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Contact Assessment

Contact Assessment. Contact Assessment and Tuberculosis Skin Testing (TST). Disclosure of Potential for Conflict of Interest. M. Ruth Deane RN BN Communicable Disease Coordinator FINANCIAL DISCLOSURE Grants/Research Support: none Speakers Bureau/Honoraria: none Consulting Fees: none.

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Contact Assessment

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  1. Contact Assessment • Contact Assessment and Tuberculosis Skin Testing (TST)

  2. Disclosure of Potential for Conflict of Interest • M. Ruth Deane RN BN • Communicable Disease Coordinator • FINANCIAL DISCLOSURE • Grants/Research Support: none • Speakers Bureau/Honoraria: none • Consulting Fees: none

  3. Purpose of the TB Investigations • Tuberculosis (TB) contact investigations are undertaken to evaluate and follow-up close contacts of active cases, in order to identify secondary cases with active disease, and to identify and treat those with latent tuberculosis infection (LTBI).

  4. Assessment of a Contact • Symptom review • The following questions should be asked: • Do you have a cough right now? Has this cough lasted longer than three weeks? • Have you coughed up any blood? • Have you lost any weight? Were you trying to loose weight? • Do you have any fever?

  5. Assessment of a contact con’t • Do you have night sweats? If yes, is there a known cause? (I.e. menopause, note as a symptom and also note the attributable cause) • Do you have any pain with breathing? • Are you fatigued? • If any symptom was present, but has since completely resolved, mark as ‘absent’ but with a brief note regarding when they occurred and how long they lasted.

  6. Referral for Sputum • Any contact with a cough lasting three weeks or longer • Should advise those without a cough, but with other symptoms of TB, that we may send for induced sputum based on CXR results

  7. Referral for sputum con’t • Need to provide specimen containers and instructions • Need three samples, at least one should be early morning • Need to be refrigerated until delivered to the laboratory

  8. TB History • Have you ever had TB? • Need documented history of fully treated disease • Have you ever had a Tuberculin Skin Test? • Need documented result, if not documented, repeat

  9. High risk conditions when associated with TB contact • HIV*** • AIDS*** • Transplantation (related to immunosuppressant therapy) • Silicosis • Chronic renal failure requiring hemodialysis

  10. Hi Risk Conditions Cont • Carcinoma of the head and neck • Recent TB infection (< 2 years) • Abnormal chest x-ray fibronodular disease • Treatment with glucocoriticoids

  11. Increased risk conditions • Tumor necrosis factor alpha (TNF) antagonists • infliximab (Remicade) • etanercept (Enbrel) • adalimumab (Humira)

  12. Increased risk conditions • Diabetes mellitus • Underweight <90% ideal body weight • Young age when infected(0-4yrs) • Cigarette smoker • Abnormal chest x-ray - granuloma

  13. The tuberculin skin test • Different types of tuberculin tests are available • The Mantoux (intradermal) tuberculin skin test is the preferred type because it is the most accurate • The tuberculin used in the skin test is also known a s Purified protein derivative or “PPD”

  14. Storage and handling of Tuberculin • Date and initial when vial is opened • Discard 30 days after opening • It is sensitive to light, keep out of light • Draw up just prior to injection • Store at 2 to 8 degrees C° in a refrigerator or cooler with ice packs

  15. Contraindications • Do not test people who: • Have a documented TST result > 10 mm • Have had TB disease in the past, confirmed • Have had severe blistering TST reactions in the past • Have severe eczema • Have a history of anaphylactic reaction to past TST

  16. Common Side Effects • Pain • itchiness • discomfort at the test site may occur • Treat with cool cloths or ice. Do not scratch.

  17. Severe side effects • Blistering • Ulcers • Necrosis • Scarring from strongly positive reactions • Anaphylactic reaction

  18. Dosage and Administration • Site: • Left inner aspect of the forearm 2-4 inches below the elbow. • Avoid areas with abrasions, swelling, visible veins or lesions that will make TST results difficult to interpret. • Cleanse skin with alcohol swab and allow to dry

  19. Dosage and Administration • Dose: • 0.1 ml of 5 TU (Tuberculin Units) of Tuberculin Purified Protein Derivative (Mantoux) • Manufactured by Aventis Pasteur, trade name Tubersol • Supplied by Manitoba TB Control Program for contact testing and select screening programs only

  20. Dosage and Administration • Route: • Intradermally with a 27 gauge, ½ inch needle and 1ml syringe. • Hold skin of the forearm tautly. • Insert needle with bevel up at a 10-15 degree angle just until the bevel disappears under the skin.

  21. Dosage and Administration • Slowly inject 0.1 ml Tubersol until activation of safety mechanism • Look for a discrete, pale elevation of the skin (wheal) • Wheal should measure 6-10 mm in diameter • Do not massage the site or cover site with a bandage

  22. Dosage and Administration • If solution leaks from the site or no wheal appears: • TST will be inaccurate • Repeat injection at least two inches from the first TST or on the other forearm

  23. Timing of administration • “TST conversion occurs within 8 weeks of exposure and infection. The traditional concept was that conversion occurred in up to 12 weeks. However, all available experimental and epidemiologic evidence consistently shows that this interval is less than 8 weeks.” CTS p 67

  24. How is the skin test read? • Test is read by a trained health worker • 48 - 72 hours after the tuberculin injection • Read the TST in good light (may want to bring a pen light) with the forearm supported on a firm surface and the elbow slightly flexed. • Reposition as necessary if interpretation is difficult

  25. How is the skin test read? • Diameter of the indurated (swelling) area is measured across the forearm • Erythema (redness) is not measured • Test result is measured in millimeters (mm)

  26. How is the skin test read? • Find induration by looking at site from the side and then by direct palpation. Mark edges of induration with a pen • Also, using a ballpoint pen, draw a line from the outer edge of the arm inward toward the induration, and stop when the pen comes against the border, repeat from the other side

  27. Only the induration is being measured. This is CORRECT.

  28. The erythema is being measured.This is INCORRECT.

  29. Routine Practices for TST reading • Wash hands with waterless hand gel or water between clients • Cleanse ruler with alcohol swab between readings • Ensure ‘cover your cough’ policy is enforced

  30. What makes the reaction significant? • Whether a reaction to the TST is classified as significant, depends on the size of the induration (swelling) and the person’s risk factors for TB

  31. Definition of a significant (positive)TST • 0-4 mm HIV infection with immune suppression and the expected likelihood of TB infection is high (e.g. close contact; abnormal x-ray)

  32. Definition of a significant (positive)TST • >5 or more millimeters (mm) • Contact to an infectious case of TB • Immunocompromised persons including HIV infection • Person with an abnormal chest radiograph, but no evidence of active TB

  33. Definition of a significant (positive)TST • > 10 or more millimeters (mm) • All other persons

  34. Recording TST results • Record the size of the induration in millimeters • Don’t write ‘negative’ or ‘neg’ but record as 0 mm • Don’t write ‘positive’ or ‘pos’, but record the actual measurement

  35. Factors that can cause a false positive reading • Infection with non-tuberculosis mycobacterium • Vaccination with BCG • Allergic reaction to bandage/tape used to cover TST • Improper administration of TST • Failure to measure induration correctly

  36. BCG can be ignored as cause of false positive if: • Was given in infancy and the person tested is now 10 years or older • There is a high probability of TB infection (close contact; high risk community or country of origin) • There is a high risk of progression from infection to disease

  37. BCG should be considered likely cause of a positive TST if: • Was given after 12 months of age AND the person is either Canadian – born non Aboriginal OR an immigrant /visitor from a low TB incidence country.

  38. BCG Scar • Presence of scar indicates that the vaccination ‘took’ or was effective and should be documented. • BCG is administered on the left (usually) shoulder in Manitoba • Other sites include the leg and back • Smallpox vaccination last given in 1970 in Manitoba. No documentation found for other countries

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