Tuberculosis primary prevention: Difference between revisions

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==Overview==
==Overview==
Many countries use [[Bacillus Calmette-Guérin|BCG]] vaccine as part of their TB control programs, especially for infants. This was the first vaccine for TB and developed at the [[Pasteur Institute]] in France between 1905 and 1921.<ref name=Bonah>{{cite journal |author=Bonah C |title=The 'experimental stable' of the BCG vaccine: safety, efficacy, proof, and standards, 1921–1933 |journal=Stud Hist Philos Biol Biomed Sci |volume=36 |issue=4 |pages=696–721 |year=2005 | pmid = 16337557}}</ref> However, mass vaccination with BCG did not start until after World War II.<ref name=Comstock>{{cite journal |author=Comstock G |title=The International Tuberculosis Campaign: a pioneering venture in mass vaccination and research |journal=Clin Infect Dis |volume=19 |issue=3 |pages=528-40 |year=1994 | pmid = 7811874}}</ref> The protective efficacy of BCG for preventing serious forms of TB (e.g. [[meningitis]]) in children is greater than 80%; its protective efficacy for preventing pulmonary TB in adolescents and adults is variable, ranging from 0 to 80%.<ref name=Bannon_1999>{{cite journal |author=Bannon M |title=BCG and tuberculosis |journal=Arch Dis Child |volume=80 |issue=1 |pages=80-3 |year=1999 | pmid = 10325767}}</ref>
Primary prevention in [[tuberculosis]] is necessary to avoid the disease transmission and causing infection in healthy people.  The [[BCG]] vaccine is given to children who are predisposed to get [[TB]] infections, such as children living in [[Endemic (epidemiology)|endemic]] countries or close contacts with a confirmed case of [[TB]]. Several preventive measures are adopted to avoid the transmission of the [[mycobacteria]] [[tuberculosis]], such as [[respiratory isolation]], use of respiratory [[masks]] among health-care workers, and emphasizing respiratory hygiene and [[cough]] etiquette.


== Primary Prevention ==
==Primary Prevention==
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===BCG Vaccine===
In South Africa, the country with the highest prevalence of TB, BCG is given to all children under the age of three.<ref>[http://web.archive.org/web/20070630073246/http://www.who.int/immunization_monitoring/data/south_africa.pdf WHO/UNICEF Review of National Immunization Coverage 1980–2005: South Africa] (PDF). World Health Organization (August 2006).  Retrieved on 2007-06-08.</ref> However, the effectiveness of BCG is lower in areas where mycobacteria are less [[prevalence|prevalent]], therefore BCG is not given to the entire population in these countries. In the USA, for example, BCG vaccine is not recommended except for people who meet specific criteria:
*Infants or children with negative skin-test results who are continually exposed to untreated or ineffectively treated patients or will be continually exposed to [[Multidrug resistance|multidrug-resistant]] TB.
*Healthcare workers considered on an individual basis in settings in which a high percentage of MDR-TB patients has been found, transmission of MDR-TB is likely, and TB control precautions have been implemented and were not successful.


Several new vaccines to prevent TB infection are being developed. The first recombinant tuberculosis [[vaccine]] entered [[clinical trial]]s in the United States in 2004, sponsored by the [[National Institute of Allergy and Infectious Diseases]] (NIAID).<ref>[[National Institute of Allergy and Infectious Diseases]] (NIAID).[http://www.nih.gov/news/pr/jan2004/niaid-26.htm First U.S. Tuberculosis Vaccine Trial in 60 Years Begins.] ''National Institutes of Health News'' 26 January 2004. Retrieved on 19 October 2007.</ref> A 2005 study showed that a [[DNA vaccine|DNA TB vaccine]] given with conventional [[chemotherapy]] can accelerate the disappearance of bacteria as well as protect against re-infection in mice; it may take four to five years to be available in humans.<ref name=Ha_2005>{{cite journal |author=Ha S, Jeon B, Youn J, Kim S, Cho S, Sung Y |title=Protective effect of DNA vaccine during chemotherapy on reactivation and reinfection of Mycobacterium tuberculosis |journal=Gene Ther |volume=12 |issue=7 |pages=634-8 |year=2005 | pmid = 15690060}}</ref> A very promising TB vaccine, [[MVA85A]], is currently in [[clinical trial|phase II trials]] in South Africa by a group led by Oxford University,<ref name=Ibanga_2006>{{cite journal |author=Ibanga H, Brookes R, Hill P, Owiafe P, Fletcher H, Lienhardt C, Hill A, Adegbola R, McShane H |title=Early clinical trials with a new tuberculosis vaccine, MVA85A, in tuberculosis-endemic countries: issues in study design |journal=Lancet Infect Dis |volume=6 |issue=8 |pages=522-8 |year=2006 |url=http://linkinghub.elsevier.com/retrieve/pii/S1473309906705527| pmid = 16870530}}</ref> and is based on a genetically modified [[vaccinia]] virus. Because of the limitations of current vaccines, researchers and policymakers are promoting new economic models of vaccine development including prizes, tax incentives and [[advance market commitments]].<ref>Webber, David and Kremer, Michael. [http://www.who.int/bulletin/archives/79(8)735.pdf Stimulating Industrial R&D for Neglected Infectious Diseases: Economic Perspectives (PDF).] ''Bulletin of the World Health Organization'' 79(8), 2001, pp. 693–801.</ref><ref>Barder, Owen; Kremer, Michael; Williams, Heidi.  [http://www.bepress.com/ev/vol3/iss3/art1 "Advance Market Commitments: A Policy to Stimulate Investment in Vaccines for Neglected Diseases,"] ''The Economists' Voice'', Vol. 3 (2006) Issue 3.</ref>
*[[Bacille Calmmette-Guerin|Bacille Calmette-Guerin]] ([[Bacille Calmmette-Guerin|BCG]]) is a live attenuated vaccine derived from [[M. bovis]] used for the [[vaccination]] against [[M. tuberculosis]].
*[[Bacille Calmmette-Guerin|BCG vaccination]] is highly recommended for each infant who is living in an endemic area of TB or who is at high risk of getting [[Tuberculosis|TB]] [[infection]] due to exposure to TB. <ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}} </ref>
*The [[BCG]] [[vaccine]] is effective and can protect against severe types of [[tuberculosis]] infections including [[miliary TB|miliary]] or [[tuberculous meningitis|meningeal tuberculosis]].
*[[BCG vaccine]] is not recommended for [[Human Immunodeficiency Virus (HIV)|HIV]] positive children; however, children with unknown [[HIV]] status and born to [[HIV]] positive women, have to be be vaccinated. <ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}} </ref>
*There is no established value of the [[vaccine]] for patients who have been infected by tuberculosis.<ref name="RoyEisenhut2014">{{cite journal|last1=Roy|first1=A.|last2=Eisenhut|first2=M.|last3=Harris|first3=R. J.|last4=Rodrigues|first4=L. C.|last5=Sridhar|first5=S.|last6=Habermann|first6=S.|last7=Snell|first7=L.|last8=Mangtani|first8=P.|last9=Adetifa|first9=I.|last10=Lalvani|first10=A.|last11=Abubakar|first11=I.|title=Effect of BCG vaccination against Mycobacterium tuberculosis infection in children: systematic review and meta-analysis|journal=BMJ|volume=349|issue=aug04 5|year=2014|pages=g4643–g4643|issn=1756-1833|doi=10.1136/bmj.g4643}}</ref>
*[[BCG]] vaccination should be given to [[health care workers]] in any of the following conditions:<ref name="CDC Vaccines"> {{cite web| url=http://www.cdc.gov/tb/publications/factsheets/prevention/BCG.htm| title=CDC Tuberculosis Fact Sheets Vaccines and Immunizayions}}</ref>
 
:*TB patients have been infected with TB  strains resistant to both [[isoniazid]] and [[rifampin]]
:*Ongoing [[Transmission (medicine)|transmission]] of [[drug-resistant TB|multi-drug resistant TB]] strains to health care workers
:*Failure of the implemented [[Tuberculosis|TB]] [[infection-control]] [[precautions]]
 
{| style="border: 0px; font-size: 90%; margin: 3px; width: 550px;" align="center"
| valign="top" |
|+
! colspan="2" style="background: #4479BA; width: 150px;" |{{fontcolor|#FFF|Contraindications for BCG}}
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |[[Immunosuppression]]
| style="padding: 5px 5px; background: #F5F5F5; width: 400px" |[[Bacille Calmmette-Guerin|BCG vaccination]] should not be given to [[immunosuppressed]] individuals (e.g., persons who are [[HIV]] infected) or who may become [[immunocompromised]] (e.g., candidates for [[organ transplant]]).
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |[[Pregnancy]]
| style="padding: 5px 5px; background: #F5F5F5;" |[[Bacille Calmmette-Guerin|BCG vaccination]] should not be given during pregnancy. Although no harmful effects of [[Bacillus Calmmette-Guerin|BCG vaccination]] on the fetus have been noticed, further studies are required to establish its safety.
|-
| colspan="2" style="padding: 5px 5px; background: #F5F5F5;" |<small>Adapted from CDC <ref name="CDC Vaccines"> {{cite web| url=http://www.cdc.gov/tb/publications/factsheets/prevention/BCG.htm| title=CDC Tuberculosis Fact Sheets Vaccines and Immunizayions}}</ref></small>
 
|}
 
===Prevention for International Travelers===
 
*Travelers must avoid prolonged close contact with known TB patients in crowded or enclosed places.
*Travelers who anticipate probable prolonged exposure to TB, such as medical staff, people in prison, or homeless shelter populations must have a [[tuberculin skin test]] ([[TST]])  or [[interferon-gamma release assay]] ([[Interferon-γ release assays|IGRA]]) test before leaving the U.S. <ref> {{cite web| url=http://www.cdc.gov/TB/topic/infectioncontrol/default.htm| title= CDC Tuberculosis Infection Control and Prevention}} </ref>
 
===Prevention in Health-Care Settings===
 
*Confirmed cases of TB during hospitalization must fulfill the following recommendations:<ref name="CDC Prevention"> {{cite web | title=Guidelines for Preventing the Transmission of M. tuberculosis in Health-Care Settings, 2005| url=http://www.cdc.gov/tb/publications/slidesets/infectionguidelines/airborne.htm}} </ref>
 
:*Single-patient room with private bathroom.
:*Healthcare workers and visitors should wear disposable respirators (at least N95).
:*Doors should be closed as much time as possible.
:*Adequate room ventilation or negative pressure.
 
===Determining the Infectiousness of TB Patients===
 
{| style="border: 0px; font-size: 90%; margin: 3px; width: 600px;" align="center"
| valign="top" |
|+
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Airborne Precautions}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |Patients who have suspected or confirmed TB disease should be considered infectious if they have the following characteristics:
 
*They are coughing, undergoing cough-inducing procedures, or have positive sputum smear results for [[acid-fast bacilli]] (AFB); and
*They are not receiving adequate [[antituberculosis treatment]], have just started treatment, or have a poor clinical or bacteriologic therapeutic response.
|-
| style=" padding: 5px 5px; background: #F5F5F5;" |[[Airborne]] precautions can be discontinued when infectious TB disease is considered unlikely and either another diagnosis explaining the clinical manifestations is established or the patient produces three consecutive negative sputum smears collected in 8 to 24-hour intervals.
 
|-
| style="padding: 5px 5px; background: #DCDCDC;" |If infectious TB is still suspected even after the collection of three negative sputum smear results, patients should not be released from airborne precautions until they receive standard [[multidrug antituberculosis]] therapy (minimum of 2 weeks) and show clinical improvement.
|-
| style="padding: 5px 5px; background: #F5F5F5;" |Patients who have [[drug-susceptible]] TB should remain under airborne precautions until they meet all of the following:
 
*Produce 3 consecutive negative sputum smears collected in 8 to 24-hour intervals.
*Receive standard multidrug antituberculosis treatment (minimum of 2 weeks period).
*Demonstrate clinical improvement.
|-
| style="padding: 5px 5px; background: #DCDCDC;" |<small> Adapted from CDC TB Infection Control in Health-Care Settings<ref>{{cite web| title=CDC Tuberculosis Infection Control in Health-Care Settings| url=http://www.cdc.gov/tb/publications/factsheets/prevention/ichcs.htm}}</ref></small>
 
|}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}


[[Category:Disease]]
[[Category:Disease]]
[[Category:Infectious disease]]
[[Category: Pulmonology]]
[[Category:Pulmonology]]
[[Category:Primary care]]
[[Category:Bacterial diseases]]
[[Category:Bacterial diseases]]
{{WH}}
{{WS}}

Latest revision as of 04:49, 27 March 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mashal Awais, M.D.[2]; Alejandro Lemor, M.D. [3]

Overview

Primary prevention in tuberculosis is necessary to avoid the disease transmission and causing infection in healthy people. The BCG vaccine is given to children who are predisposed to get TB infections, such as children living in endemic countries or close contacts with a confirmed case of TB. Several preventive measures are adopted to avoid the transmission of the mycobacteria tuberculosis, such as respiratory isolation, use of respiratory masks among health-care workers, and emphasizing respiratory hygiene and cough etiquette.

Primary Prevention

BCG Vaccine
Contraindications for BCG
Immunosuppression BCG vaccination should not be given to immunosuppressed individuals (e.g., persons who are HIV infected) or who may become immunocompromised (e.g., candidates for organ transplant).
Pregnancy BCG vaccination should not be given during pregnancy. Although no harmful effects of BCG vaccination on the fetus have been noticed, further studies are required to establish its safety.
Adapted from CDC [3]

Prevention for International Travelers

  • Travelers must avoid prolonged close contact with known TB patients in crowded or enclosed places.
  • Travelers who anticipate probable prolonged exposure to TB, such as medical staff, people in prison, or homeless shelter populations must have a tuberculin skin test (TST) or interferon-gamma release assay (IGRA) test before leaving the U.S. [4]

Prevention in Health-Care Settings

  • Confirmed cases of TB during hospitalization must fulfill the following recommendations:[5]
  • Single-patient room with private bathroom.
  • Healthcare workers and visitors should wear disposable respirators (at least N95).
  • Doors should be closed as much time as possible.
  • Adequate room ventilation or negative pressure.

Determining the Infectiousness of TB Patients
Airborne Precautions
Patients who have suspected or confirmed TB disease should be considered infectious if they have the following characteristics:
  • They are coughing, undergoing cough-inducing procedures, or have positive sputum smear results for acid-fast bacilli (AFB); and
  • They are not receiving adequate antituberculosis treatment, have just started treatment, or have a poor clinical or bacteriologic therapeutic response.
Airborne precautions can be discontinued when infectious TB disease is considered unlikely and either another diagnosis explaining the clinical manifestations is established or the patient produces three consecutive negative sputum smears collected in 8 to 24-hour intervals.
If infectious TB is still suspected even after the collection of three negative sputum smear results, patients should not be released from airborne precautions until they receive standard multidrug antituberculosis therapy (minimum of 2 weeks) and show clinical improvement.
Patients who have drug-susceptible TB should remain under airborne precautions until they meet all of the following:
  • Produce 3 consecutive negative sputum smears collected in 8 to 24-hour intervals.
  • Receive standard multidrug antituberculosis treatment (minimum of 2 weeks period).
  • Demonstrate clinical improvement.
Adapted from CDC TB Infection Control in Health-Care Settings[6]

References

  1. ↑ 1.0 1.1 "WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014" (PDF).
  2. ↑ Roy, A.; Eisenhut, M.; Harris, R. J.; Rodrigues, L. C.; Sridhar, S.; Habermann, S.; Snell, L.; Mangtani, P.; Adetifa, I.; Lalvani, A.; Abubakar, I. (2014). "Effect of BCG vaccination against Mycobacterium tuberculosis infection in children: systematic review and meta-analysis". BMJ. 349 (aug04 5): g4643–g4643. doi:10.1136/bmj.g4643. ISSN 1756-1833.
  3. ↑ 3.0 3.1 "CDC Tuberculosis Fact Sheets Vaccines and Immunizayions".
  4. ↑ "CDC Tuberculosis Infection Control and Prevention".
  5. ↑ "Guidelines for Preventing the Transmission of M. tuberculosis in Health-Care Settings, 2005".
  6. ↑ "CDC Tuberculosis Infection Control in Health-Care Settings".

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