1–5

Modules

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 

Division of Tuberculosis Elimination

Self-Study Modules on Tuberculosis

Slide Sets

Facilitator 

Guide

Table of Contents 

Introduction ................................................................................................................................... 1

Overview ........................................................................................................................................ 1

Target Audiences ........................................................................................................................ 1

About the Slide Sets ..................................................................................................................... 2

Customizing the Slide Sets .......................................................................................................... 2

To View or Order Module Materials .......................................................................................... 3

Preparation for Training .............................................................................................................. 3

Know the Content ........................................................................................................................ 3

Event Set-Up ............................................................................................................................... 3

Materials Checklist ..................................................................................................................... 4

Training Basics .............................................................................................................................. 5

Understand Your Role as the Facilitator .................................................................................... 5

Know Your Audience................................................................................................................... 5

Apply Adult Learning Principles ................................................................................................ 5

Discuss Ground Rules ................................................................................................................. 6

Utilize the “Parking Lot” ........................................................................................................... 7

Communicate Effectively and Engage Participants ................................................................... 7

Manage the Training................................................................................................................... 8

Sample Agenda ............................................................................................................................ 10

Additional Information .............................................................................................................. 11

Continuing Education Units ..................................................................................................... 11

Additional Information on TB ................................................................................................... 11

Self-Study Modules on Tuberculosis, 1-5 Slide Sets Facilitation Tips ................................... 13

Module 1: Transmission and Pathogenesis of Tuberculosis .................................................... 15

Module 2: Epidemiology of Tuberculosis ................................................................................. 41

Module 3: Targeted Testing and the Diagnosis of Latent Tuberculosis Infection and 

Tuberculosis Disease ................................................................................................................ 63

Module 4: Treatment of Latent Tuberculosis Infection and Tuberculosis Disease ................ 115

Module 5: Infectiousness and Infection Control ..................................................................... 167

Sample Course Evaluation ....................................................................................................... 199

Self-Study Modules on Tuberculosis, 1-5 Course Evaluation ................................................ 201

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Self-Study Modules on Tuberculosis, 1-5 Slide Sets 

Facilitator Guide 

Introduction

Purpose 

The purpose of this guide is to provide facilitators guidance and tips for leading a training using 

the Self-Study Modules on Tuberculosis, 1-5 Slide Sets.

Slide Set Training Package 

The Self-Study Modules on Tuberculosis, 1-5 Slide Sets training package consists of: 

 Facilitator guide 

 Presentation slides for each module 

 Participant slide handouts for each module 

Facilitator Guide 

The facilitator guide is divided into sections that contain 

 An overview of the Self-Study Modules on Tuberculosis, 1-5 Slide Sets

 Preparation information for conducting a training 

 Training basics 

 Sample agenda 

 Additional information 

 Facilitation tips for each of the five module presentations 

 Sample course evaluation 

Overview 

Target Audiences 

The target audiences for trainings using the modules slide set are outreach workers, nurses, 

physicians, administrators, health educators, and students from a variety of settings, including 

 Tuberculosis (TB) programs 

 Managed care organizations 

 Correctional facilities 

 Community-based organizations 

 Homeless shelters 

 Migrant clinics

 Substance abuse facilities 

 Nursing and medical schools 

 Community health centers 

 Other facilities and programs serving persons with or at risk for TB 
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About the Slide Sets 

The Self-Study Modules on Tuberculosis, 1-5 are a series of modules designed to provide 

education on TB in a self-study format. The Self-Study Modules on Tuberculosis, 1-5 Slide Sets

were developed as an accompaniment to the print-based modules to aid in the presentation of 

module content in a facilitator-led training. 

The Self-Study Modules on Tuberculosis Slide Sets consist of five presentations: 

 Module 1: Transmission and Pathogenesis of Tuberculosis

 Module 2: Epidemiology of Tuberculosis

 Module 3: Targeted Testing and the Diagnosis of Latent Tuberculosis Infection and 

Tuberculosis Disease 

 Module 4: Treatment of Latent Tuberculosis Infection and Tuberculosis Disease

 Module 5: Infectiousness and Infection Control 

The content and organizational flow of the slide sets matches that of the print-based modules. 

Each module presentation contains the following sections: 

 Overview and Objectives: A guide to the information participants should learn from the 

module. 

 Learning Material: The material for the module, including bullet points, diagrams, 

charts, illustrations, and photographs. 

 Study Questions: Sets of questions, spread throughout the presentations, designed to 

help participants assess how well they have learned the content of the module. 

 Case Studies: Case studies designed to help participants apply the concepts they have 

learned in the module. 

Note: The study questions and case studies in the slide sets are the same as those in the printbased modules (e.g., study question 1.1 is the same in both the print-based module and the slide 

set presentation). Answers to the study questions and case studies are animated and appear onclick throughout the presentations. Answers are also provided in the facilitation notes and at the 

end of each print-based module. Participant handouts do not contain answers to study questions 

or case studies. 

Customizing the Slide Sets 

The Self-Study Modules on Tuberculosis, 1-5 Slide Sets are in the public domain and therefore 

you are free to adapt and revise these materials. For example, content and images may be 

removed or added based on the training needs and background of the participants. However, you 

must remove the Department of Health and Human Services (DHHS) and Centers for Disease 

Control and Prevention (CDC) names and logos if changes are made. 
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To View or Order Module Materials 

To view or download the Self-Study Modules on Tuberculosis, 1-5 Slide Set materials (facilitator 

guide, presentation slides, and participant slide handouts) please visit 

www.cdc.gov/tb/publications/slidesets/selfstudymodules/default.htm. 

To view or download the Self-Study Modules on Tuberculosis, 1-5 please visit 

www.cdc.gov/tb/education/ssmodules/default.htm. If you would like to request a print copy of 

the Self-Study Modules on Tuberculosis, 1-5 please use the CDC Division of Tuberculosis 

Elimination’s online ordering system: wwwn.cdc.gov/pubs/CDCInfoOnDemand.aspx.

Preparation for Training

Know the Content 

For a training to be successful, it is critical to know the content of what you are training about. 

Even a facilitator with the best of training skills cannot hide the fact that he or she does not know 

the content. 

 Study and review the content prior to the training (not at the last minute) so you will be 

prepared. 

o Read the print-based Self-Study Modules on Tuberculosis, 1-5

o Read the Self-Study Modules on Tuberculosis, 1-5 Slide Sets facilitator guide 

o Work through study questions 

o Work through case studies 

o Review Self-Study Modules on Tuberculosis, 1-5 presentation slides 

 Anticipate areas of confusion 

 Be prepared to answer questions and explain concepts 

 Think about topics participants may find confusing 

 Plan ways to help with difficult sections and topics and how to answer any possible 

questions

Event Set-Up

It is important to have a comfortable learning environment during the training. The room should 

be set up in such a way as to allow for group discussions and ensuring that each participant can 

easily see the presenters and the slides. Two recommended styles include the banquet or chevron 

style (Figure 1). Generally, the U-shape is not recommended because it can limit some 

participants’ ability to see the slides and presenters. 

Before the training, it is important to prepare the training room. This includes: 

 Checking the room before the training day (if possible) 

 Ensuring materials and supplies are available 

 Making sure equipment works 

 Arriving at least an hour early on the training day 
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Figure 1 Room Set-Up Styles.

Banquet Style Chevron Style

Materials Checklist 

You should have the following materials when you conduct a training on the Self-Study Modules 

on Tuberculosis, 1-5:

 Materials and Supplies

Materials and Supplies for Facilitator

Self-Study Modules on Tuberculosis, 1-5 Slide Set presentations (electronic and print)

Facilitator guide for use during presentations

Pens and/or pencils

Print-based Self-Study Modules on Tuberculosis, 1-5 for reference

Materials and Supplies for Participants

Participant handouts of Self-Study Modules on Tuberculosis, 1-5 Slide Set

presentations

Print-based Self-Study Modules on Tuberculosis, 1-5 (optional)

Course evaluations 

Materials and Supplies for Training Classroom

Projection monitor (LCD) compatible with computer

Computer

Screen or wall for viewing presentations

Extension cord

Dry erase board, poster paper, or flip chart with markers

Sign in sheet for participants

Name tags/tents

Pens and/or pencils
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Training Basics

Understand Your Role as the Facilitator 

The facilitator plays a unique role in facilitating the learning experience. One of the most 

important things a facilitator can do is to create a safe and supportive environment for 

participants. Participants need to feel comfortable to 

 Ask any questions – even simple questions 

 Share answers to the study questions and case study questions – even if the answers 

might be incorrect 

Know Your Audience 

One of the most important aspects of training is knowing your audience. Knowing your target 

audience will help you best design your training. Things to think about in terms of your audience 

include: 

 Knowledge regarding topic (i.e., are participants new to the topic area or do they have 

pre-existing knowledge?) 

 Training needs 

 Skills or abilities 

 Attitudes

 Experience 

 Jobs/positions 

There are various ways to get to know your audience. You could get to know your audience by 

doing a “get-to-know-you” exercise at the beginning of the training. It is also a good idea to 

share their expectations of the course. 

Apply Adult Learning Principles 

Adults learn differently from children and therefore require different training approaches. 

Knowing how adults learn is critical to the success of the training course. Understanding adult 

learning principles helps you use the right training techniques to enhance learning. 

The following table provides principles of adult learning and describes some important training 

techniques you can use to engage the course participants. 

Principles of Adult Learning 

Principle Training Technique

1. Adults bring a wealth of knowledge 

and experience which they want to 

share.

Encourage participants to share their 

knowledge and experiences. Include 

activities that utilize their knowledge 

and experience.

2. Adults are decision-makers and selfdirected learners.

Include problem-solving activities.

3. Adults have different learning styles 

that must be respected.

Provide multiple ways for 

participants to learn the material.
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4. Adults want to participate rather than 

just listen to a lecture.

Create a participatory learning 

environment with various types of 

activities.

5. Adults are motivated by information 

or tasks that are meaningful and 

applicable to their jobs.

Relate the content to problems 

participants encounter in their jobs.

6. Adults prefer training that focuses on 

real-life problems.

Relate content to the types of 

problems they encounter in their 

jobs.

7. Adults expect their time during 

training to be used carefully.

Follow a realistic time schedule.

8. Adults feel anxious when participating 

in a group that makes them look 

uninformed, either professionally or 

personally.

Avoid criticism. Acknowledge all 

participants’ contributions.

9. Adults learn best in a positive 

environment where they feel respected 

and confident.

Create a positive environment by 

providing positive feedback and 

showing respect to all participants.

10. Adults come from different cultures, 

life-styles, religious preferences, 

genders, and ages.

Respect all differences and 

encourage participants to respect 

each other’s differences as well.

Discuss Ground Rules 

At the beginning of the training, it is very helpful to discuss “Ground Rules.” These are 

expectations of both the participants and the trainers on basic rules to follow during the training. 

 Ask the participants to share their ideas for ground rules for the training 

 Write suggestions on a flip chart 

 Review the items on the flip chart 

 Use the list below as a guide. Include any of the items below if participants do not 

mention them: 

o Arrive on time for the beginning of each session and after each break 

o Keep each session on time 

o Put cell phones on silent while in the training room 

o Treat each other as equals in the training room 

o Show respect to everyone regardless of age, gender, religion, or culture 

o Share experience and expertise. Many participants have previous experience and 

background in training. 

o All questions are good questions. Feel free to ask questions at any time. 

o Only one person should speak at a time 

o Everyone should participate and contribute. To ensure that the quieter voices are 

heard, do not allow 1 or 2 people to dominate the conversation. 

o No side-bar conversations. Comments should be made to the whole group. 

o Provide feedback, as long as it is constructive, not critical 

o Be flexible with differences in culture and language 

o Accept mispronunciation of names 
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o Wear name tags 

 Mention that ground rules are used throughout the training and new rules can be added. 

Facilitators and participants can refer to the ground rules during the training to remind 

each other about what was agreed to. 

Utilize the “Parking Lot”

The “Parking Lot” is a place where topics can be “parked” for later discussion. You can write 

questions, concerns, or topics on sticky notes to place on a board marked as the Parking Lot so 

that it can be discussed at a later time. This is a great way to manage discussions that are taking 

too long, or those that are getting off topic. 

Communicate Effectively and Engage Participants 

Communicate Effectively 

In order to be a good facilitator, you need to have good communication skills. For instance, 

facial expressions and tone of voice can influence the tone of the training (e.g., either friendly or 

unfriendly). Thus, it is important to have an approachable, friendly face during trainings so that 

people feel comfortable asking questions. 

When conducting a training, it is important to remember to use a “trainer’s voice.” This 

includes: 

 Projecting your voice so everyone can hear you 

 Varying your pitch 

 Using a comfortable and varied pace 

 Speaking at the right technical level 

 Using a friendly tone 

 Using a microphone, if necessary 

Engage Participants 

It is very important to engage participants throughout the training. One way to do this is to use 

various types of questions to 

 Encourage all participants to contribute 

 Allow for differences of opinions 

 Keep participants alert 

 Help you determine participant’s knowledge and understanding 

Types of Questions

Question 

Type Description Examples How to use

Closeended 

Generates short final 

answers such as “yes” or 

“no” or just a few words

 Is it ...?

 Do you need...?

 Have you ever...? 

Obtain a final answer, 

or conclusion, or for 

confirmation
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Openended 

Generates descriptive 

answers that encourage 

discussion

 What are some ways...?

 How can you...?

 Why would you...?

Encourage 

participation and 

sharing of knowledge 

and experiences

Probing Generates additional 

discussion or can be used 

to probe for more 

information 

 Tell me more about...?

 Would you 

elaborate....?

 What is an example...?

Encourage participants 

to explain in greater 

detail about a subject

Other Methods for Engaging the Participants 

Method Description

Analogies Compare two or more situations to help explain complex material. Analogies are 

helpful for teaching about a complex concept or process.

Stories Provide real-life situations from your experience (or the experience of others you 

know) to explain situations or provide examples. Stories are compelling and bring 

the content to life.

Statistics Provide statistics (especially from your jurisdiction) that can demonstrate the 

importance of collecting information or illustrate results of the data.

Energizers Use short physical activities to increase the energy level of participants (especially 

after lunch or when participants are getting tired).

Manage the Training 

As the facilitator, you are the manager of the training and it is up to you to keep the training on 

schedule and under control. There may be difficult situations, difficult participants, and 

unexpected circumstances to deal with. It is your responsibility to keep control and manage the 

problem, whatever it may be. 

Manage time 

Participants typically enjoy group discussions and want to share their ideas and experiences. As a 

result, it is easy for discussions to take too much time or get focused on topics that may not be 

critical to the training. It is important to know when to quit discussing a topic and move on to the 

next part of the training. ELMO (Enough, Let’s Move On) can be used as a code word to bring a 

discussion to a close. 

Manage difficult participants 

Throughout the training, continually assess the dynamics of the group. Occasionally, the learning 

environment might be disrupted by individual participants. Some characteristics of a difficult 

participant include 

 Dominating the conversation 
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 Interrupting others 

 Acting as a know-it-all 

 Not participating 

The following table includes suggestions for dealing with difficult participants. 

Method Description

Maintain control You are the manager of the training and need to stay in control. There 

may be a participant who challenges this, but it is up to you to control the 

situation in a professional manner. 

Use body 

language

 Stand next to or behind participants who are having side-bar 

conversations or are being disruptive

 Look at someone “a little too long” if they are being disruptive 

 Avoid looking at a participant who tries to dominate the conversation

Use verbal cues  For a participant who is dominating the conversation, thank him/her 

for contributing and then ask participants 

o “Are there any other opinions?” 

o “Can we hear from some other participants?”

 Encourage participants who are quiet by

o Asking for opinions from people who haven’t been commenting 

and then looking at those specific people

Refer to the 

“ground rules” 

and the “parking 

lot”

It can be helpful to remind participants of the ground rules established at 

the beginning of the course. You can always add to the ground rules 

throughout the training. If someone is talking too much about a certain 

topic, use the parking lot.

Give the person a 

specific task

If the person is busy, he/she will be less likely to be disruptive. For 

example, have the person write comments on the flip chart or have them 

help keep time.

Change the 

dynamics of the 

group by 

changing seating 

arrangements

If a participant is disruptive, change the seating arrangements.

 Strategically seat the difficult participant up front near you.

 During breaks or lunch change the seating arrangement by moving the 

name tents. Make a general statement when participants return: “In 

order to help you get acquainted with as many other participants as 

possible, the seating arrangements have been changed.” This is 

effective for separating participants who are having side bar 

conversations. 
10

Talk to the 

person outside 

the classroom 

 Address such behaviors in private at your earliest convenience (during 

a break or lunch). Tactfully tell the participant how he/she is being

disruptive. Refer to the ground rules, and reinforce the importance of 

adhering to those rules. 

 Never reprimand a difficult participant in front of the larger group! 

When training adults, it is important to show respect. If you do not, 

they may become resentful and try to challenge you throughout the 

remaining of the training.

Never lose your 

“cool” or be rude

Always treat participants in a professional manner.

Sample Agenda

The Self-Study Modules on Tuberculosis, 1-5 Slide Sets may be used either as a complete course 

or as stand-alone presentations. The sample one-day agenda (below) could serve as the basis for 

a comprehensive training that integrates the information from all five module presentations. 

Note: Times allocated for each section in the agenda are suggestions. All of the curriculum 

content is important; however, every training is different and the facilitator should adjust the 

times allocated according to the needs, knowledge, and experience of the group.

Sample One-Day Agenda 

Time Topic

8:00 – 8:30 am Course Introduction/Overview

8:30 – 9:30 am Module 1, Transmission and Pathogenesis of Tuberculosis

9:30 – 9:45 am BREAK

9:45 – 10:45 am Module 2, Epidemiology of Tuberculosis

10:45– 12:15pm Module 3, Targeted Testing and the Diagnosis of LTBI and TB Disease 

12:15 – 1:15 pm LUNCH

1:15 – 2:45 pm Module 4, Treatment of LTBI and TB Disease 

2:45 – 3:00 pm BREAK

3:00 – 4:15 pm Module 5, Infectiousness and Infection Control 

4:15 – 5:00 pm Summary and Evaluations 
11

Additional Information

Continuing Education Units 

Continuing education units (CEUs), continuing medical education (CME), continuing nursing 

education (CNEs), and continuing education contact hours (CECH) are free of charge for the 

print-based Self-Study Modules on Tuberculosis, 1-5. For more information on CEUs for this 

activity, please visit the CDC Division of Tuberculosis Elimination’s website at 

www.cdc.gov/tb/education/ssmodules/Cont_Ed_regist.htm. 

Additional Information on TB 

For additional information on TB, visit the CDC Division of Tuberculosis Elimination’s website 

at www.cdc.gov/tb. If you have questions on state-specific TB guidelines, please contact your 

state TB control office. A list of state TB control offices can be found on the CDC Division of 

Tuberculosis Elimination’s website at www.cdc.gov/tb.
12
13

Self-Study Modules on 

Tuberculosis, 1-5 Slide Sets

Facilitation Tips
14
15

Module 1: Transmission and Pathogenesis of Tuberculosis 

Facilitation Tips 

Background 

In this module, participants will learn about the history of tuberculosis (TB). Participants will 

also learn how TB is spread from person to person (transmission) and how TB disease develops 

in the body (pathogenesis). Our understanding of the transmission and pathogenesis of TB has 

guided us in developing strategies for controlling the spread of TB and for treating latent TB 

infection (LTBI) and TB disease. As public health workers, participants should understand these 

concepts so that they can educate the patients they serve. 

Learning Objectives 

After this presentation, participants will be able to

1. Briefly describe the history of TB. 

2. Explain how TB is spread (transmission).

3. Define drug-resistant TB.

4. Explain the difference between LTBI and TB disease. 

5. Explain how LTBI and TB disease develop (pathogenesis). 

6. Describe the classification system for TB. 

Module Overview

Time Activity Content Resources Needed

10 min. Presentation Introduction Slides 1-5

5 min. Presentation History of TB Slides 6-15

5 min. Presentation TB Transmission Slides 16-24

5 min. Presentation Drug-Resistant TB Slides 25-30

10 min. Presentation TB Pathogenesis Slides 31-47

10 min. Presentation Progression from LTBI to 

TB Disease Slides 48-56

5 min. Presentation Sites of TB Disease Slides 57-60

5 min. Presentation TB Classification System Slides 61-64

5 min. Case Studies Case Studies Slides 65-69

60 min. Total Time
16

Facilitation Tips

Slide 1

Self-Study Modules 

on Tuberculosis, 1-5 

Centers for Disease Control and Prevention

Division of Tuberculosis Elimination

2016

 Ask participants to introduce themselves, 

stating their names and organizations

 Provide information about the following:

oLocation of restrooms

oRefreshments, if provided

 Discuss ground rules and the parking lot

 Ask participants to sign participant roster

 Introduce yourself to participants. Include 

your name and what organization you 

represent. 

Slide 2

CDC Self-Study Modules on 

Tuberculosis, 1-5 

• Module 1: Transmission and Pathogenesis of TB

• Module 2: Epidemiology of TB

• Module 3: Targeted Testing and the Diagnosis of 

Latent TB Infection and TB Disease 

• Module 4: Treatment of Latent TB Infection and 

TB Disease

• Module 5: Infectiousness and Infection Control

Module 1 – Transmission and Pathogenesis of Tuberculosis 2

 Explain to participants that the presentations 

were created using the print-based Self-Study 

Modules on Tuberculosis, 1-5

 Ask who has worked through the print-based 

modules before

 Review slide content

 Mention that each module includes content 

about that topic

 State that study questions and case studies 

are included in each module to help reinforce 

and apply content
17

Slide 3

Self-Study Modules 

on Tuberculosis

Module 1 – Transmission and Pathogenesis of Tuberculosis 3

Transmission and

Pathogenesis of 

Tuberculosis

 Introduce Module 1

Slide 4

Module 1 – Transmission and Pathogenesis of Tuberculosis 4

Module 1: Objectives

At completion of this module, learners will be

able to

1. Describe the history of tuberculosis (TB).

2. Explain how TB is spread (transmission).

3. Define drug-resistant TB.

4. Explain the difference between latent TB infection 

(LTBI) and TB disease.

5. Explain how LTBI and TB disease develop 

(pathogenesis).

6. Describe the classification system for TB.

 State objectives of presentation 

Background and Objectives - Module 1, p. 1

Slide 5

Module 1 – Transmission and Pathogenesis of Tuberculosis 5

• History of TB

• TB Transmission

• Drug-Resistant TB 

• TB Pathogenesis

• Progression from LTBI to TB disease

• Sites of TB disease

• TB Classification System

• Case Studies

Module 1: Overview

 Review slide content 
18

Slide 6

History of TB

Module 1 – Transmission and Pathogenesis of Tuberculosis 6

 Introduce section

History of TB - Module 1, pp. 5-6

Slide 7

Module 1 – Transmission and Pathogenesis of Tuberculosis 7

• TB has affected 

humans for millennia

• Historically known by 

a variety of names, 

including:

– Consumption

– Wasting disease

– White plague

• TB was a death 

sentence for many

History of TB (1)

Vintage image circa 1919

Image credit: National Library of Medicine 

 Before showing slide, ask participants if they 

know of other names for TB

 Review slide content

History of TB - Module 1, p. 5

[Image credit: U.S. National Library of Medicine]

Slide 8

Module 1 – Transmission and Pathogenesis of Tuberculosis 8

• Until mid-1800s, many 

believed TB was 

hereditary

• 1865 Jean AntoineVillemin showed TB 

was contagious

• 1882 Robert Koch 

discovered M. 

tuberculosis, the 

bacterium that causes 

TB 

Mycobacterium tuberculosis

Image credit: Janice Haney Carr

History of TB (2)

Scientific Discoveries in 1800s

 Review slide content

 Note that the image is of Mycobacterium 

tuberculosis 

History of TB - Module 1, p. 5

[Image credit: Janice Haney Carr]
19

Slide 9

Module 1 – Transmission and Pathogenesis of Tuberculosis 9

• Before TB antibiotics, 

many patients were 

sent to sanatoriums

• Patients followed a 

regimen of bed rest, 

open air, and sunshine

• TB patients who could 

not afford sanatoriums 

often died at home

History of TB (3)

Sanatoriums

Sanatorium patients resting outside

 Review slide content 

 Explain that the image is of women at a 

sanatorium resting outside

 Note that it used to be believed that cool, 

fresh air was beneficial for TB patients

History of TB - Module 1, p. 5

Slide 10

Module 1 – Transmission and Pathogenesis of Tuberculosis 10

Breakthrough in the Fight 

Against TB (1)

Drugs that could kill TB

bacteria were discovered

in 1940s and 1950s

• Streptomycin (SM) 

discovered in 1943

• Isoniazid (INH) and

p-aminosalicylic acid (PAS) 

discovered between 1943 

and 1952 

 Review slide content 

History of TB - Module 1, p. 5

Slide 11

Module 1 – Transmission and Pathogenesis of Tuberculosis 11

Breakthrough in the Fight 

Against TB (2)

• TB death rates in U.S. began to drop 

dramatically

• Each year, fewer people died from TB

• Most TB sanatoriums in U.S. had closed by 

mid 1970s

 Review slide content 

 Mention that as the number of cases and 

deaths declined, many people began to hope 

that TB could be eliminated from the U.S., like 

smallpox and polio

History of TB - Module 1, p. 5
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Slide 12

Module 1 – Transmission and Pathogenesis of Tuberculosis 12

TB Resurgence

• Increase in TB in mid 

1980s

• Contributing factors:

– Inadequate funding for TB 

control programs

– HIV epidemic

– Increased immigration from 

countries where TB is common

– Spread of TB in homeless 

shelters and correctional 

facilities

– Increase and spread of 

multidrug-resistant TB March 16, 1992 Newsweek Magazine Cover

 Before showing the slide, ask participants 

why there was an increase in TB in the U.S. 

during the mid-1980s

 Review slide content 

TB Resurgence - Module 1, p. 5 and Module 2, p. 4

Slide 13

Module 1 – Transmission and Pathogenesis of Tuberculosis 13

• Increased governmental funding for TB control 

programs began in 1992

• Number of TB cases declined from 1993 to 2014

Reported TB Cases, U.S., 1982-2014

TB Prevention and Control Efforts

Year

No. of Cases

 Review slide content

 Point out the increase (1980s) and decrease 

(after 1993) in TB cases on the graph

 Stress that prevention and control efforts 

must be maintained since TB continues to be 

reported in almost every state and not all 

states have seen a decrease in TB cases

TB Prevention and Control Efforts - Module 2, pp. 4-5

Slide 14

Module 1 – Transmission and Pathogenesis of Tuberculosis 14

TB History Timeline

 Recap the major events in the history of TB

TB History Timeline - Module 1, p. 6
21

Slide 15

Module 1 – Transmission and Pathogenesis of Tuberculosis 15

In what year was each of the following

discoveries made?

a. TB was shown to be contagious 

1865

b. The bacterium that causes TB was discovered

1882

c. The first drug that could kill TB bacteria was 

discovered

1943

History of TB

Study Question 1.1

 Introduce study questions 

 Ask participants to turn to p. 6 (if participants 

have print-based modules)

 Ask for a volunteer to read question 

 Ask participants for answers

 Click enter for the answer to appear

Note: All study questions and case studies are animated. 

The question appears first. Click “enter” and the answer 

will appear.

Answers – Module 1, p. 26

Slide 16

TB Transmission

Module 1 – Transmission and Pathogenesis of Tuberculosis 16

 Introduce section

 Ask participants how TB is transmitted

TB Transmission - Module 1, pp. 7-8

Slide 17

Module 1 – Transmission and Pathogenesis of Tuberculosis 17

Transmission is defined as the spread of an 

organism, such as M. tuberculosis, from one 

person to another.

TB Transmission (1)

 Ask for a volunteer to read the definition of 

transmission 

Definition of Transmission – Module 1, p. 7
22

Slide 18

Module 1 – Transmission and Pathogenesis of Tuberculosis 18

• M. tuberculosis causes most TB cases in U.S.

• Mycobacteria that cause 

TB:

– M. tuberculosis 

– M. bovis

– M. africanum

– M. microti

– M. canetti

• Mycobacteria that do not 

cause TB

– e.g., M. avium-complex

M. tuberculosis

TB Transmission (2)

Types of Mycobacteria

 State that mycobacteria are members of the 

bacteria family

 Explain that not all mycobacteria cause TB

 Review slide content

Types of Mycobacteria - Module 1, p. 7

Slide 19

Module 1 – Transmission and Pathogenesis of Tuberculosis 19

• TB is spread person to 

person through the air via 

droplet nuclei

• M. tuberculosis may be 

expelled when an 

infectious person:

– Coughs

– Speaks 

– Sings

• Transmission occurs when another person 

inhales droplet nuclei

TB Transmission (3)

 Review slide content

 Note that droplet nuclei are very small 

particles, less than 1/5,000 of an inch, and 

can remain suspended in the air for several 

hours

 Emphasize that transmission is more likely to 

occur in poorly ventilated and enclosed areas

TB Transmission - Module 1, p. 7

Slide 20

Module 1 – Transmission and Pathogenesis of Tuberculosis 20

TB Transmission (4)

Dots in air represent droplet nuclei containing

M. tuberculosis

 Note that this image depicts airborne 

transmission. The individual on the left has 

infectious TB disease and is expelling it into 

the air. The individual on the right is inhaling 

the droplet nuclei into their lungs.

Note: Dots in the image are animated. Click “enter” once 

to start animation.

TB Transmission - Module 1, p. 8
23

Slide 21

Module 1 – Transmission and Pathogenesis of Tuberculosis 21

• Probability that TB will be transmitted depends 

on:

– Infectiousness of the TB patient

– Environment in which the exposure occurred

– Frequency and duration of the exposure

– Susceptibility (immune status) of the exposed 

individual

• The best way to stop transmission is to:

– Isolate infectious persons

– Provide treatment to infectious persons as soon as 

possible

TB Transmission (5)

 Emphasize that not everyone who is exposed 

to TB becomes infected; it depends on many 

factors

 Review slide content

 Note that the length of time required for a 

patient to be considered noninfectious after 

starting treatment varies

TB Transmission - Module 1, p. 8

Slide 22

Module 1 – Transmission and Pathogenesis of Tuberculosis 22

TB Transmission

Study Question 1.2

What organism causes TB?

M. tuberculosis

What are four other tuberculous mycobacteria?

M. bovis, M. africanum, M. microti, and M.

canetti

 Introduce study questions

 Ask participants to turn to p. 10 (if 

participants have print-based modules)

 Ask for a volunteer to read question 

 Ask participants for answers

Answers – Module 1, p. 26

Slide 23

Module 1 – Transmission and Pathogenesis of Tuberculosis 23

TB Transmission

Study Question 1.3

How is TB spread? 

TB is spread from person to person 

through the air via droplet nuclei 

containing M. tuberculosis.

 Read question 

 Ask participants for answers

Answers – Module 1, p. 26
24

Slide 24

Module 1 – Transmission and Pathogenesis of Tuberculosis 24

The probability that TB will be transmitted 

depends on what four factors?

• Infectiousness of the TB patient

• Environment in which exposure occurred

• Frequency and duration of the exposure

• Susceptibility (immune status) of the 

exposed individual

TB Transmission

Study Question 1.4

 Read question 

 Ask participants for answers

Answers – Module 1, p. 26

Slide 25

Drug-Resistant TB

Module 1 – Transmission and Pathogenesis of Tuberculosis 25

 Introduce section

Drug-Resistant TB - Module 1, p. 9

Slide 26

Module 1 – Transmission and Pathogenesis of Tuberculosis 26

• Caused by M. tuberculosis organisms resistant 

to at least one TB treatment drug 

• Resistant means drugs can no longer kill the 

bacteria

Drug-Resistant TB (1)

 Review slide content 

 Note that drug-resistant TB is more difficult to 

treat because there are fewer treatment 

options

Drug-Resistant TB - Module 1, p. 9
25

Slide 27

Module 1 – Transmission and Pathogenesis of Tuberculosis 27

Mono-resistant Resistant to any one TB treatment 

drug

Poly-resistant Resistant to at least any 2 TB drugs 

(but not both isoniazid and rifampin)

Multidrugresistant 

(MDR TB)

Resistant to at least isoniazid and 

rifampin, the 2 best first-line TB 

treatment drugs

Extensively 

drug-resistant 

(XDR TB)

Resistant to isoniazid and rifampin, 

PLUS resistant to any fluoroquinolone 

AND at least 1 of the 3 injectable antiTB drugs (e.g., amikacin, kanamycin, 

or capreomycin)

Drug-Resistant TB (2)

 Review slide content

 Note that XDR TB is the most difficult type of 

drug-resistant TB to treat

 Explain that patients with drug-resistant TB 

should be closely monitored to see if they are 

responding to treatment; they should also 

remain in isolation until they are no longer 

infectious

Drug-Resistant TB - Module 1, p. 9

Slide 28

Module 1 – Transmission and Pathogenesis of Tuberculosis 28

Primary 

Resistance

Caused by person-to-person 

transmission of drug-resistant 

organisms

Secondary 

Resistance 

(acquired)

Develops during TB treatment:

• Patient was not treated with an

appropriate regimen

OR

• Patient did not follow treatment 

regimen as prescribed

Drug-Resistant TB (3)

 State that drug-resistant TB can be caused in 

two ways, primary and secondary

 Review slide content

 Note that drug-resistant TB can be 

transmitted in the same way as drugsusceptible TB; however, because it takes 

longer to diagnose, patients with drugresistant TB may be infectious for longer 

periods of time

Drug-Resistant TB - Module 1, p. 9

Slide 29

Module 1 – Transmission and Pathogenesis of Tuberculosis 29

Drug-resistant TB

Study Question 1.5

What is drug-resistant TB?

Drug-resistant TB is caused by M. 

tuberculosis organisms that are resistant 

to at least one anti-TB drug. 

Drug-resistant TB can be difficult to treat.

 Introduce study questions

 Ask participants to turn to p. 10 (if 

participants have print-based modules)

 Ask for a volunteer to read question 

 Ask participants for answers

Answers – Module 1, p. 26
26

Slide 30

Module 1 – Transmission and Pathogenesis of Tuberculosis 30

Drug-resistant TB

Study Question 1.6

What is the difference between primary and 

secondary drug resistance?

• Primary resistance is caused by person-toperson transmission of drug-resistant 

organisms. 

• Secondary resistance develops during TB 

treatment. Either the patient was not 

treated with the right TB drugs or the 

patient did not follow the prescribed 

treatment regimen. 

 Read question 

 Ask participants for answers

Answers – Module 1, p. 26

Slide 31

TB Pathogenesis

Module 1 – Transmission and Pathogenesis of Tuberculosis 31

 Introduce section

 Ask participants if they can explain 

pathogenesis

TB Pathogenesis - Module 1, p. 11

Slide 32

Module 1 – Transmission and Pathogenesis of Tuberculosis 32

Pathogenesis is defined as the way an 

infection or disease develops in the body.

TB Pathogenesis (1)

 Ask for a volunteer to read the definition of 

pathogenesis 

TB Pathogenesis - Module 1, p. 11
27

Slide 33

Module 1 – Transmission and Pathogenesis of Tuberculosis 33

• LTBI occurs when tubercle bacilli are in the 

body, but the immune system is keeping them 

under control

• LTBI is detected by the Mantoux tuberculin skin 

test (TST) or by an interferon-gamma release 

assay (IGRA), such as:

– QuantiFERON®-TB Gold In-Tube (QFT-GIT)

– T-Spot®.TB test (T-SPOT)

• People with LTBI are NOT infectious

TB Pathogenesis (2)

Latent TB Infection (LTBI)

 Review slide content

LTBI – Module 1, p. 12

Slide 34

Module 1 – Transmission and Pathogenesis of Tuberculosis 34

• TB disease develops when the immune 

system cannot keep tubercle bacilli under 

control

– May develop very soon after infection or many years after infection

• About 10% of all people with normal immune 

systems who have LTBI will develop TB 

disease at some point in their lives

• People with TB disease are often infectious

TB Pathogenesis (3)

TB Disease

 Review slide content 

TB Disease – Module 1 p. 16

Slide 35

Module 1 – Transmission and Pathogenesis of Tuberculosis 35

TB Pathogenesis (4)

Droplet nuclei containing tubercle bacilli are 

inhaled, enter the lungs, and travel to small 

air sacs (alveoli)

 Review slide content 

 Explain that the dots in the air represent 

droplet nuclei being inhaled into the person’s 

lungs

TB Pathogenesis – Module 1 p. 16
28

Slide 36

Module 1 – Transmission and Pathogenesis of Tuberculosis 36

TB Pathogenesis (5)

Tubercle bacilli multiply in alveoli, where 

infection begins

 Review slide content 

TB Pathogenesis – Module 1 p. 16

Slide 37

Module 1 – Transmission and Pathogenesis of Tuberculosis 37

TB Pathogenesis (6)

A small number of tubercle bacilli enter 

bloodstream and spread throughout body

 Review slide content

 State that tubercle bacilli can reach any part 

of the body, but areas where TB disease is 

more likely to develop include:

oLungs

oKidneys

oBrain 

oBones

TB Pathogenesis – Module 1, p. 17

Slide 38

Module 1 – Transmission and Pathogenesis of Tuberculosis 38

TB Pathogenesis (7)

LTBI

• Within 2 to 8 weeks the immune system produces 

special immune cells called macrophages that 

surround the tubercle bacilli

• These cells form a barrier shell that keeps the 

bacilli contained and under control (LTBI)

 Review slide content 

 Call attention to the barrier shell around the 

bacilli that is keeping the tubercle bacilli 

contained (upper left corner of figure)

TB Pathogenesis – Module 1, p. 17
29

Slide 39

Module 1 – Transmission and Pathogenesis of Tuberculosis 39

TB Pathogenesis (8)

TB Disease

• If the immune system CANNOT keep tubercle bacilli 

under control, bacilli begin to multiply rapidly and 

cause TB disease

• This process can occur in different places in the body

 Review slide content 

 Explain that the barrier shell around the 

bacilli has broken (upper left corner of figure)

Note: The red circle around broken barrier shell 

is animated. Click “enter” for the circle to 

appear.

TB Pathogenesis – Module 1, p. 17

Slide 40

Person with LTBI Person with TB Disease 

(in the lungs)

• Has a small number of TB 

bacteria in his or her body that are 

alive, but under control

• Has a large number of active 

TB bacteria in his or her body

• Cannot spread TB bacteria to 

others

• May spread TB bacteria to 

others

• Does not feel sick, but may 

become sick if the bacteria 

become active in his or her body

• May feel sick and may have 

symptoms such as cough, 

fever, or weight loss

• TST or IGRA results usually 

positive

• TST or IGRA results usually 

positive

• Chest x-ray usually normal • Chest x-ray usually abnormal 

Module 1 – Transmission and Pathogenesis of Tuberculosis 40

LTBI vs. TB Disease (1)

 Review each row of the table, comparing LTBI 

and TB disease

 Refer participants to p. 12 to follow along

LTBI vs. TB Disease – Module 1, p. 12

Slide 41

Module 1 – Transmission and Pathogenesis of Tuberculosis 41

LTBI vs. TB Disease (2)

Person with LTBI Person with TB Disease 

(in the lungs)

• Sputum smears and cultures 

negative 

• Sputum smears and cultures 

may be positive

• Should consider treatment 

for LTBI to prevent TB 

disease

• Needs treatment for TB 

disease

• Does not require respiratory 

isolation

• May require respiratory 

isolation

• Not a case of TB • A case of TB

 Review each row of the table, comparing LTBI 

and TB disease

 Refer participants to p. 12 to follow along

LTBI vs. TB Disease – Module 1, p. 12
30

Slide 42

Module 1 – Transmission and Pathogenesis of Tuberculosis 42

TB Pathogenesis

Study Question 1.7

When a person inhales droplet nuclei containing 

M. tuberculosis, where do the droplet nuclei go?

• Most of the larger droplet nuclei become 

lodged in the upper respiratory tract, where 

infection is unlikely to develop

• However, droplet nuclei may reach the small 

air sacs of the lung (the alveoli), where 

infection may begin

 Introduce study questions

 Ask participants to turn to p. 13 (if 

participants have print-based modules)

 Ask for a volunteer to read question 

 Ask participants for answers

Answers – Module 1, p. 26

Slide 43

Module 1 – Transmission and Pathogenesis of Tuberculosis 43

After the tubercle bacilli reach the small air 

sacs of the lung (the alveoli), what happens to 

the tubercle bacilli? 

• Tubercle bacilli multiply in alveoli and 

some enter the lymph nodes and 

bloodstream and spread throughout the 

body 

• Bacilli may reach any part of the body

• Within 2 to 8 weeks, the immune system 

usually intervenes, halting multiplication 

and preventing further spread

TB Pathogenesis

Study Question 1.8

 Ask for a volunteer to read question

 Ask participants for answers

Answers – Module 1, p. 27

Slide 44

Module 1 – Transmission and Pathogenesis of Tuberculosis 44

In people with LTBI (but not TB disease), how 

does the immune system keep the tubercle 

bacilli under control?

The immune system produces special 

immune cells that surround the tubercle 

bacilli. The cells form a shell that keeps 

the bacilli contained and under control.

TB Pathogenesis

Study Question 1.9

 Ask for a volunteer to read question 

 Ask participants for answers

Answers – Module 1, p. 27
31

Slide 45

Module 1 – Transmission and Pathogenesis of Tuberculosis 45

TB Pathogenesis

Study Question 1.10

How is LTBI detected?

LTBI is detected by the Mantoux 

tuberculin skin test (TST) or blood tests 

such as interferon-gamma release 

assays (IGRAs), which include the 

QuantiFERON®-TB Gold In-tube (QFTGIT) or the T-SPOT®.TB test (T-SPOT).

 Ask participants to turn to p. 16 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 1, p. 27

Slide 46

Module 1 – Transmission and Pathogenesis of Tuberculosis 46

What are the major similarities and differences between 

LTBI and TB disease? List characteristics of each. 

TB Pathogenesis

Study Question 1.11

 Read question 

 Ask participants for answers

Answers – Module 1, pp. 27-28

Slide 47

Module 1 – Transmission and Pathogenesis of Tuberculosis 47

TB Pathogenesis

Study Question 1.12

What happens if the immune system cannot 

keep the tubercle bacilli under control and 

the bacilli begin to multiply rapidly?

When this happens, TB disease 

develops. The risk that TB disease will 

develop is higher for some people than 

for others.

 Read question 

 Ask participants for answers

Answers – Module 1, p. 28
32

Slide 48

TB Pathogenesis

Module 1 – Transmission and Pathogenesis of Tuberculosis 48

Progression from LTBI to TB Disease 

 Introduce section 

Progression from LTBI to TB Disease – Module 1, pp. 

18-19

Slide 49

Module 1 – Transmission and Pathogenesis of Tuberculosis 49

Progression to TB Disease (1)

• Risk of developing TB disease is highest the 

first 2 years after infection 

• People with LTBI can be given treatment to 

prevent them from developing TB disease

• Detecting TB infection early and providing 

treatment helps prevent new cases of TB 

disease

 Review slide content 

 Explain that since the risk of progressing to TB 

disease is the highest in the first two years 

after infection, it is important to detect TB 

infection early 

Progression to TB Disease – Module 1, p. 18

Slide 50

Module 1 – Transmission and Pathogenesis of Tuberculosis 50

• Infection with HIV

• History of untreated or 

inadequately treated TB disease

• Recent TB infection (within the 

past 2 years)

• Immunosuppressive therapy 

such as tumor necrosis factoralpha (TNF) antagonists, 

systemic corticosteroids, or 

immunosuppressive drug 

therapy following organ 

transplantation

• Abusing drugs or alcohol or 

smoking cigarettes

• Silicosis

• Diabetes mellitus

• Chronic renal failure

• Certain types of cancer (e.g., 

leukemia, cancer of the head, 

neck, or lung)

• Certain intestinal conditions

• Low body weight

Some conditions increase probability of LTBI 

progressing to TB disease

Progression to TB Disease (2)

 Review slide content

 Tell participants that some of these terms can 

be found in the glossary of print-based 

Module 1, pp. 2-4

Progression to TB Disease – Module 1, pp. 18-19
33

Slide 51

Module 1 – Transmission and Pathogenesis of Tuberculosis 51

Progression to TB Disease (3)

 Review slide content

 Emphasize that not everyone exposed to TB 

becomes infected with TB, and not everyone 

that becomes infected with TB develops TB 

disease

Progression to TB Disease – Module 1, p. 18

Slide 52

Module 1 – Transmission and Pathogenesis of Tuberculosis 52

In an HIV-infected person,

TB can develop in one of

two ways:

• Person with LTBI becomes 

infected with HIV and then 

develops TB disease as the 

immune system is weakened

• Person with HIV infection 

becomes infected with M. 

tuberculosis and then 

rapidly develops TB disease

Progression to TB Disease (4) 

TB and HIV

Image credit: Mississippi State Department of Health

 Before showing slide, ask participants what is 

the strongest known risk factor for the 

progression of TB disease in people with TB 

infection

 Note that worldwide TB is responsible for the 

deaths of 1 in 3 people living with HIV/AIDS; 

making it the leading cause of death for 

people infected with HIV

 Review slide content 

TB and HIV – Module 1, p. 19

[Image credit: Mississippi State Department of Health]

Slide 53

Module 1 – Transmission and Pathogenesis of Tuberculosis 53

Progression to TB Disease (5)

TB and HIV

People who are infected with both M. tuberculosis and 

HIV are much more likely to develop TB disease

 Review slide content

 Ask why the risk is so much greater with HIV 

infection

TB and HIV – Module 1, p. 19
34

Slide 54

Module 1 – Transmission and Pathogenesis of Tuberculosis 54

Progression to TB Disease

Study Question 1.13

What percentage of people who have LTBI 

(but not HIV infection) usually develop TB 

disease?

• About 10% of all people with LTBI will develop 

TB disease at some point

– In U.S., about 5% of recently infected will 

develop TB disease in first year or two after 

infection 

– Additional 5% will develop disease later in 

life

• Remaining 90% will remain free of disease for 

the rest of their lives

 Introduce study questions 

 Ask participants to turn to p. 20 (if 

participants have print-based modules)

 Ask for a volunteer to read question 

 Ask participants for answers

Answers – Module 1, p. 28

Slide 55

Module 1 – Transmission and Pathogenesis of Tuberculosis 55

Progression to TB Disease

Study Question 1.14

What conditions appear to increase the risk that 

LTBI will progress to TB disease? 

• Infection with HIV

• History of untreated or 

inadequately treated TB disease

• Recent TB infection (within the 

past 2 years)

• Immunosuppressive therapy 

such as tumor necrosis factoralpha (TNF) antagonists, 

systemic corticosteroids, or 

immunosuppressive drug 

therapy following organ 

transplantation

• Abusing drugs or alcohol or 

smoking cigarettes

• Silicosis

• Diabetes mellitus

• Chronic renal failure

• Certain types of cancer (e.g., 

leukemia, cancer of the head, 

neck, or lung)

• Certain intestinal conditions

• Low body weight

 Ask for a volunteer to read question 

 Ask participants for answers

Answers – Module 1, pp. 28-29

Slide 56

Module 1 – Transmission and Pathogenesis of Tuberculosis 56

Progression to TB Disease

Study Question 1.15

How does being infected with both M. tuberculosis

and HIV affect the risk for TB disease?

• Much more likely to develop TB disease

• Risk of developing TB disease is 7% to 10% EACH 

YEAR (if HIV is not being treated)

• In an HIV-infected person, TB disease can develop 

in two ways:

1. Person with LTBI becomes infected with HIV and then 

develops TB disease as the immune system is 

weakened

2. Person with HIV infection becomes infected with M. 

tuberculosis and then rapidly develops TB disease

 Ask for a volunteer to read question 

 Ask participants for answers

Answers – Module 1, p. 29
35

Slide 57

TB Pathogenesis

Module 1 – Transmission and Pathogenesis of Tuberculosis 57

Sites of TB Disease

 Introduce section

 Note that some patients who have 

extrapulmonary TB also have pulmonary TB

Sites of TB Disease, Module 1, p. 22

Slide 58

Module 1 – Transmission and Pathogenesis of Tuberculosis 58

Sites of TB Disease (1)

Bacilli may reach any part of the body, but 

common sites include:

 Review slide content 

Sites of TB Disease – Module 1, p. 22

Slide 59

Module 1 – Transmission and Pathogenesis of Tuberculosis 59

Sites of TB Disease (2)

Location Frequency

Pulmonary TB Lungs Most TB cases are 

pulmonary

Extrapulmonary TB Places other than 

lungs such as:

 Larynx

 Lymph nodes

 Pleura

 Brain

 Kidneys

 Bones and joints

Found more often in:

• HIV-infected or

other

immunosuppressed

persons

• Young children

Disseminated TB Carried to all parts 

of body, through 

bloodstream

Rare

 Review slide content

 Note that disseminated TB is rare, but very 

serious

Sites of TB Disease – Module 1, p. 22
36

Slide 60

Module 1 – Transmission and Pathogenesis of Tuberculosis 60

Sites for TB

Study Question 1.16

What part of the body is the most common

site for TB disease?

Lungs are the most common site

What are some other common sites?

- Larynx

- Lymph nodes

- Pleura (membrane around the lungs)

- Brain

- Kidneys

- Bones and joints

 Introduce study questions 

 Ask participants to turn to p. 24 (if 

participants have print-based modules)

 Ask for a volunteer to read question

 Ask participants for answers

Answers – Module 1, p. 29

Slide 61

TB Pathogenesis

Module 1 – Transmission and Pathogenesis of Tuberculosis 61

TB Classification System

 Introduce section

TB Classification System Module 1, p. 23

Slide 62

Module 1 – Transmission and Pathogenesis of Tuberculosis 62

TB Classification System (1)

Class Type Description

0 No TB exposure

Not infected 

No history of TB exposure

Negative result to a TST or to an IGRA 

1 TB exposure

No evidence of 

infection 

History of TB exposure

Negative result to a TST or an IGRA (done 

at least 8 to 10 weeks after exposure)

2 TB infection 

No TB disease

Positive result to a TST or to an IGRA 

Negative smears, molecular tests, and 

cultures 

No clinical or x-ray evidence of active TB 

disease 

Based on pathogenesis of TB

 Review slide content 

 State that this classification system is 

sometimes referred to as the American 

Thoracic Society (ATS) classification system 

TB Classification System – Module 1, p. 23
37

Slide 63

Module 1 – Transmission and Pathogenesis of Tuberculosis 63

TB Classification System (2)

Class Type Description

3 TB, clinically 

active 

Positive culture for M. tuberculosis OR

Positive result to a TST or to an IGRA, and clinical, 

bacteriological, or x-ray evidence of current active 

TB disease 

4 Previous TB 

disease

(not clinically 

active) 

Medical history of TB disease

Abnormal but stable x-ray findings 

Positive result to a TST or to an IGRA 

Negative smears, molecular tests, and cultures (if 

done)

No clinical or x-ray evidence of active TB disease 

5 TB 

suspected 

Signs and symptoms of TB disease, but diagnostic 

evaluation not complete 

Based on pathogenesis of TB

 Review slide content

 State that any TB patient with a classification 

of 3 or 5 should receive treatment for TB, and 

should be reported to the health department

TB Classification System – Module 1, p. 23

Slide 64

Module 1 – Transmission and Pathogenesis of Tuberculosis 64

TB Classification System

Study Question 1.17

What is the classification system for TB 

based on? What is it used for?

The current classification system is 

based on the pathogenesis of TB. Many 

health departments and private health 

care providers use this system when 

describing patients.

 Ask participants to turn to p. 24 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 1, p. 29

Slide 65

Case Studies

Module 1 – Transmission and Pathogenesis of Tuberculosis 65

 Introduce case studies
38

Slide 66

Module 1 – Transmission and Pathogenesis of Tuberculosis 66

Module 1: Case Study 1.1 (1)

A 30-year-old man visits the health department 

for a TST because he is required to have one 

before starting his new job as a health care 

worker. He has an 18 mm positive reaction to 

the TST. He has no symptoms of TB, and his 

chest x-ray findings are normal.

 Ask participants turn to p. 15 (if participants 

have print-based modules)

 Read case study 

Case Study 1.1 – Module 1, p. 15

Slide 67

Module 1: Case Study 1.1 (2)

Should this be considered a case of TB?

No. The man described above has LTBI. He has 

an 18 mm positive reaction to the TST, but no 

evidence of TB disease. Therefore, this is not a 

case of TB.

Should this man be considered infectious?

No, he should not be considered infectious. This 

man has LTBI, not TB disease. People with TB 

infection and no evidence of TB disease are not 

infectious. 

Module 1 – Transmission and Pathogenesis of Tuberculosis 67

 Read questions 

 Ask participants for answers

Answers – Module 1, p. 30

Slide 68

Module 1: Case Study 1.2 (1)

A 45-year-old woman is referred to the 

health department by her private 

physician because she was found to 

have LTBI as part of an employee testing 

program. She is overweight, with high 

blood pressure. Upon further 

questioning, she reports that she has 

injected illegal drugs in the past, but has 

never been tested for HIV infection.

Module 1 – Transmission and Pathogenesis of Tuberculosis 68

 Ask participants turn to p. 21 (if participants 

have print-based modules)

 Read case study 

Case Study 1.2 – Module 1, p. 21
39

Slide 69

Module 1: Case Study 1.2 (2)

What conditions does this woman have that 

increase the risk that she will develop TB 

disease?

Drug abuse increases the risk that LTBI will 

progress to TB disease. This woman may also be at 

risk for HIV infection because of her injection drug 

use. HIV is the strongest known risk factor for 

developing TB disease. This woman should be 

offered HIV counseling, testing, and referral. 

Overweight and high blood pressure are NOT risk 

factors for TB disease.

Module 1 – Transmission and Pathogenesis of Tuberculosis 69

 Read case study question 

 Ask participants for answers 

 Ask if there are any questions about Module 

1 before moving on to Module 2

Answers – Module 1, p. 30
40
41

Module 2: Epidemiology of Tuberculosis 

Facilitation Tips 

Background 

Epidemiology is the study of diseases and other health problems in groups of people. 

Epidemiologists determine the frequency and pattern (the distribution) of health problems in 

different communities. In other words, they find out who has a specific health problem, how 

often the problem occurs, and where the problem occurs. Using this information about who, 

when, and where, epidemiologists try to determine why the health problem is occurring. 

Public health officials use epidemiologic information to design ways to prevent and control the 

diseases in the community. By finding out who is at risk for a specific health problem, they can 

target their prevention and control strategies at this group. 

This module examines recent trends in TB in the United States and describes groups of people 

who are at higher risk for latent TB infection (LTBI) and TB disease. Groups of people who are 

at higher risk for TB vary from area to area; state and local health departments are responsible 

for determining specifically who is at risk in their area. 

Learning Objectives

After this presentation, participants will be able to 

1. Describe how the number of TB cases reported in the United States has changed over the 

last 60 years.

2. List five factors that contributed to the increase in the number of 

TB cases between 1985 and 1992. 

3. List three improvements TB programs were able to make with increased federal, state, 

and other funds and resources that have contributed to a decrease in TB cases since 1993. 

4. List the groups of people who are more likely to be exposed to or infected with M. 

tuberculosis. 

5. List the groups of people who are more likely to develop TB disease once infected with 

M. tuberculosis.

Module Overview

Time Activity Content Slides

5 min. Presentation Introduction Slides 1-3

15 min. Presentation Epidemiology of TB Slides 4-31

35 min. Presentation People at High Risk for TB Infection and TB 

Disease Slides 32-59

5 min. Case Studies Case Studies Slides 60-62

60 min. Total Time
42

Facilitation Tips

Slide 1

Self-Study Modules 

on Tuberculosis

Epidemiology 

of Tuberculosis

 Introduce Module 2

 Ask participants if they know what 

epidemiology is

Slide 2

Module 2: Objectives

At completion of this module, learners will be able to:

1. Describe how the number of TB cases reported in 

the U.S has changed over the last 60 years

2. List 5 factors that contributed to the increase of TB 

cases between 1985 and 1992

3. List 3 improvements TB programs made with 

increased funds that have contributed to a 

decrease in TB cases since 1993

4. List groups of people who are more likely to be 

exposed to or infected with M. tuberculosis

5. List groups of people who are more likely to 

develop TB disease once infected with M. 

tuberculosis

Module 2 – Epidemiology of Tuberculosis 2

 State objectives of presentation 

Background and Objectives - Module 2, p. 1

Slide 3

Module 2: Overview

• Introduction to TB Epidemiology

• People at High Risk for TB Infection and TB 

Disease

• Case Studies 

Module 2 – Epidemiology of Tuberculosis 3

 Review slide content 
43

Slide 4

Introduction to TB 

Epidemiology

4

 Introduce section

Epidemiology of TB - Module 2, pp. 3-5

Slide 5

Epidemiology (1)

Epidemiology is the study of the distribution 

and causes of disease and other health 

problems in groups of people.

Module 2 – Epidemiology of Tuberculosis 5

 Ask for a volunteer to read the definition 

of epidemiology 

Epidemiology definition - Module 2, p. 1

Slide 6

Epidemiology (2)

• Epidemiologists:

– Determine frequency and pattern of health 

problems in communities

– Try to figure out why health problems are 

occurring

Module 2 – Epidemiology of Tuberculosis 6

 Review slide content 

Epidemiology - Module 2, p. 1
44

Slide 7

Global Epidemiology of TB

• TB is one of the leading causes of death due 

to infectious disease in the world

• Almost 2 billion people are infected with M. 

tuberculosis

• Each year about:

– 9 million people develop TB disease

– 1.5 million people die of TB

Module 2 – Epidemiology of Tuberculosis 7

 Before showing slide, ask how many 

people in the world are infected with TB 

 State that 1/3 of the world’s population is 

infected with TB

 Review slide content

Global Epidemiology of TB - Module 2, p. 3

Slide 8

TB Reporting in U.S.

• The Report of Verified Case of Tuberculosis 

(RVCT) is the national TB surveillance data 

collection form and is used for reporting all 

verified TB cases to CDC

– The 50 states, District of Columbia, New 

York City, Puerto Rico, and 7 other 

jurisdictions in the Pacific and Caribbean 

report TB cases to CDC

• Health care providers are required by law to 

report TB cases to state or local health 

departments

Module 2 – Epidemiology of Tuberculosis 8

 Review slide content

TB Reporting in the U.S. - Module 2, p. 3

Slide 9

U.S. Epidemiology of TB

1953 - 1986

• 1953: 

– More than 84,000 cases of TB

• 1953-1984: 

– TB cases declined about 6% each year

• 1985: 

– TB cases reached a low of 22,201

• 1986: 

– Significant increase in TB cases began

Module 2 – Epidemiology of Tuberculosis 9

 Review slide content

 Emphasize that from 1953-1984 TB cases 

were declining

 Explain that one of the main reasons for 

this decline was that TB treatment drugs 

were discovered in the 1940s and 1950s

U.S. Epidemiology of TB - Module 2, p. 4
45

Slide 10

U.S. TB Resurgence (1)

1986 - 1992

Module 2 – Epidemiology of Tuberculosis 10

Reported TB Cases, U.S., 1982-2014

No. of Cases

0

5,000

10,000

15,000

20,000

25,000

30,000

 Review slide content

 Call attention to the increase in TB cases 

on the graph (1980s)

 Ask participants why they think there 

was 20% increase in TB cases in the 

1980s

U.S. TB Resurgence - Module 2, p. 4

Slide 11

U.S. TB Resurgence (2)

1986 - 1992

• Contributing factors:

– Inadequate funding for TB control and other public 

health efforts

– HIV epidemic

– Increased immigration from countries where TB is 

common

– Spread of TB in certain settings (e.g., homeless 

shelters and correctional facilities)

– Spread of multidrug-resistant TB (MDR TB)

Module 2 – Epidemiology of Tuberculosis 11

 Explain that there were several 

contributing factors to the TB resurgence 

in the U.S. 

 Review slide content

U.S. TB Resurgence - Module 2, p. 4

Slide 12

U.S. TB Control and Prevention (1) 

1993 - 2014

• 1993-2014:

– Number of TB cases reported annually in U.S. 

steadily declined

• Increased federal funds and other resources allowed 

TB programs to improve control efforts to:

– Promptly identify persons with TB

– Start appropriate initial treatment for TB cases

– Ensure patients complete treatment

– Conduct contact investigations

Module 2 – Epidemiology of Tuberculosis 12

 Review slide content

 Stress that prevention and control efforts 

must be maintained in order to prevent 

another resurgence

U.S. TB Control and Prevention - Module 2, p. 5
46

Slide 13

U.S. TB Control and Prevention (2)

1993 - 2014

Module 2 – Epidemiology of Tuberculosis 13

Reported TB Cases, U.S., 1982-2014

No. of Cases

0

5,000

10,000

15,000

20,000

25,000

30,000

 Call attention to the decrease in TB cases 

on the graph (after 1993)

 State that there were 9,421 TB cases in 

the U.S. in 2014

U.S. TB Control and Prevention - Module 2, p. 5

Slide 14

Continuing Challenges in TB 

Control

• TB is reported in almost every state and is 

increasing in some areas

• More than half of all TB cases in the U.S. are 

among foreign-born persons

• TB affects racial/ethnic minorities 

disproportionately

• MDR TB and extensively drug-resistant TB (XDR 

TB) remain serious public health concerns

Module 2 – Epidemiology of Tuberculosis 14

 Explain that there remain several areas of 

ongoing challenges in TB control 

 Review slide content

 

Continuing Challenges in TB Control –

Module 2, p. 5

Slide 15

TB Case Rates (1)

• A case rate is the number of TB cases that 

occur during a certain time period, divided 

by size of the population at that time

• Often expressed in terms of a population size 

of 100,000 persons

Module 2 – Epidemiology of Tuberculosis 15

 Review slide content

TB Case Rate - Module 2, p. 5
47

Slide 16

TB Case Rates (2)

Example:

• In the U.S. in 2014, there were 9,421 new TB 

cases in a population size of 318,857,056

9,421 x 100,000 = 2.96

318,857,056

• In 2014, the U.S. TB case rate was 2.96 TB 

cases per 100,000 persons (rounded to 3.0)

Module 2 – Epidemiology of Tuberculosis 16

 Use the example on slide to demonstrate 

how to calculate a case rate

TB Case Rate - Module 2, p. 5

Slide 17

TB Case Rates by State, 2014

Module 2 – Epidemiology of Tuberculosis 17

*Cases per 100,000

< 3.0* (2014 national average)

D.C.

 Explain that this map shows TB case rates 

by state 

 Ask which states had higher rates and 

which had lower rates 

 Point out the case rates for your area 

Note: Slide reflects 2014 surveillance data

TB Case Rates by State - Module 2, p. 6

Slide 18

TB Case Rates (3)

• Health departments, CDC, and others can 

compare the occurrence of TB in different 

places, time periods, and groups of people 

using case rates

• Comparisons have shown that rates of TB 

are higher in certain groups than in others

Module 2 – Epidemiology of Tuberculosis 18

 Review slide content

 Ask which groups have higher TB case 

rates

TB Case Rate - Module 2, p. 5
48

Slide 19

Epidemiology of TB

Study Question 2.1

What happened to the number of TB cases in 

the United States between 1953 and 1984?

From 1953 - 1984, the number of TB cases 

reported in the U.S. decreased by an 

average of 6% each year.

Module 2 – Epidemiology of Tuberculosis 19

 Introduce study questions 

 Ask participants to turn to p. 7 (if 

participants have print-based modules)

 Ask for a volunteer to read question 

 Ask participants for answers

Answers - Module 2, p. 22

Slide 20

What happened to the number of TB cases in 

the United States between 1985 and 1992?

From 1985 - 1992, the number of new TB 

cases increased by 20%.

Module 2 – Epidemiology of Tuberculosis 20

Epidemiology of TB

Study Question 2.2

 Ask for a volunteer to read question 

 Ask participants for answers

Answers - Module 2, p. 22

Slide 21

Name 5 factors that may have contributed to 

the increase in the number of TB cases 

between 1985 and 1992.

• Inadequate funding for TB control and other public 

health efforts

• HIV epidemic

• Increased immigration from countries where TB is 

common

• Spread of TB in certain settings (e.g., correctional 

facilities and homeless shelters)

• Spread of MDR TB

Module 2 – Epidemiology of Tuberculosis 21

Epidemiology of TB

Study Question 2.3

 Ask for a volunteer to read question 

 Ask participants for answers

Answers - Module 2, p. 22
49

Slide 22

Epidemiology of TB

Study Question 2.4

What happened to the number of TB cases in 

the United States from 1993 to 2014?

From 1993 to 2014, there was a steady 

decline in the number of TB cases 

reported annually in the United States.

Module 2 – Epidemiology of Tuberculosis 22

 Ask for a volunteer to read question 

 Ask participants for answers

Answers - Module 2, p. 22

Slide 23

Epidemiology of TB

Study Question 2.5

Name 3 improvements TB programs were 

able to make with increased federal, state, 

and other funds that contributed to the 

decrease in TB cases since 1993.

• Promptly identify persons with TB

• Start appropriate initial treatment for TB 

cases

• Ensure patients complete treatment

• Conduct contact investigations

Module 2 – Epidemiology of Tuberculosis 23

 Ask for a volunteer to read question 

 Ask participants for answers

Answers - Module 2, p. 22

Slide 24

Race and Ethnicity (1)

• TB affects certain racial and ethnic minorities 

disproportionately 

• In 2014, about 85% of TB cases in the U.S. 

were among racial and ethnic minorities 

• Percentage of TB cases in racial and ethnic minorities is higher than expected based on 

percentage of these minorities in the U.S. 

population

Module 2 – Epidemiology of Tuberculosis 24

 Review slide content

Race and Ethnicity - Module 2, p. 8
50

Slide 25

Module 2 – Epidemiology of Tuberculosis 25

Black or African 

American

21%

American Indian or 

Alaska Native

1%

Asian

32%

Hispanic or Latino

29%

Native Hawaiian or 

Other Pacific 

Islander

1%

White

13%

Multiple Race 2%

Race and Ethnicity (2)

Reported TB cases by race and ethnicity, U.S, 2014*

*All races are non-Hispanic. Multiple Race indicates two or more races reported for a person.

Does not include persons of Hispanic or Latino origin.

 Explain that this pie chart shows the 

reported TB cases in the U.S. in 2014 by 

race and ethnicity 

 Ask participants which groups made up 

the greatest percentage of TB cases, and 

which groups made up the least 

Reported TB Cases by Race and Ethnicity –

Module 2, p. 8

Slide 26

White

63%

Hispanic or Latino

17%

Black or African 

American 

12%

Asian

5%

Two or More Races

2%

American Indian or 

Alaska Native 

1% Native Hawaiian or 

Other Pacific 

Islander 0.2%

Module 2 – Epidemiology of Tuberculosis 26

Race and Ethnicity (3)

Racial and ethnic groups by percentage of U.S. population, 2014

 Explain that this pie chart shows the U.S. 

population broken down by race and 

ethnicity

 Ask participants what they notice when 

comparing this pie chart to the one on 

the previous slide (e.g., even though nonHispanic whites make up more than 60% 

of the U.S. population, they only account 

for 13% of the TB cases)

 Explain that this means that the 

percentage of TB cases that occur in 

minorities is higher than expected based 

on their percentages in the U.S. 

population

Reported TB Cases by Race and Ethnicity –

Module 2, p. 9
51

Slide 27

• Disparities may exist due to racial and ethnic 

minorities having other risk factors for TB, 

such as:

– Birth in a country where TB is common

– HIV infection

– Low socioeconomic status

– Exposure to TB in high-risk settings

Module 2 – Epidemiology of Tuberculosis 27

Race and Ethnicity (4)

 Review slide content

Reported TB Cases by Race and Ethnicity –

Module 2, p. 9

Slide 28

Relative Risk for TB (1)

Relative risk is a comparison of case rates 

between two groups.

Module 2 – Epidemiology of Tuberculosis 28

 Ask for a volunteer to read the definition 

of relative risk 

Relative Risk for TB - Module 2, p. 10

Slide 29

Relative Risk for TB (2)

Example:

• The case rate for Asians is 17.8 compared to 

0.6 for non-Hispanic whites. Therefore, the 

relative risk for Asians is about 29 times 

higher than non-Hispanic whites

17.8 (TB case rate for Asians) = 29.6

0.6 (TB case rate for non-Hispanic whites)

Module 2 – Epidemiology of Tuberculosis 29

 Use the example on slide to demonstrate 

how to calculate relative risk

Note: Slide reflects 2014 surveillance data

Relative Risk for TB - Module 2, p. 10
52

Slide 30

Relative Risk for TB (3)

Race and Ethnicity, 2014

Race/Ethnicity TB Case Rate Relative Risk

Asians 17.8 29.6

Native Hawaiians or 

Other Pacific Islanders 16.9 28.1

Blacks or African 

Americans 5.1 8.5

American Indians or 

Alaska Natives 5.0 8.3

Hispanics or Latinos 5.0 8.3

Multiple Race 2.8 4.6

Non- Hispanic Whites 0.6 1

Module 2 – Epidemiology of Tuberculosis 30

 Explain that in this table all case rates are 

compared to the case rate for nonHispanic whites because non-Hispanic 

whites have the lowest case rate

Relative Risk for TB - Module 2, p. 10

Slide 31

Race and Ethnicity 

Study Question 2.6

Which racial and ethnic groups are 

disproportionally affected by TB?

Asians, Native Hawaiians or Other Pacific 

Islanders, non-Hispanic blacks, Hispanics, and 

American Indians or Alaska Natives are 

disproportionately affected by TB. 

Module 2 – Epidemiology of Tuberculosis 31

 Introduce study questions 

 Ask participants to turn to p. 10 (if 

participants have print-based modules)

 Ask for a volunteer to read question

 Ask participants for answers

Answers - Module 2, p. 22

Slide 32

People at High Risk for TB 

Infection and TB Disease

32

 Introduce section 

 Ask participants who they think should 

be considered at high risk for TB 

infection

People at High Risk for TB Infection and TB Disease -

Module 2, pp. 11-15
53

Slide 33

High-Risk Groups

• High-risk groups can be divided into two 

categories:

– High risk for exposure to or infection with M. 

tuberculosis

– High risk for developing TB disease after 

infection with M. tuberculosis

Module 2 – Epidemiology of Tuberculosis 33

 Review slide content

High-Risk Groups - Module 2, p. 11

Slide 34

People at High Risk for Exposure to 

or Infection with M. tuberculosis

• Contacts

• People who have come to the 

U.S. within the last 5 years 

from areas of the world 

where TB is common

• Persons who visit areas with 

a high prevalence of TB 

disease

• People who live or work in 

high-risk congregate settings

• Health care workers who 

serve patients at increased 

risk

• Populations defined 

locally as having an 

increased incidence of 

LTBI or TB disease, 

possibly medically 

underserved, low-income 

populations, or persons 

who abuse drugs or 

alcohol

• Infants, children, and 

adolescents exposed to 

adults who are at 

increased risk for LTBI or 

TB disease

Module 2 – Epidemiology of Tuberculosis 34

 Review slide content

People at High Risk for TB Infection –

Module 2, p. 11

Slide 35

People at High Risk for Developing 

TB Disease after Infection with M. tuberculosis (1)

• People living with HIV

• Children younger than 5 years of age

• People infected with M. tuberculosis within past 2 years

• People with a history of untreated or inadequately 

treated TB disease

• People who are receiving immunosuppressive therapy

• People with silicosis, diabetes mellitus, chronic renal 

failure, leukemia, or cancer of the head, neck, or lung

Module 2 – Epidemiology of Tuberculosis 35

 Explain that anyone who has LTBI can 

develop TB disease, but that some 

people are at higher risk than others

 Review slide content

People at High Risk for Developing TB Disease -

Module 2, p. 11
54

Slide 36

• Persons who have had a gastrectomy or jejunoileal 

bypass

• Low body weight

• Cigarette smokers and persons who abuse drugs or 

alcohol

• Populations defined locally as having an increased 

risk

Module 2 – Epidemiology of Tuberculosis 36

People at High Risk for Developing 

TB Disease after Infection with M. tuberculosis (2)

 Review slide content

People at High Risk for Developing TB Disease -

Module 2, p. 11

Slide 37

High-Risk Groups for TB Infection (1)

Contacts

• Contacts are persons 

who have spent time 

with someone who has 

infectious TB disease

• May include: 

– Family members

– Coworkers

– Friends

Module 2 – Epidemiology of Tuberculosis 37

 Review slide content

Contacts - Module 2, p. 12

Slide 38

High-Risk Groups for TB Infection (2)

Foreign-Born Persons/Immigrants

In the U.S., LTBI 

and TB disease 

often occur among 

people born in 

areas of the world where TB is 

common:

– Asia

– Africa

– Russia

– Eastern Europe

– Latin America

Module 2 – Epidemiology of Tuberculosis 38

Mexico

(21%)

Philippines

(12%)

India

(8%)

Vietnam

(8%)

China

(7%)

Guatemala

(3%)

Haiti

(3%)

Other 

Countries

38%

 Review slide content

 Explain that the pie chart shows the 

overall distribution of the countries of 

birth of foreign-born persons reported 

with TB in 2014 in the U.S. The top 7

countries are highlighted.

 Ask which of these foreign-born groups 

live in the participants’ areas

Foreign-Born Persons/Immigrants –

Module 2, p. 12
55

Slide 39

Cases of TB in foreign-born and U.S.-born, 

1992 and 2014

High-Risk Groups for TB Infection (3)

Foreign-Born Persons/Immigrants

Module 2 – Epidemiology of Tuberculosis 39

1992 2014

U.S.-born

73%

Foreign-born

27%

Foreign-born

65%

U.S.-born

35%

U.S.-born

73%

Foreign-born

27% U.S.-born

34%

Foreign-born

66%

 Explain that the two pie charts show the 

percentage of TB cases by foreign-born 

and U.S. born persons in 1992 and 2014

 Explain that the percentage of TB cases in 

the U.S. that are among foreign-born 

persons has increased over the years 

(27% in 1992 vs. 66% in 2014)

Foreign-Born Persons/Immigrants –

Module 2, p. 12

Slide 40

High-Risk Groups for TB Infection (4)

Foreign-Born Persons/Immigrants

• To address high rates of TB in foreign-born 

persons, CDC and other public health 

organizations are working to:

– Improve the overseas and domestic screening 

process for immigrants and refugees

– Strengthen the notification system that alerts 

health departments about the arrival of immigrants 

and refugees with suspected TB disease

– Test recent arrivals from countries where TB is 

common for TB infection and ensure completion of 

treatment

Module 2 – Epidemiology of Tuberculosis 40

 Review slide content 

Foreign-Born Persons/Immigrants –

Module 2, p. 12

Slide 41

High-Risk Groups for TB Infection (5)

Foreign-Born Persons/Immigrants

• Individuals applying for immigration and 

refugee status from overseas:

– Must be screened for TB by panel physicians 

before entering the U.S. 

– Must have completed treatment before 

entering the U.S. if diagnosed with TB 

disease

Module 2 – Epidemiology of Tuberculosis 41

 Review slide content

 Explain that health departments are 

notified of immigrants who are suspected 

of having TB. This notification system 

allows health departments to assist 

patients to receive a medical evaluation.

Foreign-Born Persons/Immigrants –

Module 2, p. 12
56

Slide 42

High-Risk Groups for TB Infection (6)

Foreign-Born Persons/Immigrants

• Immigrants living in the U.S. who apply for 

permanent residence or citizenship:

– Must be tested for TB infection and evaluated 

for TB disease by U.S.- based civil surgeons

Module 2 – Epidemiology of Tuberculosis 42

 Review slide content

Foreign-Born Persons/Immigrants –

Module 2, p. 12

Slide 43

High-Risk Groups for TB Infection (7)

Congregate Settings

• In certain congregate settings, the risk of 

being exposed to TB is higher than other 

places. This may include:

– Correctional facilities

– Homeless shelters

– Nursing homes

– Health care facilities 

Module 2 – Epidemiology of Tuberculosis 43

 Review slide content 

Congregate Settings - Module 2, p. 13

Slide 44

High-Risk Groups for TB Infection (8)

Congregate Settings

• Risk of exposure to TB is higher than in other 

settings

• Risk is higher if facility is crowded

Module 2 – Epidemiology of Tuberculosis 44

 Review slide content 

Congregate Settings - Module 2, p. 13
57

Slide 45

High-Risk Groups for TB Infection (9)

Correctional Facilities

• Higher risk in correctional facilities may be due 

to:

– Incarcerated population includes a high proportion 

of people at greater risk for TB than overall 

population (risk factors may include HIV-infection 

and a history of homelessness or drug use)

– Physical structure of correctional facilities (e.g., 

close living quarters, overcrowding, potential for 

inadequate ventilation)

– Movement of inmates into and out of facilities can 

lead to interruption of therapy

Module 2 – Epidemiology of Tuberculosis 45

 Before showing slide, ask why groups in 

correctional settings are at higher risk for 

TB infection 

 Review slide content 

 Explain that being infected with HIV puts 

individuals at a higher risk of developing 

TB disease

Correctional Facilities - Module 2, p. 13

Slide 46

High-Risk Groups for TB Infection (10) 

Health Care Workers

• Might be exposed to 

TB at work

• Risk depends on:

– Number of persons 

with TB in facility

– Job duties

– Infection control 

procedures

Module 2 – Epidemiology of Tuberculosis 46

 Before showing slide, ask participants 

which factors can increase the risk for 

health care workers 

 Review slide content

 Explain that facilities with a high risk of 

TB transmission should ensure 

appropriate TB prevention and control 

measures are taken 

 Note that infection control procedures 

are discussed more in Module 5

Health Care Workers - Module 2, p. 13

Slide 47

High-Risk Groups for TB Infection (11) 

Populations Defined Locally

Populations that may have 

an increased risk include

• Persons experiencing 

homelssness

• Medically underserved 

populations

• Low-income groups

• Persons who abuse drugs 

or alcohol

Module 2 – Epidemiology of Tuberculosis 47

 Review slide content

Populations Defined Locally - Module 2, p. 14
58

Slide 48

High-Risk Groups for TB Infection (12) 

Populations Defined Locally

• Low-income is linked to higher risk of TB 

exposure

• Possible reasons include factors associated with 

low-income:

– Inadequate living conditions

– Crowding

– Malnutrition

– Poor access to health care

• TB rates are 10 times higher for people 

experiencing homelessness

Module 2 – Epidemiology of Tuberculosis 48

 Review slide content

Populations Defined Locally - Module 2, p. 14

Slide 49

High-Risk Groups for TB Infection (13)

Children and Adolescents

• High risk if exposed to adults 

in high-risk groups

• If a child has TB infection or 

disease, it suggests that:

– TB was transmitted 

relatively recently

– Person who transmitted TB 

to child may still be 

infectious

– Others may have been 

exposed

Module 2 – Epidemiology of Tuberculosis 49

 Review slide content

 Note that the number of reported TB 

cases in children have been decreasing 

since 1993

Children and Adolescents - Module 2, p. 14-15

Slide 50

High-Risk Groups for TB Disease (1)

Infants and Children Younger than 5 Years

High risk for rapidly developing TB disease due to 

underdeveloped immune system

Module 2 – Epidemiology of Tuberculosis 50

 Review slide content

Infants and Children - Module 2, p. 14-15
59

Slide 51

High-Risk Groups for TB Disease (2)

People Living with HIV

• HIV is the strongest known risk factor for 

developing TB disease

• TB is the leading cause of death for people 

with HIV/AIDS

• Risk of developing TB disease is 7% - 10% 

each year for people who are infected with 

both TB and HIV (if the HIV is not treated)

Module 2 – Epidemiology of Tuberculosis 51

 Review slide content

 Explain that because HIV weakens the 

immune system, people with TB infection 

and HIV infection are at a very high risk 

of developing TB disease

 Explain that the risk of developing TB 

disease is only 10% over a lifetime for 

people infected only with M. tuberculosis

People Living With HIV - Module 2, p. 15

Slide 52

High-Risk Groups for TB Infection 

Study Question 2.7

Name 7 groups of people who are more likely to 

be exposed or infected with M. tuberculosis.

• Contacts of people known or suspected to have TB

• People who have come to the U.S. within last 5 years from countries 

where TB is common

• Persons who visit areas with a high prevalence of TB disease

• People who live or work in high-risk congregate settings

• Health care workers who serve high-risk groups

• Populations defined locally as having an increased incidence of LTBI or 

TB disease, possibly medically underserved, low-income populations, or 

persons who abuse drugs or alcohol

• Infants, children, and adolescents exposed to adults who are at 

increased risk for LTBI or TB disease

Module 2 – Epidemiology of Tuberculosis 52

 Introduce study questions

 Ask participants to turn to p. 16 (if 

participants have print-based modules) 

 Ask for a volunteer to read question 

 Ask participants for answers

Answers - Module 2, p. 23

Slide 53

What are public health agencies doing to 

address the high rate of TB in foreign born 

persons?

• Improve the overseas and domestic screening 

process for immigrants and refugees

• Strengthen the notification system that alerts 

health departments about the arrival of 

immigrants and refugees with suspected TB 

disease

• Test recent arrivals from countries where TB is 

common for TB infection and ensure completion 

of treatment

Module 2 – Epidemiology of Tuberculosis 53

High-Risk Groups for TB Infection 

Study Question 2.8

 Ask for a volunteer to read question 

 Ask participants for answers

Answers - Module 2, p. 23
60

Slide 54

Why is the risk of being exposed to TB 

higher in certain settings, such as nursing 

homes or correctional facilities?

• Many people in these facilities are at 

risk for TB disease

• Risk of exposure is higher if facility is 

crowded

Module 2 – Epidemiology of Tuberculosis 54

High-Risk Groups for TB Infection 

Study Question 2.9

 Ask for a volunteer to read question 

 Ask participants for answers

Answers - Module 2, p. 23

Slide 55

What are some reasons why rates of TB 

disease are higher in correctional facilities?

• The incarcerated population contains a higher 

proportion of people at greater risk for TB than the 

general population

• An increasing number of inmates are infected with 

HIV, which means that they are more likely to develop 

TB disease if they become infected with M. 

tuberculosis

• Some correctional facilities are crowded and may have 

inadequate ventilation, which promotes the spread of 

TB

• Therapy can be interrupted when inmates are moved 

into and out of facilities

Module 2 – Epidemiology of Tuberculosis 55

High-Risk Groups for TB Infection

Study Question 2.10

 Ask for a volunteer to read question 

 Ask participants for answers

Answers - Module 2, p. 24

Slide 56

When a child has TB infection or disease, 

what does it tell us about the spread of TB in 

the child’s home or community? Name 3 

things.

• TB was transmitted relatively recently

• The person who transmitted TB to the child 

may still be infectious

• Other adults and children in the home or 

community have probably been exposed to TB

Module 2 – Epidemiology of Tuberculosis 56

High-Risk Groups for TB Infection

Study Question 2.11

 Ask for a volunteer to read question 

 Ask participants for answers

Answers - Module 2, p. 24
61

Slide 57

Name 8 groups of people who are more likely to 

develop TB disease once infected. 

Module 2 – Epidemiology of Tuberculosis 57

High-Risk Groups for TB Disease

Study Question 2.12

• People with silicosis, diabetes mellitus, chronic renal failure, 

leukemia, or cancer of the 

head, neck, or lung

• Persons who have had a 

gastrectomy or jejunoileal 

bypass

• Low body weight

• Cigarette smokers and person who abuse drugs or alcohol

• Populations defined locally as 

having an increased 

incidence of disease due to M. tuberculosis

• People living with HIV

• Children younger than 5 

years of age

• People infected with M. 

tuberculosis within the 

past 2 years

• People with a history of 

untreated or inadequately 

treated TB disease

• People receiving 

immunosuppressive 

therapy

 Ask for a volunteer to read question 

 Ask participants for answers

Answers - Module 2, p. 24

Slide 58

What is the strongest known risk factor for 

the development of TB disease?

HIV infection is the strongest known risk 

factor for developing TB disease. HIV 

infection weakens the body’s immune 

system, making it more likely for a 

person who has TB infection to develop 

TB disease.

Module 2 – Epidemiology of Tuberculosis 58

High-Risk Groups for TB Disease

Study Question 2.13

 Ask for a volunteer to read question 

 Ask participants for answers

Answers - Module 2, p. 25

Slide 59

High-Risk Groups for TB Disease

Study Question 2.14

If a person is infected with both M. 

tuberculosis and HIV, what are his or her 

chances of developing TB disease? How 

does this compare to the risk for people who 

are infected only with M. tuberculosis? 

• Risk is 7% to 10% each year if person is 

infected with both M. tuberculosis and 

HIV and the HIV is not treated

• Risk is 10% over a lifetime if person is 

only infected with M. tuberculosis 

Module 2 – Epidemiology of Tuberculosis 59

 Ask for a volunteer to read question 

 Ask participants for answers

Answers - Module 2, p. 25
62

Slide 60

Case Studies

60

 Introduce case studies

Slide 61

Module 2: Case Study 2.1

For each of the following people, choose the factor(s) known to 

increase the risk of being exposed to or infected with TB 

Person Factors

a) Mr. Petrov ___ Works at a nursing home

___ Rides the subway every day

___ Emigrated from Russia

b) Ms. Montoya ___ Was born in Latin America

___ Has a father who had pulmonary TB 

disease 

c) Ms. Parker ___ Volunteers in the emergency room of an 

inner-city hospital

___ Works in a day care center 

d) Mr. Dudley ___ Was released from prison last year

___ Sleeps in a homeless shelter 

Module 2 – Epidemiology of Tuberculosis 61

 Ask participants to turn to p. 18 (if 

participants have print-based modules)

 Read case study 

 Ask participants which factors would be 

considered risk factors for each person

Answers - Module 2, p. 26

Slide 62

Module 2: Case Study 2.2

For each of the following people, indicate the factor(s) known to 

increase the risk of developing TB disease once infected 

Person Factors

a) Mr. Sims ___ Injects heroin

___ Has HIV

b) Mr. Allen ___ Has diabetes

___ Has high blood pressure 

c) Ms. Li ___ Has chest x-ray findings suggestive of 

previous TB disease

___ Has heart problems 

d) Mr. Vinson ___ Is overweight

___ Became infected with M. tuberculosis 6 

months ago 

Module 2 – Epidemiology of Tuberculosis 62

 Ask participants to turn to p. 20 (if 

participants have print-based modules)

 Read case study 

 Ask participants which factors would be 

considered risk factors for each person

 Ask if there are any questions about 

Module 2 before moving on to Module 3

Answers - Module 2, p. 27
63

Module 3: Targeted Testing and the Diagnosis of Latent 

Tuberculosis Infection and Tuberculosis Disease 

Facilitation Tips 

Background 

In this module, participants will learn about targeted testing and the diagnosis of latent 

tuberculosis (TB) infection (LTBI) and TB disease. Targeted testing is a TB control strategy that 

is used to identify people who have LTBI and are at high risk for developing TB disease and

would benefit from treatment. LTBI is diagnosed with the Mantoux tuberculin skin test (TST) or 

an interferon-gamma release assay (IGRA), such as the QuantiFERON®-TB Gold In-Tube test 

(QFT-GIT) or the T-SPOT®.TB test (T-Spot). 

It is important to medically evaluate people who have symptoms of TB disease; if they are found 

to have TB disease, they need treatment to be cured and to help stop the transmission of TB to 

others. For this reason, the diagnosis of TB disease is crucial to controlling the spread of TB in 

homes and communities. In most cases, TB disease is diagnosed with certain laboratory tests. 

For patients who may have pulmonary TB disease, a chest x-ray is also useful for diagnosis. 

Learning Objectives 

After this presentation, participants will be able to 

1. Identify high-risk groups for targeted testing. 

2. Describe how to place, read, and interpret a Mantoux tuberculin skin test. 

3. Describe how to interpret an interferon-gamma release assay. 

4. Discuss considerations for using either the Mantoux tuberculin skin test or 

an interferon-gamma release assay for diagnosing latent tuberculosis 

infection. 

5. Describe the components of a medical evaluation for diagnosing TB 

disease.

Module Overview 

Time Activity Content Slides

2 min. Presentation Introduction Slides 1-3

10 min. Presentation Targeted Testing Slides 4-12

30 min. Presentation Diagnosis of LTBI Slides 13-75

35 min. Presentation Diagnosis of TB 

Disease Slides 76-129

3 min. Presentation Reporting TB Cases Slides 130-134

10 min. Case Studies Case Studies Slides 135-150

90 min. Total Time
64

Facilitation Tips

Slide 1

Self-Study Modules 

on Tuberculosis

Targeted Testing and 

the Diagnosis of 

Latent Tuberculosis 

Infection and 

Tuberculosis Disease

 Introduce Module 3

Slide 2

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 2

Module 3: Objectives

At completion of this module, learners will be able to:

1. Identify high-risk groups for targeted testing

2. Describe how to place, read, and interpret a Mantoux tuberculin skin test (TST)

3. Describe how to interpret an interferongamma release assay (IGRA)

4. Discuss considerations for using either the 

TST or IGRA for diagnosing latent 

tuberculosis infection (LTBI)

5. Describe the components of a medical 

evaluation for diagnosing TB disease

 State objectives of presentation

Background and Objectives - Module 3, p. 1

Slide 3

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 3

Module 3: Overview

• Targeted Testing

• Diagnosis of latent tuberculosis infection (LTBI)

– TST

– IGRAs

– TB Testing Programs, the Booster 

Phenomenon, and Two-Step Testing

• Diagnosis of TB Disease

• Reporting TB Cases

• Case Studies

 Review slide content 
65

Slide 4

4

Targeted Testing

 Introduce section

 Ask participants if they know what targeted 

testing is

Slide 5

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 5

Targeted Testing (1)

• Targeted testing is a TB control strategy 

used to identify and treat persons:

– At high risk for latent TB infection (LTBI)

– At high risk for developing TB disease 

once infected with M. tuberculosis

 Review slide content

Targeted Testing – Module 3, p. 6

Slide 6

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 6

• Identifying persons with LTBI is an important 

goal of TB elimination because LTBI 

treatment can:

– Prevent the development of TB disease

– Stop the further spread of TB to others

Targeted Testing (2)

 Review slide content

Targeted Testing – Module 3, p. 6
66

Slide 7

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 7

Targeted Testing (3)

A Decision to Test is a Decision to Treat

• TB testing activities should be done only when 

there is a plan for follow-up care

• Health care workers (HCWs) should identify and 

test persons who are at high risk

– People who are not at high risk generally 

should not be tested

 Review slide content 

 Explain that testing people who are not at 

high risk can take resources away from 

important activities. Also, positive test results 

in low-risk populations can be inaccurate.

 Note that health care agencies and other 

facilities should consult with their local health 

department before starting a TB testing 

program

Targeted Testing – Module 3, p. 6

Slide 8

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 8

Targeted Testing (4)

High-Risk Groups 

• High-risk groups can be divided into two 

categories:

– People who are at high risk for exposure to or 

infection with M. tuberculosis

– People who are at high risk for developing TB 

disease once infected with M. tuberculosis

 Review slide content 

 Explain that these are the high-risk groups 

that should be tested for TB

 Note that definition of high risk should be 

made at the local (city, county, state) level 

according to local demographics and TB 

epidemiology

Targeted Testing – Module 3, pp. 6-7

Slide 9

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 9

Targeted Testing (5)

High-Risk Groups for TB Infection

• Contacts of people known or suspected to 

have TB disease

• People who have come to U.S. within 5 years 

from areas of the world where TB is common

• People who visit areas with a high prevalence 

of TB disease

• People who live or work in high-risk 

congregate settings

 Review slide content 

 Tell participants that TB is more common in 

parts of Asia, Africa, Russia, Eastern Europe, 

and Latin America

 Ask participants what settings they think 

could be considered “high-risk congregate 

settings” (examples include nursing homes, 

homeless shelters, and correctional facilities)

Groups at High Risk for TB Infection – Module 3, p. 7
67

Slide 10

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 10

• HCWs who serve patients at increased risk 

for TB disease

• Populations defined locally as having an 

increased incidence of LTBI or TB disease 

(e.g., medically underserved, low income, or 

people who abuse drugs or alcohol)

• Infants, children, and adolescents exposed 

to adults in high-risk groups

Targeted Testing (6)

High-Risk Groups for TB Infection

 Review slide content 

Groups at High Risk for TB Infection – Module 3, p. 7

Slide 11

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 11

• People living with HIV 

• Children younger than 5 years of age

• People recently infected with M. tuberculosis 

(within the past 2 years)

• People with a history of untreated or inadequately 

treated TB disease

• People receiving immunosuppressive therapy

Targeted Testing (7)

High-Risk Groups for TB Disease after 

Infection with M. tuberculosis

 Review slide content 

Groups at High Risk for TB Disease – Module 3, p. 7

Slide 12

Targeted Testing (8)

High-Risk Groups for TB Disease after 

Infection with M. tuberculosis

• Persons with silicosis, diabetes mellitus, chronic renal 

failure, leukemia, or cancer of the head, neck, or lung

• Persons who have had a gastrectomy or jejunoileal 

bypass

• Low body weight

• Cigarette smokers and persons who abuse drugs and 

alcohol

• Persons defined locally as having an increased incidence 

of disease due to M. tuberculosis

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 12

 Review slide content 

Groups at High Risk for TB Disease – Module 3, p. 7
68

Slide 13

13

Diagnosis of Latent TB 

Infection (LTBI)

 Introduce section

Diagnosis of LTBI – Module 3, pp. 8-38

Slide 14

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 14

Diagnosis of LTBI

• Available testing methods for M. tuberculosis

infection:

– Mantoux tuberculin skin test (TST)

– Blood tests known as interferon-gamma 

release assays (IGRAs):

• QuantiFERON®-TB Gold In-Tube (QFT-GIT)

• T-SPOT®.TB test (T-Spot)

 Review slide content 

Diagnosis of LTBI – Module 3, p. 8

Slide 15

15

Diagnosis of Latent TB 

Infection (LTBI)

Mantoux Tuberculin Skin Test

Administering the Test

 Introduce section

 Ask who has had a Mantoux tuberculin skin 

test (TST)

 Ask (if appropriate) how many participants 

have administered a TST to others

 Ask if the TST can detect TB disease

Mantoux Tuberculin Skin Test – Module 3, pp. 8-24
69

Slide 16

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 16

Mantoux Tuberculin Skin Test (1)

• TST is administered by 

injection

• Tuberculin is made from 

proteins derived from 

inactive tubercle bacilli

• Most people who have TB 

infection will have a 

reaction at injection site Syringe being filled with 0.1 ml of liquid 

tuberculin

 Review slide content

 Explain that most people who have TB 

infection will have a reaction. Their immune 

system will recognize tuberculin because it is 

similar to tubercle bacilli.

 Note that the tuberculin used for the skin test 

is also known as purified protein derivative, 

or PPD. TST is also sometimes called a PPD 

skin test.

Mantoux Tuberculin Skin Test – Module 3, p. 8

Slide 17

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 17

0.1 ml of 5 tuberculin units of liquid tuberculin are 

injected between the layers of skin on forearm

Mantoux Tuberculin Skin Test (2)

HCW administering Mantoux TST

 Explain that the TST is given by using a single 

dose disposable syringe 

 Review slide content 

 Explain that a tuberculin unit is a standard 

strength of tuberculin

 State that tuberculin is NOT a vaccine

Mantoux Tuberculin Skin Test – Module 3, p. 8

Slide 18

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 18

Mantoux Tuberculin Skin Test (3)

• Forearm should be 

examined within 48 to 72 

hours by HCW

• Reaction is an area of 

induration (swelling) 

around injection site

– Induration is measured 

in millimeters

– Erythema (redness) is 

not measured Only the induration is measured

 Review slide content 

 Explain that patients should NOT be asked to 

read their own skin test results

 Explain that presence of erythema does NOT 

indicate a person has TB infection

 State that if the patient does not return in 48-

72 hours the test must be repeated

Mantoux Tuberculin Skin Test – Module 3, p. 8
70

Slide 19

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 19

Mantoux Tuberculin Skin Test 

Study Question 3.1

What is the TST used for? 

The TST is used to determine whether a 

person has TB infection.

 Introduce study questions

 Ask participants to turn to p. 10 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 3, p. 73

Slide 20

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 20

Mantoux Tuberculin Skin Test 

Study Question 3.2

How is the TST given? 

The TST is given by a needle and syringe 

to inject 0.1 ml of 5 tuberculin units of 

liquid tuberculin between the layers of the 

skin, usually on the forearm.

 Read question 

 Ask participants for answers

Answers – Module 3, p. 73

Slide 21

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 21

With the TST, when is the patient’s arm 

examined? 

The patient’s arm is examined by a health 

care worker 48 to 72 hours after the 

tuberculin is injected.

Mantoux Tuberculin Skin Test 

Study Question 3.3

 Read question 

 Ask participants for answers

Answers – Module 3, p. 73
71

Slide 22

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 22

Mantoux Tuberculin Skin Test 

Study Question 3.4

How is the induration measured? 

The diameter of the indurated area is 

measured across the forearm; erythema 

(redness) around the indurated area is not 

measured.

 Read question 

 Ask participants for answers

Answers – Module 3, p. 73

Slide 23

23

Diagnosis of Latent TB 

Infection (LTBI)

Mantoux Tuberculin Skin Test

Interpreting the Reaction

 Introduce section

Slide 24

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 24

Interpretation of TST reaction depends on size of 

induration and person’s risk factors for TB

Mantoux Tuberculin Skin Test (4)

Interpreting the Reaction

 Review slide content 

Interpreting the Reaction – Module 3, p. 12
72

Slide 25

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 25

• Induration of > 5 mm is considered positive for: 

– People living with HIV

– Recent contacts of people with infectious TB

– People with chest x-ray findings suggestive 

of previous TB disease

– People with organ transplants

– Other immunosuppressed patients

Mantoux Tuberculin Skin Test (5)

Interpreting the Reaction

 Review slide content

Interpreting the Reaction – Module 3, p. 12

Slide 26

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 26

Mantoux Tuberculin Skin Test (6)

Interpreting the Reaction

• Induration of > 10 mm is considered a positive 

reaction for: 

– People who have recently come to U.S. from 

areas where TB is common

– People who abuse drugs

– Mycobacteriology laboratory workers

– People who live or work in high-risk 

congregate settings

 Review slide content

Interpreting the Reaction – Module 3, p. 12

Slide 27

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 27

• Induration of > 10 mm is considered a 

positive reaction for: 

– People with certain medical conditions that 

increase risk for TB (e.g., silicosis, diabetes 

mellitus, severe kidney disease, certain 

types of cancer, and certain intestinal 

conditions)

– Children younger than 5 years of age

– Infants, children, or adolescents exposed to 

adults in high-risk categories

Mantoux Tuberculin Skin Test (7)

Interpreting the Reaction

 Review slide content

Interpreting the Reaction – Module 3, p. 12
73

Slide 28

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 28

• Induration of > 15 mm is considered a 

positive reaction for people who have no 

known risk factors for TB

Mantoux Tuberculin Skin Test (8)

Interpreting the Reaction

 Review slide content

 Reiterate that targeted testing should only be 

done in high-risk groups 

Interpreting the Reaction – Module 3, p. 12

Slide 29

Occupational Exposure

• For people who may be exposed to TB 

on the job (e.g., HCWs, staff of nursing 

homes or correctional facilities), 

interpretation of TST depends on:

– The employee’s individual risk factors for 

TB

– The risk of exposure to TB in the person’s 

job

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 29

 Review slide content

Interpreting the TST Reaction for Occupational Exposure 

– Module 3, p. 13

Slide 30

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 30

Mantoux Tuberculin Skin Test 

Study Question 3.5

What two factors determine the interpretation 

of a skin test reaction as positive or 

negative? What additional factor is 

considered for people who may be exposed 

to TB on the job?

• Size of induration and risk factors for TB

• An additional factor is the risk of 

exposure to TB in the person’s job

 Ask participants to turn to p. 14 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 3, p. 73
74

Slide 31

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 31

Name 5 groups of people for which > 5 mm of 

induration is considered a positive reaction? 

• People living with HIV

• Recent contacts of people with infectious TB

• People with chest x-ray findings suggestive of 

previous TB disease

• Patients with organ transplants

• Other immunosuppressed patients

Mantoux Tuberculin Skin Test 

Study Question 3.6

 Read question 

 Ask participants for answers

Answers – Module 3, p. 73

Slide 32

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 32

Mantoux Tuberculin Skin Test 

Study Question 3.7

Name seven groups of people for which > 10 mm 

of induration is considered a positive reaction.

• People who have recently come to the U.S. (within the last 5 

years) from areas where TB is common

• People who abuse drugs

• Mycobacteriology lab workers

• People who live or work in high-risk congregate settings

• People with certain medical conditions

• Children younger than 5 years of age

• Infants, children, and adolescents exposed to adults in highrisk categories

 Read question 

 Ask participants for answers

Answers – Module 3, p. 74

Slide 33

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 33

For which group of people is > 15 mm of 

induration considered a positive reaction?

People with no risk factors for TB.

Mantoux Tuberculin Skin Test 

Study Question 3.8

 Read question 

 Ask participants for answers

Answers – Module 3, p. 74
75

Slide 34

34

Diagnosis of Latent TB 

Infection (LTBI)

Mantoux Tuberculin Skin Test

Factors that Affect the Reaction

 Introduce section

Slide 35

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 35

• Factors that may cause people to have a 

positive reaction even if they do not have TB 

infection:

– Infection with nontuberculous mycobacteria (NTM)

– BCG vaccination

– Administration of incorrect antigen

– Incorrect measuring or interpretation of 

TST reaction

Mantoux Tuberculin Skin Test (9)

False-Positive Reaction

 Explain that the TST is a valuable tool, but it is 

not perfect

 Review slide content 

False-Positive Reaction – Module 3, p. 17

Slide 36

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 36

• People who have been vaccinated with BCG 

may have a false-positive TST reaction

– However, there is no reliable way to 

distinguish a positive TST reaction caused by 

BCG vaccination from a reaction caused by 

true TB infection

• Individuals should always be further evaluated 

if they have a positive TST reaction

Mantoux Tuberculin Skin Test (10)

BCG Vaccine

 Explain that BCG is a vaccine for TB that is 

used in many countries. However, it is rarely 

used in the U.S. because studies have shown 

that it is not completely effective

 Review slide content 

BCG Vaccine – Module 3, p. 17
76

Slide 37

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 37

• Factors that may cause false-negative 

reactions:

– Anergy

– Recent TB infection (within past 8 to 10 weeks)

• It can take 2 to 8 weeks after TB infection for 

body’s immune system to react to tuberculin

– Very young age (younger than 6 months)

– Recent live-virus measles or smallpox vaccination

– Incorrect method of giving the TST

– Incorrect measuring or interpretation of TST reaction

Mantoux Tuberculin Skin Test (11)

False-Negative Reaction

 Review slide content 

False-Negative Reaction – Module 3, p. 20

Slide 38

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 38

• Inability to react to skin tests due to 

weakened immune system

• Anergy testing is no longer routinely 

recommended

Mantoux Tuberculin Skin Test (12)

Anergy

 Review slide content 

 Note that HIV infection is an important cause 

of anergy, but other conditions, such as 

cancer, measles, or other viral infections can 

also weaken the immune system

Anergy – Module 3, p. 20

Slide 39

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 39

Mantoux Tuberculin Skin Test (13)

Any patient with symptoms of TB disease

should be evaluated for TB disease, regardless 

of his or her skin test reaction.

 Review slide content 

 Stress that people with symptoms of TB 

should be evaluated for TB disease right away

Mantoux Tuberculin Skin Test – Module 3, p. 21
77

Slide 40

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 40

Name four factors that may cause false-positive 

reactions to the TST.

• Infection with nontuberculous 

mycobacteria (NTM)

• BCG vaccination

• Administration of incorrect antigen

• Incorrect measuring or interpretation of 

TST reaction

Mantoux Tuberculin Skin Test 

Study Question 3.9

 Ask participants to turn to p. 18 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 3, p. 74

Slide 41

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 41

Is there a reliable way to distinguish a 

positive TST reaction caused by vaccination 

with BCG from a reaction caused by true TB 

infection?

No. Individuals who have had the BCG 

vaccine should be further evaluated for 

LTBI or TB disease the same as if 

they were not vaccinated with BCG. 

Mantoux Tuberculin Skin Test 

Study Question 3.10

 Read question

 Ask participants for answers

Answers – Module 3, p. 74

Slide 42

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 42

Name 6 factors that may cause false-negative 

reactions to the TST.

• Anergy

• Recent TB infection (within past 8 to 10 weeks)

• Very young age (younger than 6 months)

• Recent live-virus measles or smallpox 

vaccination

• Incorrect method of giving the TST

• Incorrect measuring or interpretation of TST 

reaction

Mantoux Tuberculin Skin Test 

Study Question 3.11

 Ask participants to turn to p. 22 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 3, p. 75
78

Slide 43

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 43

Mantoux Tuberculin Skin Test 

Study Question 3.12

What is anergy?

The inability to react to skin tests 

because of a weakened immune system.

 Read question 

 Ask participants for answers

Answers – Module 3, p. 75

Slide 44

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 44

After TB germs have been transmitted to 

someone, how long does it take before TB 

infection can be detected by the TST?

2 to 8 weeks

Mantoux Tuberculin Skin Test 

Study Question 3.13

 Read question 

 Ask participants for answers

Answers – Module 3, p. 75

Slide 45

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 45

Mantoux Tuberculin Skin Test 

Study Question 3.14

What should be done if a patient has a 

negative TST result, but has symptoms of TB 

disease?

Any patient with symptoms of TB disease 

should be evaluated for TB disease, 

regardless of his or her skin test reaction.

 Read question 

 Ask participants for answers

Answers – Module 3, p. 75
79

Slide 46

46

Diagnosis of Latent TB 

Infection (LTBI)

Interferon-Gamma 

Release Assays (IGRAs)

 Introduce section

 Ask who has had an IGRA test before

 Ask what an IGRA detects

Interferon-Gamma Release Assays – Module 3, pp. 25-31

Slide 47

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 47

Types of IGRAs

• QuantiFERON®-TB Gold 

In-Tube (QFT-GIT)

– Approved in 2007

• T-Spot®.TB test (T-SPOT)

– Type of ELISpot assay

– Approved in 2008

• CDC guidelines for 

IGRAs published in 2010

T-Spot®.TB testing materials

QFT-GIT testing materials

 Review slide content

 

Types of IGRAs – Module 3, p. 25

Slide 48

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 48

• Blood tests that help diagnose M. tuberculosis

infection

• Measures a person’s immune reactivity to 

M. tuberculosis

IGRAs (1)

 Review slide content

IGRAs – Module 3, p. 25
80

Slide 49

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 49

IGRAs (2)

Conducting the Test

• Confirm arrangements for testing in a qualified 

laboratory

• Arrange for delivery of the blood sample to the 

laboratory in the time the laboratory specifies

• Draw a blood sample from the patient according to 

the manufacturer’s instructions

• Schedule follow-up appointment for patient to 

receive test results

• Based on test results, provide follow-up evaluation 

and treatment as needed 

 Review slide content

Conducting an IGRA – Module 3, p. 25

Slide 50

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 50

• Blood samples are mixed with antigens (protein 

substances that can produce an immune 

response) and incubated

• If the person is infected with M. tuberculosis,

blood cells will recognize antigens and release 

interferon gamma (IFN-γ) in response

IGRAs (3)

How it Works

 Review slide content

 

How IGRAs Work – Module 3, p. 26

Slide 51

IGRAs (4)

Interpreting Results

• QFT-GIT Results

– Based on amount of IFN-γ released in 

response to M. tuberculosis antigens and 

control substances

• T-Spot Results

– Based on number of IFN-γ producing cells 

(spots) produced

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 51

 Review slide content

Interpreting IGRA Results – Module 3, pp. 26-27
81

Slide 52

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 52

IGRAs (5)

Interpreting Results

• Qualitative test 

interpretation and 

quantitative assay 

measurements should be 

reported

• Laboratories use software 

provided by manufacturer 

to calculate results QFT-GIT Results

• Results are sent to requesting 

health care provider

 Review slide content

 Note that qualitative interpretations include 

positive, negative, indeterminate, or 

borderline. Quantitative measurements are 

reported as numerical values and may be 

useful for clinical decision making in 

combination with the patient’s risk factors. 

Interpreting IGRA Results – Module 3, pp. 26-27

Slide 53

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 53

IGRAs (6)

Report of Results

IGRA Result Interpretation

Positive M. tuberculosis infection likely

Negative M. tuberculosis infection unlikely, but cannot be 

excluded especially if

1. Patient has signs and symptoms of TB 

2. Patient has a high risk for developing TB 

disease once infected with M. tuberculosis 

Indeterminate The test did not provide useful information about 

the likelihood of M. tuberculosis infection. 

Repeating an IGRA or performing a TST may be 

useful. 

Borderline 

(T-Spot only)

The test did not provide useful information about 

the likelihood of M. tuberculosis infection. 

Repeating an IGRA or performing a TST may be 

useful.

 Review slide content

Interpreting IGRA Results – Module 3, pp. 26-27

Slide 54

IGRA Recommendations (1)

• IGRAs are the preferred method of testing in

– Groups of people who might be less likely 

to return for TST reading and interpretation 

– Persons who have received the BCG 

vaccine

• TST is the preferred method of testing for 

children younger than 5 years of age

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 54

 Review slide content

 Explain that persons who may be less likely to 

return for a TST reading may include 

homeless persons or drug users

IGRA Recommendations – Module 3, p. 28
82

Slide 55

• Routine testing using both TST and IGRAs is NOT 

recommended

• Certain situations where results from both tests may 

be useful:

– When the initial test is negative and: 

• Risk for infection, progression to disease, or a 

poor outcome is high 

• There is clinical suspicion for TB disease and 

confirmation of M. tuberculosis infection is 

desired

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 55

IGRA Recommendations (2)

 Review slide content

 Explain that the risk for infection, progression 

to disease, or poor outcome may be higher 

for persons living with HIV or children 

younger than 5 years of age who are exposed 

to a person with infectious TB

 State that clinical suspicion for TB disease 

may include signs, symptoms, or radiographic 

evidence suggestive of TB disease

IGRA Recommendations – Module 3, p. 28

Slide 56

• Certain situations where results from both tests 

may be useful

– When the initial test is positive and:

• Additional evidence of infection is required 

to encourage the patient’s acceptance and 

adherence to treatment

• Person has a low risk of both infection and 

progression from infection to TB disease 

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 56

IGRA Recommendations (3)

 Review slide content

IGRA Recommendations – Module 3, p. 28

Slide 57

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 57

• Requires single patient visit to conduct test

• Results can be available in 24 hours

• Does not cause booster phenomenon which 

can happen with repeat TSTs

• BCG vaccination does not affect IGRA results

IGRA Advantages

 Review slide content 

 Explain that BCG vaccination does not affect 

IGRA results because the antigens used for 

IGRAs are not found in BCG vaccine strains

Note: Booster phenomenon is presented on slides 68-69

IGRA Advantages – Module 3, pp. 29-30
83

Slide 58

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 58

• Blood samples must be processed within 8 to 

30 hours after collection

• Errors in collecting or transporting blood 

specimens or in running and interpreting test 

can decrease accuracy 

• Limited data on its use in certain populations 

(e.g., children younger than 5, persons 

recently infected, immunocompromised 

persons, and serial testing)

IGRA Disadvantages and 

Limitations (1)

 Review slide content 

IGRA Disadvantages and Limitations – Module 3, p. 30

Slide 59

IGRA Disadvantages and 

Limitations (2)

• Limited data on its use to predict who 

will progress to TB disease

• Tests may be expensive

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 59

 Review slide content

IGRA Disadvantages and Limitations – Module 3, p. 30

Slide 60

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 60

What are the steps for conducting an IGRA?

• Confirm arrangements for testing in a qualified 

laboratory

• Arrange for delivery of the blood sample to the 

laboratory 

• Draw a blood sample from the patient according to the manufacturer’s instructions

• Schedule follow-up appointment for patient to receive 

test results

• Based on test results, provide follow-up evaluation and 

treatment as needed 

IGRAs

Study Question 3.15

 Ask participants to turn to p. 32 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 3, p. 75
84

Slide 61

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 61

How are IGRA results interpreted?

• QFT-GIT results are based on the amount of IFN-γ 

that is released in response to the antigens and 

control substances

• T-Spot results are based on the number of IFN-γ 

producing cells (spots) produced

• Both the standard qualitative test interpretation and 

the quantitative assay measurements should be 

reported

IGRAs

Study Question 3.16

 Read question 

 Ask participants for answers

Answers – Module 3, p. 76

Slide 62

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 62

IGRAs

Study Question 3.17

How should negative IGRA results be

interpreted? 

• If the result is negative, the patient is unlikely 

to have M. tuberculosis infection

• Patient may not require further evaluation 

unless they have signs and symptoms of TB 

disease

 Read question 

 Ask participants for answers

Answers – Module 3, p. 76

Slide 63

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 63

What are 5 advantages for using an IGRA as

compared to the TST?

• Requires a single patient visit

• Results can be available in 24 hours

• Does not cause the booster phenomenon 

• Laboratory test not affected by health care worker 

perception or bias

• BCG vaccine does not affect IGRA results

IGRAs

Study Question 3.18

 Read question 

 Ask participants for answers

Answers – Module 3, p. 76
85

Slide 6

4

64

Diagnosis of Latent TB 

Infection (LTBI)

TB Testing Programs, the Booster 

Phenomenon, and Two-Step Testing

 Introduce section

TB Testing Programs, Booster Phenomenon, and TwoStep Testing – Module 3, pp. 33-36

Slide 65

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 65

• Many residential facilities, health care settings, 

and other settings have TB testing programs

– Employees and residents are periodically 

given TSTs or IGRAs

• Testing programs: 

– Identify people who have LTBI or TB disease 

so they can be given treatment as needed

– Determine whether TB is being transmitted in 

facility

TB Testing Programs (1)

 Review slide content 

 Ask participants what types of TB testing 

programs are used where they work

TB Testing Programs – Module 3, pp. 33-36

Slide 66

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 66

• Employees or residents are given TSTs or 

IGRAs when they first enter facility

– If person is negative, they may be retested 

at regular intervals thereafter

TB Testing Programs (2)

Baseline Test

 Review slide content 

Baseline Test – Module 3, p. 33
86

Slide 67

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 67

TB Testing Programs (3)

Conversion

• Persons whose TST or IGRA result converts 

from negative to positive may have been 

infected with M. tuberculosis

– TST or IGRA conversions may indicate 

that TB is being transmitted in facility

 Review slide content 

 Explain that people with skin test conversions 

are at high risk for developing TB disease 

because a conversion indicates that a person 

was infected relatively recently

Conversion – Module 3, p. 33

Slide 68

 Review slide content 

Booster Phenomenon – Module 3, pp. 33-35

Slide 69

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 69

Person is skin tested years later

Person is skin tested again, up 

to 1 year later. For this 

example, we assume that the 

person was NOT exposed to 

TB during this time

Person has a positive reaction. This 

is a boosted reaction due to TB 

infection that occurred a long time 

ago, not during the time between the 

two skin tests

Occurs mainly in 

previously infected, 

older adults whose 

ability to react to 

tuberculin has 

decreased over time

Figure 3.6 

The booster phenomenon with the TST

Person becomes infected with M. tuberculosis

As years pass, 

person’s ability to 

react to tuberculin 

lessens

Person has negative reaction due to 

lessened ability to react to tuberculin

However, this skin test “jogs the 

memory” of the immune system to 

recognize and react to tuberculin

 Explain the booster phenomenon using the 

flowchart

Booster Phenomenon – Module 3, p.34
87

Slide 70

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 70

• Only conducted when TST is used

• Distinguishes between boosted reactions and reactions 

caused by recent infections

• Should be used for initial skin testing of persons who will 

be retested periodically

• If person’s initial skin test is negative, they should be 

given a second test 1 to 3 weeks later

– Second test positive: probably boosted reaction

– Second test negative: considered uninfected

Two-Step Testing

 Review slide content 

Two-Step Testing – Module 3, pp. 35-36

Slide 71

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 71

Baseline skin test

Reaction

Negative Positive

Reaction

Negative Positive

Retest 1-3 weeks later Person probably has TB infection

Person probably 

does NOT have 

TB infection

Reaction is considered 

a boosted reaction 

(due to TB infection 

that occurred a long 

Repeat at regular time ago)

intervals; a positive 

reaction will probably 

be due to a recent TB 

infection

Retesting not 

necessary

Figure 3.7 

Two-step testing with the TST

 Explain two-step testing using the flowchart

Two-Step Testing – Module 3, p. 35-36

Slide 72

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 72

What is the booster phenomenon?

• Phenomenon in which people who are skin 

tested many years after becoming infected 

with M. tuberculosis have a negative reaction 

to an initial skin test, followed by a positive 

reaction to a skin test given up to a year later

• Occurs because the ability to react to 

tuberculin lessens over time in some people

Booster Phenomenon

Study Question 3.19

 Introduce study questions 

 Ask participants to turn to p. 37 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 3, p. 76
88

Slide 73

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 73

What is the purpose of two-step testing?

To distinguish between boosted

reactions and reactions caused by recent

infection.

Two-Step Testing

Study Question 3.20

 Read question 

 Ask participants for answers

Answers – Module 3, p. 76

Slide 74

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 74

Two-Step Testing

Study Question 3.21

In what type of situation is two-step testing 

used?

It is used in many programs for skin 

testing employees when they start their 

job.

 Read question 

 Ask participants for answers

Answers – Module 3, p. 76

Slide 75

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 75

How is two-step testing done?

If a person has a negative reaction to an 

initial skin test, he or she is given a second 

test 1 to 3 weeks later.

–If reaction to second test is positive, it is 

considered a boosted reaction

–If reaction to second test is negative, 

person is considered to be uninfected

Two-Step Testing

Study Question 3.22

 Read question 

 Ask participants for answers

Answers – Module 3, p. 77
89

Slide 76

76

Diagnosis of TB Disease

 Introduce section 

Diagnosis of TB Disease – Module 3, pp. 39-68

Slide 77

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 77

• Anyone with TB symptoms or positive TST or 

IGRA result should be medically evaluated for 

TB disease

• Components of medical evaluation:

1. Medical history

2. Physical examination

3. Test for TB infection

4. Chest x-ray

5. Bacteriological examination

Medical Evaluation

 Review slide content

 Note that they key to diagnosing TB is for 

clinicians to “think TB” when they see a 

patient with symptoms of TB or abnormal 

chest x-ray findings

Medical Evaluation – Module 3, p. 39

Slide 78

78

1. Medical History

2. Physical Examination

3. Test for TB Infection

Diagnosis of TB Disease

Medical Evaluation

 Introduce section

Medical History, Physical Examination, and Test for TB 

Infection – Module 3, pp. 39-44
90

Slide 79

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 79

1. Medical History (1)

• Clinicians should ask patients if they have:

– Symptoms of TB disease

– Been exposed to a person with infectious TB 

or have risk factors for exposure to TB 

– Any risk factors for developing TB disease

– Had LTBI or TB disease before

 Review slide content

 Explain that patients who have had TB 

disease before should be asked when they 

had disease and if it was treated

 

Medical History – Module 3, pp. 39-41

Slide 80

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 80

1. Medical History (2)

General Symptoms of TB Disease

• Fever 

• Chills

• Night sweats

• Weight loss

• Appetite loss

• Fatigue

• Malaise

 Review slide content

 Explain that people with TB disease may or 

may not have symptoms. However, most 

people with TB disease will have one or more 

symptoms.

 Explain that usually when patients have 

symptoms, the symptoms have developed 

gradually and have been present for week or 

months

General Symptoms of TB Disease – Module 3, p. 40

Slide 81

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 81

• Cough lasting 3 or more weeks

• Chest pain 

• Coughing up sputum or blood

1. Medical History (3)

Symptoms of Pulmonary TB Disease

 Review slide content

Symptoms of Pulmonary TB Disease – Module 3, p. 40
91

Slide 82

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 82

• Symptoms of extrapulmonary TB disease 

depend on part of body that is affected

• For example:

– TB disease in spine may cause back pain

– TB disease in kidneys may cause blood in 

urine

1. Medical History (4)

Symptoms of Extrapulmonary TB Disease

 Review slide content

Symptoms of Extrapulmonary TB Disease – Module 3, p. 

40

Slide 83

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 83

A physical examination cannot confirm or rule out 

TB disease, but can provide valuable information

2. Physical Examination

 Review slide content

Physical Examination – Module 3, p. 41

Slide 84

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 84

3. Test for TB Infection (1)

• Types of tests available 

for diagnosing TB 

infection in U.S.:

– Mantoux TST

– IGRAs

• QFT-GIT

• T-SPOT

 Review slide content

Testing for TB Infection – Module 3, p. 42
92

Slide 85

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 85

3. Test for TB Infection (2)

• Patients with symptoms of TB disease 

should always be evaluated for TB disease, 

regardless of their TST or IGRA test result

– Clinicians should not wait for TST or IGRA 

results before starting other diagnostic 

tests

– TST or IGRA should be given at the same 

time as other steps in the diagnosis of TB 

disease

 Review slide content

 Explain that sometimes people with TB 

disease may have a negative test result

Testing for TB Infection – Module 3, p. 42

Slide 86

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 86

What are the 5 components for conducting a medical evaluation for diagnosing TB disease?

• Medical history

• Physical examination

• Test for TB infection

• Chest x-ray

• Bacteriologic examinations

Diagnosis of TB Disease

Study Question 3.23

 Introduce study questions

 Ask participants to turn to p. 43 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 3, p. 77

Slide 87

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 87

What parts of a patient’s medical history should 

lead a clinician to suspect TB?

• Symptoms of TB disease

• Exposure to a person who has infectious 

TB or has other risk factors for exposure to 

TB

• Risk factors for developing TB disease

• TB infection or TB disease in the past

Diagnosis of TB Disease

Study Question 3.24

 Read question 

 Ask participants for answers

Answers – Module 3, p. 77
93

Slide 88

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 88

What are the symptoms of pulmonary TB 

disease? What are the symptoms of 

extrapulmonary TB disease?

• General symptoms of TB disease: Weight loss, 

fatigue, malaise, fever, and night sweats

• Pulmonary: Coughing, pain in chest, coughing up 

sputum or blood

• Extrapulmonary: Depends on the part of the body 

that is affected by the disease. For example, TB of 

the spine may cause pain in the back; TB of the 

kidney may cause blood in the urine.

Diagnosis of TB Disease 

Study Question 3.25

 Read questions 

 Ask participants for answers

Answers – Module 3, p. 78

Slide 89

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 89

For patients with symptoms of TB disease, 

should clinicians wait for TST or IGRA 

results before starting other diagnostic 

tests?

No, clinicians should not wait for TST or 

IGRA results before starting other 

diagnostic tests.

Diagnosis of TB Disease 

Study Question 3.26

 Read question 

 Ask participants for answers

Answers – Module 3, p. 78

Slide 90

90

Diagnosis of TB Disease

Medical Evaluation

4. Chest X-Ray

 Introduce section

Chest X-Ray – Module 3, p. 45
94

Slide 91

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 91

• When a person has TB 

disease in the lungs, the 

chest x-ray usually 

appears abnormal. It may show:

– Infiltrates (collections 

of fluid and cells in 

lung tissue)

– Cavities (hollow 

spaces within the 

lung)

4. Chest X-Ray (1)

Abnormal chest x-ray with cavity

 Explain that chest x-rays are useful for 

diagnosing TB disease because pulmonary TB 

is the most common form of the disease

 Review slide content

 Explain that the patient in the picture has a 

cavity in the lower lobe

Chest X-Ray – Module 3, p. 45

Slide 92

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 92

• Chest x-rays can:

– Help rule out possibility of pulmonary TB 

disease in persons who have a positive TST 

or IGRA result

– Check for lung abnormalities 

4. Chest X-Ray (2)

 Review slide content

Chest X-Ray – Module 3, p. 45

Slide 93

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 93

4. Chest X-Ray (3)

• Chest x-rays cannot confirm TB disease

– Other diseases can cause lung 

abnormalities

– Only bacteriologic culture can confirm 

patient has TB disease

– Chest x-ray may appear unusual or even 

appear normal for persons living with HIV

 Review slide content

Chest X-Ray – Module 3, p. 46
95

Slide 94

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 94

Name 2 purposes of the chest x-ray. 

• Help rule out possibility of pulmonary TB 

disease in a person who has positive TST 

or IGRA result and no symptoms of TB

• Check for lung abnormalities in people 

who have symptoms of TB disease

Chest X-Ray

Study Question 3.27

 Introduce study questions

 Ask participants to turn to p. 47 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 3, p. 78

Slide 95

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 95

Chest X-Ray

Study Question 3.28

Can the results of a chest x-ray confirm that 

a person has TB disease? Why or why not?

No. A variety of illnesses may produce 

abnormalities on chest x-ray. Only 

bacteriologic culture can prove whether 

or not a patient has TB disease.

 Read question 

 Ask participants for answers

Answers – Module 3, p. 78

Slide 96

96

Diagnosis of TB Disease

Medical Evaluation

5. Bacteriologic 

Examination

 Introduce section

Bacteriological Examination – Module 3, pp. 48-68
96

Slide 97

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 97

5. Bacteriologic Examination (1)

• TB bacteriologic examination is done in a 

laboratory that specifically deals with M. 

tuberculosis and other mycobacteria

– Clinical specimens (e.g., sputum, urine) 

are examined and cultured in laboratory

 Review slide content

Bacteriological Examination – Module 3, p. 48

Slide 98

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 98

• Bacteriologic examination has 5 parts

– Specimen collection

– Examination of acid-fast bacilli (AFB) 

smears

– Direct identification of specimen (nucleic 

acid amplification)

– Specimen culturing and identification

– Drug susceptibility testing

5. Bacteriologic Examination (2)

 Review slide content

Bacteriologic Examination – Module 3, p. 48

Slide 99

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 99

5. Bacteriologic Examination (3)

Specimen Collection

• For pulmonary TB, 

specimens can be 

collected by:

– Coughing up sputum 

sample

– Inducing sputum 

sample

– Bronchoscopy

– Gastric washing

TB patient coughing up sputum in a sputum collection booth

 Review slide content

 Explain that the image is of a TB patient 

coughing up sputum. The patient is sitting in a 

special sputum collection booth that prevents 

the spread of tubercle bacilli.

Specimen Collection – Module 3, pp. 48-51
97

Slide 100

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 100

• Easiest and least expensive method is to 

have patient cough into sterile container 

• HCWs should coach and instruct patient

• Should have at least 3 sputum specimens 

examined

– Collected in 8 to 24 hour intervals

– At least one early morning specimen

5. Bacteriologic Examination (4) 

Sputum Sample Specimen Collection

 Review slide content

 Note that health care workers should always 

supervise the patient when sputum is 

collected since patients are not always 

successful in providing an adequate specimen

Specimen Collection – Module 3, pp. 48-51

Slide 101

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 101

5. Bacteriologic Examination (5) 

Induced Sputum Collection

• Induced sputum collection should be used if 

patient cannot cough up sputum on their 

own

• Patient inhales saline mist, causing deep 

coughing

• Specimen often clear and watery, should be 

labeled “induced specimen”

 Review slide content

Induced Sputum Collection – Module 3, p. 49

Slide 102

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 102

5. Bacteriologic Examination (6)

Bronchoscopy

• Bronchoscopy may be used:

– If patient cannot cough up 

enough sputum

– If an induced sputum cannot 

be obtained

• Procedure: instrument is 

passed through the mouth into 

the diseased portion of the 

lung to obtain sputum or lung 

tissue

Bronchoscopy being performed on a patient

 Review slide content

Bronchoscopy – Module 3, p. 49
98

Slide 103

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 103

5. Bacteriologic Examination (7)

Gastric Washing

• Usually only used if sample cannot be 

obtained from other procedures

• Often used with children 

• Tube is inserted through nose and into 

stomach to obtain gastric secretions that 

may contain sputum 

 Review slide content

 Explain that the goal of gastric washing is to 

get a sample of gastric secretions that 

contains sputum that has been coughed into 

the throat and swallowed

 Explain that this technique is often used in 

children because most children produce little 

or no sputum when they cough

Gastric Washing – Module 3, p. 50

Slide 104

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 104

• Specimens other than sputum may be obtained

• Depends on part of body affected

• For example:

– Urine samples for TB disease of kidneys

– Fluid samples from area around spine for TB 

meningitis

5. Bacteriologic Examination (8) 

Extrapulmonary TB

 Review slide content

Extrapulmonary TB – Module 3, p. 50

Slide 105

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 105

5. Bacteriologic Examination (9)

Examination of AFB Smears

• Specimens are 

smeared onto glass 

slide and stained

• AFB are 

mycobacteria that 

remain stained after 

being washed in 

acid solution 

AFB smear

 Review slide content

 Explain that tubercle bacilli are one kind of 

AFB

 Note that in this photograph, the AFB (shown 

in red) are tubercle bacilli

Examination of AFB Smears – Module 3, pp. 53-54
99

Slide 106

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 106

• Number of AFB on smear are counted

• According to number of AFB seen, smears are 

classified as 4+, 3+, 2+, or 1+

– For example, 4+ smear has 10 times as many AFB 

than 3+ smear

• If very few AFB are seen, the smear is classified by 

the actual number of AFB seen

• A negative smear does not rule out the possibility of 

TB 

5. Bacteriologic Examination (10)

Examination of AFB Smears

 Review slide content

 Explain that when very few AFB are seen, the 

smear is classified by the actual number of 

AFB seen and there is NOT a plus sign (+)

Examination of AFB Smears – Module 3, pp. 53-54

Slide 107

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 107

5. Bacteriologic Examination (11)

Examination of AFB Smears

Classification 

of Smear Smear Result Infectiousness of Patient

4+ Strongly positive Probably very

infectious

3+ Strongly positive Probably very

infectious

2+ Moderately positive Probably infectious

1+ Moderately positive Probably infectious

Actual number 

of AFB seen 

(no plus sign)

Weakly positive Probably infectious

No AFB seen Negative May not be

infectious

 Review slide content

 Explain that even though a smear is 

considered negative if no AFB are seen it does 

not rule out the possibility of TB disease 

because there can be AFB in the smear that 

were not seen

Examination of AFB Smears – Module 3, p. 54

Slide 108

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 108

What are the 4 ways to collect sputum 

specimens? Indicate which procedure is the 

least expensive and easiest to perform.

• Patient simply coughs up sputum and the 

sputum is collected in a sterile container. This 

is the least expensive and easiest procedure.

• Induced sputum 

• Bronchoscopy

• Gastric washing

Bacteriologic Examination

Study Questions 3.29

 Introduce study questions

 Ask participants to turn to p. 55 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 3, p. 79
100

Slide 109

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 109

What do laboratory personnel look for in a 

smear?

Acid-fast bacilli (AFB)

Bacteriologic Examination

Study Question 3.30

 Read question

 Ask participants for answers

Answers – Module 3, p. 79

Slide 110

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 110

Bacteriologic Examination

Study Question 3.31

What does a positive smear indicate about a 

patient’s infectiousness?

Patients who have many tubercle bacilli 

seen in their sputum have a positive 

smear. Patients who have positive smears 

are considered infectious because they 

can cough many tubercle bacilli into the 

air.

 Read question 

 Ask participants for answers

Answers – Module 3, p. 79

Slide 111

111

Diagnosis of TB Disease

Medical Evaluation

5. Bacteriologic 

Examination (continued)

 Introduce section
101

Slide 112

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 112

5. Bacteriologic Examination (12)

Nucleic Acid Amplification Tests (NAA)

• NAA tests directly identify M. tuberculosis

from sputum specimens by:

– Amplifying (copying) DNA and RNA 

segments

• Can help guide clinician’s decision for 

patient therapy and isolation

• Does not replace need for AFB smear, 

culture, or clinical judgment

 Review slide content

Nucleic Acid Amplification Tests – Module 3, p. 58

Slide 113

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 113

5. Bacteriologic Examination (13)

Nucleic Acid Amplification Tests (NAA)

• If NAA test and AFB smears are positive:

– Patient is presumed to have TB and should 

begin treatment 

• If NAA test is negative and AFB smears are 

positive:

– Patient may have nontuberculous 

mycobacteria infection (NTM)

 Review slide content

Nucleic Acid Amplification Tests – Module 3, p. 58

Slide 114

5. Bacteriologic Examination (14)

Xpert MTB/RIF Assay

• Xpert MTB/RIF assay is a NAA test that 

simultaneously detects Mycobacterium 

tuberculosis complex (MTBC) and resistance to 

rifampin

• To conduct this test, a sputum sample is mixed 

with the reagent that is provided with the assay

• A cartridge containing the mixture is placed in 

the GeneXpert machine

• Results are available in less than 2 hours

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 114

 Review slide content

Xpert MTB/RIF Assay – Module 3, pp. 58-59
102

Slide 115

5. Bacteriologic Examination (15)

Xpert MTB/RIF Assay

• Results that are positive for MTBC and for rifampin 

resistance indicate that the bacteria have a high 

probability of resistance to rifampin

– Should be confirmed by additional rapid testing

• If rifampin resistance is confirmed, rapid molecular 

testing for drug resistance to both first-line and 

second-line drugs should be performed so an 

effective treatment regimen can be selected

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 115

 Review slide content

Xpert MTB/RIF Assay – Module 3, pp. 58-59

Slide 116

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 116

5. Bacteriologic Examination (16)

Culturing and Identifying Specimen

• Culturing:

– Determines if 

specimen contains 

M. tuberculosis 

– Confirms diagnosis 

of TB disease

• All specimens should 

be cultured

Colonies of M. tuberculosis growing on media

 Review slide content

 Explain that the image is of colonies of M. 

tuberculosis growing on solid media

Culturing and Identifying Specimen – Module 3, pp. 59-61

Slide 117

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 117

5. Bacteriologic Examination (17)

Culturing and Identifying Specimen

• Step 1: Detect growth of mycobacteria

– Solid media: 3 to 6 weeks

– Liquid media: 4 to 14 days

• Step 2: Identify organism that has grown

– Nucleic acid probes: 2 to 4 hours

 Review slide content

 Explain that mycobacteria grow very slowly 

 Explain that it is necessary to identify the 

organism that has grown because all types of 

mycobacteria can grow on media. Laboratory 

tests must be done to determine whether the 

organism is M. tuberculosis or one of the 

nontuberculous mycobacteria.

Culturing and Identifying Specimen – Module 3, pp. 59-61
103

Slide 118

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 118

• Positive culture: M. tuberculosis identified in 

patient’s culture

– Called M. tuberculosis isolate

– Confirms diagnosis of TB disease

5. Bacteriologic Examination (18)

Culturing and Identifying Specimen

 Review slide content

Culturing and Identifying Specimen – Module 3, pp. 59-61

Slide 119

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 119

5. Bacteriologic Examination (19)

Culturing and Identifying Specimen

• Negative culture: M. tuberculosis NOT 

identified in patient’s culture

– Does not rule out TB disease

– Some patients with negative cultures are 

diagnosed with TB based on signs and 

symptoms

 Review slide content

Culturing and Identifying Specimen – Module 3, pp. 59-61

Slide 120

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 120

• Bacteriological examinations are important 

for assessing infectiousness and response 

to treatment

• Specimens should be obtained monthly until 

2 consecutive cultures are negative

• Culture conversion is the most important 

objective measure of response to treatment

5. Bacteriologic Examination (20)

Culturing and Identifying Specimen

 Review slide content

 Explain that culture conversion is when the 

culture goes from positive growth to negative 

growth of M. tuberculosis

Culturing and Identifying Specimen – Module 3, pp. 59-61
104

Slide 121

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 121

• Conducted when patient is first found to 

have positive culture for TB

• Determines which drugs kill tubercle bacilli

• Tubercle bacilli killed by a particular drug are 

susceptible to that drug

• Tubercle bacilli that grow in presence of a 

particular drug are resistant to that drug

5. Bacteriologic Examination (21)

Drug Susceptibility Testing

 Review slide content

 Explain that the drug susceptibility pattern of 

a strain of tubercle bacilli is the list of drugs to 

which the strain is susceptible and to which it 

is resistant

 Stress that it is crucial to identify drug 

resistance as early as possible to ensure 

effective treatment

Drug Susceptibility Testing – Module 3, pp. 64-66

Slide 122

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 122

5. Bacteriologic Examination (22)

Drug Susceptibility Testing

• Tests should be 

repeated if:

– Patient has 

positive culture 

after 3 months of 

treatment; or 

– Patient does not 

get better

Drug susceptibility testing on solid media

 Review slide content

 Explain that the image is of drug susceptibility 

testing on solid media. Organisms are 

resistant to the drug in the upper right 

compartment and susceptible to the drugs in 

the lower compartments. The upper left 

contains no drugs.

Drug Susceptibility Testing – Module 3, pp. 64-66

Slide 123

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 123

5. Bacteriologic Examination (23)

Types of Drug-Resistant TB

Mono-resistant Resistant to any one TB treatment 

drug

Poly-resistant Resistant to at least any two TB drugs 

(but not both isoniazid and rifampin)

Multidrugresistant 

(MDR TB)

Resistant to at least isoniazid and 

rifampin, the two best first-line TB 

treatment drugs

Extensively 

drug-resistant 

(XDR TB)

Resistant to isoniazid and rifampin, 

PLUS resistant to any fluoroquinolone 

AND at least 1 of the 3 injectable 

second-line drugs (e.g., amikacin, 

kanamycin, or capreomycin)

 Explain that these are four types of drugresistant TB

 Review slide content

Types of Drug-Resistant TB – Module 3, p. 64
105

Slide 124

5. Bacteriologic Examination (24)

Growth-Based Drug Susceptibility Testing

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 124

• Growth-based susceptibility testing can be done 

using a liquid or solid medium method

• Organisms that grow in media containing a specific 

drug are considered resistant to that drug

• Liquid medium methods are faster than solid media methods for determining susceptibility to first-line 

TB medications

• Results can be obtained within 7 to 14 days for 

liquid medium method and up to 21 days for solid medium method

 Review slide content

Growth-Based Drug Susceptibility Testing –

Module 3, p. 65

Slide 125

5. Bacteriologic Examination (25)

Molecular Detection of Drug Resistance

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 125

• Molecular tests provide preliminary guidance on 

effective therapy for TB patients

• These tests should be considered for patients 

with the following characteristics:

– High risk of rifampin resistance, including MDR TB;

– First-line drug susceptibility results are available and 

show resistance to rifampin;

– Infectiousness poses a risk to vulnerable contacts; and

– Contraindications to essential first-line medications

 Review slide content

Growth-Based Drug Susceptibility Testing –

Module 3, p. 65

Slide 126

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 126

Why is it necessary to culture a specimen?

It is necessary to culture a specimen to 

determine whether the specimen 

contains M. tuberculosis and to confirm 

diagnosis of TB disease. Additionally, 

culture is needed for genotyping and for 

performing drug susceptibility testing.

Culture Specimen

Study Question 3.32

 Introduce study questions

 Ask participants to turn to p. 67 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 3, p. 79
106

Slide 127

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 127

Culture Specimen

Study Question 3.33

What does a positive culture for 

M. tuberculosis mean? How is this important 

for the TB diagnosis?

It means that M. tuberculosis has been 

identified in a patient’s culture. A 

positive culture for M. tuberculosis

confirms the diagnosis of TB disease.

 Read question 

 Ask participants for answers

Answers – Module 3, p. 80

Slide 128

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 128

Why are drug susceptibility tests done?

To determine which drugs will kill the 

tubercle bacilli that are causing disease 

in a particular patient. Test results can 

help clinicians choose the appropriate 

drugs for each patient.

Drug Susceptibility

Study Question 3.34

 Read question 



 Ask participants for answers

Answers – Module 3, p. 80

Slide 129

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 129

Drug Susceptibility

Study Question 3.35

How often should drug susceptibility tests be 

done?

• Should be done when the patient is first 

found to have a positive culture for M. 

tuberculosis

• Tests should be repeated if a patient has 

a positive culture for M. tuberculosis

after 3 months of treatment or if a 

patient is not getting better

 Read question 

 Ask participants for answers

Answers – Module 3, p. 80
107

Slide 130

130

Reporting TB Cases

 Introduce section

Reporting TB Cases – Module 3, p. 63

Slide 131

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 131

Reporting TB Cases 

• TB programs report 

TB cases to CDC 

using a standard case 

report form called the 

Report of Verified of 

Case of Tuberculosis

(RVCT)

– All cases that meet 

criteria are called 

verified TB cases

 Review slide content

 State that health care providers are required 

by law to report TB cases to state or local 

health departments

 Note that the image is of the first page of the 

RVCT form

Reporting TB Cases – Module 3, p. 63

Slide 132

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 132

Criteria for Reporting TB Cases (1)

Cases that meet one of these four sets of 

criteria are counted as verified TB cases:

1. Patient has positive culture for M. 

tuberculosis

2. Patient has positive NAA test for M. 

tuberculosis

• NAA test must be accompanied by 

culture for mycobacteria species

 Explain that each reported TB case is checked 

to make sure it meets certain criteria. All 

cases that meet the criteria, called verified TB 

cases, are counted each year

 Review slide content

Reporting TB Cases – Module 3, p. 63
108

Slide 133

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 133

Criteria for Reporting TB Cases (2)

3. Patient has positive AFB smear, but culture 

has not been obtained or is falsely negative 

or contaminated

4. In the absence of laboratory confirmation, 

patient meets all of the following criteria:

• Positive TST or IGRA,

• Other signs and symptoms of TB disease,

• Treatment with 2 or more TB drugs, and

• A completed diagnostic evaluation.

 Review slide content

Reporting TB Cases – Module 3, p. 63

Slide 134

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 134

Criteria for Reporting TB Cases (3)

• Cases that do not meet any of these sets of 

criteria may be counted as a verified TB case 

if health care provider has reported the case 

and decided to treat the patient for TB 

disease

 Review slide content

 Provide an example of this situation (e.g., a 

patient who is anergic and has a negative 

culture for M. tuberculosis but who has signs 

and symptoms of TB disease may be counted 

as a verified case of TB if the health care 

provider has reported the case and decided 

to treat the patient for TB disease)

Reporting TB Cases – Module 3, p. 63

Slide 135

 Introduce case studies
109

Slide 136

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 136

Module 3: Case Study 3.1

Which of the following patients have a positive TST 

reaction? Circle the best answer(s).

a. Mr. West, 36 yrs. old, HIV infected, 8 mm induration

b. Ms. Hernandez, 26 yrs. old, native of Mexico, 7 mm induration

c. Ms. Jones, 56 yrs. old, diabetic, 12 mm induration

d. Mr. Sung, 79 yrs. old, nursing home resident, 11 mm induration

e. Mr. Williams, 21 yrs. old, no known risk factors, 13 mm 

induration

f. Ms. Marcos, 42 yrs. old, chest x-rays findings suggestive of 

previous TB, 6 mm induration

g. Ms. Rayle, 50 yrs. old, husband has pulmonary TB, 9 mm of 

induration

 Ask participants to turn to p. 16 (if 

participants have print-based modules)

 Read case study 

 Ask participants which of the patients have a 

positive TST reaction 

Answers – Module 3, p. 81

Slide 137

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 137

Module 3: Case Study 3.2 (1)

A 30 year-old man who recently immigrated 

to the United States from India is given a TST 

and found to have 14 mm of induration. He 

reports that he was vaccinated with BCG as a 

child. He also says that his wife was treated 

for pulmonary TB disease last year. 

 Ask participants to turn to p. 19 (if 

participants have print-based modules)

 Read case study 

Case Study 3.2 – Module 3, p. 19

Slide 138

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 138

How should this man’s results be interpreted?

• Positive reaction to TST

• Should be further evaluated for LTBI or TB 

disease

What factors make it more likely that this man’s 

positive reaction is due to TB infection?

• From area of the world where TB is 

common

• Wife had pulmonary TB

Module 3: Case Study 3.2 (2)

 Read case study questions 

 Ask participants for answers

Answers – Module 3, p. 82
110

Slide 139

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 139

Module 3: Case Study 3.3 (1)

Mr. Bell comes to the TB clinic for a TST. He 

believes that he has been exposed to TB, and 

he knows he is at high risk for TB because 

he is HIV infected. He is given a TST, and his 

reaction is read 48 hours later as 0 mm of 

induration. 

 Ask participants to turn to p. 24 (if 

participants have print-based modules)

 Read case study 

Case Study 3.3 – Module 3, p. 24

Slide 140

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 140

What are 3 ways to interpret this result?

• May not have TB infection

• May be anergic

• It may be less than 8 to 10 weeks since 

he was exposed to TB

Module 3: Case Study 3.3 (2)

 Read case study question 

 Ask participants for answers

Answers – Module 3, p. 82

Slide 141

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 141

Module 3: Case Study 3.4 (1)

Ms. Wilson is a 60-year-old nurse. When she 

started a job at the local hospital, she was 

given a TST, her first test in 25 years. Her 

reaction was read 48 hours later as 0 mm 

induration. Six months later, she was 

retested as part of the TB testing program in 

the unit where she works. Her skin test 

reaction was read 48 hours later as 11 mm of 

induration.

 Ask participants to turn to p. 38 (if 

participants have print-based modules)

 Read case study 

Case Study 3.4 – Module 3, p. 38
111

Slide 142

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 142

What are 2 ways to interpret this result?

• She was exposed to TB sometime in the 

6 months between her first and second 

skin tests

• She had a boosted reaction

Module 3: Case Study 3.4 (2)

 Read case study question 

 Ask participants for answers

Answers – Module 3, p. 83

Slide 143

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 143

Module 3: Case Study 3.5 (1)

Mr. Lee has a cough and other symptoms of 

TB disease, and he is evaluated with a chest 

x-ray. However, he is unable to cough up 

any sputum on his own for the bacteriologic 

examination.

 Ask participants to turn to p. 52 (if 

participants have print-based modules)

 Read case study 

Case Study 3.5 – Module 3, p. 52

Slide 144

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 144

What should be done?

Since he is unable to cough up sputum, 

other techniques can be used to obtain 

sputum. First, clinicians can try to 

obtain an induced sputum sample. If 

they cannot obtain the sample, a 

bronchoscopy or gastric washing may 

be done.

Module 3: Case Study 3.5 (2)

 Read case study question 

 Ask participants for answers

Answers – Module 3, p. 83
112

Slide 145

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 145

Module 3: Case Study 3.6 (1)

Ms. Thompson gave three sputum 

specimens, which were sent to the laboratory 

for smear examination and culture. The 

smear results were reported as 4+, 3+, and 

4+.

 Ask participants to turn to p. 56 (if 

participants have print-based modules)

 Read case study 

Case Study 3.6 – Module 3, p. 56

Slide 146

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 146

What do these results tell you about Ms. 

Thompson’s diagnosis and her 

infectiousness?

• Results show that Ms. Thompson’s sputum 

specimens contain many acid-fast bacilli 

• Clinicians should suspect that she has TB 

disease and should consider her infectious 

since her smears are positive

• It is possible that the AFB are mycobacteria 

other than tubercle bacilli 

• Diagnosis cannot be confirmed until culture 

results are available

Module 3: Case Study 3.6 (2)

 Read case study question 

 Ask participants for answers

Answers – Module 3, p. 84

Slide 147

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 147

Module 3: Case Study 3.7 (1)

Mr. Sagoo has symptoms of TB disease and 

a cavity on his chest x-ray, but all of his 

sputum smears are negative for acid-fast 

bacilli.

 Ask participants to turn to p. 57 (if 

participants have print-based modules)

 Read case study 

Case Study 3.7 – Module 3, p. 57
113

Slide 148

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 148

Does this rule out the diagnosis of 

pulmonary TB disease?

No

Why or why not?

M. tuberculosis may grow in the cultures 

even though there were no acid fast 

bacilli on the smear. Mr. Sagoo’s 

symptoms and his abnormal chest x-ray 

suggest that he has pulmonary TB 

disease.

Module 3: Case Study 3.7 (2)

 Read case study questions 

 Ask participants for answers

Answers – Module 3, p. 84

Slide 149

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 149

Module 3: Case Study 3.8 (1)

In the public health clinic, you see a patient, 

Ms. Sanchez, who complains of weight loss, 

fever, and a cough of 4 weeks duration. When questioned, she reports that she has 

been treated for TB disease in the past and 

that she occasionally injects heroin.

 Ask participants to turn to p. 68 (if 

participants have print-based modules)

 Read case study 

Case Study 3.8 – Module 3, p. 68

Slide 150

Module 3 – Targeted Testing and the Diagnosis of 

Latent Tuberculosis Infection and Tuberculosis Disease 150

What parts of Ms. Sanchez’s medical history 

lead you to suspect TB disease?

• Symptoms of TB disease (weight loss, 

fever, persistent cough)

• Past treatment for TB disease

• History of injecting illegal drugs

What diagnostic tests should be done?

• Chest x-ray

• Sputum smear and culture

• Drug susceptibility testing

Module 3: Case Study 3.8 (2)

 Read case study questions 

 Ask participants for answers

 Ask if there are any questions about Module 

3 before moving on to Module 4

Answers – Module 3, p. 84
114
115

Module 4: Treatment of Latent Tuberculosis Infection and 

Tuberculosis Disease 

Facilitation Tips 

Background 

In this module, participants will learn about the principles of treating latent TB infection (LTBI) 

and TB disease. A person with LTBI is treated to prevent them from progressing to TB disease. 

Some people with LTBI are at very high risk of developing TB disease, and they should receive 

high priority for LTBI treatment. Patients with LTBI who do not complete treatment as 

prescribed can develop TB disease. 

TB disease is treated to cure the patient and to stop the spread of TB. As a health care worker, 

participants may be responsible for ensuring that TB patients take their medications as 

prescribed. This is very important because patients with TB disease who do not complete 

treatment as prescribed may become infectious and spread TB to others or develop drug-resistant 

TB. 

This module also explains the possible side effects of the drugs used to treat LTBI and TB 

disease. If participants work with TB patients, they should be aware of the signs and symptoms 

of these side effects.

Learning Objectives 

After this presentation, participants will be able to

1. List the groups of people who should receive high priority for LTBI treatment.

2. Describe treatment regimens for LTBI. 

3. Describe treatment regimens for TB disease. 

4. Describe the principles of preventing drug resistance. 

5. Describe patient monitoring during LTBI and TB disease treatment.

6. Describe TB treatment adherence strategies. 

7. List the common adverse reactions to the drugs used to treat LTBI and TB disease. 

Module Overview

Time Activity Content Slides

5 min. Presentation Introduction Slides 1-4

35 min. Presentation Treatment of LTBI Slides 5-67

40 min. Presentation Treatment of TB Disease Slides 68-133

10 min. Case Studies Case Studies Slides 134-150

90 min. Total Time
116

Facilitation Tips

Slide 1

Self-Study Modules 

on Tuberculosis

Treatment of Latent 

Tuberculosis Infection 

and Tuberculosis

Disease 

 Introduce Module 4

Slide 2

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 2

Module 4: Objectives

At completion of this module, learners will be able to:

1. List groups of people who should receive high 

priority for latent TB infection (LTBI) treatment

2. Describe treatment regimens for LTBI

3. Describe treatment regimens for TB disease

4. Describe principles of preventing drug resistance

5. Describe patient monitoring during LTBI and TB 

disease treatment

6. Describe TB treatment adherence strategies

7. List common adverse reactions to drugs used to 

treat LTBI and TB disease

 State objectives of presentation 

Background and Objectives - Module 4, p. 1

Slide 3

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 3

• Treatment of LTBI

– Patient Medical Evaluation

– LTBI Treatment Regimens

– Special Considerations for LTBI Treatment

• Treatment of TB Disease

– TB Disease Treatment Regimens

Module 4: Overview

 Review slide content 
117

Slide 4

• Treatment of TB Disease (cont.)

– Special Considerations and Alternative 

Treatment Regimens

– Treatment and Monitoring Plan and Adverse 

Reactions

– Adherence and Evaluating Patients’ 

Response to Treatment

– Role of Public Health Workers

• Case Studies

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 4

Module 4: Overview (cont.)

 Review slide content

Slide 5

5

Treatment of Latent TB 

Infection (LTBI)

 Introduce section

 Ask who should be treated for LTBI

 Ask why people with LTBI should be treated 

Treatment of LTBI - Module 4, pp. 4-21

Slide 6

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 6

• LTBI is treated to prevent the development of 

TB disease

• LTBI is treated with medication 

Treatment of LTBI (1)

 Review slide content

Treatment of LTBI - Module 4, p. 4
118

Slide 7

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 7

• Targeted testing should be used to identify and 

treat people who are:

– At high risk for exposure to or infection with 

M. tuberculosis

– At high risk for developing TB disease once 

infected with M. tuberculosis

• People in these groups should receive high 

priority for LTBI treatment if they have a 

positive tuberculin skin test (TST) or interferongamma release assay (IGRA)

Treatment of LTBI (2)

 Explain that some groups are at higher risk for 

TB than others 

 Review slide content

Treatment of LTBI - Module 4, p. 4

Slide 8

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 8

High Priority for LTBI Treatment (1)

• High-priority groups for LTBI treatment if positive 

IGRA or TST result of > 5 mm

– Recent contacts of people with infectious TB 

disease

– People living with HIV

– People with chest x-ray findings suggestive of 

previous TB disease

– Patients with an organ transplant

– Other immunosuppressed patients

 Review slide content

 Explain that other immunosuppressed 

patients include patients on prolonged 

therapy with corticosteroids equivalent 

to/greater than 15mg per day of prednisone 

for one month or more or those taking TNFalpha antagonists

High Priority for LTBI Treatment - Module 4, p. 5

Slide 9

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 9

High Priority for LTBI Treatment (2)

• High-priority groups for LTBI treatment if 

positive IGRA or TST result of > 10 mm:

– People who have come to U.S. from 

countries where TB is common

– People who abuse drugs

– People who live or work in high-risk 

congregate settings

– People who work in mycobacteriology 

laboratories

 Review slide content

High Priority for LTBI Treatment - Module 4, p. 5
119

Slide 10

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 10

• High-priority groups for LTBI treatment if positive

IGRA or TST result of > 10 mm (cont.):

– People with medical conditions that increase 

risk of TB disease

– Children younger than 5 years of age

– Infants, children, and adolescents exposed to 

adults in high-risk groups

High Priority for LTBI Treatment (3)

 Review slide content

High Priority for LTBI Treatment - Module 4, p. 5

Slide 11

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 11

• Individuals without any risk factors generally 

should not be tested for TB infection 

• However, individuals with no risk factors who 

are tested and have a positive IGRA or TST 

result of > 15 mm should be evaluated for LTBI 

treatment

Low Priority for LTBI Treatment

 Review slide content

Low Priority for LTBI Treatment - Module 4, p. 4

Slide 12

12

Treatment of Latent TB 

Infection (LTBI)

Patient Medical Evaluation

 Introduce section

Patient Medical Evaluation – Module 4, pp. 5-6
120

Slide 13

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 13

Patient Medical Evaluation (1)

Medical evaluations should be done to:

1. Exclude possibility of TB disease

2. Determine whether patient has ever been 

treated for TB infection or TB disease

3. Find out if patient has any medical conditions 

that may complicate therapy

4. Establish and build rapport with patient

 Review slide content 

Patient Medical Evaluation – Module 4, pp. 5-6

Slide 14

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 14

1. Exclude possibility of TB disease

• Treating TB disease with LTBI treatment regimen 

can lead to drug resistance

• Clinicians should determine if the patient has 

symptoms of TB disease

• Clinicians should evaluate the patient with a chest 

x-ray

• Patients with symptoms or chest x-ray findings of 

TB disease should be given TB disease treatment, 

not LTBI treatment

Patient Medical Evaluation (2)

 Review slide content 

 Explain that treating TB disease with an LTBI 

treatment regimen can lead to drug 

resistance since LTBI is usually only treated 

with a single drug

Patient Medal Evaluation – Module 4, p. 5

Slide 15

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 15

Patient Medical Evaluation (3)

2. Determine whether patient has ever been

treated for TB infection or TB disease

• Patients who have been adequately 

treated should not be treated again

• TST or IGRA results cannot determine if 

patient has received treatment for LTBI or 

TB disease; or if they have been reinfected after treatment

 Review slide content 

 Explain that people who have a positive TST 

reaction will have another positive reaction if 

they are skin tested later in their lives, 

regardless of whether they have received 

treatment

 Note that there is not enough data on the 

ability of either test to detect re-infection 

after treatment for both LTBI and TB disease

Patient Medical Evaluation – Module 4, pp. 5-6
121

Slide 16

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 16

Patient Medical Evaluation (4)

3. Find out if patient has any medical conditions 

that may complicate therapy or require more 

careful monitoring. These patients include: 

• People living with HIV

• People with history of liver disorder or disease

• People who use alcohol regularly

• Women who are pregnant or just had a baby 

(within 3 months of delivery)

• People who are taking other medications that may 

increase the risk of hepatitis

 Review slide content 

Patient Medical Evaluation – Module 4, p. 6

Slide 17

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 17

Patient Medical Evaluation (5)

For patients with the medical conditions listed 

on the previous slide, baseline laboratory liver 

function tests (to detect injury to liver) are 

recommended before starting LTBI treatment.

 Review slide content 

Patient Medical Evaluation – Module 4, p. 6

Slide 18

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 18

• It is important to find 

out if:

– Patient has ever had 

adverse reactions to 

LTBI drugs

– Patient is currently 

on medications that 

may interact with 

LTBI drugs

Patient Medical Evaluation (6)

 Review slide content 

Patient Medical Evaluation – Module 4, p. 6
122

Slide 19

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 19

Patient Medical Evaluation (7)

4. Establish and build rapport with patient

• Health care workers (HCWs) should 

highlight important aspects of treatment, 

such as:

–Benefits of treatment

–Importance of adherence to treatment

–Possible adverse reactions

–Establishment of a follow-up plan

 Review slide content 

Patient Medical Evaluation – Module 4, p. 6

Slide 20

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 20

Patient Medical Evaluation (8)

Because of the interaction between TB and HIV, 

HCWs should also recommend that patients 

undergo HIV counseling and testing

 Review slide content 

Patient Medical Evaluation – Module 4, p. 6

Slide 21

21

Treatment of Latent TB 

Infection (LTBI)

LTBI Treatment Regimens

 Introduce section

LTBI Treatment Regimens – Module 4, pp. 6-9
123

Slide 22

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 22

• Isoniazid (INH) daily for 9 months is very effective in 

preventing the development of TB disease

• INH may also be given for 6 months

– Cost effective and patients may find it easier to 

adhere, BUT:

• Not as effective if given for less than 6 months

• Not recommended for people living with HIV, 

individuals with previous TB disease, or 

children

LTBI Treatment Regimens (1)

Isoniazid

 Explain that there are several treatment 

regimens available for LTBI

 Note that until recently, the standard regimen 

for LTBI was INH for 9 months

 Review slide content

Regimens for LTBI Treatment – Module 4, p. 7

Slide 23

LTBI Treatment Regimens (2)

Isoniazid and Rifapentine (12-Dose Regimen)

• Combination of INH and rifapentine (RPT) given in 12, once-aweek doses under DOT, if possible

• Recommended for patients who:

– Are 12 years of age or older

– Were recently exposed to infectious TB

– Have a TST or IGRA conversion from negative to positive

– Have chest x-ray findings of previous TB disease

• Regimen may be used in otherwise healthy HIV-infected 

persons who are:

– 12 years of age or older

– Not on antiretroviral therapy (ART), except those taking an 

efavirenz or raltegravir-based ART regimen

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 23

 Review slide content

Regimens for LTBI Treatment – Module 4, p. 7

Slide 24

LTBI Treatment Regimens (3)

Isoniazid and Rifapentine (12-Dose Regimen)

• This regimen is not recommended for

– Children younger than 2 years of age

– People with HIV/AIDS who are taking certain ART 

regimens

– People presumed to be infected with isoniazid or 

rifampin-resistant M. tuberculosis

– Pregnant women or women expecting to 

become pregnant within the 12–week regimen

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 24

 Review slide content

Regimens for LTBI Treatment – Module 4, p. 7
124

Slide 25

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 25

LTBI Treatment Regimens (4)

Rifampin

• Rifampin (RIF) is also recommended for people with 

a positive TST or IGRA result

– Especially if the person has been exposed to INHresistant TB

• RIF should be given daily for 4 months

• RIF should not be used with certain combinations of 

ART

• In some cases, rifabutin (RFB) may be substituted 

when RIF cannot be used

 Review slide content

Regimens for LTBI Treatment – Module 4, p. 8

Slide 26

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 26

LTBI Treatment Regimens (5)

Rifampin and Pyrazinamide

• CDC advises against using a combination of 

RIF and pyrazinamide (PZA) due to serious 

side effects such as:

– Severe liver injury 

– Death

 Review slide content

 

Regimens for LTBI Treatment – Module 4, p. 8

Slide 27

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 27

LTBI Treatment Regimens (6)

Drug Duration

(months)

Frequency Minimum 

Dose

Comments

INH 9 Daily 270 1. Preferred regimen is daily 

treatment for 9 months

2. DOT must be used with 

twice-weekly dosing

Twice 

weekly

76

INH 6 Daily 180 1. NOT recommended for 

people living with HIV, 

children, or people with 

chest x-rays suggestive of 

previous TB disease

2. DOT must be used with 

twice-weekly dosing

Twice 

weekly

52

Table 4.2

 Ask participants to turn to p. 8 (if participants 

have print-based modules)

 Explain that this table describes the various 

LTBI treatment regimens

 Review slide content 

Regimens for LTBI Treatment – Module 4, pp. 8-9
125

Slide 28

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 28

LTBI Treatment Regimens (7)

Drug Duration

(months)

Frequency Minimum 

Dose

Comments

INH 

and 

RPT

3 Once 

Weekly

12 1. NOT recommended for children 

younger than 2 years of age, HIVinfected patients taking certain ART 

regimens, patients with resumed INH 

or RIF-resistant TB, pregnant women, 

or women expecting to become 

pregnant

2. DOT is recommended, if possible

RIF 4 Daily 120 1. Recommended for patients who have 

INH-resistant TB 

2. NOT recommended for HIV-infected 

patients on certain combinations of 

ART. RFB may be used instead for 

some patients.

RIF/

PZA

Due to the reports of severe liver injury and deaths, RIF and PZA combinations 

generally should not be offered for treatment of LTBI

 Review slide content 

 

Regimens for LTBI Treatment – Module 4, pp. 8-9

Slide 29

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 29

Treatment of LTBI 

Study Question 4.1

What is the purpose of LTBI treatment?

To prevent people with latent TB infection 

from developing TB disease.

 Introduce study questions

 Ask participants to turn to p. 10 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 4, p. 49

Slide 30

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 30

Which groups of people should receive highpriority for LTBI treatment if they have a positive 

IGRA or TST result of > 5 mm? Name 5.

• Recent contacts of people with infectious TB 

disease

• People living with HIV

• People with chest x-ray findings suggestive of 

previous TB disease

• Patients with an organ transplant

• Other immunosuppressed patients 

Treatment of LTBI 

Study Question 4.2

 Read question 

 Ask participants for answers

 

Answers – Module 4, p. 49
126

Slide 31

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 31

Which groups of people should receive high 

priority for LTBI treatment if they have a positive 

IGRA result or a TST reaction that is > 10 mm? 

Name 7. 

• People who come to the U.S. from areas of the world where TB is 

common

• People who abuse drugs

• People who live or work in high-risk congregate settings

• People who work in mycobacteriology laboratories

• People with medical conditions that increase risk of TB disease

• Children younger than 5 years of age

• Infants, children, and adolescents exposed to adults in high-risk 

groups

Treatment of LTBI 

Study Question 4.3

 Ask for a volunteer to read question 

 Ask participants for answers

Answers – Module 4, p. 49

Slide 32

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 32

List 4 regimens that are approved for the 

treatment of LTBI.

• Isoniazid for 9 months

• Isoniazid for 6 months

• Isoniazid and rifapentine for 12, onceweekly doses (12-dose regimen)

• Rifampin for 4 months

LTBI Treatment Regimens 

Study Question 4.4

 Read question 

 Ask participants for answers

Answers – Module 4, p. 49

Slide 33

33

Treatment of Latent TB 

Infection (LTBI)

Special Considerations for LTBI 

Treatment

 Introduce section

Special Considerations for LTBI Treatment – Module 4, 

pp. 11-14
127

Slide 34

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 34

Special Considerations for LTBI (1)

Directly Observed Therapy (DOT)

• DOT is when a HCW or another designated 

person watches a patient swallow each dose of 

medication

– Used to help patients adhere to treatment

– Should be considered for people who are at 

high risk for TB or suspected to be nonadherent

– Recommended for intermittent therapy

 Review slide content

 Explain that intermittent therapy is when 

regimens are given once or twice weekly

Directly Observed Therapy – Module 4, p. 11

Slide 35

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 35

Special Considerations for LTBI (2)

Contacts

• Contacts are people who have been exposed to 

someone with infectious TB disease

• Contacts should be quickly identified, located, 

and assessed for LTBI and TB disease

– If TST or IGRA result is positive, contacts 

should be given high priority for LTBI 

treatment (once TB disease is ruled out)

– If TST or IGRA result is negative, contacts 

should be retested in 8 to 10 weeks

 Review slide content 

 Explain that contacts should be retested after 

8 to 10 weeks if their result is negative 

because sometimes it can take 2 to 8 weeks 

after TB infection for the body’s immune 

system to produce a response to the TST or 

IGRA

Contacts – Module 4, p. 11

Slide 36

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 36

• In general, contacts with positive test result 

and a documented history of completion of 

LTBI treatment do not need to be retreated

• However, retreatment may be necessary for 

persons at high risk of:

– Becoming re-infected

– Progressing to TB disease

Special Considerations for LTBI (3)

Contacts

 Review slide content 

Contacts – Module 4, p. 11
128

Slide 37

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 37

Special Considerations for LTBI (4)

Contacts at High Risk for Rapid Development of 

TB Disease

• Some contacts may be started on LTBI treatment 

even if their test result is negative, and less than 8 to 

10 weeks have passed since last exposure to TB; this 

includes:

– Children younger than 5 years of age

– People living with HIV

• Expert consultation should be sought to determine if 

contacts with immunocompromised states other than 

HIV infection could benefit from treatment even if 

they have a negative TST or IGRA result

 Review slide content 

 Explain that it is possible that some contacts 

are infected with M. tuberculosis but have a 

false-negative TST reaction because less than 

8 to 10 weeks have passed since they were 

last exposed to TB

 

Contacts at High Risk for TB Disease – Module 4, p. 12

Slide 38

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 38

• Once active TB disease is ruled out, contacts at 

high risk for TB disease should:

– Start LTBI treatment

– Be retested 8 to 10 weeks after last exposure to TB

• If negative test result: stop LTBI treatment

• If positive test result: continue LTBI treatment

• Contacts living with HIV may be given full course 

of LTBI treatment even if their second TST or 

IGRA result is negative

Special Considerations for LTBI (5)

Contacts at High Risk for Rapid Development of 

TB Disease

 Review slide content 

 Explain that LTBI treatment is started to 

prevent persons from rapidly progressing to 

TB disease

Contacts at High Risk for TB Disease – Module 4, p. 12

Slide 39

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 39

Special Considerations for LTBI (6)

Infants and Children

• Infants and children are more likely to develop 

life-threatening forms of TB disease

• Children younger than 5 years of age who have 

been exposed to TB should start taking LTBI 

treatment even if they have a negative TST or 

IGRA result because they:

– Are at high risk for rapidly developing TB 

disease

– May have a false-negative TST reaction

 Review slide content 

Infants and Children – Module 4, pp. 12-13
129

Slide 40

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 40

Special Considerations for LTBI (7)

Infants and Children 

• Infants and children should be retested 8 to 10 weeks 

after last exposure

• LTBI treatment can be stopped if ALL of the following 

conditions are met:

– Child is at least 6 months of age

– Second TST or IGRA is negative

– Second TST or IGRA was done at least 8 weeks after 

child was last exposed to a person with infectious TB 

disease

• The 12-dose regimen is not recommended for children 

younger than 2 years of age

 Review slide content 

Infants and Children – Module 4, p. 13

Slide 41

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 41

Special Considerations for LTBI (8)

Contacts of INH-Resistant TB

• Contacts of patients with INH-resistant, but RIFsusceptible TB, may be treated with a 4-month 

daily regimen of RIF

• In some patients, rifabutin (RFB) may be 

substituted if RIF cannot be used

 Review slide content 

Contacts of INH-Resistant TB – Module 4, p. 13

Slide 42

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 42

Special Considerations for LTBI (9)

Contacts of Multidrug-Resistant TB (MDR TB)

• The risk for developing TB disease should be considered 

before recommending LTBI treatment

• Contacts of patients with MDR TB

– May be treated for 6 to 12 months with an alternative 

regimen of drugs to which the M. tuberculosis isolate is 

susceptible

– Can be observed for signs and symptoms of TB 

disease without treatment

• All persons with suspected MDR LTBI should be followed 

and observed for signs and symptoms of TB disease for 2 

years, regardless of the treatment regimen

 Review slide content

 Note that an MDR TB treatment expert 

should be consulted

Contacts of Multidrug-Resistant TB – Module 4, p. 13
130

Slide 43

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 43

Special Considerations for LTBI (10)

Pregnant Women

• For most pregnant women, LTBI treatment can be 

delayed until after delivery, unless they have 

certain risk factors

• Immediate treatment should be considered if woman is living with HIV or is a recent TB contact

• Preferred LTBI treatment regimen is 9 months of 

INH with a vitamin B6 supplement 

– INH has not been shown to have harmful 

effects on the fetus

• The 12-dose regimen is not recommended for 

pregnant women or women expecting to become 

pregnant within the 12-week regimen

 Review slide content 

Pregnant Women – Module 4, p. 13

Slide 44

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 44

Special Considerations for LTBI (11)

Breastfeeding Women

• Women who are 

breastfeeding can take 

INH, but should also be 

given a vitamin B6 

supplement

• Amount of INH in 

breast milk is not 

enough to be 

considered treatment 

for infant

 Review slide content 

Breastfeeding Women – Module 4, p. 14

Slide 45

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 45

Special Considerations for LTBI (12)

People Living with HIV

• Individuals living with HIV should be treated with 9-month 

regimen of INH

• RIF should not be used for people who are taking certain 

combinations of ART

– Dose-adjusted rifabutin (RFB) may be given

• The 12-dose regimen of INH and RPT may be used for 

people living with HIV who are:

– 12 years of age or older

– Not on ART, except those taking an efavirenz or 

raltegravir-based ART regimen

 Review slide content 

People Living with HIV – Module 4, p. 14
131

Slide 46

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 46

What LTBI treatment regimen may be 

recommended for people with a positive TST 

or IGRA result who have been exposed to 

INH-resistant TB?

Treatment with rifampin for 4 months 

may be recommended in this situation.

LTBI Treatment Regimens 

Study Question 4.5

 Introduce study questions

 Ask participants to turn to p. 15 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 4, p. 50

Slide 47

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 47

In what circumstances may LTBI treatment 

be given to people who have a negative TST 

or IGRA result? 

Some contacts may start LTBI treatment if they 

have a negative TST or IGRA, but less than 8 to 10 

weeks have passed since last exposed to TB; 

these contacts include:

• Children who are younger than 5 years of age

• People living with HIV

Special Considerations for LTBI 

Study Question 4.6

 Read question 

 Ask participants for answers

 Note that expert consultation should be 

sought to determine if contacts with immune 

impairments other than HIV infection (e.g., 

contacts taking immunosuppressive 

therapies) could benefit from treatment even 

if they have a negative TST or IGRA result. 

Answers – Module 4, p. 50

Slide 48

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 48

What conditions must be met to stop LTBI 

treatment for children who are younger than 5 

years of age and have been exposed to TB?

• LTBI treatment can be stopped if ALL the 

following conditions are met:

– Child is at least 6 months of age

– Second TST or IGRA is negative

– Second TST or IGRA was done 8 to 10 weeks 

after the child was last exposed to TB

Special Considerations for LTBI

Study Question 4.7

 Read question 

 Ask participants for answers

Answers – Module 4, p. 50
132

Slide 49

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 49

Special Considerations for LTBI

Study Question 4.8

When should pregnant women be treated for 

LTBI and for how long?

• For most pregnant women with TB infection, 

LTBI treatment can be delayed until after 

delivery. If the pregnant woman is HIV-infected 

or a recent contact, immediate treatment 

should be considered. 

• Preferred treatment regimen for pregnant 

women is 9 months of INH with a vitamin B6 

supplement.

 Read question

 Ask participants for answers

Answers – Module 4, p. 51

Slide 50

50

Treatment of Latent TB 

Infection (LTBI)

Adverse Reactions and Patient 

Monitoring

 Introduce section

Adverse Reactions and Patient Monitoring – Module 4, 

pp. 17-19

Slide 51

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 51

Adverse Reactions to INH (1)

• About 10% to 20% of people treated with INH 

will have mild, abnormal liver test results 

during treatment

– In most people, liver test results return to 

normal 

 Explain that some health care workers have 

concerns about treating patients for LTBI due 

to the length of treatment and the possibility 

of adverse reactions

 Stress that, as with any treatment, the risks 

and benefits of LTBI treatment must be 

weighed for each individual

 Review slide content 

Adverse Reactions – Module 4, p. 17
133

Slide 52

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 52

Adverse Reactions to INH (2)

Hepatitis

• A major risk of INH is hepatitis (inflammation of 

the liver)

• Hepatitis prevents the liver from functioning 

normally, causing symptoms such as:

– Nausea

– Vomiting

– Abdominal pain

– Fatigue

– Brown urine

 Review slide content 

Adverse Reactions – Module 4, p. 17

Slide 53

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 53

Adverse Reactions to INH (3)

Hepatitis

• INH can cause hepatitis in anyone; however, 

hepatitis occurs in less than 1% of people 

taking INH 

• Certain risk factors increase the risk of 

serious hepatitis, such as:

– Older age 

– Alcoholism

 Review slide content 

Adverse Reactions – Module 4, p.17

Slide 54

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 54

Adverse Reactions to INH (4)

Peripheral Neuropathy

• INH can cause peripheral neuropathy

– Damage to sensory nerves of hands and feet

– Symptoms include a tingling sensation, weakened 

sense of touch, or pain in the hands, palms, soles 

and feet

• HIV, alcoholism, diabetes, and malnutrition increase 

risk for peripheral neuropathy

– People with these conditions should be given 

vitamin B6

 Review slide content 

Adverse Reaction – Module 4, p. 17
134

Slide 55

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 55

Adverse Reactions to RIF, RPT, and RFB

• Hepatitis is more likely to occur when RIF is 

combined with INH

• Other side effects of RIF, RPT, and RFB include:

– Rash

– Gastrointestinal symptoms

– Orange discoloration of urine, saliva, and tears

– Interaction with many other drugs, such as birth control 

pills and implants, warfarin, some HIV drugs, and methadone

– Hypersensitivity

 Review slide content 

 Explain that gastrointestinal symptoms may 

include abdominal pain, nausea, and anorexia

 Note that orange discoloration is considered a 

minor reaction (not serious)

Adverse Reactions – Module 4, pp. 17-18

Slide 56

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 56

• RPT may cause flu-like symptoms

• RFB may cause

– Eye inflammation

– Joint pain

– Lower white blood cell count

Adverse Reactions to RPT and RFB

 Review slide content 

Adverse Reactions – Module 4, p. 18

Slide 57

Adverse Reactions

• Patients should be instructed to report any signs and 

symptoms of adverse drug reactions to their health care 

provider

• Patients should stop taking the medication and seek medical attention immediately if symptoms of serious 

adverse reactions occur

– No appetite 

– Nausea 

– Vomiting 

– Yellowish skin or eyes 

– Fever for 3 or more days 

– Abdominal pain 

– Tingling in fingers and toes 

– Brown urine 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 57

 Review slide content 

Adverse Reactions – Module 4, p. 18 and Module 4, p. 33

Note: Adverse reactions to TB drugs are discussed more 

in-depth on slides 100-108
135

Slide 58

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 58

Patient Monitoring (1)

• All persons taking LTBI treatment should be 

educated about symptoms caused by adverse 

reactions

• Patients need to be evaluated at least monthly 

during therapy for:

– Adherence to prescribed regimen 

– Signs and symptoms of TB disease

– Adverse reactions

 Review slide content 

 Stress that patients should be instructed to 

stop taking the medication and seek medical 

attention immediately if symptoms of serious 

adverse reactions occur

Patient Monitoring – Module 4, p. 18

Slide 59

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 59

• During each monthly evaluation, patients should 

be:

– Asked whether they have nausea, abdominal 

pain, or other symptoms of adverse reactions

– Examined by HCW for adverse reactions

– Instructed to stop medications and contact 

HCWs immediately if they have signs or 

symptoms of hepatitis

Patient Monitoring (2)

 Review slide content

Patient Monitoring – Module 4, p. 18

Slide 60

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 60

• People at greatest risk for hepatitis should have 

baseline liver function tests before starting LTBI 

treatment and every month during therapy. This 

includes:

– People living with HIV

– People with history of liver disorder or disease

– People who use alcohol regularly

– Women who are pregnant or just had a baby 

– People taking medications that may increase risk 

of hepatitis

Patient Monitoring (3)

 Review slide content

Patient Monitoring – Module 4, p. 18
136

Slide 61

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 61

• For all patients, INH, RIF, and RPT should be 

stopped if liver function test results are:

– 3 times higher than upper limit of the normal 

range and patient has symptoms

OR

– 5 times higher than upper limit of the normal 

range and patient has no symptoms

Patient Monitoring (4)

 Review slide content

Patient Monitoring – Module 4, p. 19

Slide 62

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 62

• Patients should receive documentation of TST 

or IGRA results, treatment regimens, and 

treatment completion dates

– Patients should present these documents 

any time they are required to be tested for TB 

infection

• Patients should be re-educated about signs 

and symptoms of TB disease

LTBI Treatment Follow-Up

 Review slide content

LTBI Treatment Follow-Up – Module 4, p. 19

Slide 63

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 63

Name 4 reasons why patients should receive a medical evaluation before starting LTBI 

treatment.

• Exclude possibility of TB disease

• Determine whether they have ever been 

treated for TB infection or TB disease

• Identify any medical conditions that may 

complicate therapy or require more careful monitoring 

• Establish and build rapport with patient

Medical Evaluation 

Study Question 4.9

 Introduce study questions

 Ask participants to turn to p. 20 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers 

Answers – Module 4, p. 51
137

Slide 64

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 64

Why is it important to exclude the possibility 

of TB disease before giving a patient LTBI 

treatment?

Treating TB disease with LTBI treatment 

regimen (usually a single drug) can lead 

to drug resistance.

LTBI Treatment

Study Question 4.10

 Read question 

 Ask participants for answers 

Answers – Module 4, p. 51

Slide 65

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 65

What are the symptoms of hepatitis?

• Nausea 

• Vomiting

• Abdominal pain

• Fatigue

• Brown urine

Adverse Reactions

Study Question 4.11

 Read question 

 Ask participants for answers 

Answers – Module 4, p. 51

Slide 66

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 66

Who is at greatest risk for hepatitis? What 

special precautions should be taken for these 

patients?

• People with greatest risk for hepatitis are:

– People living with HIV

– People with a history of liver disorder or 

disease

– People who use alcohol regularly

– Women who are pregnant or just had a baby 

– People who are taking other medications that may increase the risk of hepatitis

• These patients should have liver function tests before 

starting LTBI treatment and during therapy

Adverse Reactions

Study Question 4.12

 Read questions 

 Ask participants for answers 

Answers – Module 4, p. 51
138

Slide 67

How often should patients be evaluated for 

signs and symptoms of adverse reactions 

during LTBI treatment?

All patients receiving LTBI treatment 

should be evaluated at least monthly 

during therapy. 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 67

Adverse Reactions

Study Question 4.13

 Read question 

 Ask participants for answers 

Answers – Module 4, p. 52

Slide 68

68

Treatment of TB Disease

 Introduce section

Treatment of TB Disease – Module 4, pp. 22-30

Slide 69

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 69

Treatment of TB Disease (1)

• Treating TB disease benefits both the person who has TB and the community

– Patient: prevents disability and death; 

restores health

– Community: prevents further transmission 

of TB

• TB disease must be treated for at least 6 months; in some cases, treatment lasts longer

 Review slide content

Treatment of TB Disease – Module 4, p. 22
139

Slide 70

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 70

Treatment of TB Disease (2)

Intensive Phase

• First 8 weeks of treatment

• Most bacilli killed during this phase

• 4 drugs used

Continuation 

Phase

• After first 8 weeks of TB disease

treatment

• Bacilli remaining after intensive

phase are treated with at least 2

drugs

Relapse

• Occurs when treatment is not

continued for long enough

• Surviving bacilli may cause TB

disease at a later time

 Review slide content

Treatment of TB Disease – Module 4, p. 22

Slide 71

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 71

Treatment of TB Disease (3)

• Intensive phase should 

contain the following 

four drugs:

– Isoniazid (INH)

– Rifampin (RIF)

– Pyrazinamide (PZA)

– Ethambutol (EMB)

Example of pills used to treat TB disease. From 

left to right: isoniazid, rifampin, pyrazinamide, 

and ethambutol.

 Review slide content

 Note that when drug susceptibility results are 

available, clinicians may change the regimen 

accordingly

Treatment of TB Disease – Module 4, p. 22

Slide 72

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 72

• Treatment must contain multiple drugs to 

which organisms are susceptible

• Treatment with a single drug can lead to the 

development of drug-resistant TB

Treatment of TB Disease (4)

 Review slide content

Treatment of TB Disease – Module 4, p. 22
140

Slide 73

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 73

• Drug resistance can develop when patients are 

prescribed an inappropriate regimen

– TB disease must be treated with at least 2 

drugs to which bacilli are susceptible

– Using only one drug can create a population 

of tubercle bacilli resistant to that drug

– Adding a single drug to failing regimen may 

have the same effect as only using one drug

Preventing Drug Resistance (1)

 Review slide content

 Explain that when two or more drugs are 

used together, each drug helps prevent the 

emergence of bacilli that are resistant to the 

other drugs

Preventing Drug Resistance – Module 4, pp. 23

Slide 74

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 74

Preventing Drug Resistance (2)

• Resistance can develop when patients do not 

take drugs as prescribed

– Patients do not take all of their pills 

– Patients do not take pills as often as 

prescribed

• When this happens, patients may expose the 

bacilli to a single drug

 Review slide content

Preventing Drug Resistance – Module 4, p. 23

Slide 75

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 75

• Factors that increase the chance of patient having or 

developing drug-resistant TB:

– Patient does not take their medicine regularly and 

completely

– Patient comes from an area of the world where drugresistant TB is common

– Malabsorption of drugs

– Patient is a contact to someone with drug-resistant TB

– Failure to improve on drug-susceptible regimen

– Patient develops TB disease again after having taken TB 

medicine in the past

Preventing Drug Resistance (3)

 Review slide content

Preventing Drug Resistance – Module 4, p. 23
141

Slide 76

76

Treatment of TB Disease

Treatment Regimens

 Introduce section

Slide 77

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 77

TB Treatment Regimens*

Table. 4.3

INTENSIVE PHASE CONTINUATION PHASE

Regimen Drugs Interval and Doses

(minimum 

duration)

Drugs Interval and 

Doses

(minimum 

duration)

Range of 

total 

doses

Comments Regimen 

effectiveness

1 INH

RIF

PZA

EMB

7 days/week for 56 

doses (8 weeks)

or

5 days/week for 40 

doses (8 weeks)

INH

RIF

7 days/week for 

126 doses (18 

weeks)

or

5 days/week for 90 

doses (18 weeks)

182 to 130 This is the preferred 

regimen for patients with 

newly diagnosed 

pulmonary TB. 

greater

lesser

2 INH

RIF

PZA

EMB

7 days/week for 56 

doses (8 weeks)

or

5 days/week for 40 

doses (8 weeks)

INH

RIF

3 times weekly for 

54 doses (18 

weeks)

110 to 94 Preferred alternative 

regimen in situations in 

which more frequent DOT 

during continuation phase 

is difficult to achieve.

3 INH

RIF

PZA

EMB

3 times weekly for 

24 doses (8 weeks)

INH

RIF

3 times weekly for 

54 doses (18 

weeks)

78 Use regimen with caution 

in patients with HIV and/or 

cavitary disease. Missed 

doses can lead to 

treatment failure, relapse, 

and acquired drug 

resistance.

4 INH

RIF

PZA

EMB

7 days/week for 14 

doses then twice 

weekly for 12 doses

INH

RIF

Twice weekly for 

36 doses (18 

weeks)

62 Do not use twice-weekly 

regimens in HIV-infected 

patients or patients with 

smear positive and/or 

cavitary disease. If doses 

are missed then therapy is 

equivalent to once weekly, 

which is inferior.

*For detailed information, refer to the Official American Thoracic Society/Centers for Disease Control and 

Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis.

 Ask participants turn to p. 24 for table 4.3

that describes recommended treatment 

regimens since it may be difficult to view the 

table on the slide (if participants have printbased modules)

 Explain that there are several options for daily 

and intermittent therapy

TB Treatment Regimens – Module 4, p. 24

Slide 78

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 78

Treatment of TB Disease

Study Question 4.14

Why must TB disease be treated for at least 6

months?

Even though most bacilli are killed in the 

first 8 weeks, some bacilli can survive. 

Therefore, treatment must continue in order 

to kill all remaining bacilli.

 Introduce study questions

 Ask participants to turn to p. 25 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 4, p. 52
142

Slide 79

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 79

Which 4 drugs are recommended for the

intensive phase of treatment for TB disease?

The intensive phase should include 

isoniazid, rifampin, pyrazinamide, and 

ethambutol.

Treatment of TB Disease 

Study Question 4.15

 Read question 

 Ask participants for answers

Answers – Module 4, p. 52

Slide 80

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 80

Why should multiple drugs be used to treat TB

disease?

Using only one drug can create a 

population of tubercle bacilli that is 

resistant to that drug. When multiple drugs 

are used together, each drug helps prevent 

the emergence of bacilli that are resistant to 

the other drugs.

Treatment of TB Disease 

Study Question 4.16

 Ask for a volunteer to read question 

 Ask participants for answers

Answers – Module 4, p. 52

Slide 81

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 81

Drug Resistance

Study Question 4.17

Name 2 factors that can lead to drug 

resistance.

Drug resistance can develop when:

• Patients are prescribed an inappropriate 

regimen for treatment

• Patients do not follow treatment regimens as 

prescribed

 Read question 

 Ask participants for answers

Answers – Module 4, p. 52
143

Slide 82

82

Treatment of TB Disease

Special Considerations

 Introduce section

Slide 83

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 83

• TB medical experts should be consulted for 

complicated and challenging TB treatment 

issues

• Consultation can be provided by State TB 

Programs and the CDC-funded TB Regional 

Training and Medical Consultation Centers 

(RTMCCs)

www.cdc.gov/TB/education/rtmc/default.htm

Special Considerations (1)

 Review slide content 

 Explain that the TB Regional Training and 

Medical Consultation Centers (RTMCCs) are 

regionally assigned to cover all 50 states and 

the U.S. territories

 Tell participants that they may learn more 

about the RTMCCs by going to the website 

shown on the slide

Slide 84

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 84

• For HIV-infected TB patients receiving ART, 

the recommended treatment is a 6-month daily 

regimen consisting of:

– An intensive phase of INH, RIF, PZA, and 

EMB for 2 months

– A continuation phase of INH and RIF for 4 months

Special Considerations (2)

People Living with HIV

 Review slide content 

 Explain that the management of HIV-infected 

TB patients is complex and therefore medical 

experts should be involved in the care and 

treatment of patients with HIV and TB

People Living with HIV – Module 4, p. 26
144

Slide 85

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 85

• ART should be initiated during TB treatment to 

improve treatment outcomes for TB patients 

living with HIV

• ART should ideally be initiated 

– Within 2 weeks of starting TB treatment for 

patients with CD4 cell counts <50/mm3

– By 8 to 12 weeks of starting TB treatment for 

patients with CD4 cell counts >50/mm3

 For patients with TB meningitis or TB involving 

the central nervous system, ART should NOT be 

initiated during the first 8 weeks of TB treatment 

Special Considerations (3)

People Living With HIV

 Review slide content 

People Living with HIV – Module 4, p. 26

Slide 86

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 86

Special Considerations (4)

People Living With HIV

• It is important to be aware of the interaction of 

RIF with some ART drugs

– Rifabutin has fewer drug interaction problems 

and may be used as a substitute for RIF for 

some patients

• DOT should be provided for all TB patients living with HIV

• For patients not receiving ART during TB 

treatment, it is recommended to extend 

treatment to 9 months

 Review slide content 

People Living with HIV – Module 4, p. 26

Slide 87

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 87

• Treatment should begin as soon as TB disease is 

diagnosed

• Regimen should consist of at least INH, RIF, and EMB for 

a minimum of 9 months

• Clinicians should seek expert consultation to evaluate 

the risks and benefits of prescribing pyrazinamide (PZA) 

on a case-by-case basis

• Streptomycin (SM) should NOT be used

• Vitamin B6 supplements are recommended for all 

pregnant women taking INH

Special Considerations (5) 

Pregnant Women

 Review slide content 

 Explain that PZA should not be used because 

effects on the fetus are unknown

 Explain that SM should not be used because it 

has harmful effects on the fetus

Pregnant Women – Module 4, p. 27
145

Slide 88

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 88

• Women being treated with first-line TB drugs 

should not be discouraged from 

breastfeeding

– Only a small concentration of the drugs is 

found in breast milk

– Not harmful to infant

Special Considerations (6)

Breastfeeding

 Review slide content 

Breastfeeding – Module 4, p. 27

Slide 89

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 89

Special Considerations (7)

Breastfeeding

• Concentration of drugs in breast milk is not 

considered effective treatment for LTBI or TB 

disease for infant

• Vitamin B6 supplements are recommended 

for all women who are taking INH and are 

breastfeeding

 Review slide content 

Breastfeeding – Module 4, p. 27

Slide 90

Special Considerations (8)

Children

• Children younger than 5 years of age should start TB 

treatment as soon as the diagnosis is suspected

• Children can be treated with INH, RIF, PZA, and EMB for 2 

months, followed by INH and RIF for 4 months

– Children receiving EMB should be monitored for 

vision changes

• A 3 drug regimen (INH, RIF, PZA) can be considered in 

the intensive phase for children who are too young to 

have their vision monitored, are not infected with HIV, 

have no prior TB treatment history, and are not at risk for 

having drug-resistant TB

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 90

 Review slide content 

Children – Module 4, p. 27
146

Slide 91

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 91

• In general, regimens used for treating pulmonary 

TB are also effective for treating extrapulmonary 

TB 

• 9 to 12 month regimen is recommended for TB of 

the meninges or central nervous system 

• 6 to 9 month regimen is recommended for bone 

and joint TB

Special Considerations (9)

People with Extrapulmonary Disease

 Review slide content 

 Note that extending treatment should be 

considered for patients with TB in any site 

that is slow to respond

People with Extrapulmonary Disease – Module 4, p. 28

Slide 92

92

Treatment of TB Disease

Alternative Regimens for Treating 

Drug-Resistant TB

 Introduce section

Slide 93

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 93

• Alternative regimens should be used for treating 

drug-resistant TB 

• Treatment of drug-resistant TB should always 

be done under the supervision of a medical 

expert 

Alternative Treatment Regimens (1)

Drug-Resistant TB

 Review slide content 

Drug-Resistant TB – Module 4, p. 28
147

Slide 94

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 94

Alternative Treatment Regimens (2)

Drug-Resistant TB

• INH-resistant TB can be treated with the 

following regimen:

– RIF, EMB, and PZA for 6 months

 Review slide content 

Drug-Resistant TB – Module 4, p. 28

Slide 95

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 95

• MDR TB is resistant to INH and RIF, and is more difficult 

to treat than drug-susceptible TB

• Drugs that can be used are less effective and are more 

likely to cause adverse reactions

• Treatment can last 18 to 24 months after culture 

conversion

• As a last resort, some patients undergo surgery to 

remove part of the disease site

• Expert consultation should be sought

Alternative Treatment Regimens (3)

MDR TB

 Review slide content

 Remind participants that MDR TB is resistant 

to both INH and RIF

Alternative Treatment Regimens – Module 4, p. 28

Slide 96

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 96

Alternative Treatment Regimens (4)

Extensively Drug-Resistant TB (XDR TB)

• XDR TB is resistant to INH, RIF, plus any 

fluoroquinolone, and at least one injectable 

second-line drug (e.g., amikacin, kanamycin, or 

capreomycin)

• XDR TB patients have less effective treatment 

options

• XDR TB is very difficult to treat 

• Expert consultation should be sought

 Explain that XDR TB is a rare type of MDR TB

 Review slide content 

Alternative Treatment Regimens– Module 4, p. 28
148

Slide 97

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 97

Alternative Treatment Regimens (5)

XDR TB

• Successful outcomes for the patient depend 

greatly on:

– Extent of drug resistance

– Severity of disease

– Whether the patient’s immune system is 

compromised

 Review slide content 

Alternative Treatment Regimens – Module 4, p. 28

Slide 98

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 98

Special Considerations 

Study Question 4.18

What treatment regimen should be used for

HIV-infected TB patients?

• 6-month daily regimen consisting of an intensive phase of 

INH, RIF, PZA, and EMB for 2 months followed by a 

continuation phase of INH and RIF for 4 months

• ART should ideally be initiated 

• Within 2 weeks of starting TB treatment for patients with CD4 cell counts <50/mm3

• By 8 to 12 weeks of starting TB treatment for patients with CD4 cell counts >50/mm3

• For patients with TB meningitis or TB involving the 

central nervous system, ART should NOT be initiated 

during the first 8 weeks of TB treatment 

 Introduce study questions

 Ask participants to turn to p. 29 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 4, p. 53

Slide 99

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 99

Special Considerations 

Study Question 4.19

In what situations should treatment for TB disease last

longer than the usual course of treatment?

• HIV-infected TB patients need a minimum of 6 months of treatment. 

If an HIV-infected patient is NOT receiving ART during TB treatment, 

it is recommended to prolong treatment to 9 months. 

• Pregnant women with TB disease should receive at least 9 months 

of treatment

• Persons with TB disease of the meninges or central nervous system 

should receive a 9 to 12-month regimen

• Persons with bone or joint TB disease should receive a 6 to 9-month 

regimen

• Extending treatment should be considered for patients with TB 

disease in any site that is slow to respond

• Treatment for MDR TB disease can last 18 to 24 months

 Read question

 Ask participants for answers

Answers – Module 4, p. 53
149

Slide 100

100

Treatment of TB Disease

Treatment and Monitoring Plan and 

Adverse Reactions

 Introduce section

Slide 101

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 101

• Every TB patient should have a specific 

treatment and monitoring plan developed in 

collaboration with local health department

• Plan should include:

– Description of treatment regimen

– Methods of:

• Monitoring for adverse reactions

• Assessing and ensuring adherence to 

treatment

• Evaluating treatment response

Treatment and Monitoring Plan

TB Disease

 Review slide content 

 Note that the treatment and monitoring plan 

should be done within one week of suspected 

diagnosis

Treatment and Monitoring Plan – Module 4, p. 31

Slide 102

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 102

• Before starting treatment for TB disease, 

patients should have baseline blood and 

vision tests to detect problems that may 

complicate treatment

– For example, patients who are taking 

ethambutol should have baseline visual 

acuity testing and testing of color 

discrimination

Monitoring Adverse Reactions (1)

TB Disease

 Review slide content 

Treatment and Monitoring Plan – Module 4, p. 31
150

Slide 103

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 103

Monitoring Adverse Reactions (2)

TB Disease

• Follow-up tests should be done periodically if:

– Results of baseline tests indicate 

abnormalities

– Patient has symptoms that may be due to 

adverse reactions

 Review slide content 

Monitoring Adverse Reactions – Module 4, p. 31

Slide 104

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 104

• Patients should be educated about symptoms 

caused by adverse reactions to drugs

• Patients should be seen by clinician at least 

monthly during treatment and evaluated for 

possible adverse reactions

• Public health workers who have regular 

contact with patients should ask about 

adverse reactions to treatment

Monitoring Adverse Reactions (3)

TB Disease

 Review slide content 

 Explain that patients should also be educated 

about minor side effects of treatment; such 

as orange discoloration of urine from rifampin

 Note that monitoring for adverse reactions 

must be individualized, depending on the 

drugs the patient is taking and the patient’s 

risk for adverse reactions

Monitoring Adverse Reactions – Module 4, pp. 31-32

Slide 105

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 105

Monitoring Adverse Reactions (4)

TB Disease

• If patient has 

symptoms of a serious 

adverse reaction, 

HCWs should:

– Instruct patient to stop 

medication

– Report situation to 

clinician and arrange for 

medical evaluation

– Note symptoms on the 

patient’s form

 Review slide content 

Monitoring Adverse Reactions – Module 4, p. 32
151

Slide 106

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 106

Adverse Reactions to TB Drugs (1)

Adverse

Reaction

Caused 

by

Signs and Symptoms Significance

of Reaction*

Allergic Any drug • Skin rash May be serious 

or minor

Eye

damage

EMB • Blurred or changed vision

• Changed color vision

Serious

Hepatitis PZA

INH

RIF

• Abdominal pain

• Abnormal liver function test 

results

• Brown urine, light colored stool

• Fatigue

• Fever for 3 or more days

• Flu-like symptoms

• Lack of appetite

• Nausea

• Vomiting

• Yellowish skin or eyes

Serious

Table. 4.4

 Ask participants turn to p. 34 (if participants 

have print-based modules)

 Explain that this table describes adverse 

reactions to TB drugs

 Review slide content

Adverse Reactions to TB Drugs – Module 4, p. 33

Slide 107

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 107

Adverse Reactions to TB Drugs (2)

Adverse

Reaction

Caused by Signs and Symptoms Significance of

Reaction*

Nervous 

system 

damage 

INH • Dizziness

• Tingling or numbness 

around the mouth

Serious

Peripheral

neuropathy

INH • Tingling sensation, 

numbness, or pain in 

hands and feet

Serious

Stomach 

upset

PZA • Stomach upset

• Vomiting

• Lack of appetite

May be serious or 

minor

Gout PZA • Abnormal uric acid

level

• Joint aches

Serious

Table. 4.4

 Review slide content

Adverse Reactions to TB Drugs – Module 4, p. 33

Slide 108

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 108

Adverse

Reaction

Caused 

by

Signs and Symptoms Significance

of Reaction*

Bleeding

problems 

due to low 

platelets

RIF • Easy bruising

• Slow blood clotting

Serious

Discoloration 

of body 

fluids

RIF • Orange urine, sweat, or tears

• Permanently stained soft 

contact lenses

Minor

Drug

interactions

RIF • Interferes with many 

medications, such as birth 

control pills or implants, blood 

thinners, some HIV medicines, 

and methadone

May be

serious

or minor 

Adverse Reactions to TB Drugs (3)

Table. 4.4

* Patients should stop medication for serious adverse reactions and consult a clinician 

immediately. Patients can continue taking medication if they have minor adverse reactions.

 Review slide content

Adverse Reactions to TB Drugs – Module 4, p. 33
152

Slide 109

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 109

What should be included in each patient’s 

treatment plan?

• Description of treatment regimen

• Methods of monitoring for adverse 

reactions

• Methods of assessing and ensuring 

adherence to the treatment

• Methods for evaluating treatment response

TB Treatment and Monitoring Plan

Study Question 4.20

 Introduce study questions

 Ask participants to turn to p. 34 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 4, p. 54

Slide 110

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 110

Name the drug or drugs that may cause each of 

the following symptoms or adverse reaction.

• Nervous system damage: 

INH

• Hepatitis: 

INH, PZA, RIF

• Eye damage: 

EMB

• Orange discoloration of the urine: 

RIF

Adverse Reactions to TB Drugs

Study Question 4.21

 Read question 

 Ask participants for answers

Answers – Module 4, p. 54

Slide 111

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 111

How often should patients be monitored for 

adverse reactions to TB drugs? 

All patients should be seen at least 

monthly during treatment and evaluated 

for possible adverse reactions.

Also, DOT providers should ask about 

any adverse reactions.

TB Treatment Monitoring 

Study Question 4.22

 Read question

 Ask participants for answers

Answers – Module 4, p. 54
153

Slide 112

112

Treatment of TB Disease

Adherence and Evaluating Patients’ 

Response to Treatment

 Introduce section

Slide 113

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 113

Adherence to TB Treatment (1)

• Most effective strategy 

to encourage adherence 

to treatment is DOT

– Should be considered 

for ALL patients

– Should be used for all 

children and 

adolescents 

– Should be done at a 

time and place that is 

convenient for patients

 Explain that in order to cure TB and prevent 

drug resistance, TB patients must adhere to 

treatment

 Explain that adherence to TB treatment can 

be difficult because patients need to take 

several different medications for many 

months

 Review slide content 

 Ask participants what adherence problems 

they have encountered with patients and 

strategies they have used to overcome them

Adherence to TB Treatment – Module 4, p. 37

Slide 114

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 114

• Incentives and enablers can be used to 

improve patient adherence

– Incentives are rewards given to patient, 

e.g., gift cards

– Enablers help patient receive treatment, 

e.g., bus tokens

Adherence to TB Treatment (2)

 Review slide content 

 Explain that incentives are small rewards 

given to patients to encourage them to take 

their medicines or keep DOT appointments

 Explain that enablers help patients receive 

treatment

 Mention that incentives and enablers are 

generally offered along with DOT

Adherence to TB Treatment – Module 4, p. 38
154

Slide 115

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 115

Adherence to TB Treatment (3)

• Patients should be 

educated about TB 

disease and 

treatment

– Cause of TB, 

transmission, 

diagnosis, and 

treatment plan

– How and when to 

take medication

 Review slide content 

Adherence to TB Treatment – Module 4, p. 38

Slide 116

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 116

• Patients not receiving DOT should be monitored 

for adherence to treatment:

– Check if patient is reporting to clinic as 

scheduled

– Ask about adherence

– Ask patient to bring medications to clinic and 

count number of pills taken

– Use urine tests to detect medication in urine

– Assess patient’s clinical response to treatment

Monitoring Patients’ Adherence to 

Therapy

 Review slide content 

 Explain that none of these methods can be 

used to prove a patient took every dose of 

medication; the best way to ensure 

adherence to treatment is to use DOT

Monitoring Adherence to Therapy – Module 4, p. 38

Slide 117

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 117

Three methods to determine whether a patient

is responding to treatment:

1. Check to see if patient has TB symptoms 

(clinical evaluation)

2. Conduct bacteriologic examination of 

sputum or other specimens

3. Use chest x-rays to monitor patient’s 

response to treatment

Evaluating Patients’ Response to 

Treatment (1)

 Review slide content 

Evaluating Patients’ Response to Treatment – Module 4, 

pp. 39-40
155

Slide 118

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 118

Evaluating Patients’ Response to 

Treatment (2)

1. Check to see if patient has TB symptoms 

(clinical evaluation)

• TB symptoms should gradually 

improve and go away after starting 

treatment

• Patients whose symptoms do not 

improve during the first 2 months of 

treatment, or whose symptoms worsen 

after initial improvement, should be 

reevaluated

 Review slide content 

 Explain that although each patient responds 

to treatment at a different pace, all patients’ 

TB symptoms should gradually improve

Evaluating Patients’ Response to Treatment – Module 4, 

pp. 39-40

Slide 119

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 119

Evaluating Patients’ Response to 

Treatment (3)

2. Conduct bacteriologic examination of sputum 

or other specimens

• Specimens should be examined every month until culture results have converted 

from positive to negative

• Any patient whose culture results have 

not become negative after 2 months of 

treatment, or whose results become 

positive after being negative, should be 

reevaluated

 Review slide content 

Evaluating Patients’ Response to Treatment – Module 4, 

pp. 39-40

Slide 120

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 120

Evaluating Patients’ Response to 

Treatment (4)

3. Use chest x-rays to monitor patient’s response 

to treatment

• Repeated x-rays are not as helpful as 

monthly bacteriologic and clinical 

evaluations

• Chest x-rays taken at end of treatment can 

be compared to any follow-up x-rays

 Review slide content

 Explain that chest x-rays can be useful for 

patients who have negative culture results 

before treatment

Evaluating Patients’ Response to Treatment – Module 4, 

pp. 39-40
156

Slide 121

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 121

Evaluating Patients’ Response to 

Treatment (5)

• TST or IGRA cannot be used to determine 

whether the patient is responding to 

treatment

• Treatment completion is defined by number 

of doses the patient takes within a specific 

time frame

• Length of treatment depends on drugs used, 

drug susceptibility test results, and the 

patient’s response to therapy

 Review slide content 

 Explain that most people who have a positive 

TST result will have a positive result again if 

they are skin tested later in their lives, 

regardless of whether they have received 

treatment 

Evaluating Patients’ Response to Treatment – Module 4, 

pp. 39-40

Slide 122

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 122

Reevaluating Patients Who Do 

Not Respond to Treatment (1)

• Reevaluating the patient means 

– Obtaining a new specimen for TB culture, and 

(if positive) drug susceptibility testing

– Assessing whether the patient has taken medication as prescribed

– Reviewing symptoms

– Performing a clinical examination

– Repeating chest x-rays

 Review slide content 

Reevaluating Patients Who Do Not Respond to 

Treatment – Module 4, p. 40

Slide 123

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 123

• Patients should be reevaluated if:

– Symptoms do not improve in first 2 months 

of therapy

– Symptoms worsen after improving initially

– Culture results have not become negative 

after 2 months of treatment

– Culture results become positive after being 

negative

– Chest x-rays show worsening

Reevaluating Patients Who Do Not 

Respond to Treatment (2)

 Review slide content 

Reevaluating Patients Who Do Not Respond to 

Treatment – Module 4, p. 40
157

Slide 124

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 124

Name 4 ways clinicians can assess whether 

a patient is adhering to treatment.

• Check whether patient is reporting to clinic as 

scheduled

• Ask patient to bring medications to each clinic 

visit and count the number of pills

• Use urine tests to detect medication 

• Assess patient’s clinical response to therapy

Adherence to Therapy

Study Question 4.23

 Introduce study questions

 Ask participants to turn to p. 41 (if 

participants have print-based modules)

 Read question

 Ask participants for answers

Answers – Module 4, p. 54

Slide 125

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 125

What is the best way to ensure that a patient 

adheres to treatment?

Directly observed therapy (DOT)

Adherence to Therapy

Study Question 4.24

 Read question 

 Ask participants for answers

Answers – Module 4, p. 54

Slide 126

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 126

How can clinicians determine whether a 

patient is responding to treatment?

• Clinical evaluations

• Bacteriologic evaluations

• Chest x-rays

Response to Treatment

Study Question 4.25

 Read question 

 Ask participants for answers

Answers – Module 4, p. 55
158

Slide 127

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 127

Under what circumstances should patients be 

reevaluated?

• Symptoms do not improve during first 2 months of 

therapy

• Symptoms worsen after improving initially

• Culture results have not become negative after 2 months of treatment

• Culture results become positive after being 

negative

• Chest x-rays show worsening

Reevaluating the Patient

Study Question 4.26

 Read question 

 Ask participants for answers

Answers – Module 4, p. 55

Slide 128

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 128

What does reevaluating the patient mean?

Reevaluating the patient means obtaining a 

new specimen for TB culture, and (if positive) 

drug susceptibility testing, assessing 

whether the patient has been taking 

medication as prescribed, reviewing 

symptoms, performing a clinical evaluation, 

and repeating chest x-rays.

Reevaluating the Patient

Study Question 4.27

 Read question 

 Ask participants for answers

Answers – Module 4, p. 55

Slide 129

129

Treatment of TB Disease

Role of Public Health Workers

 Introduce section
159

Slide 130

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 130

• Successful TB treatment is the responsibility 

of medical providers and HCWs, not the 

patient

• Case management can be used to ensure that 

patients complete TB treatment

• A health department employee is assigned 

responsibility for the management of specific 

patients

Role of Public Health Workers (1)

 Review slide content 

Role of Public Health Workers – Module 4, pp. 43-44

Slide 131

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 131

• Provide DOT

• Help monitor patients’ response to treatment

• Educate patients and families about TB

• Locate patients who have missed DOT visits or 

clinic appointments

• Act as interpreters, arrange and provide 

transportation for patients, and refer patients to 

other social services

• Work with private physicians to make sure TB 

patients complete an adequate regimen

Role of Public Health Workers (2)

 Review slide content 

Role of Public Health Workers – Module 4, pp. 43-44

Slide 132

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 132

What is the goal of case management?

To provide patient-centered care for 

completion of treatment and to ensure all 

public health activities related to stopping 

TB transmission are completed.

Role of Public Health Workers

Study Question 4.28

 Introduce study questions

 Ask participants to turn to p. 45 (if 

participants have print-based modules)

 Read question 

 Ask participants for answers

Answers – Module 4, p. 55
160

Slide 133

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 133

What should a public health worker do if he 

or she notices that a patient has symptoms 

of a serious adverse reaction?

• Instruct patient to stop taking medication

• Report situation to clinician and arrange 

for a medical evaluation right away

• Note symptoms on patient’s form

Role of Public Health Workers

Study Question 4.29

 Read question 

 Ask participants for answers

Answers – Module 4, p. 55

Slide 134

134

Case Studies

 Introduce case studies

Slide 135

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 135

Module 4: Case Study 4.1 (1)

You are sent to visit the home of a TB patient 

who was admitted to the hospital last week 

and diagnosed with infectious TB disease. 

Living in the home are his wife and his 1-

year-old daughter. Neither one has 

symptoms of TB disease. You give them both 

a TST and return 2 days later to read the 

results. You find that the wife has 14 mm of 

induration, but the daughter has no 

induration. 

 Ask participants to turn to p. 16 (if 

participants have print-based modules)

 Read case study 

Case Study 4.1 – Module 4, p. 16
161

Slide 136

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 136

Should either one receive further evaluation 

for LTBI or TB disease? 

Yes, both should receive further evaluation 

for LTBI or TB disease. 

Module 4: Case Study 4.1 (2)

 Read case study question

 Ask participants for answers 

Answers – Module 4, p. 56

Slide 137

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 137

Should either one start LTBI treatment? Explain.

Yes, both should start LTBI treatment. The 

wife is a contact of someone with infectious 

TB disease, and she has a positive TST. 

Therefore, after receiving a medical 

evaluation (and TB disease is ruled out), 

she should complete an entire course of 

LTBI treatment, regardless of her age.

Module 4: Case Study 4.1 (3)

 Ask participants why the wife should receive 

LTBI treatment

Answers – Module 4, p. 56

Slide 138

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 138

Module 4: Case Study 4.1 (4)

Should either one start LTBI treatment? Explain.

(cont.)

The daughter has a negative TST, but only one week 

has passed since her last TB exposure. It is possible 

that not enough time has passed for her to be able to 

react to the TST. 

Since it is currently impossible to tell whether she has 

TB infection and because she may develop TB 

disease very quickly after infection, she should start 

LTBI treatment now and be retested 8 to 10 weeks 

after last exposure to TB. If negative upon retest, she may stop taking medicine. If positive, she should 

complete the entire course of LTBI treatment (9 months for children).

 Ask participants why the daughter should 

receive LTBI treatment

Answers – Module 4, p. 56
162

Slide 139

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 139

Module 4: Case Study 4.2 (1)

A 65-year-old man is prescribed LTBI 

treatment with INH because he is a contact of 

a person with infectious TB disease and he 

has an induration of 20 mm to the TST. His 

baseline liver function tests are normal, but 

he drinks a six-pack of beer every day.

 Ask participants to turn to p. 21 (if 

participants have print-based modules)

 Read case study 

Case Study 4.2 – Module 4, p. 21

Slide 140

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 140

What kind of monitoring is necessary for this 

patient while he is taking INH?

• Although his liver function tests are normal, he 

is at high risk of INH-associated hepatitis 

because he is older and he abuses alcohol.

• He should be educated about the symptoms of 

adverse reactions to INH and instructed to seek medical attention immediately if these symptoms 

occur.

• He should be seen by a clinician monthly to ask 

about his symptoms, examine him for signs of 

adverse reactions, and consider performing liver 

function tests.

Module 4: Case Study 4.2 (2)

 Read case study question 

 Ask participants for answers 

Answers – Module 4, p. 57

Slide 141

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 141

Module 4: Case Study 4.3 (1)

An 18-month-old girl is admitted to the hospital 

because of meningitis. Doctors discover that 

her grandmother had pulmonary TB disease 

and was treated with a 6-month regimen. The 

medical evaluation of the child confirms the 

diagnosis of TB meningitis.

 Ask participants to turn to p. 30 (if 

participants have print-based modules)

 Read case study 

Case Study 4.3 – Module 4, p. 30
163

Slide 142

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 142

Module 4: Case Study 4.3 (2)

How long should the child be treated?

The child should be treated for 9 to 12 

months because she has TB meningitis.

 Read case study question 

 Ask participants for answers 

Answers – Module 4, p. 57

Slide 143

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 143

Module 4: Case Study 4.4 (1)

You are assigned to deliver medications to TB 

patients as part of the DOT program where you 

work. When you visit Mr. Jackson’s house, you 

ask him how he is feeling. He tells you that he 

was up all night vomiting.

 Ask participants to turn to p. 35 (if 

participants have print-based modules)

 Read case study 

Case Study 4.4 – Module 4, p. 35

Slide 144

Module 4: Case Study 4.4 (2)

What are the possible causes? What should 

you do?

His vomiting may be a symptom of 

hepatitis (caused by INH, RIF, and PZA) or 

of stomach upset due to PZA. Mr. 

Jackson should be advised to stop his 

medication, and the situation should be 

reported to the clinician immediately. Mr. 

Jackson should be given a medical 

evaluation right away.

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 144

 Read case study question 

 Ask participants for answers 

Answers – Module 4, p. 57
164

Slide 145

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 145

Module 4: Case Study 4.5 (1)

Ms. Young, a patient who started treatment for 

TB disease last week, calls the TB clinic to 

complain that her urine has changed to an odd 

color.

 Read case study 

Case Study 4.5 – Module 4, p. 36

Slide 146

Module 4: Case Study 4.5 (2)

Name 2 possible causes, and explain how each 

would affect the color of urine.

One possible cause is the discoloration of body 

fluids, a common side effect of RIF. This would cause 

Ms. Young’s urine to turn orange. This is NOT a 

serious condition.

Another possible cause is hepatitis, which can be 

caused by INH, RIF, or PZA. Hepatitis, a serious 

condition, would cause Ms. Young’s urine to turn 

dark. If Ms. Young’s urine is brown, the situation 

should be reported to the clinician and Ms. Young 

should receive a medical examination right away.

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 146

 Read case study question 

 Ask participants for answers 

Answers – Module 4, p. 58

Slide 147

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 147

Module 4: Case Study 4.6 (1)

Mr. Vigo was diagnosed with smear-positive 

pulmonary TB disease in January. He was 

treated with INH, RIF, and PZA by his private 

physician. He visited his physician again in 

March. His drug susceptibility test results were 

not available at the time of this appointment. 

Nevertheless, the physician discontinued his 

prescription of PZA and gave him refills of INH 

and RIF. Mr. Vigo visited his physician again in 

April. He had a persistent cough, and his 

sputum smear was found to be positive. 

 Ask participants to turn to p. 42 (if 

participants have print-based modules)

 Read case study 

Case Study 4.6 – Module 4, p. 42
165

Slide 148

Module 4: Case Study 4.6 (2)

What should be done next?

Mr. Vigo’s persistent cough and positive sputum smear 

indicate that he is not responding to therapy. The most 

likely explanations are: 

• He is not taking his medications as prescribed,

• The regimen he has been prescribed is not adequate to 

treat his TB and he may have drug-resistant TB, or

• A combination of the two factors listed above.

The initial drug susceptibility test results should be located, 

and susceptibility tests should be repeated on a recent 

sputum specimen. In addition, his adherence should be 

evaluated, and he should be given DOT if possible.

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 148

 Read case study question 

 Ask participants for answers 

Answers – Module 4, p. 58

Slide 149

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 149

Module 4: Case Study 4.7 (1)

Ms. DeVonne began treatment for pulmonary 

TB disease 2 months ago, at the beginning of 

September. You have been supervising her 

DOT. During the first few weeks of therapy, 

you noticed that Ms. DeVonne’s symptoms 

were improving a little. However, at a visit in 

October, you see that Ms. DeVonne is 

coughing up blood, and she tells you that she 

feels like she has a fever.

 Ask participants to turn to p. 46 (if 

participants have print-based modules)

 Read case study 

Case Study 4.7 – Module 4, p. 46

Slide 150

Module 4: Case Study 4.7 (2)

What should you do?

You should report her symptoms to the clinician and 

arrange for her to receive a medical evaluation right 

away. Also, you should note her symptoms on her record.

Symptoms becoming worse after improving initially 

indicates that she is not responding to therapy. Because 

she is receiving DOT, she is probably taking her 

medications as prescribed. Therefore, the most likely 

explanation is that she has drug-resistant TB.

Ms. DeVonne’s initial drug susceptibility test results 

should be located, and drug susceptibility tests should be 

repeated on a recent sputum specimen.

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 150

 Read case study question 

 Ask participants for answers 

 Ask if there are any questions about Module 

4 before moving on to Module 5

Answers – Module 4, p. 59
166
167

Module 5: Infectiousness and Infection Control 

Facilitation Tips 

Background 

In this module, participants will learn about the factors that determine the infectiousness of a 

person with TB disease. This will help participants decide whether a particular patient should be 

considered infectious. Participants will also learn about the precautions they should take if they 

come in contact with patients who are considered infectious to prevent the spread of TB in health 

care settings and communities. These precautions, or measures, are part of a TB infection-control 

program that each health care setting should develop to minimize the risk for transmission of 

Mycobacterium tuberculosis.

Learning Objectives 

After this presentation, participants will be able to 

1. Describe the factors that determine the infectiousness of a TB patient. 

2. Describe the main goals of a TB infection-control program. 

3. Describe the three levels of control measures that are the basis of an effective infectioncontrol program.

4. Describe the purpose and the characteristics of a TB airborne infection isolation room.

5. Describe the circumstances when personal respirators should be used. 

Module Overview

Time Activity Content Resources Needed

2 min. Presentation Introduction Slides 1-3

10 min. Presentation Infectiousness Slides 4-12

15 min. Presentation TB Infection Control Slides 13-27

25 min. Presentation TB Infection Control Measures Slides 28-60

3 min. Presentation TB Risk Assessment Slides 61-65

5 min.

Presentation Infection Control in 

Nontraditional Facility-Based 

Settings

Slides 66-72

5 min. Presentation TB Infection Control in the 

Home Slides 73-81

10 min. Case Studies Case Studies Slides 82-93

75 min. Total Time
168

Facilitation Tips

Slide 1

Self-Study Modules 

on Tuberculosis

Infectiousness 

and Infection Control

 Introduce Module 5

Slide 2

Module 5 – Infectiousness and Infection Control 2

Module 5: Objectives

At completion of this module, learners will be able to:

1. Describe the factors that determine the 

infectiousness of a TB patient

2. Describe the main goals of a TB infection-control 

program

3. Describe the three levels of control measures that 

are the basis of an effective TB infection-control 

program

4. Describe the purpose and the characteristics of a 

TB airborne infection isolation (AII) room

5. Describe the circumstances when personal 

respirators should be used

 State objectives of presentation

Objectives - Module 5, p. 1

Slide 3

Module 5 – Infectiousness and Infection Control 3

• Infectiousness

• TB Infection Control

– TB Infection Control Measures

– TB Risk Assessment

– Infection Control in Nontraditional FacilityBased Settings

– TB Infection Control in the Home

• Case Studies

Module 5: Overview

 Review slide content
169

Slide 4

4

Infectiousness

 Introduce section

 Ask participants which factors are associated 

with infectiousness

Infectiousness - Module 5, pp. 4-5

Slide 5

Module 5 – Infectiousness and Infection Control 5

• Infectiousness is directly related to number 

of tubercle bacilli TB patients expel into air

• TB patients generally expel more tubercle 

bacilli if their cough produces a lot of 

sputum

• Only people with TB of the lungs, airway, or 

larynx are infectious 

Infectiousness (1)

 Review slide content

Infectiousness - Module 5, pp. 4-5

Slide 6

Module 5 – Infectiousness and Infection Control 6

Infectiousness (2)

Factors generally associated with infectiousness:

• Presence of cough • Not covering mouth

when coughing

• Cavity in the lung • Not receiving adequate

treatment or prolonged 

illness

• Acid-fast bacilli on

sputum smear

• Undergoing cough

inducing procedures

• TB of lungs, airway, or

larynx

• Positive sputum cultures

 Review slide content

Infectiousness - Module 5, pp. 4-5
170

Slide 7

Module 5 – Infectiousness and Infection Control 7

Infectiousness (3)

• Infectiousness appears to decline rapidly 

after adequate treatment is started; however:

– How quickly infectiousness declines 

varies from patient to patient (weeks to 

months) 

– Patients with drug-resistant TB may not 

respond to initial drug regimen; meaning 

they may remain infectious for longer

 Review slide content

Infectiousness - Module 5, pp. 4-5

Slide 8

Module 5 – Infectiousness and Infection Control 8

• Patients can be considered non-infectious 

when they meet all of the following criteria:

– Received adequate treatment for 2 weeks or 

longer

– Symptoms have improved

– Three consecutive negative sputum smears 

from sputum collected in 8 to 24 hour 

intervals (at least one early morning 

specimen)

Infectiousness (4)

 Review slide content

Infectiousness - Module 5, pp. 4-5

Slide 9

Module 5 – Infectiousness and Infection Control 9

Infectiousness (5)

• Children are less likely 

than adults to be infectious

– Children generally do 

not produce a lot of 

sputum when they 

cough

• Young children can still 

transmit TB if they exhibit 

signs of infectiousness

 Before showing slide, ask participants if 

children are more or less likely than adults to 

be infectious 

 Review slide content 

 Explain that children can transmit TB to 

others if they have signs of infectiousness, 

such as a positive AFB smear or cavity in their 

lung 

Infectiousness - Module 5, pp. 4-5
171

Slide 10

Module 5 – Infectiousness and Infection Control 10

Infectiousness

Study Question 5.1

List 7 factors that affect the infectiousness of a 

TB patient.

• Presence of a cough

• Chest x-ray showing cavity in lung

• Positive acid-fast bacilli sputum smear result

• TB of lungs, airway, or larynx

• Patient not covering mouth or nose when coughing

• Not receiving adequate treatment or having 

prolonged illness

• Undergoing cough-inducing procedures

 Introduce study questions 

 Ask participants to turn to p. 6 (if participants 

have print-based modules) 

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 37

Slide 11

Module 5 – Infectiousness and Infection Control 11

Infectiousness

Study Question 5.2

Why does the site of disease affect the 

infectiousness of a TB patient?

• Usually only people with pulmonary or 

laryngeal TB are infectious. These people 

may be coughing and expelling tubercle 

bacilli into air.

• People with extrapulmonary TB are generally 

not infectious

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 37

Slide 12

Module 5 – Infectiousness and Infection Control 12

When can a TB patient be considered 

noninfectious? List all 3 criteria.

When they meet all of the following criteria:

–Received adequate TB treatment for a 

minimum of 2 weeks

–Symptoms have improved 

–3 consecutive negative sputum smears from 

sputum collected in 8-24 hour intervals (one 

being early morning specimen)

Infectiousness 

Study Question 5.3

 Read question 

 Ask participants for answers

Answers - Module 5, p. 37
172

Slide 13

13

TB Infection Control

 Introduce section

TB Infection Control - Module 5, pp. 8-35

Slide 14

Module 5 – Infectiousness and Infection Control 14

• Infection control is an important strategy to 

prevent the spread of TB

– Several outbreaks of TB in health care 

settings, including multidrug-resistant TB 

(MDR TB) and extensively drug-resistant TB 

(XDR TB), have occurred

• All health care and congregate settings should 

implement TB infection-control measures

TB Infection Control (1)

 Review slide content

TB Infection Control - Module 5, p. 8

Slide 15

Module 5 – Infectiousness and Infection Control 15

• TB is most likely to be transmitted when 

health care workers (HCWs) and patients 

come in contact with persons who:

– Have unsuspected TB disease

– Are not receiving adequate treatment

– Have not been isolated from others

TB Infection Control (2)

 Review slide content 

 Explain that TB can be transmitted in just 

about any setting but that it is most likely to 

be transmitted in health care settings with 

these three characteristics 

TB Infection Control - Module 5, p. 8
173

Slide 16

Module 5 – Infectiousness and Infection Control 16

TB Infection Control (3)

Role of the Health Department

• Health department TB control programs 

should:

– Ensure each of their clinics develop a TB 

infection-control program

– Provide consultation about TB infection 

control to other health care and congregate 

settings

 Review slide content 

TB Infection Control - Module 5, p. 9

Slide 17

Module 5 – Infectiousness and Infection Control 17

TB Infection Control (4) 

Role of the Health Department

• Health departments should specifically assist 

health care settings with:

– Understanding infection control principles

– Reporting confirmed or suspected TB cases

– Conducting contact investigations 

– Ensuring a plan for TB patients to receive follow-up 

care after discharge

– Conducting risk assessments, testing, surveillance, 

and outbreak investigations

– Planning and implementation of TB control 

activities

 Review slide content 

 Explain that health departments should work 

closely with health care facilities to help them 

report confirmed or suspected TB cases as 

quickly as possible 

TB Infection Control - Module 5, p. 9

Slide 18

Module 5 – Infectiousness and Infection Control 18

TB Infection-Control Program (1)

• Main goals of a TB infection-control program 

are to ensure early and prompt:

– Detection of TB disease 

– Airborne precautions (e.g., isolation of 

people who have or are suspected of having 

TB disease)

– Treatment of people who have or are 

suspected of having TB disease 

 Review slide content 

TB Infection Control Program - Module 5, p. 10
174

Slide 19

Module 5 – Infectiousness and Infection Control 19

• HCWs should suspect TB disease 

in anyone with any of these 

symptoms:

– Persistent cough

– Chest pain

– Bloody sputum

– Weight loss or loss of appetite

– Fever

– Chills

– Night sweats

TB Infection-Control Program (2)

Detection of TB disease

 Review slide content 

 Explain that in areas where TB is common 

staff at health care facilities should stay alert

for TB; especially staff at public health and 

community clinics 

TB Infection-Control Program - Module 5, p. 10

Slide 20

Module 5 – Infectiousness and Infection Control 20

• When a health care worker suspects that a 

patient has TB disease, the patient should be:

– Placed in an area away from other patients 

and evaluated

– Given a surgical mask to wear

– Given tissues and asked to cover nose and mouth when coughing or sneezing

TB Infection-Control Program (3) 

Detection of TB disease

 Before showing slide, ask what a health care 

worker should do if they suspect a patient has 

TB disease 

 Review slide content 

TB Infection Control Program - Module 5, p. 10

Slide 21

Module 5 – Infectiousness and Infection Control 21

• Airborne precautions should be taken for any 

person who has signs or symptoms of TB 

disease

• If facility has an AII room, TB suspects and 

TB patients should be placed there

• Health care settings, such as TB clinics, 

should implement a respiratory-protection 

program

TB Infection-Control Program (4)

Airborne Precautions

 Before showing slide, ask what airborne 

precautions should be taken for a person who 

has signs or symptoms of TB disease 

 Review slide content 

 Explain that if a facility does not have an AII 

room, patients who have or are suspected of 

having TB should be placed in an area away 

from other patients 

 Explain that for settings other than clinics, 

patients with suspected TB should be 

promptly referred for a medical evaluation 

TB Infection Control Program - Module 5, pp. 11-12
175

Slide 22

Module 5 – Infectiousness and Infection Control 22

• Patients diagnosed with TB should start 

treatment immediately

• DOT should be used to ensure adherence

TB Infection-Control Program (5)

Treatment

 Review slide content 

 Emphasize that DOT is the best way to ensure 

adherence to treatment 

TB Infection Control Program - Module 5, p. 12

Slide 23

Module 5 – Infectiousness and Infection Control 23

TB Infection Control

Study Question 5.4

Under what circumstances is TB most likely to 

be transmitted in health care facilities?

TB is most likely to be transmitted when 

health care workers and patients come into 

contact with persons who:

• Have unsuspected TB disease

• Are not receiving adequate treatment

• Have not been isolated from others

 Introduce study questions 

 Ask participants to turn to p. 13 (if 

participants have print-based modules) 

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 37

Slide 24

Module 5 – Infectiousness and Infection Control 24

TB Infection Control

Study Question 5.5

How can the health department assist health 

care settings in preventing the spread of TB?

The health department can help health care facilities 

with:

• Understanding infection control principles

• Reporting confirmed or suspected TB cases

• Conducting contact investigations

• Ensuring there is a plan for TB patients to receive follow-up 

care after they are discharged

• Risk assessments, testing, surveillance, and outbreak 

investigations

• Planning and implementing TB control activities

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 38
176

Slide 25

Module 5 – Infectiousness and Infection Control 25

What are the main goals of a TB infection-control 

program?

The main goals are to detect TB disease early 

and to promptly isolate and treat people who 

have TB disease.

TB Infection Control

Study Question 5.6

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 38

Slide 26

Module 5 – Infectiousness and Infection Control 26

What would make a health care worker 

suspect that a patient has TB disease? 

• Persistent cough

• Bloody sputum

• Weight loss or loss of appetite

• Fever

• Night sweats

TB Infection Control

Study Question 5.7

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 38

Slide 27

Module 5 – Infectiousness and Infection Control 27

What should be done when a health care worker 

suspects that a patient has TB disease?

The patient should be

• Placed in an area away from other patients and 

evaluated

• Given surgical mask to wear

• Given tissues and asked to cover nose and mouth when coughing or sneezing

Patients who are diagnosed with TB should start 

appropriate treatment at once

TB Infection Control

Study Question 5.8

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 38
177

Slide 28

28

TB Infection Control 

TB Infection Control Measures

 Introduce section 

TB Infection Control Measures - Module 5, p. 16

Slide 29

Module 5 – Infectiousness and Infection Control 29

TB Infection Control Measures (1)

Hierarchy of Infection Control

Respiratory Protection

Administrative Controls

Environmental Controls

 Explain that there are three levels of infection 

control 

 Review slide content 

TB Infection Control Measures - Module 5, p. 16

Slide 30

Module 5 – Infectiousness and Infection Control 30

Three levels of control measures:

• Administrative controls: managerial measures 

to reduce risk of exposure to M. tuberculosis

• Environmental controls: engineering systems 

to prevent the spread of and reduce the 

concentration of infectious M. tuberculosis 

droplet nuclei in air

• Respiratory-protection controls: personal 

protection to further minimize risk for exposure 

to M. tuberculosis

TB Infection Control Measures (2)

 Review slide content 

TB Infection Control Measures - Module 5, p. 16
178

Slide 31

31

TB Infection Control 

TB Infection Control Measures

Administrative Controls

 Introduce section 

 Ask participants what types of administrative 

controls should be used 

Administrative Controls - Module 5, pp. 17-19

Slide 32

Module 5 – Infectiousness and Infection Control 32

• Administrative controls:

– First and most important level of TB 

infection-control program

– Goal is to reduce risk of exposure to 

persons who might have TB disease

Administrative Controls (1)

 Review slide content 

Administrative Controls - Module 5, p. 17

Slide 33

Module 5 – Infectiousness and Infection Control 33

• Administrative control activities:

– Assigning someone responsibility for TB 

infection control

– Developing and implementing a written TB 

infection control plan

– Conducting a TB risk assessment

– Ensuring availability of prompt laboratory 

processing, testing, and reporting of results

Administrative Controls (2)

 Review slide content 

 Explain that a TB risk assessment consists of 

evaluating the risk of transmission 

 Explain that an infection control plan should 

specify policies and practices to ensure 

prompt detection, isolation, and treatment or

transfer of persons who have suspected or 

confirmed disease 

 Explain that laboratory services help to 

determine if patients are still infectious and if 

they need to remain in an AII room 

Administrative Controls - Module 5, p. 17
179

Slide 34

Module 5 – Infectiousness and Infection Control 34

• Administrative control activities (cont.):

– Implementing effective work practices for 

managing patients who may have TB 

– Ensuring proper cleaning and sterilization or 

disinfection of equipment

– Educating, training, and counseling HCWs 

about TB

– Testing and evaluating workers who are at risk 

for TB or may be exposed to TB

Administrative Controls (3)

 Review slide content 

 Explain that all health care workers should be 

educated about basic TB concepts, infection 

control, and the importance of testing 

programs 

 Explain that TB testing programs can protect 

both workers and patients. Each health care 

setting should determine if and how often 

serial testing is offered depending upon the 

risk of TB transmission in their setting 

Administrative Controls - Module 5, p. 18

Slide 35

Module 5 – Infectiousness and Infection Control 35

• Administrative control 

activities (continued):

– Applying epidemiologybased prevention 

principles

– Using posters to remind 

patients of proper cough 

etiquette

– Coordinating efforts 

between health 

departments and high 

risk settings

Administrative Controls (4)

 Review slide content 

 Emphasize that state or local health 

department TB control programs and highrisk health care and congregate settings 

should establish regular communication 

Administrative Controls - Module 5, p. 19

Slide 36

36

TB Infection Control 

TB Infection Control Measures

Environmental Controls

 Introduce section 

Environmental Controls - Module 5, pp. 19-22
180

Slide 37

Module 5 – Infectiousness and Infection Control 37

• Second level of infection-control program

• Consist of technologies that are designed to 

prevent the spread and reduce the 

concentration of TB in the air

– Ventilation technologies

– High efficiency particulate air filtration 

(HEPA)

– Ultraviolet germicidal irradiation (UVGI)

Environmental Controls

 Review slide content 

 Explain that the specifics of environmental 

controls will differ for each health care setting 

Environmental Controls - Module 5, p. 19

Slide 38

Module 5 – Infectiousness and Infection Control 38

• Ventilation is the movement of air in a 

building and the replacement of air inside 

with air from outside 

• Ventilation technologies include:

– Natural ventilation

– Mechanical ventilation

Ventilation Technologies (1)

 Review slide content 

 State that when fresh air enters a room, it 

dilutes the concentration of particles in room 

air, such as droplet nuclei containing M. 

tuberculosis

Environmental Controls - Module 5, p. 20

Slide 39

Module 5 – Infectiousness and Infection Control 39

• Doors and windows 

should be open 

• Fans can be used to 

distribute air

• HCW should sit near 

fresh air source

• Can be useful for 

nontraditional settings 

that do not have a central 

ventilation system

Ventilation Technologies (2)

Natural Ventilation

 Review slide content 

 Explain that natural ventilation relies on open 

doors and windows to bring in air from the 

outside 

 State that waiting rooms, shelter dormitories, 

or other rooms in which people congregate 

should have an operable door, window, or 

skylight kept open as often as possible 

Environmental Controls - Module 5, p. 19
181

Slide 40

Module 5 – Infectiousness and Infection Control 40

Ventilation Technologies (3) 

Mechanical Ventilation

• Refers to the use of technological equipment to 

circulate and move air

• Consists of two types of technologies

– Local exhaust ventilation

– General ventilation

• Should be used by hospitals, TB clinics, and 

other settings where TB patients are expected

 Review slide content 

Environmental Controls - Module 5, p. 20

Slide 41

Module 5 – Infectiousness and Infection Control 41

Ventilation Technologies (4)

Mechanical Ventilation

• Local exhaust ventilation

– Stops airborne contaminants from spreading 

into general environment

– Includes external hoods, booths, and tents

– Should be used for cough-inducing 

procedures

 Review slide content 

Environmental Controls - Module 5, p. 20

Slide 42

Module 5 – Infectiousness and Infection Control 42

• General ventilation systems:

– Dilute contaminated air

– Remove contaminated air

– Control airflow patterns in patient and 

procedure rooms (e.g., negative pressure 

in AII room)

Ventilation Technologies (5)

Mechanical Ventilation

 Review slide content 

Environmental Controls - Module 5, p. 21
182

Slide 43

Module 5 – Infectiousness and Infection Control 43

Ventilation Technologies (6)

Mechanical Ventilation

• AII rooms are designed to 

prevent spread of droplet 

nuclei expelled by patient

– Negative pressure

– Clean air flows from 

corridors into AII room

• Air cannot escape AII

room 

– Exhausted outdoors or 

passed through filter

Image credit: Curry International TB Center

 Explain that in TB clinics, hospitals, and other 

inpatient settings, patients known or 

suspected of having TB disease should be 

placed in an AII room 

 Review slide content 

 Note that air from AII rooms can be 

exhausted outdoors because any infectious 

droplet nuclei will be diluted in the outdoor 

air and killed by sunlight 

Environmental Controls - Module 5, p. 21

Slide 44

Module 5 – Infectiousness and Infection Control 44

HEPA Filters

• HEPA filters are special 

filters used to remove 

droplet nuclei from air

• Must be used when 

releasing air from:

– Local exhaust 

ventilation booths to 

surrounding area

– AII room to general 

ventilation system

Image credit: Curry International TB Center

 Review slide content 

 Use the image to illustrate how air circulates 

through the room 

Environmental Controls - Module 5, p. 21

Slide 45

Module 5 – Infectiousness and Infection Control 45

UVGI

• UVGI is air cleaning 

technology that 

consists of lamps that 

give off UV light, which 

can kill tubercle bacilli

• Should be used with 

other infection control 

measures

• UV light can be harmful 

to skin and eyes

Image credit: Curry International TB Center

 Review slide content 

 State that because UV light can be harmful to 

skin and eyes the lamps must be installed in 

upper part of rooms or corridors or placed in 

exhaust ducts 

Environmental Controls - Module 5, p. 22
183

Slide 46

46

TB Infection Control 

TB Infection Control Measures

Respiratory-Protection Controls

 Introduce section 

 Ask what types of respiratory protection 

controls should be used by the patient and 

the health care worker 

Respiratory-Protection Controls - Module 5, pp. 22-24

Slide 47

Module 5 – Infectiousness and Infection Control 47

• Third level of infection-control that includes:

– Implementing a respiratory-protection 

program

– Training health care workers on respiratoryprotection

– Educating patients on respiratory hygiene

Respiratory-Protection Controls (1)

 Review slide content 

 Note that all health care settings that use 

respiratory-protection controls are required 

by the Occupational Safety and Health 

Administration (OSHA) to develop, 

implement, and maintain a respiratoryprotection program 

 Explain that respiratory-protection controls 

reduce the risk of TB transmission in settings 

where administrative and environmental 

controls may not fully protect persons against 

droplet nuclei 

Respiratory-Protection Controls - Module 5, p. 22

Slide 48

Module 5 – Infectiousness and Infection Control 48

Respiratory-Protection Controls (2) 

Personal Respirators

• Respirators filter out droplet nuclei 

• Should be used in:

– TB AII rooms

– Rooms where cough-inducing or aerosol 

generating procedures are done

– Ambulances transporting infectious TB 

patients

– Homes of infectious TB patients 

 Review slide content 

Respiratory-Protection Controls - Module 5, p. 22
184

Slide 49

Module 5 – Infectiousness and Infection Control 49

Respiratory-Protection Controls (3)

Personal Respirators

• Important that 

respirator fits 

properly:

– Fit test used to 

determine which 

respirator to wear

– User seal check 

should be done 

each time a 

respirator is put on

Health care worker undergoing a fit test

Image credit: Paul Jensen

 Review slide content 

 Emphasize that the most important factor to 

consider when selecting respirator is whether 

the respirator fits properly 

 Explain that the image is of a health care 

worker undergoing a fit test for a personal 

respirator 

Respiratory-Protection Controls - Module 5, p. 23

Slide 50

Module 5 – Infectiousness and Infection Control 50

Respiratory-Protection Controls (4)

Personal Respirators

• Respirators that can be 

used to protect against M. tuberculosis:

– Nonpowered respirators with N95, N99, N100, R95, 

R99, R100, P95, P99, and 

P100 filters

– Powered air-purifying 

respirators (PAPRs) with 

high-efficiency filters

– Supplied-air respirators

Image credit: Greg Knobloch

 Review slide content 

 Explain that the top image shows nonpowered respirators 

 Explain that the bottom image is of a woman 

wearing a powered air-purifying respirator 

(PAPR) 

Respiratory-Protection Controls - Module 5, p. 23

Slide 51

Module 5 – Infectiousness and Infection Control 51

• Important to understand the difference between 

respirators and surgical masks

– Respirators protect individuals from inhaling 

droplet nuclei

– Surgical masks stop droplet nuclei from 

being exhaled into air by infectious TB 

patients or suspects

Respiratory-Protection Controls (5)

Respirators and Surgical Masks

 Review slide content 

 Explain that respirators protect individuals 

from becoming infected with M. tuberculosis

and that surgical masks protect individuals 

from expelling infectious droplet nuclei 

Respiratory-Protection Controls - Module 5, p. 23
185

Slide 52

Module 5 – Infectiousness and Infection Control 52

Health care worker wearing a personal respirator

Respiratory-Protection Controls (6)

Respirators

 Explain that this image is of a health care 

worker wearing a personal respirator 

Respiratory-Protection Controls - Module 5, p. 24

Slide 53

Module 5 – Infectiousness and Infection Control 53

Patient wearing a surgical mask

Respiratory-Protection Controls (7)

Surgical Masks

 Explain that this image is of a patient wearing 

a surgical mask 

 Emphasize that patients should not wear 

respirators because respirators are designed 

to prevent persons from inhaling droplet 

nuclei 

Respiratory-Protection Controls - Module 5, p. 24

Slide 54

Module 5 – Infectiousness and Infection Control 54

What are the three levels of control that form 

the basis of a TB infection-control program?

• Administrative controls

• Environmental controls

• Respiratory-protection controls

TB Infection-Control

Study Question 5.9

 Introduce study questions 

 Ask participants to turn to p. 26 (if 

participants have print-based modules) 

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 38
186

Slide 55

Module 5 – Infectiousness and Infection Control 55

Administrative Controls

Study Question 5.10

List 5 administrative control measures that 

should be taken in health care settings to reduce 

the risk of exposure to persons who may have TB 

disease.

• Assign responsibility for TB infection control

• Conduct TB risk assessment

• Develop and implement a written TB infection-control plan

• Ensure prompt availability of recommended laboratory processing, 

testing, and reporting of results

• Implement effective work practices for the management of patients 

• Ensure proper cleaning, sterilization, or disinfection of equipment

• Train and educate health care workers

• Test and evaluate health care workers for TB

• Apply epidemiology-based prevention principles

• Use posters and signs educating and advising respiratory hygiene and 

cough etiquette

• Coordinate efforts with health department and high-risk health care and 

congregate settings

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 39

Slide 56

Module 5 – Infectiousness and Infection Control 56

Where should sputum induction, 

bronchoscopy, or other cough-inducing 

procedures be done?

These medical procedures should be done 

in special AII rooms or sputum induction 

booths to prevent any droplet nuclei 

expelled during the procedure from 

reaching other parts of the facility.

Environmental Controls

Study Question 5.11

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 39

Slide 57

Module 5 – Infectiousness and Infection Control 57

Environmental Controls

Study Question 5.12

What is a TB AII room? What are the 

important characteristics of an AII room?

Airborne infection isolation (AII) rooms 

have special characteristics to prevent 

spread of droplet nuclei expelled by a TB 

patient. They are at negative pressure 

relative to other parts of the facility, and air 

from the room is exhausted directly to the 

outdoors or passed through a filter.

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 39
187

Slide 58

Module 5 – Infectiousness and Infection Control 58

How do ventilation systems help prevent the 

spread of TB? 

Ventilation systems maintain negative 

pressure and exhaust air properly. These 

systems can also be designed to minimize 

the spread of TB in other areas of the 

facility. 

Ventilation Systems 

Study Question 5.13

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 40

Slide 59

Module 5 – Infectiousness and Infection Control 59

Ventilation Systems 

Study Question 5.14

Give 4 examples of settings where personal 

respirators should be used. 

• TB AII rooms

• Rooms where cough-inducing procedures 

are done

• Ambulances or other vehicles transporting 

infectious TB patients

• Homes of infectious TB patients

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 40

Slide 60

Module 5 – Infectiousness and Infection Control 60

What is the difference in use between a 

respirator and a surgical mask?

• Respirators protect individuals from 

inhaling droplet nuclei 

• Surgical masks stop droplet nuclei from 

being exhaled into the air by the person 

wearing them 

Respiratory Protection-Controls

Study Question 5.15

 Read question 

 Ask participants for answers

Answers - Module 5, p. 40
188

Slide 61

61

TB Infection Control 

TB Risk Assessment

 Introduce section 

TB Risk Assessment - Module 5, pp. 28-30

Slide 62

Module 5 – Infectiousness and Infection Control 62

TB Risk Assessment (1)

• Administrative control measure

• Helps to inform infection control plan

• Determines types of controls needed for 

setting

• Serves as an initial and ongoing monitoring 

and evaluation tool for infection-control 

program

• Helps determine frequency of employee 

testing

 Explain that every health care and congregate 

setting should conduct initial and ongoing 

evaluations of the risk for transmission of M. 

tuberculosis

 Review slide content 

TB Risk Assessment - Module 5, p. 28

Slide 63

Module 5 – Infectiousness and Infection Control 63

• Risk assessment examines many factors, 

including:

– Number of patients with TB disease in setting

– Promptness of detection, isolation, and 

evaluation of patients with suspected or 

confirmed TB

– Evidence of transmission of M. tuberculosis

in setting

– Community rate of TB disease

TB Risk Assessment (2)

 Review slide content 

TB Risk Assessment - Module 5, p. 28
189

Slide 64

Module 5 – Infectiousness and Infection Control 64

• Low risk

– Persons with TB disease are not expected to be 

encountered

• Medium risk

– Possible exposure to persons with TB disease

– Possible exposure to clinical TB specimens

• Potential ongoing transmission

– Setting where there is evidence of person-to-person 

transmission of M. tuberculosis in past year

TB Risk Classification

 Explain that the risk level will vary from 

setting to setting. There are three TB risk 

classifications 

 Review slide content 

TB Risk Assessment - Module 5, p. 28

Slide 65

Module 5 – Infectiousness and Infection Control 65

TB Risk Classification Frequency for TB Testing

Low Risk

• Conduct baseline test when health

care worker is hired

• No further testing needed unless

exposure occurs

Medium Risk

• Conduct baseline test when

health care worker is hired

• Repeat test annually

Potential Ongoing 

Transmission

• Conduct baseline test when health

care worker is hired

• Repeat test every 8 to 10 weeks 

until there is no evidence of M. 

tuberculosis transmission in 

setting

TB Testing Frequency

 Explain that TB risk assessment helps to 

determine the need for a TB testing program 

and the frequency of the testing 

 Review slide content 

TB Risk Assessment - Module 5, p. 30

Slide 66

66

TB Infection Control 

Infection Control in 

Nontraditional 

Facility–Based Settings

 Introduce section 

Infection Control in Nontraditional Facility-Based Settings 

- Module 5, pp. 30-32
190

Slide 67

Module 5 – Infectiousness and Infection Control 67

• Nontraditional facility-based settings where TB 

patients receive care should establish and 

follow an infection-control program

• Includes settings such as:

– Nursing homes

– Correctional facilities

– Homeless shelters

– Drug treatment centers

– Emergency medical services

– Home-based health care

– Outreach settings

Special Considerations (1)

 Review slide content 

 Explain that the main goal should be to detect 

TB disease early and arrange for isolation and 

treatment of patients suspected of having TB 

 Local health departments and congregate 

settings should collaborate to provide training 

and education about TB as well as conducting 

contact investigations when necessary 

Infection Control in Nontraditional Facility-Based Settings 

- Module 5, p. 30

Slide 68

Module 5 – Infectiousness and Infection Control 68

• Medical settings within correctional facilities 

should:

– Classify as medium risk or higher

– Test all staff annually

– Implement a respiratory-protection program 

with at least one AII room

Special Considerations (2)

Correctional Facilities

 Review slide content 

Infection Control in Nontraditional Facility-Based Settings 

- Module 5, pp. 30-31

Slide 69

Module 5 – Infectiousness and Infection Control 69

• Medical settings within correctional facilities 

should (cont.):

– Have inmates with suspected or confirmed TB 

disease wear surgical mask when transported

– Establish and maintain a tracking system for 

inmate testing and treatment

Special Considerations (3)

Correctional Facilities

 Review slide content 

 State that confidentiality of inmate 

information should be ensured during testing 

for signs and symptoms of TB 

Infection Control in Nontraditional Facility-Based Settings 

- Module 5, p. 31
191

Slide 70

Module 5 – Infectiousness and Infection Control 70

• Should observe the same TB infectioncontrol measures as outpatient clinics

• Several factors in shelter environment can 

influence likelihood of TB transmission:

– Crowdedness of shelter

– Ventilation system of shelter

Special Considerations (4)

Homeless Shelters

 Explain that TB is more common in the 

homeless population than the general 

population 

 Review slide content 

Infection Control in Nontraditional Facility-Based Settings 

- Module 5, p. 31

Slide 71

Module 5 – Infectiousness and Infection Control 71

• EMS workers should be included in TB testing 

program based on risk for the setting

• Persons with infectious TB who are transported 

in ambulance should wear surgical mask

• Drivers, health care workers, and other staff 

should consider wearing a respirator

• Ambulance should allow for maximum amount 

of outdoor air to be circulated in vehicle

Special Considerations (5)

Emergency Medical Services (EMS)

 Explain that even though the overall risk of 

transmission of M. tuberculosis in EMS 

settings is low, there has been documented 

transmission 

 Review slide content 

Infection Control in Nontraditional Facility-Based Settings 

- Module 5, p. 31

Slide 72

Module 5 – Infectiousness and Infection Control 72

• LTCFs (e.g., hospices and nursing homes) 

should:

– Symptom screen and possibly test new 

employees and residents

– Have administrative and environmental 

controls IF they accept patients with 

infectious TB

• Persons with TB disease who are noninfectious can stay in LTCFs and do not need 

AII room

Special Considerations (6)

Long-Term Care Facilities (LTCFs)

 Review slide content 

 Emphasize that patients with suspected or 

confirmed infectious TB disease should not 

stay in a long-term care facility unless 

adequate administrative and environmental 

controls are in place 

Infection Control in Nontraditional Facility-Based Settings 

- Module 5, p. 32
192

Slide 73

73

TB Infection Control 

TB Infection Control in the Home

 Introduce section 

 Ask what type of TB infection control should 

be used in the home for the family and for 

the health care worker 

TB Infection Control in the Home - Module 5, pp. 32-33

Slide 74

Module 5 – Infectiousness and Infection Control 74

TB Infection Control in the Home (1)

Patient Returning Home

TB patients and TB suspects may be sent 

home after starting treatment, even though 

they may be infectious

 Review slide content 

TB Infection Control in the Home - Module 5, p. 32

Slide 75

Module 5 – Infectiousness and Infection Control 75

TB Infection Control in the Home (2) 

Patient Returning Home

• Criteria for patient to return home:

– Follow-up plan has been made with the 

local TB program

– Patient on TB treatment and DOT arranged

– No infants or children younger than 5 years 

of age or persons with 

immunocompromising conditions in home

 Explain that TB patients can return home

even if they do not have three negative 

sputum smears, if certain criteria are met 

 Explain that patients with TB disease are 

allowed to go back home if all of the criteria 

are met 

 Review slide content 

TB Infection Control in the Home - Module 5, p. 32
193

Slide 76

Module 5 – Infectiousness and Infection Control 76

• Criteria for patient to return home (cont.):

– All household members have already been 

exposed to TB patient

– Patient is willing to not travel outside of 

home until sputum smear results are 

negative

TB Infection Control in the Home (3) 

Patient Returning Home

 Review slide content 

TB Infection Control in the Home - Module 5, p. 32

Slide 77

Module 5 – Infectiousness and Infection Control 77

• TB patients and members of household 

should take steps to prevent spread of TB

• Patients with TB should be instructed to:

– Cover mouth and nose with tissue when 

coughing or sneezing

– Sleep alone

– Not have visitors until noninfectious

TB Infection Control in the Home (4) 

Patient Returning Home

 Review slide content 

 Note that it is more likely that TB patients 

transmitted TB to members of their 

household before their TB was diagnosed and 

TB started; however, steps should still be 

taken to prevent the spread of TB in the 

home when the patient returns 

TB Infection Control in the Home - Module 5, p. 32

Slide 78

Module 5 – Infectiousness and Infection Control 78

• HCWs should:

– Be trained in detecting TB signs and symptoms

– Take precautions to protect themselves:

• Instruct patient to cover mouth when coughing

• Wear personal respirator

• Collect sputum in well-ventilated areas

• Participate in TB testing and prevention programs

TB Infection Control in the Home (5)

Health Care Workers (HCWs)

 Review slide content 

TB Infection Control in the Home - Module 5, p. 33
194

Slide 79

Module 5 – Infectiousness and Infection Control 79

TB Risk Assessment

Study Question 5.16

What are 3 different TB risk classifications 

that can be assigned to health care settings?

• Low risk

• Medium risk

• Potential ongoing transmission

 Introduce study questions 

 Ask participants to turn to p. 34 (if 

participants have print-based modules) 

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 40

Slide 80

Module 5 – Infectiousness and Infection Control 80

Depending on risk classification, how often 

should health care settings test workers for TB? 

• Low Risk Settings

– Conduct TB baseline test when HCW is hired

– No further testing needed unless exposure occurs 

• Medium Risk Settings

– Conduct TB baseline test when HCW is hired

– Repeat test annually

• Potential Ongoing Transmission

– Conduct baseline test when HCW is hired

– Repeat test 8-10 weeks until there is no longer evidence of M. 

tuberculosis transmission in the setting

TB Risk Assessment

Study Question 5.17

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 41

Slide 81

Module 5 – Infectiousness and Infection Control 81

TB Infection Control in the Home

Study Question 5.18

What precautions should a health care worker take when visiting the home of a TB 

patient who may be infectious?

• Instruct patients to cover mouth and nose with a 

tissue when coughing or sneezing

• Wear a personal respirator

• Collect sputum specimen in a well-ventilated 

area

• Participate in a TB testing and prevention 

program

 Read question 

 Ask participants for answers 

Answers - Module 5, p. 41
195

Slide 82

82

Case Studies

 Introduce case studies 

Slide 83

Module 5 – Infectiousness and Infection Control 83

Module 5: Case Study 5.1

For each of the following situations, decide 

whether the patient should be considered 

infectious or non-infectious, and explain why.

 Read case study 

 Ask participants for answers

Case Study 5.1 – Module 5, p. 7

Slide 84

Module 5 – Infectiousness and Infection Control 84

Two weeks ago, Mr. Lopez had a sputum 

smear that was positive; since then no 

sputum specimens have been tested. Mr. 

Lopez started self-administered TB treatment 

7 days ago. He still has a cough.

Module 5: Case Study 5.1

Question 5A

 Ask participants to turn to p. 7 (if participants 

have print-based modules) 

 Read case study 

 Ask participants for answers

Case Study 5.1 – Module 5, p. 7
196

Slide 85

Module 5 – Infectiousness and Infection Control 85

Module 5: Case Study 5.1

Question 5A: Answer

• Mr. Lopez should be considered infectious

• Should be given his treatment by DOT to 

ensure he receives adequate treatment

• Does not meet the criteria for 

noninfectiousness because:

– He has been receiving treatment for only 7 days, 

not 2 weeks

– His symptoms have not improved

– He does not have 3 consecutive negative sputum 

smears

Answers - Module 5, p. 42

Slide 86

Module 5 – Infectiousness and Infection Control 86

Module 5: Case Study 5.1

Question 5B

Ms. Nguyen, a patient with pulmonary TB, 

has been receiving DOT treatment for 6 

weeks and no longer has symptoms of TB. 

She has had three sputum smears. The first 

one was positive, but the last two were 

negative.

 Read case study question

 Ask participants for answers 

Case Study 5.1 – Module 5, p. 7

Slide 87

Module 5 – Infectiousness and Infection Control 87

Module 5: Case Study 5.1

Question 5B: Answer

• Ms. Nguyen should be considered infectious 

until she has 3 consecutive negative sputum 

smears

• She meets the first 2 criteria for 

noninfectiousness:

– Has been receiving treatment for at least 2 

weeks

– Her symptoms have improved

Answers - Module 5, p. 42
197

Slide 88

Module 5 – Infectiousness and Infection Control 88

Module 5: Case Study 5.1

Question 5C

Mr. Martin started DOT treatment for 

pulmonary TB in April. His symptoms went 

away and his sputum smears were negative 

in May. However, the outreach worker was 

unable to locate him on June 5th and has not 

been able to contact him since that time. Mr. 

Martin returned to the TB clinic on August 

2nd, and was still coughing.

 Read case study question

 Ask participants for answers 

Case Study 5.1 – Module 5, p. 7

Slide 89

Module 5 – Infectiousness and Infection Control 89

Module 5: Case Study 5.1

Question 5C: Answer

• Mr. Martin, at this point, should be 

considered infectious

• He might have been noninfectious in May, 

but it appears that he may be infectious 

again

– Has been coughing and has not received 

adequate treatment since June 4th

• Should be evaluated for infectiousness and 

nonadherence to treatment

Answers - Module 5, p. 42

Slide 90

Module 5 – Infectiousness and Infection Control 90

Module 5: Case Study 5.2 (1)

You are checking patients into the TB clinic. 

An elderly man comes to the desk and says 

he was told to come and get checked 

because one of his friends has TB. You 

notice that he looks sick and is coughing 

frequently. The waiting room is full of 

patients, and you know it will probably be 

more than an hour before the physician can 

see him.

 Ask participants to turn to p. 15 (if 

participants have print-based module)

 Read case study

Case Study 5.2 – Module 5, p. 15
198

Slide 91

Module 5 – Infectiousness and Infection Control 91

Module 5: Case Study 5.2 (2)

• What should you do?

– Suspect that this man has infectious TB 

and work with clinical staff to ensure he is 

evaluated for TB quickly

– Give him a surgical mask, instruct him to 

keep it on, and ask him to cover his mouth 

and nose when coughing or sneezing. 

– Move the man to an area away from other 

patients right away

 Read case study question 

 Ask participants for answers

Answers - Module 5, p. 43

Slide 92

Module 5 – Infectiousness and Infection Control 92

Module 5: Case Study 5.3 (1)

You are sent to deliver directly observed 

therapy (DOT) to a woman who started 

treatment last week for suspected pulmonary 

TB. Her sputum smear results are not back 

yet. You are asked to collect another sputum 

specimen while you are at the woman’s 

home.

 Ask participants to turn to p. 35 (if 

participants have print-based modules)

 Read case study

Case Study 5.3 – Module 5, p. 35

Slide 93

Module 5 – Infectiousness and Infection Control 93

Module 5: Case Study 5.3 (2)

• What precautions should you take?

• Instruct patient to cover her mouth and 

nose when she coughs or sneezes. 

• Wear a personal respirator when visiting 

her home. 

• Collect sputum in well-ventilated area, 

away from other household members. 

• Participate in a TB testing and 

prevention program

 Read case study question 

 Ask participants for answers

 Ask if there are any questions about Module 

5

Answers - Module 5, p. 43
199

Self-Study Modules on 

Tuberculosis, 1-5 Slide Sets

Sample Course Evaluation
200
201

Self-Study Modules on Tuberculosis, 1-5 Course Evaluation 

Thank you for participating in this training. Please complete this evaluation form to the best of 

your ability. In this evaluation form, there are no wrong or right answers. You do not need to 

put your name on this form – your responses will be anonymous. 

For each item below, please circle one response. 

Strongly

Disagree Disagree Neutral Agree Strongly Agree

1. The training was well 

organized 1 2 3 4 5

2. The training sessions were 

relevant to my needs 1 2 3 4 5

3. The presenters were well 

prepared 1 2 3 4 5

4. The presenters were 

receptive to participant 

comments

1 2 3 4 5

5. The study questions helped 

me learn the material 1 2 3 4 5

6. The case studies helped me 

learn the material 1 2 3 4 5

7. There was enough time to 

cover all the material 1 2 3 4 5

8. The training enhanced my 

knowledge in TB 1 2 3 4 5

9. The learning environment 

was conducive to learning 1 2 3 4 5

10. The course was consistent 

with the stated objectives 1 2 3 4 5

 

OVER 
202

11. What did you like best about this course? 

12. What did you like least about this course? 

13. What topics would you like MORE emphasis on? 

14. What topics would you like LESS emphasis on? 

15. Additional Comments: 

Thank you for completing this form! 
CS253781-H