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US Public Health Service. Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd edition. Washington (DC): Department of Health and Human Services (US); 1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Clinician's Handbook of Preventive Services

Clinician's Handbook of Preventive Services. 2nd edition.

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43Tuberculosis (Including Prophylaxis and BCG Vaccination)

In 1995, a total of 22,860 new cases of active tuberculosis (TB) were reported in the United States. This marked the third consecutive year that the number of reported cases decreased and reflected the lowest rate of reported TB cases since national surveillance began in 1953. During the 1980s and early 1990s, the number of TB cases increased significantly. Factors that contributed to the increase included adverse social and economic conditions, the human immunodeficiency virus (HIV) epidemic, immigration of individuals with Mycobacterium tuberculosis infection, and clinician and patient noncompliance with recommended screening and treatment regimens. Efforts to control the spread of TB were also complicated by the emergence of strains of M. tuberculosis resistant to multiple drugs.

The more recent decline in the number of TB cases probably reflects a number of factors, according to the Centers for Disease Control and Prevention, including (1) improved laboratory methods to allow prompt identification of M. tuberculosis; (2) broader use of drug-susceptibility testing; (3) expanded use of preventive therapy in high-risk groups; (4) decreased transmission of M. tuberculosis in congregate settings (eg, hospital and correctional facilities) because of implementation of infection-control guidelines; and (5) improved follow-up of persons with TB.

In the United States, control of tuberculosis depends on screening high-risk populations and providing preventive therapy to persons in whom active disease is most likely to develop. Groups at high risk for TB infection include: (1) close contacts of persons known or suspected to have TB; (2) persons infected with HIV; (3) persons who inject illicit drugs or other locally identified high-risk substance abusers (eg, crack cocaine users); (4) persons who have medical risk factors known to increase the risk for TB disease if infection occurs; (5) residents and employees of high-risk congregate settings (eg, correctional institutions, nursing homes, mental institutions, other long-term residential facilities, and shelters for the homeless); (6) health care workers who serve high-risk clients; (7) foreign-born persons, including children, who have arrived within 5 years from countries with a high incidence or prevalence of TB; and (8) some medically underserved, low-income populations. Conditions and chronic diseases that predispose patients to development of TB disease include HIV infection, diabetes mellitus, end-stage renal disease, and hematologic and reticuloendothelial diseases; history of intestinal bypass or gastrectomy, chronic malabsorption syndromes, silicosis, cancers of the upper
gastrointestinal tract or oropharynx, prolonged steroid use and immunosuppressive therapy; and being 10% or more below desirable body weight.

Prophylaxis with isoniazid is very effective in preventing the onset of clinical tuberculous disease. Use of isoniazid for 12 months in an at-risk population has been shown to reduce the occurrence of TB disease by 54% to 88%. Its efficacy is directly related to the length of prophylaxis, the extent of patient compliance with the prophylactic regimen, and the susceptibility of the infecting organism to isoniazid. The effectiveness of bacillus of Calmette and Guérin (BCG) vaccination is considerably less certain; effectiveness rates varied from 0% to 76% in major trials.

See chapter 9 for information on TB screening, preventive therapy, and BCG immunization in children and adolescents.

Tuberculosis is currently designated as an infectious disease notifiable at the national level. Refer to Appendix C for further information on nationally notifiable diseases.

Recommendations of Major Authorities

Screening

  • All major authorities, including American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American Thoracic Society, Canadian Task Force on the Periodic Health Examination, Centers for Disease Control and Prevention, and US Preventive Services Task Force --
  • Tuberculin skin testing should be performed on all individuals at high risk. The need for repeat skin testing should be determined by the likelihood of continuing exposure to infectious TB.

Prophylaxis

  • American Thoracic Society (ATS), Canadian Task Force on the Periodic Health Examination, Centers for Disease Control and Prevention (CDC), and US Preventive Services Task Force --
  • Adults with a reactive skin test and no evidence of active disease should be considered for preventive therapy with isoniazid based on age and risk factors. ATS and CDC also recommend that anergic patients recently exposed to an active TB case or from populations where the prevalence of TB is greater than 10% (injection drug users, homeless individuals, migrant laborers, and first-generation immigrants from Asia, Africa, or Latin America) should be considered for isoniazid prophylaxis even when their skin test is negative.

BCG Vaccination

  • American Thoracic Society, Centers for Disease Control and Prevention (CDC), and US Preventive Services Task Force --
  • Vaccination with BCG is not recommended for adults in the United States. However, CDC recommends that BCG vaccination should be considered for health care workers who work in settings in which (a) a high percentage of TB patients are infected with M. tuberculosis resistant to both isoniazid and rifampin, (b) transmission of such drug-resistant M. tuberculosis strains is likely, and (c) comprehensive infection control precautions have been implemented and have not been successful.
  • Canadian Task Force on the Periodic Health Examination --
  • recommends BCG vaccination for tuberculin-negative contacts of persons with active TB in Canadian communities in which the infection rate is high.

Basics of Tuberculosis Screening

1.

Use the Mantoux test exclusively in high-risk populations. The Mantoux test is the standard methods of testing. Multiple-puncture tests should not be used to determine whether a person is infected.

2.

For the Mantoux test, administer 0.1 mL of purified protein derivative (PPD) containing 5 tuberculin units (TU) on the volar or ventral surface of the forearm. Administer the injection intradermally using a disposable tuberculin syringe with the bevel of the needle facing upward. The injection should produce a pale, discrete 6-mm to 10-mm weal on the skin.

3.

Read the test results 48 to 72 hours after administration by palpating the margin of induration and measuring the diameter transverse to the long axis of the forearm. It may be helpful to outline the margin of induration with a ballpoint pen. Always record the actual millimeters of induration, not the erythema surrounding the induration. Simply recording "positive" or "negative" is not precise enough and may lead to improper treatment.

4.

Absence of a tuberculin reaction does not exclude a diagnosis of TB infection, especially when symptoms suggest the presence of active disease. Induration of less than 5 mm may occur early in the course of TB infection or in individuals with altered immune function. Anergy testing with at least two other delayed-type hypersensitivity skin tests (eg, Candida, mumps, or tetanus toxoid) may be conducted in conjunction with PPD testing in adults at risk for decreased cell-mediated immune function (including persons with HIV infection). The scientific basis for anergy testing is tenuous, however, and no standardization exists for most skin-test antigens used for anergy testing. Therefore, anergy testing is not part of routine screening for TB infection.

5.

Reactions to PPD may wane with age but can be restored by repeat testing. Because of this "booster effect," patients (particularly those over age 55 years) who undergo repeat testing may be falsely classified as new converters and unnecessarily treated with isoniazid. Some authorities recommend initially screening adults in institutional and hospital settings using a two-step PPD testing procedure. If the first Mantoux test result is negative, perform a second test 1 to 2 weeks later. Reaction to the "booster" test usually indicates old -- not new -- TB infection. CDC recommends this two-step procedure for the initial screening of residents and employees of long-term care facilities, such as nursing homes, adult foster-care homes, and board and care homes.

6.

A small percentage of tuberculin reactions may be caused by errors in administering the test or reading the result, cross-reaction with antigens shared between mycobacteria, and vaccination with BCG. The probability that a positive skin test results from infection with M. tuberculosis rather than from BCG vaccination increases: (1) as the size of the reaction increases; (2) when the patient is a contact of a person who has TB; (3) when the patient has a family history of TB or the incidence/prevalence of TB in their country of origin is high; and (4) as the interval between vaccination and tuberculin testing increases (vaccination-induced reactivity is unlikely to occur for 10 years after vaccination).

7.

Live vaccines, such as measles-mumps-rubella (MMR) and oral polio vaccine (OPV), may interfere with the response to the Mantoux test. To avoid confusion, administer live vaccines and the TB test concurrently, or delay the TB test for 4 to 6 weeks.

Basics of Tuberculosis Prophylaxis

1. Indications

CDC has issued recommendations for preventive therapy in previously untreated adults without evidence of active TB (Table 43.1). Certain anergic patients should be considered for preventive therapy regardless of their skin test reaction. Other groups for whom prophylaxis is indicated include adults who have had close contact with a person with infectious TB in the past 3 months and individuals who are members of populations in which the prevalence of TB is greater than 10% (eg, injection drug users, homeless persons, migrant laborers, and persons born in Asia, Africa, or Latin America).

2. Dose and Administration

Initiate preventive therapy with isoniazid (INH). The correct daily dose of isoniazid for adults is 5 mg/kg (maximum, 300 mg) taken orally. For noncompliant adult patients, isoniazid may be administered by a health professional on a twice-weekly schedule of 15 mg/kg per dose (maximum, 900 mg). In general, continue isoniazid prophylaxis for at least 6 months, up to a maximum of 12 months. Patients who are HIV-positive or have evidence of prior untreated TB on chest X-ray should receive isoniazid prophylaxis for 12 months. If a patient has had contact with a person known to have infectious TB that is resistant to isoniazid, consider administering preventive therapy with rifampin (600 mg by mouth daily for 1 year).

3. Contraindications/Precautions

Contraindications to isoniazid prophylaxis include acute or active liver disease of any etiology or previous adverse reaction to isoniazid. Among adults over 35 years of age, the incidence of mild isoniazid-induced liver function test abnormalities is 10% to 20%. During the course of therapy, adults over age 35 years should undergo baseline and periodic (monthly) testing for transaminase (ALT or AST) levels. If the transaminase level is three to five times higher than the upper limit of the laboratory normal range, consider discontinuing isoniazid. Closely monitor individuals who use alcohol daily or in whom chronic liver disease is suspected for isoniazid-induced hepatitis. Supplementation with pyridoxine (vitamin B6, 50 mg by mouth daily) may be helpful in preventing neuropathy in certain patients on isoniazid, such as those with diabetes, uremia, alcoholism, or malnutrition. Delay therapy for pregnant women who are candidates for preventive treatment until after delivery. If it is likely that the woman has been recently infected, therapy may be instituted after completion of the first trimester of pregnancy.

4. Adverse Reactions

While patients are taking isoniazid, monitor them monthly for signs and symptoms of adverse reactions. These include drug fever or rash, hypersensitivity reactions, peripheral neuritis, and hepatitis. Signs and symptoms of hepatitis include loss of appetite, nausea, vomiting, persistent dark urine, jaundice, fever, and abdominal tenderness — especially in the right upper quadrant. Patients who are taking other medications concurrently with isoniazid should be monitored for potential drug interactions.

Basics of BCG Vaccination

1. Indications

Routine BCG vaccination is not recommended for adults in the United States.

2. Dose and Administration

The Tice ® strain is the only BCG preparation currently available in the United States. The dose and administration is the same for both adults and children ( see chapter 9 for details).

3. Precautions

Do not administer BCG vaccine to individuals who may be immunocompromised or immunosuppressed, including those with known or suspected HIV infection.

4. Adverse Reactions

Side effects occur in 1% to 10% of vaccinated individuals and may include severe or prolonged ulceration at the vaccination site, lymphadenitis, and lupus vulgaris.

Patient Resources

  • Tuberculosis: Get the Facts; Tuberculosis: Connection between TB and HIV; Questions and Answers about TB. Centers for Disease Control and Prevention, Attn: Information, Technology and Services Office, NCHSTP, CDC, 1600 Clifton Rd NE, M/S E-06, Atlanta, GA 30333; or National Center for HIV, STD, and TB Prevention Voice Information System: (404)639-1819.
  • Facts About the TB Skin Test; Facts About Tuberculosis. American Lung Association, 1740 Broadway, New York, NY 10019-4374; (212)315-8700.

Provider Resources

  • Multidrug Resistant Tuberculosis; TB Care Guide; Core Curriculum on Tuberculosis; TB Treatment: A Clinical Care Guide; Improving Patient Adherence to Tuberculosis Treatment; Reported TB in the United States; Tuberculosis Control Laws-United States. To order these and other documents, contact the Centers for Disease Control and Prevention, Attn: Information, Technology and Services Office, NCHSTP, CDC, 1600 Clifton Rd, NE, M/S E-06, Atlanta, GA 30333; or the National Center for HIV, STD, and TB Prevention Voice Information System: (404)639-1819.

Selected References

  1. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination . Kansas City, Mo: American Academy of Family Physicians; 1997.
  2. American College of Obstetricians and Gynecologists. Guidelines for Women's Health. Washington, DC: American College of Obstetricians and Gynecologists; 1996.
  3. American Thoracic Society. Control of tuberculosis in the United States. Am Rev Respir Dis . 1992; 146:1623–1633. [PubMed: 1456588]
  4. American Thoracic Society. Treatment of tuberculosis and tuberculosis infection in adults and children. Am J Respir Crit Care Med . 1994; 149:1359–1374. [PubMed: 8173779]
  5. American Thoracic Society/Centers for Disease Control. Diagnostic standards and classification of tuberculosis. Am Rev Respir Dis . 1990; 142:725–735. [PubMed: 2389921]
  6. Canadian Task Force on the Periodic Health Examination. Screening and isoniazid prophylactic therapy for tuberculosis. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 62.
  7. Centers for Disease Control and Prevention. Prevention and control of tuberculosis in correctional facilities: recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR . 1996; 45(No. RR-8):1–27.
  8. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities, 1994. MMWR. . 1994; 43(No. RR-13):1–132. [PubMed: 8602125]
  9. Centers for Disease Control. Prevention and control of tuberculosis in facilities providing long-term care to the elderly: recommendations of the Advisory Committee for Elimination of Tuberculosis. MMWR . 1990; 39(No. RR-10):7–20. [PubMed: 2165558]
  10. Centers for Disease Control. Prevention and control of tuberculosis in U.S. communities with at-risk minority populations and prevention and control of tuberculosis among homeless persons: recommendations of the Advisory Council for Elimination of Tuberculosis. MMWR . 1992; 41(No. RR-5):1–23. [PubMed: 1314322]
  11. Centers for Disease Control. Purified protein derivative (PPD) tuberculin anergy and HIV infection: guidelines for anergy testing and management of anergic persons at risk of tuberculosis. MMWR . 1991; 40(No. RR-5):27–33. [PubMed: 2034206]
  12. Centers for Disease Control and Prevention. Screening for tuberculosis and tuberculosis infection in high-risk populations: recommendations of the Advisory Committee for the Elimination of Tuberculosis. MMWR . 1995; 44(No. RR-11):19–34. [PubMed: 7565540]
  13. Centers for Disease Control and Prevention. Tuberculosis morbidity, United States, 1995. MMWR . 1996; 45:365–370. [PubMed: 8606685]
  14. Centers for Disease Control and Prevention. The role of BCG vaccine in the prevention of tuberculosis in the United States: a joint statement by the Advisory Committee for Immunization Practices and the Advisory Committee for Elimination of Tuberculosis. MMWR . 1996; 45(No. RR-4):1–18. [PubMed: 8602127]
  15. Centers for Disease Control. The use of preventive therapy for tuberculous infection in the United States: recommendations of the Advisory Committee for the Elimination of Tuberculosis. MMWR . 1990; 39(No. RR-8):9–12. [PubMed: 2111877]
  16. Frieden TR, Sterling T, Pablos-Mendez A. The emergence of drug-resistant tuberculosis in New York City. N Engl J Med . 1993; 328:523–526. [PubMed: 8381207]
  17. Iseman MD, Cohn DL, Sbarbaro JA. Directly observed treatment of tuberculosis: we can't afford not to try it. N Engl J Med . 1993; 328:576–578. [PubMed: 8426627]
  18. Physician's Desk Reference. Oradell, NJ: Medical Economics Company; 1993:898-899, 1689-1692.
  19. Pust RE. Tuberculosis in the 1990's: resurgence, regimens, and resources. South Med J . 1992; 85:584–593. [PubMed: 1604386]
  20. US Preventive Services Task Force. Screening for tuberculosis infection (including BCG immunization)In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 25.

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