1. Wyoming Department of Health Communicable Diseases 307-777-8939
Tuberculosis
Wyoming Department of Health
Communicable Diseases

2. What is Tuberculosis?
An infection caused by Mycobacterium tuberculosis
Spread person to person through droplets released from an infected person by sneezing, coughing, singing or laughing
Can be classified as:
Active TB Disease
Latent TB Infection (LTBI)

3. Transmission Occurs when an individual inhales infected droplets
Depends on
Infectiousness of TB infected individual
Environment in which the exposure took place
Closed, tight environments pose a greater risk of transmission
Length of exposure
The longer the exposure, the greater the risk
Virulence of TB bacteria

4. Who is at risk? HIV Infected Individuals
Individuals born in TB endemic countries
Individuals who have been in contact with someone with TB
Alcohol and illicit drug users
Individuals with conditions that may compromise the immune system
Individuals who were previously treated incorrectly for TB infection

5. TB Worldwide 1/3 of the World’s population is infected with TB
Approximately 9 million people became infected with TB in 2010
1.4 million people die from TB each year
TB is the leading cause of death among individuals with AIDS

6. TB in the United States
The rate of TB in the US in 2010 was 3.6 cases per 100,000 population
The rate has been steadily decreasing since 1992
A total of 11,182 cases were reported in 2010
Hawaii reported the highest case rate of 8.8 cases per 100,000 population
Maine reported the lowest case rate of 0.6 cases per 100,000 population
Center for Disease Control and Prevention (2011, October 7). Reported Tuberculosis in the United States, 2010.

7. TB in Wyoming Wyoming is a low incidence state
Reported case rate of 1.3 per 100,000 population in 2010
This number increased by 0.9 cases per 100,000 population from 2009
Wyoming had the 42nd highest case rate in 2010
Active TB Disease is a REPORTABLE disease in Wyoming

8. Active TB Disease Infectious stage of TB
Manifests six or more weeks after exposure
Occurs when the body cannot control the TB bacteria in the body
Symptoms may include:
Prolonged Cough
Unexplained Weight Loss
Fever
Night Sweats
Chest Pain
Blood in Sputum
Patients diagnosed with active TB disease should:
Be isolated and provided with a mask to wear for doctor appointments, etc
Immediately start a treatment regimen
If HIV status is unknown, an HIV test should be done in order to correctly prescribe the best treatment regimen

9. Diagnosis of Active TB Physical Exam/Symptom evaluation Chest X-ray
Cannot confirm TB Disease
Used to detect lung abnormalities or rule out disease
Bacteriologic Cultures (AFB smears)
Used to confirm/rule out TB disease
Sputum sample, bronchoscopy, gastric washing
Sputum Sample
Most cost-effective
Patient coughs sputum into a sterile container at least 3 different times in 8-24 hour intervals, at least one being an early morning specimen

10. Active TB Treatment
Treatment must last 6 months or more (depends on patient’s response to the treatment regimen)
2 phases of treatment
Initial Phase
First 8 weeks of treatment
4 drugs used
Isoniazid (INH)
Rifampin (RIF)
Pyrazinamide (PZA)
Ethambutol (EMB)
Kills most bacteria
Continuation Phase
Starts after the first 8 weeks of treatment until treatment is complete
At least 2 drugs used
Kills remaining bacteria

11. Active TB Treatment
Adherence to proper treatment is essential in treating active TB and avoiding drug resistance
Drugs should be taken as prescribed
This time should be convenient for the patient
Can be monitored by Direct Observed Therapy (DOT)
A medical provider watches the patient take the medication in person, by webcam or other means
Drug resistance can occur if
An improper treatment regimen is prescribed
The patient does not take all of their medication as prescribed

12. Active TB Treatment Evaluation
The patient should be evaluated regularly to ensure the patient is properly responding to treatment by
Symptom evaluation
Chest x-ray
Sputum smears or other bacteriologic specimens
Patients should be reevaluated and treatment regimen should be assessed if:
Symptoms do not improve after 2 months of therapy
Symptoms worsen
Positive cultures remain after 2 months of treatment
Culture results become positive after having a negative culture

13. Active TB Treatment Evaluation
Liver function tests
INH can impact the liver causing hepatitis, liver function tests should be routinely performed on individuals that:
Are HIV positive
Have conditions that may cause hepatitis
Are taking other medications which may cause hepatitis
Are pregnant
Use alcohol regularly
Have symptoms of hepatitis

14. Extrapulmonary TB
More common in young children and HIV infected individuals
Symptoms often coincide with the location of infection
Infection can spread to:
Brain
Kidneys
Bones/Joints
Pleura
Lymph nodes
Larynx
Miliary (Disseminated) TB (very rare)
All parts of the body can be infected
Travels through blood stream
Tuberculous lymphadenitis

15. Extrapulmonary TB
Tests for Extrapulmonary TB are bacteriologic tests of samples taken from affected areas such as:
Urine sample for kidney
Spinal fluids for TB meningitis
Etc.
Extrapulmonary TB can be treated with 9 months of INH or RIF
Duration of treatment can be shortened to 6 months if a combination of four drugs are used daily for the first two months
For more information visit

16. Latent TB Infection (LTBI)
Occurs when an individual inhales infected droplets but the bodies immune system keeps the bacteria under control in the body
Can progress to active TB disease if the immune system cannot continue to control the infection
Asymptomatic
Should be treated to prevent progression to active disease
Is not infectious at this stage

17. Targeted Screening for TB
The CDC recommends that the following should be screened for TB:
Close contacts to individuals with active TB disease
HIV Infected individuals
Injection drugs users and users of other high risk substances
Individuals with medical conditions that are at greater risk for TB
Individuals/Employees in high risk congregate settings
Healthcare workers who serve high-risk clients
Individuals born in countries with high prevalence/incidence
Infants and children exposed to high risk adults
WDH recommends that all healthcare facilities conduct the CDC evaluation to determine the frequency for employee screening.

18. Diagnosis TARGETED Screening/Risk Assessment
A risk assessment should be completed to determine if someone is at risk for TB
This assessment and other resources can be found at
TST/IGRA
If risks are present, a TST test should be placed
BCG status should be ignored after 1 year of vaccination
IGRA is another option but there is limited availability and should be approved by WDH TB Program staff before testing
Chest x-ray
A chest x-ray should be done to rule out active infection if the TST or IGRA is positive

19. Tuberculin Skin Test (TST)
Administration
0.1 mL of PPD tuberculin solution
Inject intradermally on the forearm
Produce a 6 to 10 mm wheal
Reading
Read the test hours later
Measure the induration, NOT the erythema
Measure transversely across forearm
Record induration in mm, no induration = 0mm
Positivity depends on risk factors!

20. LTBI Treatment
Treatment of LTBI is essential in preventing progression into active disease
Treatment regimen is recommended for 9 months but can be done in 6 under specific circumstances
6 month regimen is not recommended for those living with HIV, previous TB disease, or children
INH is the recommended medication
RIF can be given to people who cannot take INH
RIF should not be used in conjunction with certain anti-retroviral medications
For more information visit

21. Progression of Disease
Progression of LTBI to Active TB Disease is 7%-10% over the lifetime unless other conditions exist
Individuals with LTBI are more likely to progress to active infection within 2 years of becoming infected
Progression of LTBI to Active TB is more likely if:
LTBI is untreated
LTBI is treated improperly
The immune system is compromised (HIV, certain cancers, immune suppressants, etc.)
HIV infected individuals with LTBI have a 7%-10% chance of progression to active infection EVERY YEAR.

22. Prevention The spread of TB can be prevented by:
Quickly identifying individuals with TB by targeted testing of those at risk
Isolating individuals with active disease
Correctly utilizing PPE when dealing with an Active TB patient
Promptly starting appropriate treatment for those diagnosed with TB
Verifying that patients are compliant with and complete treatment (DOT)

23. References
Center for Disease Control and Prevention. (2011, May 25). Tuberculosis- Testing and Diagnosis. Retrieved from
Center for Disease Control and Prevention. (2011, October 11). Tuberculosis- Data and Statistics. Retrieved from
Center for Disease Control and Prevention. (2011, November 2). Tuberculosis- Treatment. Retrieved from
Center for Disease Control and Prevention. (2010, July 1). Tuberculosis- Basic TB Facts. Retrieved from
Center for Disease Control and Prevention. (2010, July 1). Tuberculosis- Infection control and prevention. Retrieved
from