Tuberculosis Alert for Healthcare Providers

Posted March 6, 2018. Past health advisories and alerts are archived for historical purposes and are not maintained or updated.

Situation

The Spokane Regional Health District (SRHD) TB Program has noted a recent increase in reported tuberculosis disease cases. The reported cases have been a combination of extrapulmonary (specifically the cervical lymph nodes) and pulmonary sites.

Epidemiology

One fourth of the world’s population is infected with TB. In 2016, 10.4 million people around the world became sick with TB disease. There were 1.7 million TB-related deaths worldwide. A total of 9,272 TB cases (a rate of 2.9 cases per 100,000 persons) were reported in the United States in 2016 (https://www.cdc.gov/tb/statistics/default.htm). Approximately two-thirds of these cases are individuals born abroad in the 22 countries considered to be “high burden” countries. These include countries in Eastern Europe, Africa, Asia, the Caribbean, Latin America, and the Pacific Islands.

Transmission of the tuberculosis bacteria occurs through the air from person to person. In the US, an estimated 85% of individuals with TB disease represent reactivation of latent tuberculosis infection (LTBI). Risk factors for TB disease include:

• Foreign borne from “high burden” nations, especially recent immigration
• Close contact to individuals with infectious TB disease
• Children < 5 years
• Injection drug use
• Homeless, correctional facilities, institutional residence
• Immune compromised, especially HIV, TNF-alpha inhibitors, corticosteroids
• Advanced renal disease, poorly controlled DM

Presentation

Individuals with pulmonary tuberculosis may clinically present with symptoms of a cough lasting for 3 weeks or longer, chest pain, hemoptysis, weakness or fatigue, weight loss, decreased appetite, fever, and night sweats. Symptoms of extrapulmonary tuberculosis are dependent on the area affected.

ACTIONS REQUESTED OF ALL CLINICIANS:

1. Suspect tuberculosis disease in cases with compatible symptoms.
2. Screen with:
   • Tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA) (i.e., QuantiFERON Gold)
     1. IGRAs recommended with individuals 5 years or older
     2. TSTs are recommended in children <5 years of age
        *A TST is an acceptable alternative in situations where an IGRA in not available, too costly, or too burdensome.
   • Chest Radiograph
     1. Persons >5 years of age should have a posterior-anterior radiograph (single-view)
     2. Children < 5 years of age should have both posterior-anterior and lateral views (2-view)
   • Radiographic findings suggestive of TB disease include:
     1. Air-space opacity or consolidation, often referred to as air-space disease
     2. Interstitial opacity
     3. Nodules or masses
     4. Apical consolidation
     5. Hilar lymphadenopathy
     6. Pulmonary cysts or cavitations
     7. Pleural space abnormalities
   • Sputum Examination
     • Three consecutive sputums should be collected 8-24 hours apart with one being a first-morning specimen
     • Order an Acid-Fast Bacilli (AFB) smear and culture on each specimen (min. requirement)
     • Nucleic Acid Amplification testing (NAAT) may be ordered through the Washington State Public Health Lab (WAPHL). Contact WAHPL at (206) 418-5400 for ordering information
3. Report cases to the SRHD TB Program by faxing the completed SRHD TB Reporting form along with all labs, radiographic and microbiology reports