NWT TUBERCULOSIS MANUAL JuneNovember 2014 2014 | www.hss.gov.nt.ca | www.hss.gov.nt.ca Table of Contents Section 1: Purpose and Introduction 1-1 Purpose 1-2 Acknowledgements 1-2 Introduction 1-3 Section 2: Description of TB 2-1 Etiology 2-2 Pathogenesis 2-2 Primary TB (Early Disease Progression) 2-3 Latent TB Infection (LTBI) 2-3 Reinfection 2-3 Reactivation (Late Disease Progression) 2-4 Transmission 2-5 Factors that Increase the Risk of Transmission 2-7 Transmission Outcomes 2-8 Risk Factors 2-11 Section 3: Bacillus Calmette-Guérin (BCG) Vaccination 3-1 Description 3-2 Indications for Use 3-3 Infants in High Risk Communities 3-3 Travellers 3-3 Occupational Setting 3-4 Booster Doses and Revaccination 3-4 Administration Procedure 3-4 Safety 3-6 Contraindications 3-6 Adverse Reactions 3-7 Management of BCG Abscess 3-8 Important Considerations 3-9 BCG Vaccine Usage in Canada 3-9 Section 4: TB Screening 4-1 Components of Screening 4-2 The Tuberculin Skin Test (TST) 4-3 TST Technique 4-3 Special Considerations Using TST 4-13 Two-Step TST: Distinguishing Between the Booster Phenomenon and Conversion 4-14 Contraindications to TST 4-16 Precautions with TST 4-16 Interferon Gamma Release Assay (IGRA) 4-17 NWT TuberculosisNWT Tuberculosis Manual Manual - November - June 2014 i Section 5: TB Assessment 5-1 Rationale 5-2 Signs and Symptoms 5-4 Baseline Investigations 5-5 Goals of Treatment 5-5 Section 6: Diagnosis of TB (Latent vs. Active Disease) 6-1 Latent TB 6-1 Diagnosis of Latent Tuberculosis Infection (LTBI) 6-2 Guidelines for Use: TST or IGRA 6-2 Tuberculin Skin Test (TST) 6-3 Chest Radiography 6-3 Active TB 6-6 Diagnosis of Active TB 6-6 Respiratory TB 6-6 Clinical Presentation 6-6 Microbacteria Testing: AFB Smear and Culture 6-9 Respiratory Specimen Collection 6-11 Non-respiratory TB 6-17 Clinical Presentations 6-17 Radiography 6-18 Section 7: Management of TB 7-1 Management of Suspect TB 7-2 Medical Transportation of a Confirmed or Suspected Case 7-3 Infection Control Measures in the Management of TB 7-7 Criteria for Discontinuing Airborne Precautions for TB 7-13 Direct Observed Treatment (DOT) 7-14 Discharge Planning 7-14 Section 8: Treatment for Tuberculosis 8-1 Latent TB 8-3 Indications and Objectives for Treatment 8-3 Treatment, Duration and Adherence 8-4 Special Considerations in the Treatment of LTBI 8-6 Monitoring Treatment of LTBI 8-7 Adverse Reactions/Treatment Induced Side Effects 8-9 Follow-Up after LTBI Treatment and Management Following Re-Exposure 8-12 Active TB 8-13 Objectives of Treatment 8-13 Principles of Treatment 8-13 Special Considerations in the Treatment of Active TB Disease 8-18 Anti-Tuberculosis Drugs 8-19 Monitoring of Treatment of Active TB 8-23 Adverse Reactions/Treatment Induced Side Effects 8-25 Completion of Treatment 8-30 iiNWT Tuberculosis Manual - JuneNovember 2014 2014 Surveillance 8-30 Drug-Resistant Tuberculosis 8-30 Multidrug-Resistant (MDR-TB) and Extensively Drug-Resistant (XDR-TB) Tuberculosis 8-34 Non-respiratory TB 8-36 Diagnosis of Non-respiratory TB 8-36 Treatment of Non-respiratory TB 8-36 Section 9: Contact Tracing 9-1 Contact Tracing Algorithms 9-2 Contact Tracing and Contact Investigations 9-5 Goals and Objectives of Contact Tracing 9-5 Factors Contributing to Transmission 9-5 Prioritization of Contact Follow-Up 9-6 Steps in a Contact Investigation 9-7 Evaluation of Contacts for the Presence of Active Disease and Evidence of Recent Infection 9-9 Organizing an Investigation: Identification and Interview of Contacts 9-10 Screening Contacts in a Contact Investigation 9-13 INH Preventive Treatment for Contacts 9-14 Evaluation of Contact Investigation 9-14 Section 10: Role of Public Health in TB Prevention and Control in the NWT 10-1 Notification and Reporting of Suspect and Confirmed Cases of TB 10-2 Directly Observed Treatment (DOT) and Directly Observed Preventive Treatment (DOPT) 10-4 Surveillance 10-5 Managing an Outbreak 10-7 Section 11: Pediatric TB 11-1 Pediatric Population 11-2 Transmission and Pathogenesis 11-2 Latent TB 11-3 Pediatric LTBI Treatment 11-3 Active TB 11-5 Pediatric Active TB Disease Treatment 11-5 Management and Treatment of Active Disease 11-6 Monitoring and Follow-up 11-10 Management of Children with Close Contact to Smear (-), Culture (+) TB 11-12 Management of Children wtih Close Contact to Smear (+) TB 11-13 Section 12: Populations at Risk 12-1 Overview of Screening Populations at Risk 12-2 Immigrant Screening in the Northwest Territories 12-3 Homeless Populations and Injection Drug Use 12-6 Institutionalized Population – Correctional Facilities 12-7 HIV and TB 12-8 NWT TuberculosisNWT Tuberculosis Manual Manual - November - June 2014 iii Section 13: 13: Caring Caring for for the the Deceased Deceased with with TB TB 13-113-1 General Policy and Procedures 13-2 Section 14: 14: History History and and Epidemiology Epidemiology of TB of in TB the in NWT the NWT 14-114-1 NWT History 14-2 WWorldorld TB Day 14-4 Epidemiology of TB in the NWT 14-4 Global Occurrence of TB 14-7 Section 15: 15: A A Glossary Glossary of ofTerms Terms and and TB Classifications TB Classifications 15-115-1 Section 16: 16: Forms Forms 16-116-1 1. NWT TB Assessment Form 16-2 2. NWT LatentTB Initiation Tuberculosis Form Infection (LTBI) Treatment Initiation form 16-4 3. NWT TB Case LLTBITBI TX Completion Form 16-5 4. NWT LLTBITBI Tuberculosis Community Surveillance Form 16-6 5. NWT TTuberculosisuberculosis Surveillance & Screening Form 16-7 6. NWT TTuberculosisuberculosis Case and Contact Tracing Record 16-8 7. NWT Communicable Disease Passenger Declaration Form 16-9 8. NWT Latent TTuberculosisuberculosis Infection (LTBI) Drug Treatment & Progress Record 16-10 9. NWT Active TB Drug TTreatmentreatment & Progress Record 16-12 10.10. AEFI Form 16-15 11.11. Common Abbreviations in NWT TB Program 16-19 12.12. Medication Information 16-21 Section 17: 17: Specimen Specimen Collection Collection Procedures Procedures 17-117-1 Section 18: 18: List List of of Figur Figureses 18-118-1 Section 19: 19: List List of of Tables Tables 19-119-1 iv NWT Tuberculosis Manual - JuneNovember 2014 2014 Section 1: Purpose and Introduction Section 1 Purpose and Introduction Purpose 1-2 Acknowledgements 1-2 Introduction 1-3 NWT TuberculosisNWT Tuberculosis Manual Manual - November - June 2014 1-1 Section 1: Purpose and Introduction Purpose This manual provides the Northwest Territories (NWT) standards for the prevention, detection, and treatment of tuberculosis (TB) to health professionals. It will be updated at regular intervals to reflect new developments in TB prevention and control. The purpose of this manual is to: 1 2 3 Provide education Provide individual Provide standards for and program and population-based diagnosing, treating, standards to prevent surveillance standards monitoring, and the spread of TB. to encourage early contact tracing for detection of TB. active TB disease and latent TB infection. Acknowledgements The Department of Health and Social Services would like to thank all community, regional and departmental personnel who have contributed their expertise to the updating of the NWT Tuberculosis Manual 2014. Especially: • Community Health Nurses • Members of the former Canadian TB Committee • Public Health Nurses • Regional and Territorial Public Health Officers • Public Health and Preventive Medicine Residents • Specialists at Stanton Territorial Hospital • TB Specialists from the University of Alberta 1-2NWT Tuberculosis Manual - JuneNovember 2014 2014 Section 1: Purpose and Introduction Introduction This TB manual will serve as a resource guide to all Health Care Providers (HCPs) who provide clinical support, treatment and/or management to patients with tuberculosis in the Northwest Territories (NWT). Many HCPs in Canada have limited experience with tuberculosis management. This manual provides information and direction to: • Increase awareness among HCPs about TB in the NWT • Clarify roles and responsibilities of HCPs in public health management activities for TB • Familiarize HCPs about TB screening, disease prevention, treatment and community follow-up • Describe the TB prevention and control program in the NWT as required by the Public Health Act (2009) and related regulations • Provide references and resources for supplemental information on TB The information in this manual is based on the recommendations of the Tuberculosis Committee of the Canadian Thoracic Society in the 7th edition of the Canadian Tuberculosis Standards (2013) as well as other relevant national and international standards in TB diagnosis, treatment and control. Tuberculosis remains an important global issue and has become more difficult to clinically manage. Many related issues contribute to its complexity, such as an increasing epidemic of people living with Human Immunodeficiency Virus (HIV) and TB disease. Canada is not considered a high burden TB country. However, subgroups of the Canadian population suffer from a higher burden of active TB or are at increased risk of being infected, leading to the spread of the disease in and outside these subgroups. One such subgroup is the Aboriginal peoples of Canada, who are disproportionately impacted by this disease. The NWT, with over half the population self-identifying as Aboriginal, does not escape the ongoing threat of TB. The NWT rate of TB is significantly higher than the national Canadian average. Whenever a diagnosis of TB is being considered, the Office of the Chief Public Health Officer (OCPHO) must be notified immediately in accordance with thePublic Health Act (2009). OCPHO staff will provide field staff with guidance and direction regarding disease investigation, control measures, and follow-up. TB has serious implications for a patient’s family and community. The management of TB is a high priority public health issue.