1. Tuberculosis Control What’s New

2. TB Regional Nurse Update Teri Lee Dyke, RN, BSN, CIC Julie McCallum, RN, MPH Regional TB Nurse Consultants

4. Summary of New Recommendations from MI ACET A positive TST result in Michigan shall be based on the CDC guidelines HCWs who administer and read TST shall achieve certification through the TST course Testing for HIV shall be performed on all active cases of TB DOT is the standard of care for the management of all active cases of TB

5. Classifying the Tuberculin Reaction ≥5 mm is classified as positive in – HIV-positive persons – Recent contacts of TB case – Persons with fibrotic changes on chest radiograph consistent with old healed TB – Patients with organ transplants and other immunosuppressed patients

6. Classifying the Tuberculin Reaction ≥10 mm is classified as positive in – Recent arrivals from high-prevalence countries – Injection drug users – Residents and employees of high-risk congregate settings – Mycobacteriology laboratory personnel – Persons with clinical conditions that place them at high risk – Children <4 yrs, or children and adolescents exposed to adults in high-risk categories

7. Classifying the Tuberculin Reaction ≥15 mm is classified as positive in – Persons with no risk factors identified – Targeted skin testing programs should only be conducted among high-risk groups

8. NEW CDC TST Video 30 minute videotape provides a detailed demonstration of the steps involved in administering and reading the Mantoux TST Ordering information – Online: www.cdc.gov/nchstp/tbwww.cdc.gov/nchstp/tb – Mail or fax the Materials Order Form – Call 1-888-232-3228, then select 2, 5, 1, 2, 2 and request order #00-5457

9. TB Educational Offerings and Services TST Basic Certification and Recertification N-95 Respirator Training and Fit Testing General TB In-service Contact Investigation Course Orientation for new staff Technical support and assistance for TB control programs

10. TB Educational Offerings Tuberculosis Case Management –MNA approval for 4.8 contact hours for nurses –Will be available at regional sites across state TST Train the Trainer Course –“To go show” available in June, 2003 –Contact your regional nurse for more information

11. Contact Information Southeastern Michigan Teri Lee Dyke terileedyke@voyager.net phone: (517) 484-7283 fax: (517) 484-2118 Western and Northern Michigan Julie McCallum jmccallum@alam.org phone: (616) 942-0513 fax: (616) 942-0650

12. TB Epidemiology

13. Michigan TB Cases 1997 - 2002 199719981999200020012002 3.8/100,000 population 3.9/100,000 population 3.6/100,000 population 2.9 /100,000 population 3.3/100,000 population 3.2/100,000 population 373385351287330315

14. Percentage of Total Michigan TB Cases Foreign Born

15. Treatment of Tuberculosis (revised) American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America

16. What’s New In This Document  The responsibility for successful treatment is clearly assigned to the public health program or private provider, not to the patient.  It is strongly recommended that the initial treatment strategy utilize patient-centered case management with an adherence plan that emphasizes direct observation of therapy.  Recommended treatment regimens are rated according to the strength of the evidence supporting their use. Where possible, other interventions are also rated.

17. What’s New In This Document  Emphasis is placed on the importance of obtaining sputum cultures at the time of completion of the initial phase of treatment in order to identify patients at increased risk of relapse.  Extended treatment is recommended for patients with drug- susceptible pulmonary tuberculosis who have cavitation noted on the initial chest film and who have positive sputum cultures at the time 2 months of treatment is completed.

18. What’s New In This Document  Treatment completion is defined by number of doses ingested, as well as the duration of treatment administration.

19. New Blood Test for LTBI

20. What is the QuantiFERON-TB Test? The QuantiFERON® -TB assay is an in-vitro diagnostic laboratory test that utilizes whole-blood in the detection of infection with Mycobacterium tuberculosis. QuantiFERON®-TB was approved by the FDA for clinical use in the USA on November 29, 2001. In 2003, The US Centers for Disease Control and Prevention approved its use in both low and high-risk TB populations.

21. How does QuantiFERON Work? Blood samples are mixed with antigens to produce an immune response If individual has LTBI, blood cells release interferon-gamma QuantiFERON results are based on the amount of interferon gamma released compared to the other antigen controls

22. Interpreting QuantiFERON Results The QuantiFERON Test (QFT) and the Tuberculin Skin Test (TST) do not measure the same components of immunologic response and are not interchangeable Confirmation of QFT with a TST is possible because use of QFT does not affect the TST. However, a TST will affect the QFT result, therefore QFT should be done before placing the TST Probability of LTBI is highest when both QFT and TST are both positive Additional tests are necessary to rule out active TB

23. What are the Advantages? QFT only requires a single patient visit Controls for reactivity to non-TB mycobacteria as well as a patient’s immune response Eliminates the booster phenomenon Less subject to reader bias and error

24. What are the Disadvantages? Blood samples must be processed within 12 hours Currently there is limited labaroatory and clinical expertise with QFT As with TST, additional tests are needed to rule out TB disease and confirm LTBI

25. Because of insufficient data on which to base recommendations, QFT is not recommended for: Evaluation of persons with suspected active tuberculosis. Assessment of contacts of persons with infectious tuberculosis (conversion rates and concordance has not been studied). Screening of children aged <17 years, pregnant women, or for persons with clinical conditions that increase the risk for progression of LTBI to active TB (e.g., human immunodeficiency virus infection). Confirmation of TST results because injection of PPD for TST might affect subsequent QFT results Diagnosis of M. avium complex disease.

26. QFT can be considered for LTBI screening as follows (CDC Recommendations): Initial and serial testing of persons with an increased risk for LTBI (e.g., recent immigrants, injection-drug users, and residents and employees of prisons and jails) Initial and serial testing of persons who are, by history, at low risk for LTBI but whose future activity might place them at increased risk for exposure, and others eligible for LTBI surveillance programs (e.g., health-care workers and military personnel) Testing of persons for whom LTBI screening is performed but who are not considered to have an increased probability of infection (e.g., entrance requirements for certain schools and workplaces)

27. Additional Information http://www.cellestis.com http://www.fda.gov http://www.cdc.gov/nchstp/tb/default.htm

28. MDCH TB Program Contact Information Susan Spieldenner, RN TB Program Coordinator (517) 335-8173 Spieldenners@michigan.gov Gabe Palumbo, MBA,MPH CDC Public Health Advisor (517) 335-8798 Palumbog@michigan.gov

29. Community Diagnosis Kabul, Afghanistan