated by law (i.e., teachers) Need to assess patient’s beliefs, concerns and motivation regarding LTBI Rx, and have an individualized risk-benefit discussion Not-so-clear cases: 30 y.o. Hispanic woman with hx +TST at age 20, no Rx, no known risk factors 43 y.o. Hispanic woman tested +TST (not documented) during pregnancy, no Rx, now with diabetes 52 y.o. man with former heavy EtOH, hx +TST, started but did not finish LTBI Rx 12 y.o. US born student with no TB risk factors with 11 mm TST upon entry to new school; last TST in kindergarten negative

The Children’s Clinic, Serving Children and Their Families Other LTBI Rx Dilemmas Patients who report prior +TST (without documentation) with indication for Rx… Repeat TST or not? Patients with ill-defined (“just don’t feel good”) symptoms on INH, but normal LFTs and nothing on exam… Continue or hold INH? Different approach if higher risk for TB disease? When do you check an IGRA, and what do you do with discordant results?

The Children’s Clinic, Serving Children and Their Families Case #1 66 y.o. Cambodian female with diabetes, first seen in clinic 12/08 and sent to hospital with pneumonia PPD was positive, but also had high LFTS 444 - neg AFB and culture Pneumonia resolved (f/u CXR 2 months later normal) LFTs returned to almost normal, but patient very frail and noted to have Hep C; difficult social situation and awaiting hepatic consult Presented again several months later with URI sxs, then worsening respiratory sx; sent back to hosp to R/O TB Now upper lobe process; CT in hosp showed some cavitary lesion, but no caseating granuloma on path Had lung wedge resection - neg AFB smear, but after discharge sputum grew out TB

The Children’s Clinic, Serving Children and Their Families Case #2 44 y/o Mexican immigrant in US many years but travels back and forth to visit extended family in Mexico, no hx TST Came for PE; based on TB risk assessment (freq travel to Mexico), PPD placed and was + CXR neg - LFTS tested and were WNL No other risks - started INH - seen at month 1 then month 3, then month 6 (called for refill on meds) - hard to come in At month 6 visit c/o 2 weeks of fatigue, malaise and dark urine (did not stop meds): LFTS 1300s: meds stopped.   Work up neg for viral hep (turns out he drinks some- although he says not heavy) LFTs gradually resolved over the year, however still has splenomegaly and stable but reduced platelets suggestive of hypersplenism

The Children’s Clinic, Serving Children and Their Families Thank you! Any questions? Contact: Patty Bellas pbellas@thechildrensclinic.org