Practical Applications of ACHA TB Guidelines ACHA 2010

Practical Applications of ACHA TB Guidelines ACHA 2010 Annual Meeting, Philadelphia June 4, 2010 Susan Even, MD (University of Missouri) Sharon Mc. Mullen, RN, BSN (University of Pennsylvania) Brenda Johnston, RN, MSN (Oklahoma City University) Tim Crump, RN, MSN, FNP (University of Portland) 1

Introduction Guidelines released June 2008 -1 year of work by task force Update needed to strengthen public health measures on campuses to prevent TB and to include IGRAs TB Subcommittee - part of Coalition of Emerging Public Health Threats and Emergencies Request -present program to illustrate application of guidelines 2

Presentation Goals • Review guidelines • Describe implementation at a large private university in east (University of Pennsylvania) • Describe implementation at a small, private university in southern midwest (Oklahoma City University) • Q & A (providing input for a FAQ document for ACHA) 3

ACHA Guidelines for Tuberculosis Screening and Targeted Testing of College and University Students 4

Purpose Highlight screening and testing as key strategy for controlling and preventing infection on campuses Target population – incoming students who are at increased risk for TB Review appropriate follow up care for students diagnosed with latent tuberculosis infection (LTBI) or TB disease 5

Definitions Screening – identification of high risk students who need testing, commonly by a questionnaire Testing – procedure for diagnosing LTBI; using Mantoux tuberculin skin test (TST) or blood tests using interferon gamma release assay (IGRA) 6

Definitions Population risks vs Medical risks

Definitions Population risks – epidemiological and populationbased risk factors of incoming students that increase their likelihood having LTBI, therefore targeting these for testing Medical risks – factors placing an individual who is already infected with TB (LTBI) at high risk for progressing to active disease 8

Whom to Screen All incoming students using screening questionnaire • Highest risk group – international students from countries with increased incidence of TB • High- incidence – countries with annual TB disease greater or equal to 20 cases per 100, 000 • Close contacts to known or suspected TB disease • Workers in high risk congregate settings (healthcare facilities, nursing homes, homeless shelters, corrections institutions, etc) • Persons who inject illicit drugs, etc • Travelers to areas of high incidence of TB (no evidencebased data regarding length of time) -consider provider visit to assess significance of potential exposure 12

Whom to Screen Continuing students – usually a program rather than an institutional requirement When specific activities place them at risk (study abroad, research, volunteering, etc. ) Health professions students -annual requirement usually monitored by specific program 13

Whom to screen Medical Clinic setting As part of routine evaluation, clinicians should screen for both risk of LTBI and risk of LTBI progressing to TB disease AND conduct appropriate testing 14

When to Screen and Test Prior to arrival on campus, give questionnaire Review with verification of prematricuation immunization requirements Test high risk students only – no sooner than 3 – 6 mos before arrival Complete by second semester/quarter registration 15

How to Test - TST Tuberculin Skin Test (TST) Mantoux Test – intradermal injection of 0. 1 ml PPD (5 tuberculin units) History of BCG doesn’t preclude TST Delay 4 – 6 weeks after a live virus vaccine (usually MMR) May give concurrently with live virus vaccine without compromising results 16

How to Test - TST Two-step testing: Initial testing for persons retested periodically (health professions students, volunteers) TST #2 is performed 1 to 3 weeks after TST #1 is negative If TST #2 is positive, LTBI is diagnosed (identifying a childhood infection) 17

Interferon Gamma Release Assays (IGRAs) • May be used in all circumstances where TST is used • Use with caution in immunocompromised individuals • Has greater specificity than TST – no reaction to BCG or most non-tuberculous mycobacteria • Usually single test is adequate making compliance easier • Cost and availability are limitations • CDC does not support use of IGRA as a confirmatory test after positive TST however, this practice is prevalent in the US (following international use) 18

How to Interpret the TST Read 48 -72 hours after injection; measure induration in transverse diameter; record in mm of induration (0 mm if no indiration) Interpretation – based on induration and risk factors 19

How to Interpret the TST >5 mm is positive in the following: Recent contacts of individuals with infectious TB disease Chest x-ray with fibrotic changes consistent with past TB disease Organ transplant recipients and other immunosuppressed persons Persons with HIV/AIDS 20

How to Interpret the TST >10 mm is positive in the following: • Persons born or residing in high prevalence country • History of illicit drug use • Mycobacteriology lab personnel • Workers, volunteers of high risk congregate settings, including health care facilities • Persons with clinical conditions including diabetes, silicosis, chronic renal disease, leukemia, lymphoma, cancers of head, neck or lungs, body weight >10% below ideal, gastrointestional conditions such as gastrectomy, intestinal bypass, malabsorption syndromes 21

How to Interpret the TST >15 mm is positive in the following: Persons with no known risk factors for TB disease 22

What to do When the TST or IGRA is Positive Chest x-ray and medical evaluation (review signs and symptoms) If abnormal x-ray OR any signs and symptoms of TB • Must exclude active TB disease • Sputum smears and cultures, chest CT, bronchoscopy If normal x-ray and medical evaluation • Diagnose LTBI • Recommend treatment for LTBI • Contact with public health officials (reportable in some states) 23

What to do When the TST or IGRA is Positive Reasons to treat LTBI • Reduce risk for progression to TB disease (90%) • Reduce burden of TB in US Highest risk of progression from LTBI to TB disease • TST or IGRA conversion within 2 year • HIV/AIDS or other clinical conditions with increased risk due to impaired immunity 24

What to do When the TST or IGRA is Positive LTBI Treatment Options INH daily for 9 months–preferred, 6 months minimum Directly Observed Therapy (DOT) – two times per week at higher dose Rifampin in exposures to known INH-resistant disease 25

What to do When the TST or IGRA is Positive Completion of treatment high priority Provide education in primary language when possible (refer to translated chart) Insure confidentiality Consider incentives Gain trust by case management with culturally competent provider 26

What to do When the TST or IGRA is Positive Monitoring of treatment Monthly symptom checks If symptoms suggest adverse reactions - laboratory testing Routine testing only if increased risk of complications 27

What to do When the TST or IGRA is Positive Conditions requiring routing laboratory monitoring Regular use of alcohol History of liver disorder, risk of hepatic disease HIV/AIDS Pregnancy or up to 3 months post-partum Medications with risk of liver toxicity 28

What to do When the TST or IGRA is Positive Post-treatment follow up Provide documentation of TST or IGRA results, chest x-ray results, dosage and duration of medication treatment Reinforce signs and symptoms of TB disease with instructions to seek medical attention upon developing any 29

Student Health Service 30

Facts and Figures Private, 280 -acre urban campus 24, 000 students 20, 000 full-time (½ undergrad, ½ grad) 3, 500 international students 3000 health professional students Student Health Service: 45, 000 visits/year Primary Care, Women’s Health, Sports Medicine, Travel, Immunization/Allergy, Podiatry, Lab, Health Ed, Public Health, Massage/Acupuncture 31

Immunization Requirements Required: Hepatitis B: 3 doses MMR: 2 doses Varicella: 2 doses or hx of disease Meningococcal Screening for TB infection Web-based data entry and faxed records Student Immunization compliance: ~97% 32

Goals 1. 2. 3. 4. 5. Screening Documentation Testing for TB Infection +TTBI follow up Compliance 33

Screening for TB Infection Method: web-based questionnaire Who gets screened? All 8000 matriculating, full-time students per year Who gets tested? Anyone whose answers “yes” to a screening question Health professional students annually Goal: to find LTBI 34

Screening Questions Have you ever : 1. been in close contact with anyone with active TB? 2: worked/volunteered with people in prisons? 3: worked/volunteered with the homeless? 4: worked/volunteered with refugees? 5: worked/volunteered with people in hospitals? 6: been diagnosed with diabetes? 7: been diagnosed with cancer? 8: Do you have a history of prolonged use of corticosteroids and/or immunosuppressive treatment? 9: Are you HIV positive? 10: Country of Origin: 35

Non-TB Endemic Countries American Samoa Andorra Antigua and Barbuda Australia Austria Barbados Belgium Bermuda Canada Cayman Islands Chile Costa Rica Cuba Cyprus Czech Republic Denmark France Germany Greece Grenada Holland/Netherlands Hungary Iceland Ireland Israel Italy Jamaica Jordan Libyan Arab Jamahiriya Luxembourg Malta Monaco New Zealand Niue Norway Oman Puerto Rico Saint Kitts and Nevis Saint Lucia San Marino Slovenia Sweden Switzerland Tokelau Trinidad and Tobago Turks and Caicos Islands United Kingdom USA Dominica Finland Montserrat Virgin Islands, British Virgin Islands, US 36

Assessment of Volunteers 4 x 4 Rule 4 hours a day 4 days a week 4 weeks in a month 37

TTBI Documentation Acceptable proof of +PPD: Dates of placement AND reading Size in mm Official letterhead or signature of provider “Positive" on an imm. card is not sufficient Acceptable proof of a negative IGRA: Official lab report with reference ranges noted < 12 months old Not accepted: proof of negative PPD 38

Chest XRay Documentation Acceptable proof of cxr: Official US radiologist's report Dated AFTER the positive PPD Negative reading Not accepted: “Negative cxr” on immunization card is not sufficient International chest xray reports Cxr films 39

Prior Treatment Documentation Acceptable proof of treatment completion: Official letterhead (or signed by the supervising healthcare provider) Name(s) and dosage(s) of the medications Initiation and completions dates Not accepted: “Treated for TB” on an immunization card is not sufficient 40

Testing for TB Infection Method: PPD 5500 PPDs placed annually 3100 incoming international students, returning travelers 2400 Health professional, including 1000 2 steps 1200 SON 770 SOM 430 SDM 41

PPD Reading Within 2 -3 days Nurse reads PPD No self-readings If negative, student is compliant If positive, nurse will: TB Symptom Check Order cxr Review instructions with student Send links to on LTBI, BCG Student is not compliant until cxr is done 42

2 Step PPDs Required for incoming health prof students Timing: placed 1 -3 weeks apart Purpose: assess remote TB exposure 43

Follow-up of positive results 350 positive PPDs (6%) PHN tracks each +PPD monthly 100% compliant with TB Symptom Check 97% compliant with required cxr Follow-up eval for LTBI treatment (~50%) Not required but strongly encouraged 12% accept medications for LTBI Rifampin vs INH Monitored via secure message each month Completion of Therapy Letter 44

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Compliance Registration hold Students cannot register for the next semester’s classes if there is an SHS hold on their account Exception Health professional schools track/enforce their program-specific requirement of annual PPDs 46

STUDENT HEALTH AND DISABILITY SERVICES 47

Introduction Private, faith-based (Methodist) University on 60 acre urban campus in the lower Midwest 3, 200 students 3, 000 full-time 1, 800 undergraduate 500 graduate 5 doctoral 600 law 446 International students – most from China, Taiwan, Korea, West Africa, India, Saudi Arabia. Few from Europe and Canada. 274 Health professional students (Nursing) 48

Student Health Services 2, 300 visits per year Services: Primary care Women’s Health Immunization and Allergy Laboratory Health Education Disability Services is part of program 49

Staffing Nurse Director – also serves as Disability Services Coordinator, 12 months ARNP - full-time, 10 months + 1 day/week in summer RN – full-time, 10 months Office manager – full-time, 12 months Receptionist - full-time, 12 months 50

TB Screening All international students, on matriculation Must be done during first semester Nursing students’ deadlines vary by program 51

Documentation Accepted from Abroad Must be documented on our form, include date of placement and reading, resulted in mm Notation of “negative” is not accepted Documentation less than 12 months old For positive results when CXR films sent with patient – send to Oklahoma City/County Health Dept. TB Control Center (OCCHD TBCC) for evaluation. Borderline results (between 5 and 9 mm), we re-test. 52

Compliance Account and registration holds for non-compliance. Holds go on mid-way during first semester. Student reminded by e-mail and via advisors. Those with positive PPD are not off hold until CXR and IGRA are resulted. Nursing students cannot attend clinical if noncompliant. 53

Testing type PPD Student pays $15 SHIP does not pay Why not IGRA’s? Cost Done free at OCCHD TBCC for positive PPD 54

Follow-up of Positive Results RN does TB symptoms check Appt. for IGRA, CXR made at OCCHD TBCC Student e-mailed date and time of appt. Counseling for LTBI is done by OCCHD TBCC who provides treatment and monitoring for free. 55

IGRA Began looking into IGRA in mid-2007. Not available in Oklahoma until early 2009 OCCHD TBCC began offering free QFT in March, 2009. 40 students referred March 1, ’ 09 -Mar 1, ‘ 10 20% of positive PPDs (8 students) have been QFT positive. 60% started medication, 40% refused treatment 56

Active TB No cases of active tuberculosis on our campus since late 2001. At that time, international student population was much larger than today. The End…. 57

Provocative Thoughts Prompted by the Advent of IGRAs 58

Question to SHS Listserv In March 2010, I queried the SHS Listserv about the difference in our international students in the incidence of + TST versus + IGRA. Anecdotally, we have noted dramatically fewer + IGRA’s than + TST among our international students. 59

Study at ASU: TST & IGRA Dr Sanford Ho at Arizona State University described a study at their health center. The Quantiferon Gold Test was used as a confirmatory test for 40 international students with + ppd’s. The number of females and males were equal, and the majority of the patients were between 20 -29 years of age (55%), while less than 8% were 40 years or older. A total of 24 (60%) had a history of BCG vaccination, 12 (30%) were not sure (but were more likely to have received BCG due to country of birth). 60

Study at ASU: TST & IGRA Only 12 (30%) patients had a positive QFT-G, resulting in a positive predictive value of 0. 3 of a positive PPD for diagnosing latent tuberculosis infection (LTBI). Of those patients who have received BCG vaccination, 8 (33%) tested positive on the QFT-G assay while 3 (25%) tested positive from the group with an unclear BCG history. Therefore, it can be inferred that 16 (67%) of the patients reviewed who had previous BCG vaccination as well as 9 (75%) of those with unclear BCG history had a false positive PPD skin test. 61

This raises the possibility: Would screening international students w/ IGRA rather than TST identify fewer positives? Could this save costs in terms of unnecessary CXR’s and prophylactic INH? Might we lower costs and improve patient care? 62

Another SHS Response “If the only worldwide test easily available for years has been the tuberculin skin test (TST), then are all data on the incidence of latent TB infection (LTBI) based on this test? Now that we can do IGRA tests which show many fewer positives than TST, does this mean that the incidence of LTBI is really much lower? ? ? I feel like I need an TB expert AND an epidemiologist to help us wrap our minds around this question. ” 63