2018 American Academy of Pediatrics (AAP) RED BOOK - Updated Recommendations for Pediatric Tuberculosis Testing, LTBI Treatment and Rifampin Dosing

Department Resources

July 5, 2018

Health Advisory

The 2018 AAP Red Book has been updated, including recommendations for Pediatric Tuberculosis (TB) testing, Latent TB Infection (LTBI) treatment and Rifampin dosing.
Treatment of LTBI in any individual is encouraged to decrease the rate of active TB in Fairfax County.
Reactivation of latent Tuberculosis increases in adolescents.
Treatment of LTBI is well tolerated in children and can prevent the development of active contagious TB disease later in life.

Interferon gamma release assays (IGRAs) can be used in immunocompetent children two years of age and older (previously five years of age and older) in all situations when a TST would be used.
IGRAs are particularly useful or preferred for persons who have received BCG vaccination.
The recommendations on IGRA risk factors and frequency of testing are the same as those for TST.
Because IGRAs and TST can be negative in individuals with recent exposure or who have active disease, the need for clinical judgment is strongly recommended.
For persons in which an IGRA serology is not possible, TST remains an appropriate alternative.

Three treatment options are offered and considered adequate, depending on the circumstances for individual patients. The 12-week Isoniazid-Rifapentine (3HP) Regimen, once a week, is now recommended in children two years of age and older. This regimen is usually given by directly observed therapy. Other alternatives for treatment remain 4 months of Rifampin, once a day, or 9 months of Isoniazid, once a day.
- The Red Book does not state a specific preference among the regimens, but orders them in the following way: 12 weeks Isoniazid-Rifapentine (3HP), 4 months of Rifampin, and 9 months of Isoniazid, and states that some experts view 3HP as the preferred regimen.
- 3HP should not be used in children under two years of age because of the lack of Rifapentine metabolism pharmacologic data.
- LTBI treatment options for adolescents and adults is the same as for children. 1) 12 weeks of once a week Isoniazid-Rifapentine (3HP), 2) 4 months of daily Rifampin, and 3) 9 months of daily Isoniazid.

The 2018 Red Book recommends that Rifampin dosing, as part of treatment for active TB disease, be increased to 15-20 mg/kg/day and states that at least 20 mg/kg/day should be used for life-threatening disease and for any indication in infants and toddlers. Rifampin is used along with INH, Ethambutol and Pyrazinamide to treat active TB disease.

The Virginia Department of Health has recently released the 2018 list of countries identified as meeting the World Health Organization’s (WHO) definition for high burden of TB incidence (20/100,000). Persons from these high burden countries should be screened for TB and TB infection. The 2018 list of high burden countries is attached.
Active TB disease is a Reportable Disease under Virginia Code. Providers must immediately report cases of active TB to Fairfax County Health Department at 703-246-2433.
The Health Department is available for consultation and treatment of Fairfax County residents with TB disease, Latent TB Infection and for evaluation of individuals with signs/symptoms consistent with TB. The Fairfax County Health Department Intake/Referral line is 703-246-2433. The TB Physician Consultant can also be reached through this number for discussion of a case or for additional questions.