Continuing Education Tuberculosis
CE 1.5HOURSContinuing EducationTuberculosis:A New ScreeningRecommendation andan Expanded Approachto Elimination in theUnited StatesA review of risk assessment, testing, and treatment.ABSTRACT: Nurses play a critical role in the diagnosis and treatment of tuberculosis and in the prevention oftuberculosis transmission through infection control practices. To eliminate tuberculosis in the United States,however, an expanded approach to testing and treating people with latent tuberculosis infection must beimplemented. Recently, the U.S. Preventive Services Task Force (USPSTF) issued a new recommendationstatement on latent tuberculosis infection testing that expands nurses’ opportunities to identify at-riskpopulations for tuberculosis prevention. In combination with newer testing methodologies and shortertreatment regimens, implementation of the USPSTF recommendation has the potential to remove previously existing barriers to screening and treatment of both patients and health care providers. This articleprovides a general overview of tuberculosis transmission, pathogenesis, and epidemiology; presents preventive care recommendations for targeted testing among high-risk groups; and discusses the USPSTF recommendation’s applicability to public health and primary care practice in the United States.Keywords: latent tuberculosis infection, tuberculosis, tuberculosis disease, tuberculosis testing, tuberculosis treatmentAnurse at your clinic had been coughing fora few months, but dismissed it as seasonalallergies. The nurse’s annual tuberculosis testwas positive, and after a chest X-ray, medical examination, and sputum laboratory results, the nurse was24AJN August 2017 Vol. 117, No. 8diagnosed with tuberculosis. The health departmentestimates that the nurse may have been infectiousfor two months prior, exposing patients, visitors,and staff to Mycobacterium tuberculosis. Immunocompromised adult patients and children who hadajnonline.com
By John Parmer, PhD, MS, Leeanna Allen, MPH, BS, and Wanda Walton, PhD, MEdHealth workers from the Duval County Health Department and other Florida health agencies test homeless citizens for tuberculosis indowntown Jacksonville. Photo by Bob Mack, AP Photo / The Florida Times-Union.been in close contact with the nurse are of specialconcern to the health department. Clinic staff members are concerned about the risk of transmittingtuberculosis to their own families.This fictional scenario describes one way tuberculosis can present a risk to health care workers, theirfamilies, and their patients. Tuberculosis in healthcare workers is not common, but still occurs too frequently in the United States. According to data fromthe National Tuberculosis Surveillance System, approximately 350 health care workers were diagnosedwith tuberculosis in 2015, accounting for 3.9% oftotal cases.1 Tuberculosis transmission involving healthcare workers has been seen in hospitals, clinics, andlong-term care facilities.2-4 The adoption of tuberculosis infection control measures has decreased thenumber of tuberculosis outbreaks and incidents oftuberculosis transmission to patients and health careworkers. Proven tuberculosis control practices, suchas infection control measures and active tuberculosiscase finding and treatment, are essential elements ofajn@wolterskluwer.coma tuberculosis elimination strategy. This article willdiscuss preventing tuberculosis disease from developing through targeted testing and treatment of latenttuberculosis infection to provide an even greater impact on reducing future cases of tuberculosis disease.Background. Tuberculosis was a leading cause ofdeath in the United States in the early 20th century.Medical and public health interventions resulted ina steady decline in cases that began in the mid-1950sand continued until the early 1990s, when a tuberculosis resurgence occurred. The resurgence was associated with the emergence of the HIV epidemic,increased immigration from countries with high tuberculosis rates, and declines in funding of tuberculosiscontrol programs in many jurisdictions. After a majorreinvestment in tuberculosis control activities at alllevels of government, tuberculosis cases began to decline again in 1993. However, after two decades ofdecline, tuberculosis incidence in the United States hasnow stalled at approximately three cases per 100,000persons. In fact, after having declined yearly fromAJN August 2017 Vol. 117, No. 825
Figure 1. Reported Tuberculosis Cases in the United States, 1982–2015Number of Cases30,00025,00020,00015,00010,0005,00001982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 2015Years1993 to 2014, the overall number of tuberculosiscases in the United States increased slightly in 2015,from 9,406 to 9,557.1 (See Figure 1.)Epidemiologic modeling suggests that tuberculosis elimination, defined as less than one tuberculosiscase per 1 million persons per year, will not occur bythe end of this century given the annual declines observed over the past two decades.5 Achieving tuberculosis elimination in the United States will requirea substantial improvement in identification and treatment of latent tuberculosis infection among high-riskgroups who live in this country, while at the sametime continuing to focus on active tuberculosis casefinding and treatment. New and expanded approachesto and partnerships for tuberculosis prevention andcontrol are necessary to achieve this goal.1In 2016, the U.S. Preventive Services Task Force(USPSTF) issued a recommendation statement ontesting asymptomatic adults ages 18 and older whoare at increased risk for tuberculosis.6 This was thefirst USPSTF recommendation statement issued ontuberculosis testing since 1996.7 It urges health careproviders to assess their patients’ risk of latent tuberculosis infection by considering the country oforigin of foreign-born persons and whether patientslive or have lived in high-risk congregate settings suchas homeless shelters and correctional facilities. TheUSPSTF assigned a “B” grade to its screening recommendation, meaning that the recommended servicehas more potential benefits than potential harms forthe population covered.6 Under the Affordable CareAct, services recommended by the USPSTF withgrades of “A” or “B” should be provided with no copay or deductible costs for insured persons.8This new screening recommendation complementsexisting guidelines for latent tuberculosis infectiontesting, including those of the Centers for Disease26AJN August 2017 Vol. 117, No. 8Control and Prevention (CDC), the American Academy of Pediatrics, and the American Thoracic Society.9-12 In addition to removing cost barriers, newertesting methodologies and shorter treatment regimens have the potential to remove previously existing barriers such as multiple clinic visits for testingand long months of treatment. (For recommendations from the USPSTF and the CDC, see Latent Tuberculosis Infection Screening Recommendations.)TRANSMISSION, PATHOGENESIS, EPIDEMIOLOGYTransmission. Tuberculosis is most commonly spreadfrom person to person through the air. When a person with infectious tuberculosis disease coughs, speaks,or sings, tiny particles containing M. tuberculosis areexpelled into the air.13 These particles, called dropletnuclei, are about 1 to 5 microns in diameter—lessthan 1/5000th of an inch. Droplet nuclei can remainsuspended in the air for several hours, depending onthe environment.14 If another person inhales air thatcontains these droplet nuclei, infection may occur;but not everyone who is exposed to a person withinfectious tuberculosis disease becomes infected withM. tuberculosis. The probability that tuberculosis willbe transmitted depends on patient characteristics andenvironmental factors. For example, a person whohas tuberculosis disease of the lung or throat is mostinfectious when chest radiographs show cavitation,and the person doesn’t cover her or his mouth andnose when coughing. Environmental factors, such asexposure to M. tuberculosis in a small, enclosed spacewith recirculated air containing infectious dropletnuclei, increase the probability of transmission ofM. tuberculosis.10Pathogenesis. When a person inhales air withdroplets containing M. tuberculosis, most of the largerdroplets become lodged in the upper respiratory tract,ajnonline.com
where infection is unlikely to develop. Infection mostoften occurs when smaller droplet nuclei containingtubercle bacilli reach the alveoli of the lungs. In thealveoli, most of the tubercle bacilli are killed by theimmune system. However, the few remaining live bacilli can multiply and spread throughout the body viathe bloodstream. Tuberculosis disease is most likelyto develop in the apex of the lung, but can also occurin the kidneys, the brain, and bone. Tubercle bacillican also spread through lymphatic channels to thelymph nodes.In people who have a healthy immune system, thebody is able to stop the multiplication of the bacilliwithin weeks after infection, preventing further spread.At this point, the person has latent tuberculosis infection, which can be detected by a tuberculosis testtwo to eight weeks after infection. A person who haslatent tuberculosis infection isn’t considered a case oftuberculosis and isn’t infectious—that is, she or hecannot spread the infection to others.15When the immune system can’t stop tuberculosisbacteria from growing, latent tuberculosis infectionprogresses to tuberculosis disease. Without treatment,approximately 5% of people with latent tuberculosis infection develop tuberculosis disease within oneto two years after becoming infected. Another 5%of people with untreated latent tuberculosis infection will get sick years later, when their immune system becomes weak for another reason. Therefore,without treatment, approximately 10% of peoplewith latent tuberculosis infection will progress totuberculosis disease.16 For the differences betweenlatent tuberculosis infection and tuberculosis disease, see Table 1.Epidemiology. Among the 9,557 tuberculosiscases reported in the United States in 2015, a third(n 3,186; 33.3%) occurred among U.S.-born persons; two-thirds (n 6,350; 66.4%) occurred amongforeign-born persons.1 Tuberculosis disease is a nationally notifiable disease: health care providers arerequired by law to notify state public health authorities of a case of tuberculosis disease. However, latenttuberculosis infection is not a nationally notifiabledisease. Latent tuberculosis infection data collectionand surveillance varies from state to state. The CDCestimates that up to 13 million people in the UnitedStates are living with latent tuberculosis infection andthat more than 85% of U.S. cases of tuberculosis disease each year are the result of reactivated infectioninstead of recent transmission.5, 17The rest of this article will focus on improving theidentification and treatment of latent tuberculosisinfection among high-risk populations, includingforeign-born persons living in the United States, thosewho live or have lived in high-risk congregate settings, and those who work in health care settings.We discuss preventive care recommendations fortargeted testing among these and other high-riskajn@wolterskluwer.comgroups and their applicability to U.S. public healthand primary care practice.LATENT TUBERCULOSIS INFECTION RISK ASSESSMENT,TESTING, AND DIAGNOSISRisk assessment. People at risk for developing tuberculosis disease fall into two broad categories:those at increased risk for exposure to tuberculosisdisease and those at increased risk for progressionto tuberculosis disease if infected. Foreign-born persons, those who live or have lived in congregate settings, and health care workers are among those whohave an increased likelihood of exposure to peoplewith tuberculosis disease and should be tested fortuberculosis infection.10 In addition, people withclinical conditions or other factors associated withan increased risk of progression from latent tuberculosis infection to tuberculosis disease should alsoLatent Tuberculosis Infection ScreeningRecommendationsU.S. Preventive Services Task ForceScreening for Latent Tuberculosis Infection in AdultsForeign bornPeople who were born in, or are former residents of, countrieswith increased tuberculosis llarticle/2547762Congregate settingsPeople who live in, or have lived in, high-risk congregate settings(such as homeless shelters and correctional ullarticle/2547762Centers for Disease Control and PreventionRecommendations for Tuberculosis TestingHealth care workersGuidelines for preventing the transmission of Mycobacteriumtuberculosis in health care 1.htm?s cid rr5417a1 ePeople exposed to someone with tuberculosis diseaseGuidelines for the investigation of contacts of persons with infectious 415a1.htmPeople with weakened immune systemsTargeted tuberculin testing and treatment of latent rhtml/rr4906a1.htmChildrenRecommendations for preventive pediatric health care:www.aap.org/en-us/Documents/periodicity schedule.pdfAJN August 2017 Vol. 117, No. 827
Table 1. The Difference Between Latent Tuberculosis Infection and Tuberculosis DiseaseA Person with Latent Tuberculosis Infection . . .A Person with Tuberculosis Disease . . . has no symptoms has symptoms that may include a bad cough lasting 3 weeks or longer pain in the chest coughing up blood or sputum weakness or fatigue weight loss no appetite chills fever sweating at night does not feel sick usually feels sick cannot spread tuberculosis bacteria to others may spread tuberculosis bacteria to others usually has a skin test or blood test resultindicating tuberculosis infection usually has a skin test or blood test resultindicating tuberculosis infection has a normal chest radiograph and a negativesputum smear may have an abnormal chest radiograph, orpositive sputum smear or culture needs treatment for latent tuberculosis infectionto prevent tuberculosis disease needs treatment to treat tuberculosis diseasebe tested.9 For a complete list of factors associatedwith increased risk of exposure to or infection withM. tuberculosis, as well as factors associated withincreased risk of progression from latent tuberculosis infection to tuberculosis disease, see TuberculosisRisk Factors.15, 18Foreign-born persons. The USPSTF recommendation statement on latent tuberculosis infectionscreening encourages health care providers to consider foreign-born patients’ country of origin in assessing their risk of latent tuberculosis infection. Therecommendation applies to asymptomatic adultsages 18 years and older who were born in or areformer residents of countries with increased tuberculosis prevalence.6, 19According to the CDC, the disparity in tuberculosis incidence in the United States between U.S.-bornand foreign-born persons continued to increase in2015, with a case rate among the foreign born thatwas approximately 13 times higher than that amongthe U.S. born (15.1 versus 1.2 cases per 100,000 persons).1 More than half (57%) of all foreign-born persons with tuberculosis disease in the United Statesoriginated in five countries: Mexico, the Philippines,India, Vietnam, and China.1 Haiti and Guatemalaare also important contributors to U.S. tuberculosis disease cases. For complete and current data on tuberculosis rates by country, see the World Health Organization’s Global Tuberculosis Report 2016 at www.who.int/tb/publications/global report/en. Because ofregional variations in at-risk populations, the USPSTF28AJN August 2017 Vol. 117, No. 8encourages clinicians to consult local or state publichealth agencies for additional details on specific atrisk populations in their community.6Cases among foreign-born persons most often occur years after their arrival in the United States, whichis consistent with disease progression after years ofuntreated latent tuberculosis infection.1 Treating thosewith latent tuberculosis infection could, therefore, havea significant impact on reducing future cases of tuberculosis disease. Health care providers who care forlarge numbers of foreign-born persons should, therefore, be prepared to offer testing for tuberculosis infection. In addition to offering to test those born incountries with high tuberculosis prevalence, healthcare providers may also consider offering testing tothose who have traveled to or resided in countrieswith a high tuberculosis prevalence, especially thosewho have had exposure to local at-risk populations.People who live or have lived in congregate settings.The USPSTF recommendation statement includesthose who live or have lived in high-risk congregatesettings, such as shelters, prisons, nursing homes, andresidential institutions. In 2015, among those in theUnited States ages 15 years and older with tuberculosis disease, the CDC found that 5.5% had beenhomeless within the past year, 1.9% had been longterm care facility residents, and 3.6% had been in acorrectional facility at the time of diagnosis.1 Published prevalence rates of latent tuberculosis infectionin these settings vary widely, ranging from 23.1% to87.6% among prisoners, and from 18.6% to 79.8%ajnonline.com
among the homeless.20 Therefore, providers may findadditional opportunities for testing by asking patients whether they live or have lived in congregatesettings.Health care workers are potentially at increasedrisk for exposure as a result of their work with people who have undiagnosed tuberculosis disease. Recommended tuberculosis testing programs in healthcare settings include initial two-step tuberculosis skintesting or a tuberculosis blood test upon hire, andannual or serial testing as determined by state regulations and facility risk assessment.10 As a result ofthese testing programs, many health care workersare aware that they’re infected with tuberculosis. Fortheir own health and because active tuberculosis disease puts patients, coworkers, and family membersat risk, these health care workers should considerlatent tuberculosis infection treatment to preventprogression to disease.Health care workers who have had a positive testresult for tuberculosis infection should be promptlyevaluated for tuberculosis disease. Of special concernare health care workers with a newly positive testresult for tuberculosis infection, as recent infectionis a risk factor for progression to tuberculosis disease. In fact, the greatest risk for progression occurswithin the first two years after infection. Once tuberculosis disease has been ruled out, treatment forlatent tuberculosis infection should be offered tohealth care workers who are eligible through employee health services or in coordination with a private physician. Results from tuberculosis tests andrecords of completed treatment for latent tuberculosis infection should be documented as part of the employee’s health record. Regulations on tuberculosistesting, treatment, and infection control for healthcare workers vary from facility to facility. For assistance with the planning and implementation of tuberculosis control activities in the health care setting,and for information on state and local regulations,health care facilities should coordinate with a localor state tuberculosis control program. A completelist of state tuberculosis control programs can befound at www.cdc.gov/tb/links/tboffices.htm.People who have been exposed to someone withtuberculosis disease. Contact investigations are usedto identify people exposed to those with infectioustuberculosis disease (referred to as contacts), assessexposed contacts for tuberculosis infection, and provide appropriate treatment for contacts found to havelatent tuberculosis infection or tuberculosis disease.Tuberculosis patients in the United States have, onaverage, 11 contacts who may be at risk for tuberculosis infection; and of those, an average of threecontacts become infected and may develop disease ifnot diagnosed and treated.21 Public health departmentsmake every effort to identify those who have beenin close contact with someone who has infectiousajn@wolterskluwer.comtuberculosis disease, and they can provide information on exposure risk to concerned individuals whoknow someone who has been included or have themselves been included in contact investigations.People with weakened immune systems. Certainclinical conditions can weaken the immune systemand, therefore, increase the risk of progression to tuberculosis disease among those with latent tuberculosis infection. People who have HIV, patients receivingimmunosuppressive medications such as chemotherapy or tumor necrosis factor-α inhibitors, and organtransplant recipients are at increased risk. Other medical conditions associated with an increased risk ofprogression from latent tuberculosis infection to tuberculosis disease include silicosis, diabetes mellitus,chronic renal failure or hemodialysis, gastrectomy,jejunoileal bypass, and head and neck cancer.18 Tuberculosis testing in these populations is recommendedTuberculosis Risk Factors15, 18People at high risk for exposure to or infection with Mycobacteriumtuberculosis include: close contacts of a person with infectious tuberculosis disease persons who are from, or who frequently travel to, areas of theworld with high rates of tuberculosis persons who live or work in high-risk congregate settings (forexample, nursing homes, homeless shelters, or correctionalfacilities) health care workers who serve patients who are at increasedrisk for tuberculosis diseasePeople at high risk for developing tuberculosis disease after infection with M. tuberculosis include: children younger than 5 years of age persons with any of the following: HIV infection substance abuse silicosis diabetes mellitus severe kidney disease low body weight organ transplant head and neck cancer gastrectomy/gastric bypass persons receiving immunosuppressive therapy, including medical treatments with tumor necrosis factor-α antagonists or corticosteroids, or specialized treatment for rheumatoid arthritis orCrohn’s disease cigarette smokers and persons who abuse drugs or alcohol persons recently infected with M. tuberculosis (within the past2 years) persons with a history of untreated or inadequately treatedtuberculosis diseaseAJN August 2017 Vol. 117, No. 829
as part of standard disease management for theseconditions or as indicated prior to the use of certainmedications.9Children, especially those younger than five yearsof age, who test positive for tuberculosis infection arelikely to be in the early stage of infection and are athigh risk for progression to active disease, with potential for disseminated tuberculosis and tuberculosis meningitis.9, 22 Adolescents’ and young adults’ riskof developing active tuberculosis disease after exposure is less than that of young children, but greaterthan that of middle-aged and older adults.9 A diagnosis of latent tuberculosis infection or tuberculosisdisease in children younger than 15 years of age isa public health problem of special significance because it is a marker for recent tuberculosis transmission.The American Academy of Pediatrics recommendsannual tuberculosis infection testing for children infected with HIV and incarcerated adolescents. Childrenwho are known contacts of a person with confirmedor suspected tuberculosis disease and children whowere born in or have traveled to a high-risk countryshould also be tested for tuberculosis infection.11 Clinicians may also want to consider the potential riskof tuberculosis infection in children who live in homeswith visitors from high-risk countries who may haveactive tuberculosis disease.The U.S. Food and Drug Administration has approvedtwo IGRAs that are commercially available in theUnited States: the QuantiFERON–TB Gold In-Tubetest and the T-SPOT.TB test.6, 18The TST is administered using the Mantoux technique by injecting 0.1 mL (5 tuberculin units) of purified protein derivative solution intradermally, usuallyon the forearm.9 A person given the TST must returnwithin 48 to 72 hours to have a trained health careworker look for a reaction on the arm showing induration, and if present, measure its size using a ruler.Redness or erythema by itself is not considered part ofthe reaction. The TST result depends on the size of theinduration. It also depends on the person’s risk of being infected with tuberculosis bacteria and the risk ofprogression to tuberculosis disease if infected.23Some who are infected with M. tuberculosis mayhave a negative reaction to the TST if many years havepassed since infection occurred. Yet they may havea positive reaction to a subsequent TST because theinitial test stimulated their ability to react to the test.This is commonly referred to as the “booster phenomenon” and may incorrectly be interpreted as a TSTconversion (going from negative to positive, indicating recent infection). For this reason, the “two-stepmethod” is recommended at the time of initial testing for those who will be tested periodically, such ashealth care workers. If the reaction to the first-step TSTMore than 85% of U.S. cases of tuberculosis diseaseeach year are the result of reactivated infection insteadof recent transmission.Testing. There are two kinds of tests that can detect M. tuberculosis in the body: the tuberculin skintest (TST) and tuberculosis blood tests. A positiveTST or tuberculosis blood test only indicates infection with M. tuberculosis; further tests are requiredto rule out tuberculosis disease.Tuberculosis blood tests are called interferon-gammarelease assays (IGRAs), and they’re used to determinewhether a person is infected with M. tuberculosis bymeasuring the immune response to tuberculosis proteins in whole blood.23 IGRAs require a single venousblood sample and laboratory processing eight to 30hours after collection. According to the CDC, to conduct the tests, “Specimens are mixed with peptidesthat simulate antigens derived from M. tuberculosisand controls. In a person infected with M. tuberculosis, the white blood cells recognize the simulatedantigens and release interferon-gamma (IFN- γ); results are based on the amount of IFN- γ released.”1830AJN August 2017 Vol. 117, No. 8is classified as negative, a second-step TST is administered one to three weeks later. Based on the resultsof the second-step TST, the person will be diagnosedas positive or negative for tuberculosis infection.18There are several advantages of IGRAs over theTST. First, whereas the TST requires two visits (oneto place the test and a second for it to be read), anIGRA requires only a single visit to draw blood. Second, IGRA results are available within 24 hours—as compared with 48 to 72 hours for the TST—andcan be communicated to the patient without requiringa second in-person visit.18 Last, bacille Calmette–Guérin (BCG) vaccination, commonly used in manycountries with high tuberculosis incidence to preventtuberculosis meningitis in infants and young children,can cause false-positive TST reactions24; IGRAs useM. tuberculosis–specific antigens that don’t respondto BCG antibodies. TST reactivity caused by the BCGvaccine generally wanes with the passage of time, butajnonline.com
periodic skin testing may prolong (boost) reactivity.In general, a positive TST result indicates latent tuberculosis infection, especially in at-risk persons.9 Giventhat it is not possible to determine if a positive TST reaction is due to BCG vaccination or infection withM. tuberculosis, the CDC recommends that TSTreactions should be interpreted based on risk stratification regardless of BCG vaccination history.23The TST is considered safe in children and is preferred over IGRAs in children less than five years ofage because of difficulty in getting a blood draw.23IGRAs are the preferred tests for tuberculosis infection in children five years and older who have beenvaccinated with BCG, although the TST is also acceptable.11, 24, 25These advantages make IGRAs the preferred testfor people (including children five years old and older)who have received BCG vaccination, and also forthose unlikely to return for a TST reading.23 A positive IGRA or TST result should be documented andincluded in the patient’s medical record. Additionalinformation on the use and interpretation of the TSTand IGRA is available at www.cdc.gov/tb/publications/factsheets/testing/tb testing.htm.Diagnosis. A diagnosis of latent tuberculosis infection is made if a person has a positive IGRA orTST result and a medical evaluation does not indicate tuberculosis disease.23 Tuberculosis disease isdiagnosed by medical history, physical examination,chest radiograph, and other laboratory tests. The presence of tuberculosis disease must be excluded beforetreatment for latent tuberculosis infection is initiated.While drug susceptibility testing (DST) is used todetermine the most effective treatment regimen fortuberculosis disease, DST is not possible for latenttuberculosis infection, as its methods require a positive patient specimen. However, if a person to betreated for latent tuberculosis infection is a contactof a known source of infection (source case), andDST results are available for that source, and thesource case has drug-resistant tuberculosis disease,the treatment regimen should be modified appropriately.18LATENT TUBERCULOSIS INFECTION TREATMENTTreatment of latent tuberculosis infection is essential to controlling and eliminating tuberculosis inthe United States, because it substantially reducesthe risk that latent tuberculosis infection will pro gress to tuberculosis disease. Treatment for latent tuberculosis infection is 90% effective in preventingactivation of tuberculosis disease.9 Onc
The nurse's annual tuberculosis test was positive, and after a chest X-ray, medical exami-nation, and sputum laboratory results, the nurse was diagnosed with tuberculosis. The health department . required by law to notify state public health authori-ties of a case of tuberculosis disease. However, latent tuberculosis infection is not a .
genitourinary tuberculosis - laryngeal tuberculosis - lymph node tuberculosis - miliary tuberculosis - neurological tuberculosis - pericardial tuberculosis - tuberculosis in otorhinolaryngology - tuberculosis meningitis - tuberculosis pleu
388-78A-2481 Tuberculosis—Testing method—Required. 388-78A-2482 Tuberculosis—No testing. 388-78A-2483 Tuberculosis—One test. 388-78A-2484 Tuberculosis—Two step skin testing. 388-78A-2485 Tuberculosis—Positive test result. 388-78A-2486 Tuberculosis—Negative test result. 388-78A-2487 Tuberculosis—Declining a skin test.
Tibèkiloz (tuberculosis)30 Teve (tuberculosis)30 12, 30Maladi touse (tuberculosis) 30Maladi pwatrin (tuberculosis) Maladi ti kay ("little house illness")3, 31, 32 This nickname refers to the tradition of requiring a TB patient to sleep in quarters separate from their family. 31"Grow thin, spit blood" (tuberculosis)
BAB II TINJAUAN PUSTAKA 2.1. Konsep dasar Tuberculosis Paru (TBC) 2.1.1 Definisi Tuberculosis Paru Tuberkulosis (TB) adalah suatu penyakit menular yang sebagian besar disebabkan kuman mycobacterium tuberculosis. Kuman tesebut biasanya masuk ke dalam tubuh manusia melalui udara pernafasan ke
On the other hand, it is estimated that around 70% of new adult cases of tuberculosis in South Africa are co-infected with HIV. Tuberculosis is the commonest cause of morbidity and mortality among HIV-infected persons in South Africa and studies have shown that tuberculosis accelerates HIV disease progression.
to initiating ENSPRYNG. Consider anti-tuberculosis therapy prior to initiation of ENSPRYNG in patients with a history of latent or active tuberculosis in whom an adequate course of treatment cannot be confirmed, and for patients with a negative test for latent tuberculosis but having risk factors for tuberculosis infection.
Jun 07, 2016 · Drug-Resistant Tuberculosis: A Survival Guide for Clinicians, Third Edition was created through a collaboration of the Curry International Tuberculosis Center (CITC) and the State of California Department of Public Health, Tuberculosis Control Branch (CDPH). CITC is a project of the Universit
Paediatric Anatomy Paediatric ENT Conditions Paediatric Hearing Tests and Screening. 1 Basic Sciences HEAD AND NECK ANATOMY 3 SECTION 1 ESSENTIAL REVISION NOTES medial pterygoid plate lateral pterygoid plate styloid process mastoid process foramen ovale foramen spinosum jugular foramen stylomastoid foramen foramen magnum carotid canal hypoglossal canal Fig. 1 The cranial fossa and nerves .
