Tuberculosis Manual - Gov

1 Tuberculosis ManualTuberculosis and Chest ServicePublic Health Services BranchCentre for Health ProtectionDepartment of HealthGovernment of the HKSARTUBERCULOSIS Manual (Hong Kong SAR 2006)ISBN 962-8868-10-1978-962-8868-10-0 Published in February 2006 Printed in Hong Kong SARA ddress: Tuberculosis and Chest ServiceWanchai Chest Clinic99 Kennedy RoadHong Kong SAR Copyright 2006 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, ortransmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise,without the prior permission of the copyright great care has been exercised in ensuring the accuracy of the information compiled in thismanual, the editor and publisher shall not be responsible for any errors, omissions or inaccuracies in thispublication.

2 Readers are also reminded to refer to relevant sources for updated information (TB) is a long-existing infectious disease. With the advent of effective treatment in theform of short course service programmes in 1970s, it was once thought that the disease could beeliminated quite soon. However, since late 1980s and early 1990s, for a number of reasons, TB becameresurgent alongside rampant drug resistance and HIV co-infection in various parts of the world. In April1993, the World Health Organisation declared TB as a global emergency. Today, TB remains animportant infectious disease Hong Kong, the TB notification rate has become rather stagnant in the last decade, despite anoverall downward trend in the past 50 years.

3 The rate now stands just below 100 per 100,000 population,with around 7,000 cases each year. With such an endemicity, medical practitioners in various fields arelikely to encounter TB cases from time to guidelines have been promulgated on various aspects of TB from time to time. This Manual isprepared as another step to facilitate the clinical management of TB in the local settings. Apart from theprofessional staff of the TB and Chest service, a large number of experts in different fields havecontributed much of their effort and time in making the publication of this Manual possible. The chaptersare based on a careful review of information from multiple sources, including overseas and local studies,international guidelines, expert opinions and local experiences where appropriate.

4 Through thededication of the contributors, vigorous attempt has been made to strive for high-standard evidence-based medicine suited for the control of TB in the local the huge volumes of literature on this important topic, this Manual does not mean to be acomprehensive text. Instead, it aims to serve as a handy synopsis of updated guidelines and resources forthe reference of local professionals. Although the contributors have tried to ensure that the information isup-to-date at the time of writing, there remains an ongoing need to keep abreast of new scientificadvances and changes in practices. Readers are therefore encouraged to refer to other relevant sources orvisit our TB website at for updated information wherever TamCC Leung(Editors)Hong Kong SAR 20063 LIST OF CONTRIBUTORSKF AuMBChB(CUHK), MRCP(UK) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of HealthCK Chan MBBS(HK), FHKAM(Medicine) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of HealthHS Chan MBBS(HK), FHKAM(Medicine)Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hospital AuthorityKS Chan MBBS(HK), FHKAM(Medicine)Department of Pulmonary and Palliative Care, Haven of Hope Hospital, Hospital AuthorityM Chan-Yeung MBBS(HK), FHKAM(Medicine)

5 Department of Medicine, Queen Mary Hospital, University of Hong KongMY Chan Senior Medical TechnologistPublic Health Laboratory Services Branch, Centre for Health Protection, Department of HealthSL Chan MBBS(HK), FHKAM(Medicine)Private practitioner (Specialist in Respiratory Medicine)YC Chan MBBS(HK), FHKAM(Medicine) Tuberculosis and Chest Unit, Wong Tai Sin Hospital, Hospital AuthorityKC Chang MBBS(HK), FHKAM(Medicine) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of HealthDSC Hui MD(UNSW), FHKAM(Medicine)Department of Medicine, Prince of Wales Hospital, Chinese University of Hong KongKM Kam MBBS(HK), DABMMP ublic Health Laboratory Services Branch, Centre for Health Protection, Department of HealthCW Lam MBBS(HK), FHKAM(Medicine)Department of Respiratory Medicine, Ruttonjee Hospital, Hospital AuthorityWS Law MBChB(CUHK), FHKAM(Medicine) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of HealthSN Lee MBChB(CUHK), FHKAM(Medicine) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of HealthCC Leung MBBS(HK), FHKAM(Medicine) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of HealthECC Leung MBBS(HK), FRCP(Canada) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of HealthTYW Mok MBBS(HK), FHKAM(Medicine)Respiratory Medical Department, Kowloon HospitalWH Seto MBBS(Singapore), FHKAM(Pathology)

6 Department of Microbiology, Queen Mary Hospital, Hospital AuthorityLB Tai MBChB(CUHK), FHKAM(Medicine) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of HealthCM Tam MBBS(HK), FHKAM(Medicine) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of HealthCY TamMBBS(HK), FHKAM(Medicine)Department of Medicine, Tuen Mun Hospital, Hospital AuthorityKWT Tsang MD(Glas,Hons), FRCP(Edin,Glas,Lond)Department of Medicine, Queen Mary Hospital, University of Hong KongMY Wong MBChB(CUHK), MRCP(UK) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of HealthPC Wong MBBS(HK), FHKAM(Medicine) Tuberculosis and Chest Unit, Grantham Hospital, Hospital AuthorityWS WongSenior Medical TechnologistPublic Health Laboratory Services Branch, Centre for Health Protection, Department of HealthWW Yew MBBS(HK), FHKAM(Medicine) Tuberculosis and Chest Unit, Grantham Hospital, Hospital AuthorityCW YipBSc, PhDPublic Health Laboratory Services Branch, Centre for Health Protection, Department of HealthWC Yu MBBS(HK), FHKAM(Medicine)Department of Medicine, Princess Margaret Hospital, Hospital AuthorityRWH Yung MBBS(HK), FHKAM(Pathology)

7 Infection Control Branch, Centre for Health Protection, Department of Health4 AcknowledgementWe would like to thank our colleagues in the Hospital Authority, the two Universities and theDepartment of Health for their support, contribution, and comments during the preparation of the variouschapters of this TB Manual : Dr. KF Au, Dr. CK Chan, Dr. HS Chan, Dr. KS Chan, Prof. M Chan-Yeung,Ms. MY Chan, Dr. SL Chan, Dr. JWM Chan, Dr. YC Chan, Dr. KC Chang, Dr. KL Choo, Dr. CM Chu,Dr. SS Ho, Prof. DSC Hui, Dr. KM Kam, Dr. FY Kong, Dr. CW Lam, Dr. WS Law, Dr. SN Lee, Leung, Dr. HM Ma, Dr. TYW Mok, Dr. WH Seto, Dr. L So, Dr. LB Tai, Dr. CY Tam, Prof. KWTT sang, Dr. ML Wong, Dr. MY Wong, Dr. PC Wong, Mr. WS Wong, Dr. KS Yee, Dr. WW Yew, Yip, Dr.

8 WC Yu, Dr. RWH Yung. The advice from Dr. PY Leung (Controller, Centre for HealthProtection) and Dr. PY Lam (Director of Health) is also very encouraging. Last but not least, the high-spirited nursing team and clerical staff of the TB & Chest Service have provided all the necessaryassistance and support to make this publication EditorsLIST OF ABBREVIATIONSACHAir changes per hourARTAnti-retroviral therapyARIA nnual risk of Tuberculosis infectionATSA merican Thoracic SocietyBCGB acille Calmette Gu rinCIConfidence intervalDHDepartment of HealthDOTD irectly observed treatmentDOTSD irectly observed treatment, short courseERSE uropean Respiratory SocietyFDAFood and Drug Administration (of the United States)FDCF ixed-dose combination tabletsHAHospital AuthorityHAARTH ighly active anti-retroviral therapyHEPAHigh efficiency particulate air filterHCWH ealth care workersHIVH uman immunodeficiency virusIUATLDI nternational Union Against Tuberculosis and Lung DiseasesMDR-TBMultidrug-resistant tuberculosisMOTTM ycobacterium other than tuberculosisMTBM ycobacterium tuberculosisOROdds ratioPCRP olymerase chain reactionPPDP urified protein derivativePHLCP ublic Health Laboratory Centre (of Department of Health)RFLPR estriction fragment length polymorphismRRRelative riskST(Drug) sensitivity or susceptibility testsTBTuberculosisTB&CSTuberculosis & Chest Service (of Department of Health)TBCCCTB Control Coordinating Committee (of Department of Health)TBSCTB Subcommittee (of the Hospital Authority)

9 TSTT uberculin test or tuberculin skin testWHOW orld Health Organisation5 LIST OF TABLEST able Basic demographics of Tuberculosis patients in 2004 in Hong KongTable Modes of presentation of Tuberculosis patients in 2004 in Hong KongTable Disease characteristics among Tuberculosis patients in 2004 in Hong KongTable Radiation dose of some conventional X-ray examinations and computerised tomography examinationsTable Results of chest radiograph screening for household contacts (2004)Table Risk factors for adverse drug events complicating anti- Tuberculosis treatmentTable Some common and important drug interactions with rifamycins and fluroquinolonesTable Management of common adverse drug eventsTable Rates of liver dysfunction among elderly and young patients from a local studyTable Rates of liver dysfunction and symptomatic hepatitis among patients given anti- Tuberculosis drugs,among Hepatitis B carriers as compared with non-carriers.

10 And among Hepatitis B carriers not given anti- Tuberculosis drugsTable HBsAg seropositivity rates among Tuberculosis patients treated at chest clinics during a 2-month periodfrom March 2005 to May 2005 Table Anti- Tuberculosis drugs and potential for hepatotoxicityTable The five principal elements of DOTS strategyTable Types of relationship between patient and the health-care providerTable Promoting DOT at the clinic levelTable Case detection and treatment success rates for Hong Kong and some neighbouring countriesTable Factors to be considered during cost-benefit assessment of contact investigationTable Tuberculosis contact investigation in the Tuberculosis & Chest Service, Department of HealthTable Criteria for evaluation of the risk of Tuberculosis transmission and informing flight crew and passengersof the potential exposureTable Factors associated with a false-negative tuberculin testTable Positive and negative predictive values of tuberculin skin testTable Cut-off values of tuberculin test for diagnosis and treatment of latent Tuberculosis infectionTable Work practice for treatment of latent Tuberculosis infectionTable Results of meta-analyses on BCG efficacyTable Estimated dissemination rates and concentrations of infectious particles ( Tuberculosis and measles) indifferent clinical scenariosTable Number of reported cases of Tuberculosis in health care workers (1997 2004)