Guidelines on the Prevention and Control of Tuberculosis in Ireland

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<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCKey Recommendations1 Epidemiology and Surveillance of TB in Ireland1.1 Case definitions specified by the European Commission should be applied for the purposes ofnotification and submission of data for epidemiological surveillance and disease control. These casedefinitions are available on the Health Protection Surveillance Centre (HPSC) website at www.hpsc.ie/hpsc/NotifiableDiseases/CaseDefinitions/ (section 1.4).1.2 Once a diagnosis of tuberculosis (TB) is either laboratory confirmed or strongly suspected on clinicalgrounds, the medical officer of health (MOH) should be notified by the clinical director of thelaboratory and/or clinician as soon as possible and ideally at the time of diagnosis (section 1.5).1.3 Reporting of outbreaks of TB is a mandatory requirement (section 1.5).1.4 Detailed surveillance information should be recorded on the national tuberculosis notificationdatabase (NTBSS) and submitted to the Health Protection Surveillance Centre (HPSC). It is plannedthat TB surveillance will be included in the Computerised Infectious Disease Reporting System (CIDR)(section 1.5).2 Methods of TB Screening2.1 The standard tuberculin skin test (TST) recommended for use in Ireland is the Mantoux 2TU/0.1mltuberculin PPD. Mantoux 10TU/0.1/ml tuberculin PPD is not recommended for use in Ireland (section2.3).2.2 In all cases, the TST (Mantoux test) should be administered intradermally (section 2.3).2.3 The TST (Mantoux test) result should be read within 48 to 72 hours of receiving the test. Thetransverse diameter of the area of induration (and not the erythema at the injection site) is measuredwith a ruler and the result recorded using millimetres (section 2.3).2.4 The TST (Mantoux test) should be used as the first line test for the diagnosis of latent TB infection(LTBI) in contacts of infectious TB cases and others considered to be at high risk of LTBI. Those withpositive TST results should be considered for Interferon Gamma Release Assay (IGRA) testing (section2.6). IGRA should be considered on a case-by-case basis in adults and children as per the generalrecommendations in section 8.7.2.5 IGRA tests should not be used in the first instance for the diagnosis of active TB disease. Appropriatemicrobiological and molecular investigations remain the gold standard for the diagnosis of active TBdisease (section 2.6).2.6 Chest X-ray is not considered the “gold standard” for the diagnosis of pulmonary TB (section 2.8).3 Management of Latent TB Infection3.1 The following groups should be prioritised for the treatment of LTBI: 1) Recent converters; 2) HIVpositiveindividuals; 3) Those aged less than 5 years; 4) Persons receiving immunosuppressive therapye.g. Tumour Necrosis Factor-α (TNF-α) antagonists; 5) Persons with evidence of old healed TBlesions on chest X-ray; 6) Foreign-born persons from countries of high TB endemnicity (≥ 40 casesof TB/100,000 population notified per year); 7) Homeless persons; 8) Intravenous drug users and 9)healthcare workers (HCWs) (section 3.3).-ix-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSC3.2 For the treatment of LTBI in the groups outlined in 3.1, the following is recommended:3.2.1 Groups 1-5: LTBI treatment should be offered to those in all age groups3.2.2 Groups 6-8: LTBI treatment should be offered to all those aged ≤55 years if supervisedtherapy i.e. directly observed therapy (DOT) is available. Otherwise, it should be offered tothose aged ≤35 years. These groups should be closely monitored for isoniazid toxicity.3.2.3 Group 9: The age limit for LTBI treatment should be assessed on a case-by-case basis i.e.treat all HCWs where the risk of progression from LTBI to TB disease is high regardless ofage. Where the risk of progression is low, the upper age limit for LTBI treatment is ≤ 35years.3.2.4 For all other persons not mentioned above, the upper age limit for LTBI treatment shouldbe ≤35 years (section 3.3).3.3 Care should be taken when prescribing LTBI therapy for those with co-morbidities which increasethe likelihood of hepatoxicity (section 3.3).3.4 Directly observed therapy (DOT) should be provided for those being treated for LTBI in groups 6,7 and 8 i.e. immigrants from areas of high TB endemnicity, homeless persons and intravenous drugusers (section 3.4).3.5 It is recommended that audits of compliance with LTBI therapy are undertaken (section 3.4).3.6 The recommended treatment regimens for LTBI in adults are: (i) isoniazid for a minimum ofsix months with an optimum duration of nine months or (ii) rifampicin for four months or (iii) acombination of rifampicin and isoniazid for a duration of at least three months and an optimum offour months (section 3.4).3.7 The recommended treatment regimens for LTBI in children are: (i) isoniazid for a minimum ofsix months with an optimum duration of nine months or (ii) rifampicin for six months or (iii) acombination of rifampicin and isoniazid for a duration of four months (section 3.4).3.8 Physicians experienced in the management of children with LTBI should supervise therapy inchildren (section 3.4).3.9 Consultation with a respiratory physician or infectious disease consultant should be sought for themanagement of persons with active TB or LTBI who have been exposed to patients with MDR-TB orXDR-TB (section 3.5).3.10 Clinicians may choose to undertake baseline liver function tests (LFTs) for all patients aged over 14years at the start of treatment for LTBI. However, this is not universally obligatory (section 3.6).3.11 A consultant with expertise in TB should always be consulted when treating a patient with LTBI withdocumented hepatotoxicity (section 3.7).3.12 Breastfeeding is not a contraindication to LTBI therapy. Isoniazid or rifampicin are not secreted insufficient quantities in breast milk to harm the baby (section 3.7).3.13 Ideally monthly clinical monitoring (or at the discretion of the physician) is indicated for all patientson LTBI treatment (section 3.7).3.14 Prior to commencing TNF-α antagonists, patients should be thoroughly assessed by the treatingphysician for clinically active TB disease and for LTBI (section 3.8).-x-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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