This document provides a summary of a desk guide created for school nurses on tuberculosis (TB) protocols and directly observed therapy (DOT) administration. The guide was created as part of a master's degree program placement with the Texas Department of State Health Services TB Elimination Division. It includes information on TB statistics in Texas, testing and treatment protocols, and target testing guidelines. It also describes the methods used to create the guide, including research, writing, review, and evaluation. The results of an anonymous survey administered to school nurses found that the guide addressed all relevant TB topics and was easy to understand. Recommendations include officially publishing and distributing the guide to improve TB education and care for school nurses.
2. Project Type
Development of TB Education
Materials for school
Healthcare Staff
Project Title
A Comprehensive Desk- Guide
on TB Protocols and DOT
Administration for School
Nurses
INTRODUCTION
3. Background
Academic Information
Des Moines University- College of Health
Sciences
Master of Public Health (MPH) Candidate 2016
DSHS Placement
DSHS TB Elimination Division
Health Service Region 4/5N- TB Prevention
& Immunization Clinic
DSHS Supervisor- Suzanne Fisher, MPA-HCA,
BSN-RN
Sub Office- Nacogdoches, TX
4. Texas TB statistics
A total 1,269 TB cases were reported in Texas in 2014
5 in 100,000 Texans had active TB last year compared to the national
average of 3 in every 100,000
55% of reported TB cases in 2014 were among Hispanics, 18% were
among African Americans, 9% percent were among Whites, and 18%
were among Asians.
On average 57 cases have large contact investigations with more than
50 contacts identified.
TB rates are higher along the Texas-Mexico border and TB/HIV co-
infection is more commonly found in urban areas of Texas
5. TB Demographics in Texas Counties
County Cases
Harris 320
Dallas 167
Bexar 89
Tarrant 77
Hidalgo 70
Cameron 67
El Paso 43
Travis 49
Collin 27
Webb 25
Highest incidence of TB Cases in Texas Counties, 2014
6. Regional TB statistics in Texas
Health
Service
Region
Number
of Cases
Percentage
of Cases (%)
1 52 4.09
2/3 305 24.03
4/5N 43 3.38
6/5S 387 30.5
7 82 6.46
8 132 10.4
9/10 56 4.41
11 189 14.9
Texas 1269 100
7. Why is there need for a TB Desk-Guide for
school Nurses? Situation?
Very little formal state literature that addresses the problem of TB on
school campuses and/or is catered towards school nurses
The Texas Health guide for schools has only allocated 2 pages on the
topic of TB.
Most of the students diagnosed with TB take their medication on
school campuses (DOT), hence a well trained nursing workforce is
crucial to eradicate TB in school going children.
The Need!
-A need for a state literature based on the CDC/DSHS
guidelines that goes into more detail about the TB Topics such as
TST reading/interpretation and DOT administration.
.
8. What is the purpose of this?
The purpose of this desk-guide is to
Educate and train the school nurses on the right protocol
handling TB cases on school campuses.
Let’s Begin!!!
9. Borderline- High Risk Counties of Texas
The rate of tuberculosis in these counties is twice the average of the
state
Brooks Calhoun Cameron Cherokee
Collingsworth Edwards Frio Garza
Hansford Jack La Salle Lipscomb
Martin Moore Nacogdoches Parmer
Reagan Terry Val Verde Webb
Zavala
11. What is Tuberculosis /Transmission
and Pathogenesis
Tuberculosis is
caused by the
Mycobacterium
tuberculosis (M.
tuberculosis) and is
spread by airborne
droplet nuclei
The transmission of
TB is causes by the
prolonged contact
with the infected
individual.
Transmission occurs
by coughing,
sneezing, laughing
or singing
Any untreated
person with active
pulmonary TB
disease can infect an
estimated 10-14
people in a year
12. TB is categorized into two-related conditions: latent TB infection and
active TB disease.
Latent TB Infection Active TB Disease
Inactive Tubercle Bacilli in the body Active Tubercle bacilli in the body
Tuberculin skin Test (TST) or Interferon-
gamma release assay (IGRA) usually
positive
TST or IGRA usually positive
Chest radiograph usually negative/normal Chest Radiograph usually positive/abnormal
Sputum smear and culture
negative/normal
Sputum smear and culture positive
Lack of symptoms Symptoms such as cough, fever. Weight loss
Not infectious Often infectious before treatment
Difference between TB infection and TB
Disease
13. Symptoms of TB
These symptoms are more common in adults and older children (American
Academy of Pediatrics [AAP], 2000). Symptoms of TB include one or more
of the following:
Fever
Persistent cough (3
weeks)
Weight loss/failure
to gain weight
Lymphadenopathy
(LAD)
Fatigue
Night Sweats Chest Pain
Hemoptysis
Chills
14. How to Test for TB (TB blood test) vs. Skin Test)
TB
blood
tests
Interferon-gamma release
assays or IGRAs- measures how
the immune system reacts to
the bacteria that cause TB.
Two IGRAs are approved by the
U.S. Food and Drug
Administration (FDA) and are
available in the United States
QuantiFERON®–TB Gold In-
Tube test (QFT-GIT)
T-SPOT®.TB test (T-Spot)
15. How to Test for TB (TB Blood Test)
TB Skin
Testing
The diagnostic tool for
detection of TB infection is
the tuberculin skin test
(TST) using the Mantoux
method.
“Target testing” is
recommended, and
Routine testing should not
be done in low prevalence
areas
As the school nurse, you
may be asked to do the
testing for a “high-risk
child”
16. High Risk for TB
People at High Risk for an LTBI infection People at High Risk for active TB disease
Close contacts of people known or suspected
to have TB
People living with HIV
People, including children, who have come to
the United States (within the last 5 years) from
areas of the worlds where TB is common (for
example, Asia, Africa, Russia, Eastern Europe,
or Latin America)
People recently infected with M. tuberculosis
(within the past 2 years)
Low-income groups with poor access to health
care, including homeless people
People with medical conditions known to
increase the risk for TB
o Silicosis
o Diabetes mellitus
o Severe kidney disease and certain
intestinal conditions
o Certain types of cancer & Organ transplant
o Immunosuppressive therapy (prolonged
use of corticosteroids and (TNF-alpha)
17. People at High Risk for an LTBI infection People at High Risk for active TB disease
People who inject illegal drugs People who inject illegal drugs
People who live and work in high-risk
residential settings (for example, nursing
homes, homeless shelters, or correctional
facilities)
Infants and children younger than 4 years
Healthcare workers who serve high risk
clients
Low body weight
Healthcare or ethnic minority populations, as
locally defined
Infants, children and adolescents exposed to
adults in high-risk groups
High Risk for TB Cont’d
18. What constitutes as Target Testing TB
Targeted testing is a TB control strategy that is used to identify and
treat persons who are at high risk for LTBI or at high risk for
developing TB disease.
During patient evaluations, healthcare providers should identify and
test persons who are at high risk for TB.
Testing activities should only done when there is a plan for follow-up
care to evaluate and treat all individuals diagnosed with LTBI or TB
disease. “The decision to test is the decision to treat”.
People who are not high risk for LTBI generally should not be tested.
Testing in low-risk populations can take resources away from other
important activities.
19. How to determine if you repeat a TB Skin test
on a child?
How to perform a TB test?
TST using the Mantoux method is the only skin testing method that should be used. Before
administration, it is important to obtain the student/patient’s TST history.
No
Has the child ever tested positive using the Mantoux TST
method?
If No IF Yes
Yes No
Yes No
Does the documentation have the dr. signature, date, mm?
?reading?
Child is exempt Is there documented
history of treatment?
Ask for written documentationProceed with the TST
Proceed Wit the TestChild may be exempt;
inquire with DSHS
21. TB Treatment Plan
Medicine Dosage and Timings
Isoniazid (INH)
9 months/ *2 every week= 76 doses
These two doses must be 72 hours apart
(at least alternative days). For instance,
(M & Th), (Tu & F) or (M & F)
Latent TB Infection Treatment Plan
Medicine Dosage and Timings
Isoniazid and Rifampin (INH/RIF)
7 days a wk. (14days)
2 days a wk. (60 days)
Total of 40 doses
Isoniazid and Pyrazinamide
(INH/PZA)
7 days a wk. (14days)
2 days a wk. ( 6 months)
= Total of 76 doses
Active TB Disease Treatment Plan
22. Methods of the Project
Literature research on educational
TB resources
Annotation of the previously written
material for the project.
Proposed modifications to the
DSHS and submitted work plan
for approval
Initiate and complete writing phase
References and appendix
Phase I- Project Research & Writing
23. Methods Continued
Submit for review to DSHS
Supervisor
Create an anonymous feedback
survey and administer to a
sample of school nurses.
Gather the survey results and
discuss feedback
Finalize the document.
Submission to DSHS for
publication and usage as a future
resource
Phase II- Project Evaluation and
Analysis
24. Results
100% of the respondees
found it to be a helpful
addition to TB training &
related educational
materials.
For 100% of the
respondees, it took less
than an hour to read
100% of the respondees
indicated that the guide
addressed all the relevant
TB related topics for school
nurses
100% of the respondees
indicated the guide
provides detailed
instructions on Direct
Observed Therapy (DOT)
with visual aids
67% of the respondees
found the guide “easy to
read” whereas 33% found
the guide “very easy to
read”
25. Recommendations
Officially publish
the desk- guide
under as a DSHS
resource
Distribution of the
guide to all the
school nurses and
school campus
DOT providers
Continued Training
and CE for school
nurses on TB
related topics
26. References
Adverse Reactions. (2008, April). Retrieved 11 05, 2015, from Curry International Tuberculosis Center:
www.currytbcenter.ucsf.edu/drtb
Arbex, M. A., Varella, M. d., Siqueira, H. R., & Mello, F. A. (2010). Antituberculosis drugs: Drug interactions, adverse effects, and
use in special situations. Part 1: First-line drugs. J Bras Pneumol, 626-640.
Clinic Locations- Region 4/5 N. (2016, May). Retrieved November 5, 2015, from http://www.dshs.state.tx.us/region4-5/Clinic-
Locations.pdf
CDC | TB | Basic TB Facts. (2012). Retrieved from Centers of Disease Control and Prevention website:
http://www.cdc.gov/tb/topic/basics
Diagnostic Standards and Classification of Tuberculosis. (1990). American Review of Respiratory Disease, 142(3), 725-735.
doi:10.1164/ajrccm/142.3.725
Direct Observed Therapy [Photograph]. (2014). Retrieved from https://results.usaid.gov/georgia/health/tuberculosis#fy2014
Graham, S. M. (2015). Desk-Guide For Diagnosis and Management of TB in Children. Retrieved from International Union against
TB and Lung Disease (The Union) website: http://www.theunion.org/what-we-do/publications/technical/desk-guide-for-
diagnosis-and-management-of-tb-in-children
Health Service Region 4/5N Tuberculosis Elimination Program. (2015, March). Retrieved from
http://www.dshs.state.tx.us/region4-5/tuberculosis.shtm
How To Administer, Read and Interpret TB. (2014). Retrieved from
http://www.parsterileproducts.com/products/products/aplisol/administer-read-interpret.php
Mantoux- Tuberculin Skin Test [Poster]. (2012). Retrieved from
http://www.cdc.gov/tb/publications/Posters/images/Mantoux_wallchart.pdf
Self-Study Module on Tuberculosis: Transmission and Pathogenesis of Tuberculosis. (2008). Retrieved from US Department of
Health and Human Services & Centers for Disease Control and Prevention- Division of Tuberculosis Elimination website:
http://www.cdc.gov/tb/education/ssmodules/pdfs/module1.pdf
Self-Study Module on Tuberculosis: Treatment of Latent Tuberculosis Infection and Tuberculosis Disease. (2008). Retrieved from
US Department of Health and Human Services & Centers for Disease Control and Prevention- Division of Tuberculosis
Elimination website: http://www.cdc.gov/tb/education/ssmodules/pdfs/module4.pdf
Self-Study Modules on TB: Targeted Testing and the Diagnosis of Latent Tuberculosis Infection and Tuberculosis Disease.
(2008). Retrieved from US Department of Health and Human Services & Centers for Disease Control and Prevention- Division of
Tuberculosis Elimination website: http://www.cdc.gov/tb/education/ssmodules/pdfs/module3.pdf
Texas Department of State Health Services- Health Service Region 4/5N: Tuberculosis Manual ( ). (2015). Tyler, TX: Texas
Department of State Health Services.
Tuberculosis Control Laws and Policies: A handbook for Public Health and Legal Practioners. (2009). Retrieved from Centers for
Disease Control and Prevention website: http://www.cdc.gov/tb/programs/TBLawPolicyHandbook.pdf
Tuberculosis Day. (2015). Retrieved from http://www.earthtimes.org/newsimage/world-tuberculosis-day_24-3-2013.jpg
Working towards a TB and HIV free community [Photograph]. (2013, February). Retrieved from
http://emailblog.graphicmail.com/mobile-marketing-case-study-tbhiv-care-association/
Let’s dive into some statistics. For instance, Co-infection with TB and diabetes is also more common along the border than in the rest of the state.
Above in the graph are 10 of the Texas counties with highest TB incidence rates in 2014. These top 10 counties account for 934 cases out of the 1269 cases which is about 73.6% of the total TB cases in the state of TX IN 2014. One of the reason that Harris county has a large number of active TB disease because the city of Houston is the immigration hub where all the immigrant population and refugees go to get checked for TB.
In Health Service Region 4/5N, we had approximately 43 cases of active TB disease and LTBI’s in 2014. That’s about 3.4% of the total number of cases in the state. Even with the lowest percentage of TB incidence rate in the state, we have 21 public health clinics with ___________ clinics committed to providing TB services. One can imagine the benefits of the desk-guide in regions with higher incidence rates of TB for instance region 6/5S, and region 2/3. In fact, the school nurses of the entire state can benefit from this desk-guide.
HOW MANY SCHOOL DISTRICTS in TX? How many of the TB cases are pediatric including LTBI?
The probability of these being treated in the school is high, so, Any body between 5-17 are in done in school
Given than 3.5 is just in region 4/5 , than the need is higher in other regions
So, than let’s ask the question of Why is there need for a TB Guide for school Nurses? What is the Situation? Currently, There is no formal literature out there that addresses the problem of TB on school campuses. The Texas Health guide for schools only allocated 2 pages to the topic of TB. Hence, there is a need for state literature that goes into more detail
Why is the purpose of this TB Guide? The purpose of this guide is to educate the school nurses on the right protocol if and when a TB case arrives on a school campus. Due to confidentiality of the patient information and HIPPA laws, it is significant to adequately train the state’s school nursing staff, so they are well prepared when a school student is diagnosed with TB.about the topics of TB.
Because TB is one of the communicable disease with a low incidence rate, that is not taught heavily in school (1 paragraph to TB). But when it happens, it is serious. Hence, we need a well trained school nursing staff to assess and control the situation before any panick happends on the school campuses.
The new jersey manual and CDC module is the current one!
The above chart lists the name of counties with TB cases that are twice the average TX. Nacogdoches county where I am placed for this internship is also classified as a high risk county!
Oover the span of there years
alk about the region, where is it (Distance from capital), the number of counties, the schools, demographics of the region. immigrant population coming in from foreign countries causing a high number of TB cases. I am working at a sub office in Nacogdoches, TX. A percentage of _______% people diagnosed in our county.
Wendy’s notes
Overview of the Project Outside factors Influences driving the Need for the Project
The above table lists the percentage of TB cases with various risk factors. These risk factors were previously present in the patient at the time of TB diagnosis. One of these risk factors is an HIV positive status with a co-infection of TB. The reason many HIV patients get co-infected with TB is because _________________________________there are 11 risk factors in the top 10 counties of TX.
If there are kids that are HIV positive, or diabetes than the risk factors are higher and the timeline from EXPOSURE TO developing active disease is shortened
Now, lets talk a little bit about TB. Here is a diagram that describes the process of TB transmission and pathogenesis. TB is caused by the Mycobacterium tuberculosis (M. tuberculos)
LTBI is when you have the infection but it has not been activated. It is not just exposure!!!!
DSHS lab started doing quant test to determine if the patient has a LTBI
However, according to CDC the QFT-GIT is gold standard in testing which excludes BCG from being in the test.
Intravenous corticosteroids, and TNF-alpha (Tumor necrosis factor-alpha)the contact to the Co ase, the area wehre TB is common. US. Is the only county that treats latent TB. 5-10% of the cases convert form LTBI to the active TB disease, and this even higher if they have diabetes, HIV or other immunosuppressive risk factors
“The decision to test is the decision to treat”. Because if you don’t follow-up treatment, there is a higher chance for drug resitance which makes treatment even more difficult to folow
A positive TB skin test will always come out positive in any TST. Hence, before TST is administered to a patient, the school nurse must ask her self the series of following questions. It should be noted that a patient who has never been treated for TB can be tested multiple times with a 90 day gap in between each TST.
It is very important that the school nurse accurately interpret the results of the TB skin test. Different sizes of indurations are considered positive in different population groups. For instance, an induration of 5 mm is considered positive in HIV infected person or with other known disease, whereas an induration of 10mm or more is considered positive in immigrants and TB health professional. Hence, a patients in medical and social history is important before deciding a test result is positive. For unsure results, the doctors can prescribe a chest X RAY to confirm diagnosis.
The above are the two standard treatment plan for our two different types of TB patients. This is an overview of how the treatment [plan will look like. Not like anitbiotics!
Here is the method section of the entire project. This section has been strategically divided into two phases. The first phase consisted of extensive literature research, reading previous state literature on TB. This phase also included the actual writing of the guide followed by scheduled edits and reviews by supervisor.
The phase II of the guide consisted of project evaluation and data analysis. In this phase several (20) schools of the East Texas area were contacted to read the guide and provide feedback through an anonymous survey. This was followed by an analysis of the survey results and implementation of any recommendations with the supervisor’s approval.
Above are the results of the survey I conducted to gather the feedback of the school nurses. The survey consisted of 6 closes-ended questions and 4 open ended questions. After the data analysis on the survey, I have put together 5 main key findings. These findings highlight the need and importance of educational TB literature that is catered specifically to the school nurses and school related healthcare workers. Shoud I do a comment slide?
Here are few of the recommendations that I have from the project.
Official publication of the desk-guide from DSHS as a educational resource
Distribution of the print copy in top 10 counties and online publication on DSHS website for access to school nurses of the entire TX
Continuing training of healthcare professionals and school nurses with CE courses on TB related topics
All of this will help the states public health work force to “Think TB” and no TB diagnosis will go untreated or undertreated.
Why is HIV/TB co-infection common in urban areas?
Immunosuppression as a result of HIV infection increases the frequency and speed of progression from latent tuberculosis (TB) infection to active TB(1, 2). According to the World Health Organization (WHO), TB is one of the major causes of death among HIV infected people, and TB/HIV co-infection has been found to reduce the effectiveness of directly observed therapy (DOT) treatment of TB (3, 4).
