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/HPSCContact investigation for patients whose culture converts back to positiveIn some instances, a TB patient’s culture may convert to negative and then become positive again. Thismay happen if a patient is lost to follow-up and discontinues medications before completing treatment or iftreatment was not adequate because of multidrug resistance.If the patient is located after a treatment lapse of three months or longer and if the patient’s cultures havebecome positive again or if the patient relapses while on treatment after becoming culture negative, asecond window period should be defined and the patient should be re-interviewed. Contacts identifiedduring the initial investigation should be re-evaluated if they were exposed again. If new contacts areidentified, they should be tested and evaluated. 77Contact investigation among children and adolescentsContact investigations for children with suspected TB are generally conducted to identify the adult sourcecase.Because TB among infants and young children usually occurs within weeks to months of contractinginfection with M. tuberculosis, having a child with disease is a marker of recent transmission from someonein the child’s environment. 51 Children younger than 10 years with pulmonary TB are rarely contagiousbecause their pulmonary lesions are small (paucibacillary disease), cough is not productive, and few or nobacilli are expulsed. 109 However, children or adolescents of any age with characteristics of adult-type TB(i.e. productive cough and cavitary or extensive upper lobe lesions on chest X-ray) should be consideredpotentially infectious at the time of diagnosis. 51A negative TST does not exclude LTBI or TB disease. Approximately 10 to 15% of immunocompetentchildren with culture-documented disease do not react initially to a TST. 109 Host factors such as youngage, poor nutrition, immunosuppression, other viral infections (especially measles, varicella and influenza),recent TB infection and disseminated TB disease can decrease TST reactivity. Many children and adults coinfectedwith HIV and M. tuberculosis do not react to a TST.In the interpretation of a positive TST among child contacts of contagious TB cases, current US guidelinesdisregard previous BCG immunisation. 109Young child contacts aged under five years of an infectious TB caseFollowing exposure to a case of infectious/presumed infectious TB, children should have a TST and anevaluation for TB disease (chest X-ray and physical examination). Once active TB has been ruled out,children with positive skin tests should receive a full course of treatment for LTBI (chapter 3). Thosewho have negative skin test results should also receive treatment for presumed LTBI (chapter 3). Thisintervention is especially critical for infants and toddlers < 3 years but is recommended for all children aged< 5 years. 51 Those with a negative TST result should be retested eight weeks after exposure to infectiousTB has ended. If the TST result is still negative in an immunocompetent individual, isoniazid can bediscontinued (continue for further 7 months i.e. a total of 9 months if immunocompromised). If the secondtest is positive, treatment should be continued for a further 7 months i.e. a total of 9 months. 51;109-103-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCFigure 8.2: Algorithm for children aged between four weeks and five years who are closecontacts*of infectious/presumed infectious TB casesNote:For all at outset (regardless of BCG status)• Medical history• Physical examination.• Chest X-rayIf relevant symptoms or chest X-ray abnormalRefer to consultant paediatrician for fullevaluation for TB disease≤ 5mmIsoniazid 10mg/kgand Mantoux 2TU>5mmContinue IsoniazidRepeat Mantoux (8 weeks)Mantoux >5mmYesNoYesAssess for clinicaldiseaseNoStop IsoniazidAdvise BCG ifunvaccinatedTreat andnotifyLTBItreatmentJanuary 2014: The following amendment has been made to Figure 8.2: “Mantoux > 5mm AND increase on initial test > 5mm”changed to “Mantoux > 5mm”.The algorithm presented here is a guideline only and should be interpreted in accordance with the clinicalcontext.Note: IGRA may be considered on a case by case basis as per the general recommendations in section 2.6.Management of newborn infant contact of TB 109Management of the newborn infant is based on categorisation of the maternal (or household contact)infection. Although protection of the infant from TB disease is of paramount importance, contact betweeninfant and mother should be allowed when possible.Mother (or household contact) with TB diseaseInvestigation of all household members should be conducted without delay. If the mother has TB disease,the infant should be evaluated for congenital TB. The mother (or household contact) and the infant shouldbe separated until the mother (or household contact) has been evaluated and the mother (or householdcontact) and infant are receiving appropriate anti-TB therapy, the mother wears a mask, and the motherunderstands and is willing to adhere to infection control measures. Once the infant is receiving isoniazid,separation is not necessary unless the mother (or household contact) has possible MDR-TB or has pooradherence to treatment and DOT is not possible.If congenital TB is excluded, it is recommended that isoniazid is given until the infant is three months ofage, when a TST should be performed. If the TST result is positive, the infant should be reassessed for TBdisease. If TB disease is excluded, isoniazid should be continued for a total of nine months. The infant* See Table 8.3 for definition of a close contact-104-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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