TB Infection: Diagnosis and Treatment

1 Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 1 TB Infection: Diagnosis and Treatment Michael Cooper, MD, MS Section of Epidemiology State of Alaska Updated May 2015 Objectives Describe approved tests for diagnosing TB infection Describe acceptable regimens for TB infection Treatment Objectives Describe approved tests for diagnosing TB infection Tuberculin Skin Test (TST) TB Blood Tests (IGRA QFT, T Spot) Describe acceptable regimens for TB infection Treatment 9H, 4R, 3HP (6H, 6R) Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 2 Objectives - Additional TB in Alaska history very brief Basic understanding of TB Infection Logistics of TB control in Alaska Good resources* AD 400 probable TB St.

2 Lawrence Island 1500 s probable TB Pt. Barrow Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 3 1700 s Russian explorers and traders 1800 s Gold/fish/whales 1880 1953 Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 4 Organic Act - 1884 1931 - Alaska Native Service Territory - 1912 Native Health = Bureau of Education - 1930 First Health Commissioner - 1945 USPHS IHS - 1955 1880 1953 1926-1930 AK Native TB death rate 655/100,000 1952 1,823/100,000 TB Incidence AK Native 1930-1936 AK Native TB death rate 810/100,000 1943 2,000-4,000 active TB cases 70 beds 1880 1953 Parran Report 1953-1954 Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 5 Tuberculosis is the Alaskan Scourge It still shows the scars of an exploited colony.

3 Health deplorable We must help Alaskans to help themselves..disgraceful burden of disease in our own country Achilles heel defense Parran Report 1953-1954 White Alaska young, vigorous, urbanized life-expectancy as favorable Native Alaska sickness, crippling conditions, premature death ..a degree exceeded in very few parts of the world. Parran Report - Two Worlds Alaska Historical TB Rates Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 6 Active TB Rate by year, Alaska, 1992-2013 Incidence of TB in Alaska by Region 2008 - 2013 Region 2008 (cases/rate) 2009 (cases/rate) 2010 (cases/rate) 2011 (cases/rate) 2012 (cases/rate) 2013 (cases/rate) Anchorage/ Mat-Su 19 ( ) 12 ( ) 18 ( ) 29 ( ) 10 ( ) 25 ( ) Gulf 2 ( ) 1 ( ) 0 ( ) 5 ( ) 3 ( ) 4 ( ) Interior 4 ( ) 4 ( ) 11 ( ) 4 ( ) 4 ( ) 1 ( ) Northern 6 ( ) 5 ( ) 11 ( ) 8 ( ) 16 ( ) 10 ( ) Southeast 3 ( ) 2 ( ) 2 ( ) 1 ( ) 5 ( ) 1 ( ) Southwest 17 ( ) 13 ( ) 15 ( ) 20 ( ) 28 ( ) 30 ( ) STATE TOTAL 50 ( ) 37 ( ) 57 ( 8/0) 67 ( ) 66 ( ) 71 ( ) TB Cases, by Race, Alaska, 2001-2010 0 10 20 30 40 50 60 70 80 White AI/AN Asian/PI Afr Am % Population % TB cases Navigating Frontiers in TB Case Management.

4 Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 7 TB Cases, by Race, Alaska, 2001-2010 0 10 20 30 40 50 60 70 80 White AI/AN Asian/PI Afr Am % Population % TB cases Brief thoughts on LTBI Brief thoughts on LTBI Why not screen and treat everyone? Challenging foe! Slow growing, dormant Suboptimal tests Suboptimal drug regimens Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 8 Tuberculosis terminology Tuberculosis terminology Latent TB Disease Active Disease Inactive Disease Infection Latent Infection LTBI Tuberculosis terminology Disease Infection Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 9 TB Pathophysiology Small, et al NEJM 2001 TB Pathophysiology Small, et al NEJM 2001 Infection and Disease Latent TB Infection (LTBI) TB Disease No symptoms Symptoms may include.

5 Productive cough > 3 weeks Weight loss Sweats at night Hemoptysis Fatigue Fever / chills Not sick Usually feels sick Cannot infect others Often infectious (+) TST or IGRA (+) TST or IGRA Normal CXR & negative AFB smears May have abnormal CXR & (+) AFB smears or culture Needs TX for LTBI to prevent progression to active TB disease Needs Treatment for active disease Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 10 Infection and Disease Latent TB Infection (LTBI) TB Disease No symptoms Symptoms may include: Productive cough > 3 weeks Weight loss Sweats at night Hemoptysis Fatigue Fever / chills Not sick Usually feels sick Cannot infect others Often infectious (+) TST or IGRA (+) TST or IGRA Normal CXR & negative AFB smears May have abnormal CXR & (+) AFB smears or culture Needs TX for LTBI to prevent progression to active TB disease Needs Treatment for active disease Infection and Disease Latent TB Infection (LTBI) TB Disease No symptoms Symptoms may include.

6 Productive cough > 3 weeks Weight loss Sweats at night Hemoptysis Fatigue Fever / chills Not sick Usually feels sick Cannot infect others Often infectious (+) TST or IGRA (+) TST or IGRA Normal CXR & negative AFB smears May have abnormal CXR & (+) AFB smears or culture Needs TX for LTBI to prevent progression to active TB disease Needs Treatment for active disease Latent Infection to Active Disease- Reactivation Lifetime risk estimate 10% Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 11 Latent Infection to Active Disease- Reactivation Lifetime risk estimate 10% Increased risk for disease HIV, tobacco, alcoholism, IDDM, malignancy, immune suppression (glucocorticoids, TNF inhibitors, malnutrition, renal Resource - Resource - Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 12 Resource - LTBI Prevalence in AK?)

7 True or False 90% of third graders in YK are infected with TB Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 13 True or False 90% of third graders in YK are infected with TB True or False 90% of third graders in YK are infected with TB 1950 (89%) Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 14 What is the prevalence of LTBI in Alaska? Unknown LTBI is not reportable in Alaska SOA provides medications SOA manages many LTBI cases No database, no surveillance School screening (changing) What is the prevalence of LTBI in Alaska? Unknown Estimates: One third of the world infected ~2% of born individuals ~20% of Foreign Born (NHANES 1999-2000) Latent TB Infection Tests Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 15 Latent TB Infection Tests Tuberculin Skin Test (TST) TB Blood Tests Interferon Gamma Release Assays (IGRA) Quantiferon TB Gold In-Tube (QFT-GIT) T Spot Latent TB Infection Tests TST advantages TST disadvantages IGRA advantages IGRA disadvantages Who should use IGRA?

8 Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 16 Who should use IGRA? Who should use IGRA? BCG vaccinated Low return rate Some contacts ?low risk - No Who should use IGRA be screened? Higher risk close contacts, foreign-born Both tests have limitations Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 17 Tuberculin Skin Test (TST) TST is: A) A good test B) A lousy test C) Better than TB blood tests D) Worse than TB blood tests E) All of the above Tuberculin Skin Test (TST) TST is: A) A good test B) A lousy test C) Better than TB blood tests D) Worse than TB blood tests E) All of the above Treatment for LTBI Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease.

9 Diagnosis and Treatment 18 Treatment for LTBI Standard regimens 9 months of isoniazid (INH, H) 6 months of isoniazid 4 months of rifampin (RIF, R) 6 months of rifampin 3 months of isoniazid plus rifapentine (3HP) Resources CDC LTBI App - Case Presentation 45 yo from the Philippines TB screening Denies symptoms Denies TB contacts What next? Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 19 Case Presentation 45 yo from the Philippines TB screening TB test? TST or IGRA? Case Presentation Do they give BCG in the Philippines? Resource - Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 20 Case Presentation Does SOA pay for IGRA?

10 Can your lab do an IGRA? Can this patient get a TST with BCG hx? Case Presentation 45 yo from the Philippines TB screening Patient states she had a positive TST in past Can you trust this? Can you do another TST? Case Presentation 45 yo from the Philippines TB screening TST is 11mm. Is that positive? Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 21 TST Interpretation Resource Alaska Tuberculosis Program Manual Case Presentation 45 yo from the Philippines TB screening Do they need a chest radiograph? Two view or single PA? What if she had one three months ago? Navigating Frontiers in TB Case Management: Strengthening Partnerships for Improved Patient Outcomes June 2, 2015 Curry International Tuberculosis Center TB Infection and TB Disease: Diagnosis and Treatment 22 Case Presentation 45 yo from the Philippines TB screening TST positive (could it be due to BCG?)