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

2. 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.

3. 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

4. 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

5. 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

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

7. 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)

8. 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

9. 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  

10. 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?

11. 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 years for people without additional risk factors.
BCG: Place TST no sooner than 1 year after BCG placement.

12. 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.

13. 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

14. 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

15. The Children’s Clinic, Serving Children and Their Families

16. 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.

17. The Children’s Clinic, Serving Children and Their Families

18. 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

19. 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?

20. 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 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

21. 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

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