Health Advisory
Summary
- 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.
Suggested Actions
TB Testing
- 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.
LTBI Treatment
- 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.
Rifampin Dosing for Active TB Disease
- 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.
Additional Information
- 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.