County of San Diego Tuberculosis Report, September 1, 2015
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County of San Diego Tuberculosis Report
Volume 1, Issue 1: Data through July 2015; Report released September 1, 2015.
Update on Regimens for Latent Tuberculosis Infection (LTBI)
The number of individuals reported with active TB in San Diego County declined 53% between 1993 (469 cases) and 2014 (220 cases) (1). In recent years, however, the downward trend has slowed locally, as well as across the United States. Modeling studies (2) suggest that to reach TB elimination goals (1 case per million), it will not be enough to merely identify and treat those who have active TB disease. It will be imperative to increase TB prevention several-fold specifically by testing, identifying, and treating individuals with LTBI before they develop active TB disease.
To advance efforts, providers should be aware of new tools and strategies in the fight against TB and put them into practice:
Use more specific tests for TB infection when possible. While not a panacea, the interferon gamma release assays [IGRA (QuantiFERON®, TSpot.TB®)] are more specific for TB infection than the TB skin test, especially for those with prior vaccination for TB. It is the preferred test for your patients with a history of vaccination for TB or those who may not return for their TB skin test to be read (3). The specificity afforded by IGRAs will reduce the number of patients who are falsely positive and permit increased focus on those who are most likely to benefit from treatment.
Shorter course treatment options can increase adherence. Isoniazid (INH) for 9 months remains a recommended treatment option for individuals with LTBI. However, in 2011, the CDC added the 12 dose, once weekly (3 month) regimen of INH and rifapentine (rifamycin with longer half-life) to their recommended regimens. Four Health departments across the United States are increasingly using a daily 4-month regimen of rifampin based on CDC guidance and a lower risk profile (5). Beyond having less risk of hepatotoxicity, both short-course regimens have shown higher rates of patient adherence and completion than 9 months of INH.
Focus on risk. Although an estimated 4% of the U.S. population has LTBI (6), not all are at the same risk of progression to TB disease. Increased attention is needed to assure the highest risk groups are prioritized for testing and subsequent treatment. Specific groups to consider for routine testing are diabetics, patients with end-stage renal disease, and those with HIV infection or other significant immune compromising conditions (7). From 2010 to 2013, 34% of those with active TB in San Diego had at least one of these conditions. Be especially cognizant of testing your patients with one of these medical conditions if they were born in, travel to, or visit friends and relatives outside the United States (including Mexico). It is also important to test your patients who are from Asia, Africa, and Latin America; children, young adults, and new entrants from these areas are groups to consider for routine testing for LTBI.
For more information, go to cdc.gov/tb/education/provider_edmaterials.htm or cdc.gov/tb or sandiegotbcontrol.org or call (619) 692-8621.
References:
- TB Control Program Annual 2013 Report; www.sandiegotbcontrol.org; Oct 2013.
- Hill, AN, et al: Modelling TB trends in the USA; Epidemiol.Infect 140(10):1862-72;Oct 2012.
- Mazurek, GH, et al; Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium tb Infection; MMWR Recs and Reports;59(RR05):1–25;June 2010.
- Recommendations for Use of an INH-Rifapentine Regimen With Direct Observation to Treat Latent Mycobacterium tb Infection;MMWR 60(48)1650-53;Dec 2011.
- Ziakas,PD, et al; 4 Months of Rifampin Compared with 9 Months of Isoniazid for the Management of Latent Tuberculosis Infection: A Meta-analysis and Cost-effectiveness Study That Focuses on Compliance and Liver Toxicity; ClinInfectDis:49 (12):1883-1889;2009.Clinical Infectious Diseasescid.oxfordjournals.org.
- Bennett DE,etal: Prevalence of tuberculosis infection in the United States population: The national health and nutrition examination survey,1999 2000;AmJRespCritCareMed:177(3):348-55;Feb 2008.
County of San Diego TB Clinics: www.sandiegotbcontrol.org
Phone: (619) 692-8600
Provider TB Reporting: (619) 692-8610; fax (619) 692-5516
To Sign up to Receive Quarterly TB Reports, Email Yolanda.Lopez@sdcounty.ca.gov