CDC Clinician Communication Update - June 7, 2007

The following is a summary of clinical guidance for evaluation and management of persons potentially exposed to XDR TB on two recent transatlantic flights.

If you have any questions on these or other clinical issues, please write to us at coca@cdc.gov.

Introduction

Dear Healthcare Professional,

A person with recently diagnosed culture-confirmed, extensively drug-resistant pulmonary tuberculosis (XDR TB) traveled on the following two extended flights (more than 8 hours in duration) in May 2007:

For purposes of this XDR TB contact investigation, all U.S. residents and citizens who were on the flights listed above are to be considered contacts of the XDR TB patient.

If a person identifies themselves as a passenger on one of these flights, we are requesting your assistance to perform TB evaluation and testing, or to refer the passenger to the appropriate state or local TB Control office so TB testing, evaluation and follow-up can be performed.

TB Controller Officers - State (PDF)

TB Controller Officers - City (PDF)

Specific information must be collected on each passenger as part of this contact investigation. Please access the XDR TB Contact Investigation Form (PDF) and enter the requested information.

Please keep a copy of this completed form for your records, give a copy to the person tested, and also please contact your State or Local TB Control office.

For any inquiries related to this investigation, please call your State or Local TB Control office:

TB Controller Officers - State (PDF)

TB Controller Officers - City (PDF)

Below on this update are the latest algorithms for evaluation and management of both non-immunocompromised and immunocompromised contacts of this XDR TB patient.

We greatly appreciate your assistance on this important international XDR TB contact investigation.

Summary of Post-exposure TB Evaluation & Testing

As noted above, for purposes of this XDR TB contact investigation, all U.S. residents and citizens who traveled on either of the flights listed above are to be considered contacts of the XDR TB patient. Among persons who are infected with M. tuberculosis (i.e., latent tuberculosis infection), it can take 8 to 10 weeks following exposure until the tuberculin skin test (TST) result or QuantiFERON®-TB Gold (QFT-G) becomes positive.

A first-round TST or QFT-G, not both, should be performed as soon as possible following exposure to the XDR TB patient.

If the first round of symptom screening and TST or QFT-G result is negative, a second TB evaluation and TST or QFT-G is performed 8-10 weeks following the last known exposure to the XDR TB patient on the flight (i.e., Round 2 testing).

A second-round of TB evaluation and testing should be done because a negative TST or QFT-G result obtained < 8 weeks after exposure may be considered unreliable for excluding latent tuberculosis infection (LTBI).

For purposes of a contact investigation, a TST result of = 5 mm induration is positive for any contact.

Persons with a documented prior positive TST or QFT-G result, or those who have been previously diagnosed with TB disease, do not need to be retested.

However, these persons should still undergo TB evaluation, which may include signs and symptoms screening and chest X-ray.

Persons who have a history of BCG vaccination should also undergo TB evaluation and testing. Use of TST or QFT-G can be used in BCG-vaccinated persons. In persons previously vaccinated with BCG, a TST result of = 5 mm induration is also considered a positive result and warrants further evaluation.

Consultation with a TB expert, especially one with experience in managing MDR or XDR TB, is strongly recommended. This is recommended especially for any contact suspected of having active TB disease who has a positive TST or QFT-G result or who is immuncompromised, regardless of TST or QFT-G result.

Resources for consultation:

1. Local or state TB control program
2. TB Regional Training and Medical Consultation Centers

Evaluation Algorithm for Non-immunocompromised Contacts

Management of Non-immunocompromised Contacts with Positive TST or QFT-G Results

Evaluation Algorithm for Immunocompromised Contacts

Management of Immunocompromised Contacts with Positive TST or QFT-G Results

Notes for Algorithms: Medical Evaluation of XDR TB Contacts

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