Latent TB Infection Updates for AZ CHCs

Disclaimer "This presentation is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3,278,366. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government." The views and opinions expressed in this presentation are not necessarily those of the Pacific AIDS Education and Training Centers (PAETC), the Regents of the University of California or its San Francisco campus (UCSF or collectively, University) nor of our funder the Health Resources and Services Administration (HRSA). Neither PAETC, University, HRSA nor any of their officers, board members, agents, employees, students or volunteers make any warranty, express or implied, including the warranties of merchantability and fitness for a particular purpose; nor assume any legal liability or responsibility for the accuracy, completeness or usefulness of information [,apparatus, product] or process assessed or described; nor represent that its use would not infringe privately owned rights. 1 Before we begin. . . Link to CDC Website to Watch Thu's Personal TB Story 2 Video for 2 Latent TB Infection (LTBI): Updates for AZ Community Health Centers Cherie Stafford, RN, MSN/MPH TB Nurse Coordinator Arizona Department of Health Services April 13, 2021 Polling slide: Have you known anyone who was ill due to TB? (choose all that apply) Family member My friend or coworker My patient No one that I know personally 4 Objectives Review latest statewide TB data Know where to find the latest updates on LTBI testing and treatment With a special focus on HIV Apply 2021's Clinical Recommendations on LTBI Testing and Treatment to community health settings Discuss how to address current challenges in testing and treatment, such as drug shortages & impurities, and the COVID vaccine 5 Anything taken directly from a source should have a hyperlink to that source (or citation with previous hyperlink) 5 Polling slide: What is TB? (choose all that apply) TB = Tuberculosis An ancient disease caused by mycobacteria An airborne disease A disease found in cows A curable disease A preventable disease 6 6 TB = Tuberculosis Mycobacterium Tuberculosis Complex (MTB) 7 Factors that Increase Risk of Spreading TB TB disease of the lungs or larynx Poor cough hygiene Aerosolizing procedure at site of disease Higher burden of disease (smear positive sputum smears) Cavitary disease Early diagnosis with treatment can Stop TB from spreading to others 8 TB is Preventable Community Health Centers are important partners for diagnosing and treating Latent TB Infection (LTBI) Someone with LTBI is not sick and cannot spread TB to others Targeted testing followed by treatment of LTBI can prevent someone from developing TB disease and passing it onto friends and family (and coworkers and patients!) 9 TB is Curable If you think someone needs treatment for TB disease, regardless of site of disease, report it to your local health department (LHD) Case management is key to ensure completion of treatment 10 2 Steps to Prevent M. bovis (cow TB) Test cows for TB Pasteurization Keep your family safe: Make sure your Queso Fresco is Pasteurized! 11 Polling slide: Which do you think it closest to the US 2020 TB case rate? 52.6 per 100,000 10.4 per 100,000 2.2 per 100,000 10 per 1,000,000 1 per 1,000,000 12 10.4 the peak in the early 1990's. 52.6 the official rate in 1953. if under 1 case/million, then reach goal of elimination. 12 TB diagnosis decreased in the US in 2020 Hx 5-yr [2016-2020] Rate/100,000 There were 7,163 reported TB cases in the US, for an incidence rate of 2.2 per 100,000. This was a 20% decrease from 2.7 in 2019. ADHS data is available on our website LTBI is not reportable (except in children 5 years of age and younger) in AZ AZ experienced a 27% decrease in reported TB numbers, with a 31% decrease in case rate (per 100,000) Slide 12 14 2020 LTBI Treatment Guidelines 15 Polling question: Which is the preferred regimen for treatment of LTBI? Isoniazid 300 mg every day for 9 months (9H) Rifampin 600 mg every day for 4 months (4R) Isoniazid 900 mg and Rifapentine 900 mg once a week for twelve weeks (3HP) It depends upon patient preference and potential drug interactions 16 Recommendations for Regimens to Treat Latent TB Infection 17 Dosages for Recommended Latent TB Infection Treatment Regimens 18 Latent Tuberculosis Infection Treatment Regimens 19 Regimens for Treating LTBI 20 Visualization of number of pills 20 LTBI Treatment & HIV 3HP preferred, if not contraindicated by drug interactions 9INH if 3HP cannot be used Include B6 25-50 mg with INH containing regimens Resource is updated twice a year 21 Updated Practical Resources 22 Free CE available through CDC 23 Polling question: Should everyone be tested for LTBI? Yes No I don't know 24 Targeted TestingTB Risk AssessmentScreening Questionnaire 25 25 Tuberculosis Risk Assessment Example is for asymptomatic adults. Re-testing should only be performed in persons who previously tested negative and who have new risk factors since the last assessment. For patients with TB symptoms or abnormal chest x-ray consistent with active TB disease Evaluate for active TB disease. Do not start treatment for LTBI until active TB has been ruled out. Please note: A negative tuberculin skin test or interferon gamma release assay does not rule out active TB disease. 26 Adult Screening for LTBI testing: Travel or residence in a country with an elevated TB rate > 1 month Includes countries other than the United States, Canada, Australia, New Zealand, western or northern European countries Medical conditions increasing risk for progression to TB disease Radiographic evidence of prior healed TB, low body weight (10% below ideal), silicosis, diabetes mellitus, chronic renal failure or on hemodialysis, gastrectomy, jejunoileal bypass, solid organ transplant, head and neck cancer Immunosuppression, current or planned HIV infection, injection drug use, organ transplant recipient, treated with TNF-alpha antagonist (e.g., infliximab, etanercept, others), steroids (equivalent of prednisone > 15 mg/day for > 1 month) or other immunosuppressive medication Close contact to someone with infectious TB disease 27 Should they be tested for LTBI?Yes, No, Maybe? Dialysis patient who is being worked up for a kidney transplant. A US born male who served in the Navy, with deployments in Asia (including the Philippines). A health care worker whose baseline QFT was negative two years ago. Last summer she spent three months in Peru visiting family. A patient comes in saying that his mom called saying that his uncle has TB. 28 How about a patient recently diagnosed with HIV? Test for LTBI at diagnosis Repeat if there are ongoing risks for exposure Repeat once CD4 >200 If there is an exposure to potentially infectious TB, coordinate with the local health department for testing, reporting, and to see if window prophylaxis is needed. If test is positive for LTBI, rule out TB disease before starting preventative treatment 29 Risk of Disease Progression 30 updated source document 30 Risk of Disease Progression 31 Polling question: Which of the following do you use in your practice to test for TB Infection? (all the apply) TST QFT T-spot I don't know 32 The Options TST IGRA T Spot QFT 33 Which to choose? Logistics Cost Patient & Provider preference Section 1 : Testing and Treatment of Latent Tuberculosis Infection in the United States NSTC/NTCA Clinical Recommendations | February 2021 34 If I can see chat: what are some reasons for preferring IGRA's? How about the TST? 34 Differences Between QFT and T-Spot QFT T-Spot Initial process Process whole blood within 16 hours Process peripheral blood mononuclear cells within 8 hours (30 if T-Cell Xtend) MTB Antigen Single mixture of synthetic peptides representing ESAT-6, CFP-10, & TB7.7 Separate mixtures of synthetic peptides representing ESAT-6 & CFP-10 Measurement IFN-g concentration Number of IFN-g producing cells (spots) Possible results Positive, negative, indeterminate Positive, negative, indeterminate, borderline Link to CDC website for TB testing fact sheets 35 IGRA Results: What does it mean? Negative = Negative TST Positive = Positive TST Indeterminate = Test failure. - Readminister. It may be due to lab error or patient anergy. 36 How to Interpret QFT-Plus Results Lack of immune response? Control Failure? The current cut off is 0.35 Borderline results may account for conversions/reversions Link to QuantiFERON-TB Gold Plus Marketing Pamphlet 37 How to Interpret T-Spot Results 38 If Invalid, is it due to Nil or Positive Control? Invalid? Control Failure? Lack of immune response? 39 TST Quality Assurance CDC's MMWR: Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health Care Settings, 2005. Appendix F: Link to CDC Guidance on MMWR 40 It's positive. . .what's next? Section 3: Testing and Treatment of Latent Tuberculosis Infection in the United States NSTC/NTCA Clinical Recommendations | February 2021 If needed 41 Flyer for New Mexico Department of Health 42 HIV Test?Hepatitis screen? 43 Baseline lab tests (ALT/AST, CBC) Not routinely indicated unless: Pregnant or postpartum (within 3 months post delivery) Daily or heavy alcohol use (monitor closely) Liver disease, hepatitis, or history of elevated liver enzymes All patients with HIV infection Current IV drug use Taking other hepatotoxic medications Repeat at least monthly if abnormal. Monitor all patients for symptoms of possible hepatotoxicity and test if symptoms develop. Hold TB meds if ALT/AST >3 times normal with symptoms, or >5 times normal without symptoms 44 Who would benefit from taking Vitamin B6 with INH? People at risk for neuropathy such as: Pregnant/Postpartum/breastfeeding women Diabetics People living with HIV People with heavy alcohol use Malnutrition (or diets without milk/meat) Chronic renal failure Exclusively breastfeed infants (reportable! consult with TB expert) 25 to 50 mg every day (or 50 mg once a week for 3HP) Note: cumulative high doses (100 to 200 mg a day) can cause toxicity that manifests as neuropathy 45 Current Events: COVID-19 Vaccine & TB Tests(TST/IGRA) Per CDC: 46 Current Events: COVID-19 Vaccine & TB Tests (TST/IGRA) COVID-19 vaccines should not be delayed due to testing for LTBI. Timing recommendation: TST or IGRA before the COVID vaccine (can be at same encounter) Options for recently vaccinated people: Wait 4 weeks after second shot OR Can perform TST/IGRA, with plans to repeat in future (at least 4 weeks after second shot) if negative. 47 Current Events: Health Care Worker TB Screening Requirements Arizona Administrative Code: R9-10-113 pg 26 & 27 Applies to health care facilities licensed by the state of Arizona Refers to CDC's 2005 MMWR Updated every 5 years (last in 2018/19). Request for early update has been made. CDC Updates (2019) Companion Document (2020) provides guidance on how to implement Caveat for medium risk health care facilities in AZ: annual testing still required based on AAC Most facilities are low risk in AZ (Appendix B) 48 What would implementation of new guideline look like? Baseline Screening of all Health Care Personnel (see Appendix 2 on who is Health Care Personnel) with Appendix 3 (or similar document) Baseline Testing of all Health Care Personnel (if they do not have a documented history of TB infection or disease) with blood test or TST. Note that TST should be a two-step in circumstances following Box 1 of the 2005 MMWR. Encourage LTBI treatment. For untreated LTBI, Appendix 4. They will then be screened annually (Appendix 7). Annual TB Education. (see Appendix 6). Annual Facility Risk Assessment (Appendix B of 2005 MMWR. See Appendix 1 for suggested amendments to wording.) If there are any TB exposures in the facility, coordination and sharing of contact investigation data with local health department. DRAFT 49 Current Events: Drug Impurities 50 Current Events: Drug Impurities Nitrosamines detected in Rifampin and Rifapentine are not among the 7 known carcinogens. Neither are recalled. More details here. None were found in Rifabutin No recommended changes in treating LTBI or TB disease Updates, such as useful patient education or health care worker FAQs will be posted to our webpage: Updated resource 51 Current Events: Drug shortages Check with your pharmacy to make sure Rifapentine is available for the full course of treatment. If not available, there are other treatment options. If treatment is delayed, will it be a missed opportunity? Highest risk of developing TB disease is in the first 2 years after infection Immunosuppression increases risk Will this delay other medical services? 52 Reporting TB in AZ LTBI is reportable in children 5 years of age and younger TB disease is reportable to the local health authority. Rule of thumb: if you are thinking they need treatment for TB disease, contact the local TB program. Who is your local health authority? Your county health department or if the patient lives on tribal lands, the tribal health department. 53 Where do I Report TB in AZ? Link to ADHS Communicable Disease Reporting for Healthcare Providers 54 LTBI: Targeted Testing Project With the exception of children 5 and under, and contacts to potentially infectious TB, LTBI is not required reporting. ADHS is looking to expand voluntary reporting for targeted testing. If your health center is interested in participating, contact us at [email protected] 55 LTBI or TB?Question 1 Latent TB Infection Tuberculosis (TB) May feel sick and may have symptoms such as a cough, fever, and/or weight loss 56 LTBI or TB?Question 2 Latent TB Infection Tuberculosis (TB) Treatment option: 12 weeks of once a week Rifapentine/INH (3HP) 57 LTBI or TB?Question 3 Latent TB Infection Tuberculosis (TB) Sputum may be AFB smear positive 58 LTBI or TB?Question 4 Latent TB Infection Tuberculosis (TB) Collected specimens may culture out MTB 59 LTBI or TB?Question 5 Latent TB Infection Tuberculosis (TB) Cannot spread TB bacteria to others 60 LTBI or TB?Question 6 Latent TB Infection Tuberculosis (TB) Treatment option: 4 months Rifampin daily 61 LTBI or TB?Question 7 Latent TB Infection Tuberculosis (TB) May require respiratory isolation precautions 62 LTBI or TB?Question 8 Latent TB Infection Tuberculosis (TB) Never treat with a single drug. Standard treatment starts with four drug therapy: (RIPE). 63 LTBI or TB?Question 9 Latent TB Infection Tuberculosis (TB) Reportable disease (regardless of age or site of disease) 64 LTBI or TB?Question 10 Latent TB Infection Tuberculosis (TB) Is not currently sick. Can be treated to prevent future illness 65 Review: LTBI or TB? Latent TB Infection Cannot spread TB bacteria to others Is not currently sick. Can be treated to prevent future illness Treatment option: 12 weeks of once a week Rifapentine/INH (3HP) Treatment option: 4 months Rifampin daily Tuberculosis (TB) May feel sick and may have symptoms such as a cough, fever, and/or weight loss Sputum may be AFB smear positive Collected specimens may culture out MTB May require respiratory isolation precautions Never treat with a single drug. Standard treatment starts with four drug therapy: (RIPE). Reportable disease (regardless of age or site of disease) 66 Review: Difference Between LTBI and Active TB? 67 Online Active TB Risk Tool Link to Online TST/IGRA Interpreter Tool 68 Thank you for helping to eliminating TB in our lifetime! Any Questions? 69 Resources For Health Care Workers LTBI Screening, Diagnosis, Treatment: Video Latent Tuberculosis Infection: A Guide for Primary Health Care Providers. Poster summarizing TST: Training for Staff on TST's video: Guide: 70 Patient Education The TB cycle: Latent Infection handout: Handout In Spanish: Video in English: Video in Spanish: 71