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Slide 1: Tuberculosis Update for School Nurses June 18, 2015 Slide 2: Tuberculosis in Children and Adolescents Peter N. Wenger, MD Saint Peter’s University Hospital Slide 3: Definitions Pediatric tuberculosis (TB): TB disease in a person <15 years of age Latent TB infection (LTBI) – infection with M. tuberculosis without evidence of active disease in a person <15 years of age Infectious TB: TB disease in the lungs or larynx in a person who has the potential to transmit infection to other people Slide 4: Epidemiology - Global Leading cause of infectious disease morbidity and mortality Approximately 1/3 of the world’s population (>1.9 billion people) are infected with M. tuberculosis In the 2000s: 90 million new cases 30 million deaths Among children <15 years of age: ~13 million cases 14% of total cases 5 million deaths 17% of total mortality Case fatality rate: 39% 2012 Estimated: 8.6 million new cases 530,000 in children (<15 yrs of age): 74,000 deaths Slide 5: Epidemiology: United States TB in children and adolescents appears to be declining Annual case notifications in persons <18 years of age decreased from 997 (2007) to 818 (2010) Between 2008 and 2010 69% of children and adolescents with reported TB were born in the US Of these 66% had at least one foreign-born parent 4% of pediatric TB patients had parents who were both born in the US (international adoptees?) Between 2008 and 2010 of the 2628 children and adolescents with TB with known race/ethnicity 45% - Hispanic 27% - Black 20% - Asian 7% - White 1% - Native American (including Native Alaskan) Slide 6: Epidemiology – United States TB cases 2013 9,582 cases reported in total 485 (5.1%) in the pediatric age group 297 (61.2%) in those 0-4 years of age 188 (38.8%) in those 5 – 18 years of age Slide 7: Transmission of M. tuberculosis to Children Children are most commonly exposed in the immediate household by a family member with active disease Casual extra-familial contact is less often the source of infection Children rarely infect other children or adults: Tubercle bacilli are relatively sparse in secretions Paucibacilliary TB (smear negative, culture positive) Children with pulmonary TB rarely cough Cough, when present, lacks the tussive force needed to aerosolize bacilli Slide 8: Risk of Tuberculosis Disease by Age Risk of disseminated Risk of tuberculosis/tuberculosis pulmonary meningitis following tuberculosis primary infection following primary infection <1 years 10-20% 30-40% Risk of no disease following primary infection 50% Comments High rates of morbidity and mortality 1-2 years 2-5% 10-20% 75% High rates of morbidity and mortality 2-5 years 0-5% 5% 95% .. 5-10 years <0-5% 2% 98% “Safe school years” >10 years <0-5% 10-20% 80-90% Effusions or adult-type pulmonary disease Table 1: Risk of pulmonary and extrapulmonary disease in children following infection with Mycobacterium tuberculosis Newton S, et al. Lancet ID 2008 after Marais BJ, et al. Int J Tuberc Lung Dis 2004 Slide 9: Increased Risk of Progression of LTBI to TB Disease Age groups: Infants and young children Post pubertal adolescents Recent infection: Highest risk in first 6 months after infection Remains high for 2 years Recent immigration Immunodeficiency: HIV infection, Hodgkin disease, lymphoma, diabetes mellitus, chronic renal failure, malnutrition Immunosuppressive drugs: prolonged or high-dose corticosteroid therapy, chemotherapy, tumor necrosis factor (TNF-alpha) antagonists used to treat rheumatoid arthritis and Crohn disease Slide 10: Clinical Manifestations Pulmonary disease and associated intrathoracic adenopathy most common presentation of TB in children Common symptoms are often nonspecific Chronic, unremitting cough that is not improving and present for>3 weeks Fever >38°C for at least 2 weeks, other common causes excluded Weight loss or failure to thrive (based on growth chart) Children, 5 – 10 years may present with clinically silent but radiographically apparent disease Infants more likely to present with signs and symptoms of lung disease Elucidating the epidemiologic risk factors for TB vital in evaluation for TB Adolescents can present with features common in children or adults Slide 11: Extrapulmonary tuberculosis In the context of exposure to TB, presence of any of the following signs should prompt evaluation for extrapulmonary TB Superficial lymph nodes (scrofula) Fixed, painless, enlarged superficial nodes (usually cervical) TB meningitis Meningitis not responding to antibacterial medications, with a subacute onset, communicating hydrocephalus, stroke, and/or elevated intracranial pressure Pleural TB Pleural effusion Pericardial TB Pericardial effusion Abdominal TB Distended abdomen with ascites, abdominal pain, jaundice, or unexplained chronic diarrhea Slide 12: Extrapulmonary TB TB of the joint Nontender joint effusion Vertebral TB (Pott’s disease) Back pain, gibbus deformity (a form of structural kyphosis) especially of recent onset (uncommon) Skin Warty lesion(s), papulonecrotic lesions, lupus vulgaris, erythema nodosum may be a sign of tuberculin hypersensitivity Renal Sterile pyuria, hematuria Eye Iritis, optic neuritis, phylctenular conjunctivitis Slide 13: Pediatric TB Cases by Site of Disease, 1993–2012 Percentage of pediatric TB cases Pulmonary 70.6% Extrapulmonary 22.2% Both 7.2% Table 2: Types of pediatric TB cases between 1993 and 2012 Percentage of any extrapulmonary involvement (totaling 29.4%) Lymphatic 18.8% Meningeal 3.4% Miliary 1.4% Bone & Joint 1.5% Other 4.3% Table 3: Percentage of extrapulmonary sites with any extrapulmonary involvement in all TB cases, from 1993 to 2012 Slide 14: Tuberculosis in Adolescents Adolescents develop tuberculosis in one of two ways: Reactivation of infection acquired during childhood The closer to puberty at the time of infection the greater the risk of reactivation Chronic pulmonary tuberculosis Progression of infection acquired during adolescence to disease: Classic primary disease Progressive primary pulmonary tuberculosis Chronic pulmonary tuberculosis Slide 15: Adolescents: Reactivation Tuberculosis Constitutional symptoms often more prominent than respiratory symptoms Weight loss and fever are very common Cough, chest pain, hemoptysis Drenching night sweats occur several times per week Cavitary lesions frequently seen Slide 16: Significance of Tuberculosis in Children Public Health: Diagnosis of LTBI or tuberculosis disease in a child is considered a “sentinel public health event” usually representing recent transmission of TB within a community Personal Health: High rates of morbidity and mortality Slide 17: Prevention of TB in Children: Potential Missed Opportunities Failure to find and appropriately manage adult source cases (case finding) Delay in reporting the initial diagnosis of TB Contact investigation interview failure Delay in evaluation of exposed children Failure to completely evaluate exposed children Failure to prescribe INH “window prophylaxis” LTBI diagnosed; treatment not prescribed Failure to complete treatment for LTBI Slide 18: TB Control: Targeted TB Testing What is Targeted TB Testing? Identifies persons at high risk of infection with M. tuberculosis Identifies persons at high risk of progressing to disease should they be infected Slide 19: Why Use Risk-Based Targeted TB Testing? Why not use routine, universal, administratively mandated TB testing? Why not use the Tuberculin Skin Test (TST) or Interferon Gamma Release Assay (IGRA) as a screening tool? Daycare Schools Colleges Summer camps Answer: Limitations of the TST/IGRA Universal testing means that large numbers of low risk children will be tested: Inefficient use of healthcare resources Even if the specificity of the test approaches 99%, testing of persons in lowprevalence groups would result in mostly false-positives IGRA specificity reduces but does not eliminate false positives in low risk population Slide 20: Targeted TB Testing Risk assessment: Signs and symptoms consistent with TB disease Contact and source-case investigations >1 risk factor identified on screening risk-assessment questionnaire General pediatric practice School-based healthcare High risk of progression due to underlying conditions: HIV infection, Hodgkin disease, lymphoma, diabetes mellitus, chronic renal failure, malnutrition, prolonged or high-dose corticosteroid therapy, chemotherapy, tumor necrosis factor (TNF-alpha) antagonists Slide 21: Control of TB in the United States Contact investigations The most reliable TB control program is based upon aggressive and expedient contact investigations, rather than routine screening of large populations High priority contact Household Age <5 years Medium risk condition Procedure Congregate, Time Can be complex and may require lots of detective work Slide 22: Targeted TB Testing Risk-Assessment Questionnaire Has a family member or contact had TB disease? Has a family member had a positive TB test? Was your child born in a high-risk country (i.e. outside US, Canada, Australia, New Zealand, or Western European countries) Slide 23: Using the Risk Assessment Questionnaire At first contact with child and every 6 months until age 2 years After age 2 years, ask risk assessment questions every year if possible Anytime a risk factor is identified, a TST or IGRA should be performed Slide 24: TST and IGRA TST preferred, IGRA acceptable Children <5 years of age Positive result of either test is considered significant IGRA preferred, TST acceptable Children ≥5 years of age who have received BCG vaccine Children ≥5 years of age who are unlikely to return for TST reading Slide 25: TST and IGRA TST and IGRA should be considered: The initial and repeat IGRA are indeterminate The initial test is negative (TST or IGRA) and: Clinical suspicion for TB is moderate to high Risk of progression and poor outcome is high The initial TST is positive and: >5 years of age and a history of BCG vaccination Additional evidence needed to increase compliance Nontuberculosis mycobacterial disease is suspected Slide 26: Limitations TST and IGRA by themselves cannot distinguish between infection and disease In circumstances of moderate to high clinical suspicion for TB disease, negative results in either/or TST and IGRA do not exclude the diagnosis The IGRA should not be used in children <2 years of age unless TB disease is suspected In children 2 through 4 years of age, there are limited data about it’s usefulness in determining TB infection, but can be performed if disease is suspected Children with a positive IGRA result should be considered infected with MTB complex TST results may be confounded by previous BCG administration (agedependent) and infection with nontuberculosis mycobacteria Indeterminate IGRA results do not exclude TB infection and may necessitate repeat testing Should not be used to make clinical decisions Slide 27: Mycobacteriologic Diagnosis of Tuberculosis Adults: 70-90% have a sputum that is (+) for M. tuberculosis Children: Tubercle bacilli are relatively few in number Sputum generally cannot be obtained from children <10 yrs old Gastric aspirates in children with PTB 30-40 % sensitive in children 60-70% sensitive in infants Bronchoalveolar lavage (BAL): Sensitivity may be less than gastric aspirates Slide 28: Establishing a definitive diagnosis of TB disease in children is often associated with great difficulty! Slide 29: Treatment of Latent Tuberculosis Infection INH 10-15 mg/kg (max., 300 mg) PO daily for 270 doses Efficacy approaches 100% Alternative: Twice weekly directly observed (DOT) INH 20-40 mg/kg (max., 900 mg) PO for 72 doses Monitor index case isolate sensitivities Hepatotoxicity from INH is rare in children: Monthly assessment for clinical evidence of hepatotoxicity should be made: malaise, loss of appetite or weight, nausea, vomiting, abdominal pain, jaundice Routine monitoring of LFTs is not indicated Slide 30: Treatment of Latent Tuberculosis Infection Rifampin 10-15 mg/kg/day (max. 600 mg) po daily for 6 months is an alternative INH not tolerated Index patient isolate INH-resistant Rifapentine/INH 12 week course 900mg/900mg maximum taken once a week via Direct Observed Therapy (DOT) MDR-LTBI: TREAT???? NOT TREAT???? Treatment can reduce risk of disease by up to 2/3 Regimen based on susceptibilities of index patient isolate Slide 31: Treatment of TB in Children & Adolescents If INH resistance rate >4% or if other risk for resistance include four drugs in initial regimen: Isoniazid (10 mg/kg/day, range 10-20, max. 300) Rifampin (15 mg/kg/day, range 10-20, max. 600) Pyrazinamide (20-30 mg/kg/day) Ethambutol (15-25 mg/kg/day) Treatment complicated by child unfriendly preparations of the medications Directly observed therapy (DOT) Monitor liver transaminases? – Depends on severity of disease Follow susceptibility studies of Mtbc isolate (index and/or child isolate) Important to be familiar with resistance patterns in the community Slide 32: Directly Observed Therapy in Schools June 18, 2015 Lillian Pirog, RN Slide 33: Topics Factors that influence adherence to TB medication regimens Strategies for overcoming barriers and achieving success Slide 34: Directly Observed Therapy Directly observed therapy (DOT) involves a healthcare or outreach worker watching as a patient swallows their anti-tuberculosis medications DOT is the standard of care for TB disease Should be used with any intermittent treatment Slide 35: Directly Observed Therapy - 2 DOT can be provided almost anywhere… Home or home of babysitter Daycare School Health department Workplace Slide 36: Directly Observed Therapy - 3 Can be supervised by: Physician Health Department Nurse Trained Outreach Worker School Nurse Should not be supervised by: Parents or other close family member Slide 37: Factors that May Affect Adherence Reactions to medication administration vary depending on: Length of medication regimen Relationships with caregiver or person administering medication Medication side effects – nausea or the bitter taste of the medication Reactions of others Remember children usually do not feel sick yet are expected to take medication daily for 6-9 months Slide 38: Removing Barriers to Adherence - 1 General tips for medication administration Administer medication at same time every day Establish a routine-around meal time Start off on positive note-praise efforts to cooperate Avoid distractions-quiet room Ignore behaviors that interfere with administration Usually after 2 weeks child will take medications without difficulty Slide 39: Steps to successfully administer medication The most important recommendation is to keep the volume to the smallest amount possible Goal is to administer all 4 TB medications in the total volume of 5-10mL Pills should be crushed to a fine powder Slide 40: Steps to successfully administer medication (2) Open capsules of Rifampin and add powder to crush pill Then add less than 5mL of very warm water to dissolve the granules Finally add a small amount of fruit, yogurt, applesauce, juice or anything the child likes Slide 41 Shows photo of chocolate pops that a nurse made to help a child take their medicine Slide 42: Assessing for Adverse Reactions Report any adverse reactions immediately to the healthcare provider Use the following questions to assess: Do you have any of the following? Abdominal pain Nausea or vomiting Loss of appetite Fatigue Rash Are you taking any medications other than anti-TB medications? Has there been a change in your appetite? What color is your urine? Slide 43: DOT in the School Setting: Some Basics Obtain parental consent- signed agreement Maintain confidentiality-private area for DOT Ensure good communication between school and physician- report to MD problems such as frequent absences, or adverse reactions Use DOT log and monitor adherence rate Slide 44: DOT in the School: Variables Affecting Adherence - 1 School nurse may be covering more than one school Lack of back-up or coverage Poor communication between nurse and attendance office Ask parent to call the school nurse directly regarding any absences Timing Work with the child to find the best time for them (morning, lunch, etc.) Extended absences (i.e., suspension) Health department will need a copy of the school calendar and to be notified if the child is absent so DOT can be done at home Multiple social problems Peer pressure Slide 45: DOT - Challenges Lack of cooperation from parent or school-stigma attached to TB Older child who refuses meds Try to determine cause, is it due to medication side effects or time given, you may just need to alter the time of dosing Slide 46: Resources Tuberculosis Handbook for School Nurses http://globaltb.njms.rutgers.edu/educationalmaterials/productfolder/tbhandbook.html Management of Multidrug-Resistant Tuberculosis in Children: A Field Guide http://sentinel-project.org/2014/07/22/second-edition-of-management-of-multidrugresistant-tuberculosis-in-children-a-field-guide/ Slide 47: Tuberculosis Testing and Reporting Guidelines for New Jersey Schools Karen Galanowsky, RN, MPH Nurse Consultant New Jersey Department of Health Tuberculosis Program Slide 48: Tuberculosis Testing Guidance The New Jersey Department of Health, Tuberculosis Program, provides annual guidance to the New Jersey Department of Education regarding tuberculosis (TB) testing of students as a condition for admission to NJ schools The regulation and enforcement of these recommendations is the responsibility of the Department of Education, NOT the Department of Health Slide 49: Purpose of these School Guidelines The purpose of these guidelines is to identify new students and employees who are at the highest risk of latent TB infection (LTBI) so that they can receive treatment and prevent the development of TB disease at a later time These recommendations restrict TB screening in NJ schools to teachers/other employees and ONLY those students who are at the highest risk for latent TB infection Slide 50: Targeted Testing The CDC and New Jersey Department of Health, TB Program, do not recommend TB screening for the general population including school employees and students Knowledge of the result of a TB test provides no benefit to the school WITHOUT treatment for LTBI The decision to test is a decision to treat Rate of false tuberculin testing increases in proportion to the decreased risk for LTBI Slide 51: Targeted Testing Targeted tuberculosis testing is recommended to: Detect persons with LTBI who would benefit from treatment De-emphasize testing of groups that are not at high risk for TB Reduce the waste of resources and prevent inappropriate treatment Slide 52: Requirements for TB Testing of Students These requirements pertain to TWO GROUPS of students ONLY Students born in country where there is a high incidence of TB and entering school in the US for the first time, regardless of age or grade Students transferring into the NJ school system directly from a country with a high incidence of TB, regardless of age or grade Slide 53: Exceptions TB testing is not required IF the student has attended school in another state prior to entering the NJ school system Students entering grades preschool – five TB testing is not required if the student has a documented TB test at the age of 3 years or older, regardless of the result of that test Students entering grades six – twelve TB testing is not required if the student has a documented negative TB test in the last six months, or a positive test, regardless of when the test was done Slide 54: Religious Exemptions Any student with parents claiming religious exemptions cannot be compelled to submit to TB testing Each school district is responsible for obtaining documentation of the religious exemption In lieu of a TB test, an assessment for TB symptoms must be done and documented The symptom assessment may be done by the school nurse and complete for Assessment Form (TB-5) and chest X-ray If TB symptoms are identified, a medical evaluation to rule out active disease must be completed and documented Slide 55: Requirements for TB Testing of Employees A TB test is required prior to employment of all newly hired full and part-time employees, student teachers, school bus drivers, and other persons who have contact with the students 20 hours per month or more Slide 56: Exemptions New employees, student teachers and contractors who have a documented negative TB test result within the last six months or a positive TB test, regardless of when the test was done Employees transferring between school districts or from a non-public school within NJ with a documented TB test result upon his/her initial employment in a NJ school Religious exemptions – same as for students Slide 57: TB Testing An interferon gamma release assay (IGRA) blood test or a Mantoux tuberculin skin test (TST) is acceptable for TB testing in schools The two acceptable IGRA tests are the Quantiferon-TB Gold or T-Spot A “positive” IGRA indicates the “likely presence of MTb” A 10 mm or greater TST is considered a positive reaction Slide 58: Positive IGRA/TST Follow-up Any student/employee/contractor with a positive IGRA or TST is required to have a medical evaluation and chest X-ray to rule out active TB disease Students/employees/contractors with a positive IGRA or TST do not have to be held out of school/work until the medical evaluation and chest X-ray is done provided there are no TB symptoms If the appointment with the MD and chest X-ray cannot be obtained prior to school, a symptom assessment should be done by the school nurse The student/employee should not be excluded from school unless symptomatic for TB Slide 59: Positive IGRA/TST Follow-up It is the responsibility of the school nurse to obtain the chest X-ray results and prescribed treatment, and treatment outcomes for LTBI and retain this information on site The school nurse can provide directly observed therapy (DOT) for LTBI treatment during school hours and monitor for side effects of medication if ordered by the physician Need parental consent MD orders DOT form medication(s) Slide 60: Evaluation of Symptoms A symptom assessment and documentation is important to do at the time of the TST administration/reading or IGRA Any person with symptoms of pulmonary TB should be medically evaluated regardless of the result of the IGRA or TST and excluded from school until TB disease is ruled out The Symptom Assessment Form (TB-5) can be found on the NJDOH TB Website If the individual is diagnosed with pulmonary TB disease, he/she must be excluded from school until determined to be non-infectious as indicated in writing by the treating physician Slide 61: Reporting Requirements Schools are no longer required to submit the “Annual Report of TB testing in Schools” (TB-57) to the NJDOH, TB Program The TB-57 Report should be kept up-to-date and onsite at each school A copy should be sent to the school superintendent and the county TB Program The report is for each current calendar year and should only include testing from that period Slide 62: Reporting Requirements - 2 All TB forms can be found on the TB website under the “FORMS” tab: http://web.doh.state.nj.us/apps2/forms/subforms.aspx?pro-aids#tb Tuberculosis Testing Outcomes should be completed as follows: If no TB testing is required and no “significant reactors identified - 1/15/16 TB testing done and “significant” reactors identified - 3/15/16 Slide 63: Question #1 Can a chest X-ray be substituted for the TB test? Yes, provided the physician agrees Yes, if the school has written policies relating to this Yes, only in the case of religious exemption No, a chest X-ray always has to be done Slide 64: Question #2 Are students coming in from another US state or US city required to receive a TB test? Yes, they might have lived in a city with a high number of TB cases No, the school TB testing program is focused on students born in high TB incidence countries who are entering school in NJ for the first time Yes, they went on a two week vacation to a high incidence county last summer No, they were probably tested in another state/city Slide 65: Question #3 Are students returning from vacation/travel out of the country required to have a TB test before entering school again? No, there is no need to re-test these students unless there was known TB exposure during the travel/vacation or TB symptoms Yes, if they traveled or vacationed in a high incidence country Yes if the school district writes policies accordingly Slide 66: Question #4 A student came from a high incidence country and started school before TST was done. The child relocated to another school. Should a TST be done by the second school? No, the child was already in school Yes, the second school needs to do a TST and follow-up No, only a symptom assessment should be done No, only chest X-ray should be done Slide 67: Questions Verbal questions by phone Un-mute your phone by pressing #6 After your question, re-mute your phone by pressing *6 Introduce yourself and say from where you are calling Type your questions by clicking on the Q&A icon, priority will be given to verbal questions Slide 68: GTBI on Social Media Like us on Facebook http://facebook.com/GlobalTuberculosisInstitute Follow us on Twitter http://twitter.com/@NJMS_GTBI Subscribe to us on YouTube https://www.youtube.com/user/globaltbinstitute Subscribe to iTunes U https://itunes.apple.com/us/itunes-u/id893709690 Slide 69: Medical Consultation Information Line 1-800-4TB-DOCS (482-3627) Slide 70: Thank you for your participation!