PROVIDER ALERT and FAQ
Introduction
An infant in your care has been identified as a contact to a person with infectious TB disease while the infant was in the NICU at <facility name here>.The person with TB disease was not diagnosed until after the time visiting the NICU.
The <health department name>has been working to assure a full and complete contact investigation is conducted. In addition health department name> has been in close contact with pediatric TB experts at the <associated RTMCC and/or and the Centers for Disease Control and Prevention (CDC)for consultation and suggested courses of investigation, testing, diagnosis and treatment of the patient and all potential contacts.
As we have now been able to identify a patient of yours as a contact, we are seeking your assistance and cooperation in the ongoing investigation, diagnosis and possible treatment of this infant.
I.TUBERCULOSIS (TB) IN INFANTS AND YOUNG CHILDREN
How is TB in infants and young children different than in adults?
If infected, infants and young children are more likely than adults to develop active TB disease, possibly progressing to active TB in a matter of weeks or months. In addition, the presentation of TB in children is often distinctly different than that in adults. Young children suffer more extrapulmonary and disseminated TB than adults. Very young children are at particular risk of acute hematogenous dissemination (miliary disease) and meningitis. Children frequently have more subtle and modest symptoms when diagnosed with TB.
How is TB diagnosed in infants and young children?
As in adults, TB is diagnosed on the basis of history, physical examination, and chest radiograph. However, diagnosis in children is challenging, as many may have no symptoms. Approximately 30–60% of children diagnosed with active TB in the United States have no symptoms reported by the parent at the time of diagnosis. Sometimes, poor weight gain may be the only finding of active TB.
Frontal and lateral chest radiographs are recommended by experts for the evaluation of children suspected of having intrathoracic TB. Adenopathy is seen frequently in young children with TB and is reported to be present in 85% of children less than 3 years of age. Because radiologic findings for TB in children can be different from those commonly seen in adults, it is important that radiographs be interpreted by someone experienced in the interpretation of pediatric radiographs.
Bacteriologic confirmation of TB disease in infants and young children is often challenging because of the difficulty in obtaining a specimen for mycobacterial culture. Unless a child is able to produce sputum, gastric aspiration provides the best clinical specimen and is fairly noninvasive.
What signs and symptoms of TB disease should I look for in infants and young children?
In infants, common clinical manifestations of TB are nonspecific and include respiratory symptoms (cough and increased work of breathing), fever, hepatic and/or splenic enlargement, poor feeding, irritability, lethargy, lymphadenopathy, skin lesions (papulopustular, necrotic, atrophic), and ear discharge.
Symptoms in children include cough, fever, and weight loss or failure to thrive. Miliary or acute disseminated TB may cause additional nonspecific symptoms such as fatigue, anorexia, vomiting, and diarrhea.
II. TESTING AND DECISION TO TREAT INFANTS EXPOSED IN NEONATAL INTENSIVE CARE UNIT
Can I manage the testing and treatment of my patient independent of the health department?
Collaboration with<health department name> is requested for three reasons:
1)TB testing and treatment in infants requires expertise and knowledge to ensure the best results. health department name> is consulting with pediatric TB experts to ensure the most appropriate care is provided to infants exposed to TB in the NICU. We are obtaining expert advice for testing recommendations, clinical guidelines for TB infection, clinical guidelines for treatment of TB disease, and recommendations for how to monitor treatment.
2)For best results, treatment should be given under direct observation to ensure adherence and close monitoring. Providing this level of care is generally beyond the capacity of non-public health practitioners.
3)health department name> needs to track outcomes of contacts to determine the scope of transmission resulting from this exposure and make decisions about future investigation activities.
4)Because this is a Public Health matter in addition to being a personal health matter, the <health department name> has an ability to assist the family with the cost of testing and treatment. All TB infection and disease medications are provided free of charge to all patients.
Are there any tests I should do before I refer my patient to the health department that will help expedite diagnosis and treatment decisions?
1)The health department is actively in the process of communicating with the family of the infant to assess exposures and to confirm testing. Initial testing is scheduled for <date>and will be provided free of charge. This will include a tuberculin skin test and a T-Spot (Interferon Gamma Release Assay) as has been recommended by the experts.
2)Your patient will also need a chest radiograph and a physical examination which we are requesting you schedule as quickly as possible after the testing. It would be helpful if you made the appointment now in anticipation of the results coming to you late next week.
3)Monthly monitoring with the examination form is requested until the infant reaches six months or you determine an adequate immune system has been developed if that is greater than six months.
Should treatment be given as a precaution during this six month diagnostic process regardless of the initial testing results?
1)The experts at the <consultation entity, RTMCC> have advised at this time prophylactic treatment should be considered only on a case by case situation after full review of the testing results, chest radiograph and physical examination. It is most important that TB disease be fully ruled out before any consideration for treatment is pursued to assure additional resistance is not developed.
2)<health department name> will assist you with direct consultation with the experts on your individual patient if you have questions or concerns beyond what the <health department name> TB staff are able to assist you with.
IV. TREATMENT OF INFANTS AND CHILDREN WITH LATENT TB INFECTION
How will children diagnosed with latent TB infection be treated?
If the child in your care is diagnosed with TB infection, the <health department name> will work with you through the guidance of expert TB consultation network to develop the appropriate treatment plan. To promote adherence and maximize the benefits of therapy, children should be treated under direct observation.
V. ROLE OF THE PROVIDER
What is my role in evaluating patients for whom<health department name is recommending testing as part of this TB contact investigation?
health department name> is asking providers to perform physical examinations on their patients to help diagnose or rule out active TB disease. health department name> will provide an examination form for you to complete. Upon completion of the examination form you are asked to return a copy to <health department name> for the review of the consultants and for use in tracking the contact investigation outcomes to determine if transmission is likely and the investigation should be expanded. Please send a copy of all chest x-ray films to JCDHE for expert consultant review along with the examination form.
Moving forward, please remain alert for signs and symptoms of TB in your patient. Feel free to refer parents to JCDHE if they would like more information.
Whom can I call if I have more questions regarding an infant under my care?
health department name> TB Clinic – dedicated number?