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/HPSCtheir youth. Among the foreign-born, prevalence of infection is correlated with incidence of TB in theircountry of origin and the age of immigration.The contacts of active TB cases also have a high prevalence of TB infection with the risk of infection beinghigher if the index case is pulmonary sputum smear positive or if the contact is close. However, absolutelevels of risk have been estimated in relatively few of the studies that measured the prevalence of infectionin non-contacts in the general population. 36In 2005, a study was undertaken in a large Dublin teaching hospital which reviewed the screening data fortwo groups of persons, namely new employees (n= 2,410) and a high-risk group of HIV positive patientsattending the hospital (n= 331). 80 Cases with positive TSTs were offered chest X-rays and if clear of TB werecategorised as LTBI. The study found that 31.7% of the HCWs had LTBI while 11% of the HIV positive grouphad LTBI.There is little information in relation to the prevalence of LTBI in Ireland.Diagnosis of LTBIThere is no gold standard test for LTBI and therefore diagnosis of active or latent TB involves a numberof tests. In asymptomatic persons, exposure to and potential infection with TB can be demonstrated bya positive TST or a positive IGRA. In practice, the TST is the standard method of determining whethera person is infected with M. tuberculosis. Reliable administration and reading of the TST requiresstandardisation of procedures, training, supervision and practice. Individuals with positive skin tests areregarded as having been infected with TB. Neither TST nor IGRA can distinguish active TB disease fromLTBI. Further details on the diagnosis of LTBI i.e. TSTs, IGRA and chest X-rays are outlined in chapter 2.3.2 Risk Factors for LTBITB may be transmitted from a person with active TB disease and is much more likely to be transmittedfrom an active respiratory TB case. However, some individuals are more likely than others to develop TBinfection when exposed. The most important risk factors for developing TB infection are the extent of theexposure and the infectivity of the source case. 52 Risk factors for developing TB infection are outlined asfollows:• Closeness of contact with a source case: close contacts at greatest risk• Duration of exposure to a source case: brief exposure carries low risk• Sputum status of source case: sputum smear positive case carries greatest risk• Extent of pulmonary disease of source case: cavitation and cough carry greatest risk• Laryngeal TB: carries the highest transmission risk• Age: prevalence increases with age but incidence is highest in young children. In young children,the risk of disease after infection is up to 40% 81• Cough frequency of source case: higher cough frequency results in higher risk. However,cough frequency is a less statistically significant indicator of infectivity than extent of disease orbacteriological status• Delay in diagnosis or appropriate treatment of source case: effective chemotherapy of thesource case progressively reduces infectiousness (and therefore risk to contacts)• Open skin TB abscess: dressing or irrigation of an open abscess can lead to infection• Residence in institutions.BRisk factors for LTBI progressing to active TB diseaseThe risk of an individual with latent TB developing active TB varies depending on a number of factors(tables 3.2 and 3.3). 52-27-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCTable 3.2: Risk factors for developing active TB disease following LTBIRisk factorTime since infectionAgeDose of infectionSize of tuberculin reactionPredisposing medicalconditionsImmunosuppressivetreatmentImmigrants who haverecently arrived from a highincidence countryBody weightCommentRisk is highest in the first two years after infectionInverse association: Peaks in increased risk occur in the preschool yearsand adolescence/early childhoodRisk higher if the source case is smear positive; less if smear negative/culture positive; minimal if culture negativeThe larger the reaction the greater the risk of subsequent disease.However, there is a substantial degree of variation in the extent ofincreased risk associated with larger tuberculin reactions (table 2.1,chapter 2) 82HIV is the strongest risk factor. Other risk factors include: chronic renalfailure or receiving haemodialysis, diabetes, haematological malignancy,jejeunoileal bypass or gastrectomy, silicosis, alcoholism and drugaddiction including injecting drug users and solid organ transplantationCurrent or recent oral steroids, some cancer therapy, immunosuppressivedrugs, receiving Tumour Necrosis Factor-α (TNF-α) antagonist treatmentRisk is highest in the first two years 83;84There is an increased risk associated with being underweight ormalnourishedReproduced with kind permission from <strong>Guidelines</strong> for tuberculosis control in New Zealand. New Zealand Ministry of Health (2003).Available at www.moh.govt.nz/moh.nsf/pagesmh/2046?Open-28-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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