Tuberculosis Manual Tuberculosis and Chest Service Public Health Services Branch Centre for Health Protection Department of Health Government of the HKSAR TUBERCULOSIS MANUAL (Hong Kong SAR 2006) ISBN 962-8868-10-1 978-962-8868-10-0 Published in February 2006 Printed in Hong Kong SAR Address: Tuberculosis and Chest Service Wanchai Chest Clinic 99 Kennedy Road Hong Kong SAR © Copyright 2006 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. Although great care has been exercised in ensuring the accuracy of the information compiled in this manual, the editor and publisher shall not be responsible for any errors, omissions or inaccuracies in this publication. Readers are also reminded to refer to relevant sources for updated information wherever appropriate. 2 PREFACE Tuberculosis (TB) is a long-existing infectious disease. With the advent of effective treatment in the form of short course service programmes in 1970s, it was once thought that the disease could be eliminated quite soon. However, since late 1980s and early 1990s, for a number of reasons, TB became resurgent alongside rampant drug resistance and HIV co-infection in various parts of the world. In April 1993, the World Health Organisation declared TB as a global emergency. Today, TB remains an important infectious disease worldwide. In Hong Kong, the TB notification rate has become rather “stagnant” in the last decade, despite an overall downward trend in the past 50 years. The rate now stands just below 100 per 100,000 population, with around 7,000 cases each year. With such an endemicity, medical practitioners in various fields are likely to encounter TB cases from time to time. Local guidelines have been promulgated on various aspects of TB from time to time. This manual is prepared as another step to facilitate the clinical management of TB in the local settings. Apart from the professional staff of the TB and Chest service, a large number of experts in different fields have contributed much of their effort and time in making the publication of this manual possible. The chapters are based on a careful review of information from multiple sources, including overseas and local studies, international guidelines, expert opinions and local experiences where appropriate. Through the dedication of the contributors, vigorous attempt has been made to strive for high-standard evidence- based medicine suited for the control of TB in the local scene. With the huge volumes of literature on this important topic, this manual does not mean to be a comprehensive text. Instead, it aims to serve as a handy synopsis of updated guidelines and resources for the reference of local professionals. Although the contributors have tried to ensure that the information is up-to-date at the time of writing, there remains an ongoing need to keep abreast of new scientific advances and changes in practices. Readers are therefore encouraged to refer to other relevant sources or visit our TB website at www.info.gov.hk/tb_chest for updated information wherever necessary. CM Tam CC Leung (Editors) Hong Kong SAR 2006 3 LIST OF CONTRIBUTORS KF Au MBChB(CUHK), MRCP(UK) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of Health CK Chan MBBS(HK), FHKAM(Medicine) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of Health HS Chan MBBS(HK), FHKAM(Medicine) Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hospital Authority KS Chan MBBS(HK), FHKAM(Medicine) Department of Pulmonary and Palliative Care, Haven of Hope Hospital, Hospital Authority M Chan-Yeung MBBS(HK), FHKAM(Medicine) Department of Medicine, Queen Mary Hospital, University of Hong Kong MY Chan Senior Medical Technologist Public Health Laboratory Services Branch, Centre for Health Protection, Department of Health SL Chan MBBS(HK), FHKAM(Medicine) Private practitioner (Specialist in Respiratory Medicine) YC Chan MBBS(HK), FHKAM(Medicine) Tuberculosis and Chest Unit, Wong Tai Sin Hospital, Hospital Authority KC Chang MBBS(HK), FHKAM(Medicine) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of Health DSC Hui MD(UNSW), FHKAM(Medicine) Department of Medicine, Prince of Wales Hospital, Chinese University of Hong Kong KM Kam MBBS(HK), DABMM Public Health Laboratory Services Branch, Centre for Health Protection, Department of Health CW Lam MBBS(HK), FHKAM(Medicine) Department of Respiratory Medicine, Ruttonjee Hospital, Hospital Authority WS Law MBChB(CUHK), FHKAM(Medicine) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of Health SN Lee MBChB(CUHK), FHKAM(Medicine) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of Health CC Leung MBBS(HK), FHKAM(Medicine) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of Health ECC Leung MBBS(HK), FRCP(Canada) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of Health TYW Mok MBBS(HK), FHKAM(Medicine) Respiratory Medical Department, Kowloon Hospital WH Seto MBBS(Singapore), FHKAM(Pathology) Department of Microbiology, Queen Mary Hospital, Hospital Authority LB Tai MBChB(CUHK), FHKAM(Medicine) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of Health CM Tam MBBS(HK), FHKAM(Medicine) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of Health CY Tam MBBS(HK), FHKAM(Medicine) Department of Medicine, Tuen Mun Hospital, Hospital Authority KWT Tsang MD(Glas,Hons), FRCP(Edin,Glas,Lond) Department of Medicine, Queen Mary Hospital, University of Hong Kong MY Wong MBChB(CUHK), MRCP(UK) Tuberculosis and Chest Service, Public Health Services Branch, Centre for Health Protection, Department of Health PC Wong MBBS(HK), FHKAM(Medicine) Tuberculosis and Chest Unit, Grantham Hospital, Hospital Authority WS Wong Senior Medical Technologist Public Health Laboratory Services Branch, Centre for Health Protection, Department of Health WW Yew MBBS(HK), FHKAM(Medicine) Tuberculosis and Chest Unit, Grantham Hospital, Hospital Authority CW Yip BSc, PhD Public Health Laboratory Services Branch, Centre for Health Protection, Department of Health WC Yu MBBS(HK), FHKAM(Medicine) Department of Medicine, Princess Margaret Hospital, Hospital Authority RWH Yung MBBS(HK), FHKAM(Pathology) Infection Control Branch, Centre for Health Protection, Department of Health 4 Acknowledgement We would like to thank our colleagues in the Hospital Authority, the two Universities and the Department of Health for their support, contribution, and comments during the preparation of the various chapters of this TB manual: Dr. KF Au, Dr. CK Chan, Dr. HS Chan, Dr. KS Chan, Prof. M Chan-Yeung, Ms. MY Chan, Dr. SL Chan, Dr. JWM Chan, Dr. YC Chan, Dr. KC Chang, Dr. KL Choo, Dr. CM Chu, Dr. SS Ho, Prof. DSC Hui, Dr. KM Kam, Dr. FY Kong, Dr. CW Lam, Dr. WS Law, Dr. SN Lee, Dr. ECC Leung, Dr. HM Ma, Dr. TYW Mok, Dr. WH Seto, Dr. L So, Dr. LB Tai, Dr. CY Tam, Prof. KWT Tsang, Dr. ML Wong, Dr. MY Wong, Dr. PC Wong, Mr. WS Wong, Dr. KS Yee, Dr. WW Yew, Mr. CW Yip, Dr. WC Yu, Dr. RWH Yung. The advice from Dr. PY Leung (Controller, Centre for Health Protection) and Dr. PY Lam (Director of Health) is also very encouraging. Last but not least, the high- spirited nursing team and clerical staff of the TB & Chest Service have provided all the necessary assistance and support to make this publication possible. from The Editors LIST OF ABBREVIATIONS ACH Air changes per hour ART Anti-retroviral therapy ARI Annual risk of tuberculosis infection ATS American Thoracic Society BCG Bacille Calmette Guérin CI Confidence interval DH Department of Health DOT Directly observed treatment DOTS Directly observed treatment, short course ERS European Respiratory Society FDA Food and Drug Administration (of the United States) FDC Fixed-dose combination tablets HA Hospital Authority HAART Highly active anti-retroviral therapy HEPA High efficiency particulate air filter HCW Health care workers HIV Human immunodeficiency virus IUATLD International Union Against Tuberculosis and Lung Diseases MDR-TB Multidrug-resistant tuberculosis MOTT Mycobacterium other than tuberculosis MTB Mycobacterium tuberculosis OR Odds ratio PCR Polymerase chain reaction PPD Purified protein derivative PHLC Public Health Laboratory Centre (of Department of Health) RFLP Restriction fragment length polymorphism RR Relative risk ST (Drug) sensitivity or susceptibility tests TB Tuberculosis TB&CS Tuberculosis & Chest Service (of Department of Health) TBCCC TB Control Coordinating Committee (of Department of Health) TBSC TB Subcommittee (of the Hospital Authority) TST Tuberculin test or tuberculin skin test WHO World Health Organisation 5 LIST OF TABLES Table 3.1. Basic demographics of tuberculosis patients in 2004 in Hong Kong Table 3.2. Modes of presentation of tuberculosis patients in 2004 in Hong Kong Table 3.3. Disease characteristics among tuberculosis patients in 2004 in Hong Kong Table 4.1. Radiation dose of some conventional X-ray examinations and computerised tomography examinations Table 6.1. Results of chest radiograph