# Presentation: 850214

## COCA Conference Call – 6/19/07Summary of Clinical Guidance: Evaluation and Management of Persons Potentially Exposed to XDR TB on Two Recent Transatlantic Flights

- Division of Tuberculosis Elimination
- Centers for Disease Control and Prevention (CDC)

## Situational Review

- CDC is currently investigating a case of extensively drug resistant tuberculosis (XDR TB). The case involves a U.S. citizen with potentially infectious XDR TB who traveled to and from Europe on commercial flights between May 12 and May 24, and then re-entered the U.S. at the Canada-U.S. border via automobile.
- Since May 25, the patient has been hospitalized in airborne isolation or wearing an appropriate mask, and is now receiving medical therapy for XDR TB.

## Timeline

## CDC Letter to Healthcare Providers

- 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:
- Date From To Airline / Flight#
- May 12/13 Atlanta, Georgia Paris, France Air France #385 // Delta #8517
- May 24 Prague, Czech Republic Montreal, Canada Czech Air #104
- XDR TB is defined as a subtype of multidrug resistant TB (MDR TB) (i.e., an isolate resistant to at least isoniazid and rifampin),
- with additional resistance to at least two of the most important second-line antibiotics (i.e., a fluoroquinolone and an injectable agent
- [amikacin, kanamycin, or capreomycin]).
- Since May 25, the patient has been hospitalized in airborne isolation or wearing an appropriate mask, and is now receiving
- medical therapy for XDR TB. He has remained relatively asymptomatic, and his sputum smear results were negative for acid fast bacilli (AFB),
-  both before and after his travel; however, his sputum culture results are positive for XDR TB.
- This is the first investigation of a case of XDR TB during air travel. Due to the serious nature of this strain of TB disease,
- CDC is recommending that all U.S. residents and citizens on these two flights receive evaluation, testing, and follow-up for TB infection.
- We are requesting your assistance to perform TB evaluation and testing on any person identified as a contact on one of these flights.
- Access the XDR TB Contact Investigation Form (PDF - 83K) 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 inquiries related to this investigation, please call your State or Local Health Department. For more information about XDR TB.
- We greatly appreciate your assistance on this important international XDR TB contact investigation.

## Principles of TB Testing

- 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 baseline test should be followed-up in 8-10 weeks with subsequent retesting

## Event-Specific Considerations

- 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 via TST or QFT-G.
- However, it is important to note that these persons should still undergo TB evaluation, which may include signs and symptoms screening and chest X-ray.** **

## 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

-     1) Management of contacts to XDR-TB patients is complex and largely based on expert opinion. Individual patient decisions may need to vary from these algorithms based on individual circumstances. Consultation with a TB expert, especially one with experience in managing MDR or XDR TB, is strongly recommended, especially for any contact suspected of having TB disease, who has a positive TST or QFT-G result or  who is immuncompromised regardless of TST or QFT-G result. For purposes of this investigation, immunocompromised contacts are those in the highest risk category according to the Targeted Tuberculin Testing and Latent Tuberculosis Treatment guidelines. (http://www.cdc.gov/MMWR/preview/MMWRhtml/rr4906a1.htm)

## Notes for Algorithms (cont.)

- 2) Resources for consultation:a) Local or state TB control program. http://www.cdc.gov/tb/pubs/tboffices.htmb) Tuberculosis Regional Training and Medical Consultation Centers http://www.cdc.gov/tb/rtmcc.htm
- 3) Use of TST or QFT-G is recommended (not both). Persons with a documented prior positive TST or QFT-G result do not need to be retested. However, it is important to note that these persons should still undergo TB evaluation, which may include signs and symptoms screening and chest X-ray.

## Notes for Algorithms (cont.)

- 4) Per ATS/CDC/IDSA guidelinesDiagnostic  Standards. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htmTB Treatment Guidelines. http://www.cdc.gov/tb/pubs/PDF/1376.pdf  LTBI Guidelines. http://www.cdc.gov/MMWR/preview/MMWRhtml/rr4906a1.htmContact Investigation.  http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htmQuanitFERON-TB Gold®  http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a4.htm5) Examples: work or residence in a homeless shelter or correctional facility, travel to, or residence in countries with TB incidence of at least 20 per 100,000

## Notes for Algorithms (cont.)

- 6) If infected, immunocompromised persons are at a high risk to progress to active TB.   It is impossible to definitively determine if a positive TST or QFT-G result occurred due a prior TB exposure.  INH or rifampin are the only known effective LTBI treatment regimens, some clinicians may elect to treat immunocompromised contacts who have a positive TST or QFT-G result with INH even if the contact does not have a known prior TB exposure or history of spending time in an environment where TB exposure is a significant possibility. Other factors that may be considered in determining whether the positive TST or QFT-G is likely a result of infection from the patient on the flight include proximity to TB patient (seated within 2 rows of patient) and if TST or QFT-G converted from negative to positive 8–10 weeks post exposure.

## Medical Evaluation of XDR TB Contacts 

## Questions ?Email coca@cdc.gov