April 2020
Wisconsin Tuberculosis (TB) Program Information During the COVID-19 Response
Background
As public health departments shift staff and resources to meet the needs of the COVID-19 response, it is important to take steps to ensure that people who are receiving treatment for TB disease can continue their treatment, even if routine health care services are affected. The Centers for Disease Control and Prevention (CDC) has information on planning for public health emergencies in TB programs.
TB and COVID-19 Co-Infection
Patients with TB disease could become infected with COVID-19. In this situation, a TB patient’s condition may unexpectedly deteriorate (e.g., new acute cough, fever, or shortness of breath). TB patients have respiratory compromise from their TB, making them at greater risk for severe COVID-19 infection. Therefore, respiratory infection control precautions, which TB programs are familiar with, are of even greater importance. COVID-19 guidance for personal protective equipment (PPE) for health care personnel (HCP) is available at the Wisconsin Department of Health Services (DHS) COVID-19: Personal Protective Equipment website. For more details on TB respiratory protection during shortages of PPE, please see below.
Prioritization of TB Services
In the event that TB services may be disrupted or discontinued due to the COVID-19 response, the Wisconsin TB Program recommends prioritization of TB services (Table 1).
Table 1. Prioritization of TB Services
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High Priority Activities
- Evaluation of patients with suspected or newly diagnosed TB
- Care for patients with active TB disease
- Consider video/electronic directly observed therapy (VDOT) when appropriate, see below.
- Care for children on window prophylaxis
- Evaluation of high risk contacts (e.g., children, immunocompromised, household members, those exposed during medical procedures) to a patient with infectious TB
- Initiation of treatment for LTBI in patients with high risk for progression (e.g., children, immunocompromised)
- Care for patients that have already started treatment for latent TB infection (LTBI)
- Prioritize patients that have high risk for progression to TB disease (see above).
- For the 3 months isoniazid (INH) and rifapentine (3HP) regimen, consider VDOT or self-administered therapy (SAT) when appropriate, see below.
- Perform monthly evaluations for patients being treated for LTBI remotely, as appropriate, see below.
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Activities to Continue, as Resources Allow
- TB Class B Evaluation and follow-up (except in individuals identified as TB Class B1 and/or high risk for progression, see above)
- Initiation of treatment for patients with LTBI (except in those with high risk for progression, see above)
- If initiating treatment for LTBI, consider LTBI regimens that can be self-administered by the patient. See below for recommendations for 3HP by SAT.
- Evaluation of medium and low risk contacts (those not considered “high risk contacts”, see above)
- Follow-up of LTBI reports from patients at low or medium risk for infection. See publication P-02540 for strategies on prioritization of follow-up for positive interferon gamma release assay (IGRA) reports.
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Activities that Could be Placed on Hold
- Targeted screening and testing
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Video or Electronic Directly Observed Therapy (VDOT)
VDOT is an alternative method to in-person DOT in which a patient is remotely observed (e.g., over a smartphone) taking his or her TB medication. VDOT requires less staff time and allows for better social distancing. The CDC has developed a VDOT Toolkit, “Implementing an Electronic Directly Observed Therapy Program.” VDOT is not appropriate for all situations (Table 2). New patients need instruction and in-person evaluation when starting treatment; VDOT is not appropriate for initial visit(s).
Table 2. Criteria for Use of VDOT*
Patients that could be considered for VDOT
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Patients that should NOT be considered for VDOT
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- Stabilized on treatment for at least two weeks
- Demonstrated adherence to treatment
- English speaking or ability to effectively communicate with the health care worker
- Drug susceptible disease
- No current alcohol or drug use
- Managing physician accepts the VDOT approach
- Proficiency in using a smartphone or other technology
- Able to accurately identify each medication
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VDOT for patients with infectious TB can be considered if other criteria (above) are met.
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- Adherence issues
- Language barriers
- Multi-drug resistance
- Minors without accompanying adult
- Immunocompromised
- Patient experiences adverse drug reactions
- Patient at risk for hepatic complications while receiving anti-TB medications
- Patient with disabilities that prevent full participation in VDOT such as hearing or vision disabilities, or physically challenged
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*Adapted from CDC VDOT Toolkit: https://www.cdc.gov/tb/publications/pdf/TBeDOTToolkit.pdf
Recommendations for Self-Administered Therapy (SAT) with 3HP
The CDC now recommends use of the 3HP regimen as self-administered therapy (SAT) in persons 2 years old and older in the United States. This recommendation updates the 2011 recommended use of the 3HP regimen by directly observed therapy (DOT). Clinicians should make joint decisions about SAT with each individual patient (or parent/legal guardian), considering program resources and the patient’s age, medical history, social circumstances, and risk factors for progression to severe TB disease. The updated recommendations appeared in an article in the Morbidity and Mortality Weekly Report (MMWR) published June 28, 2018. Although the Wisconsin TB Program has not previously recommended 3HP by SAT, it is considered a reasonable option during the COVID-19 response.
Remote Monthly Evaluations
For patients being treated for LTBI, monthly evaluations for adverse drug reactions could be administered remotely (e.g., phone, Skype) in the following situations:
- Stabilized on treatment for at least two weeks
- Demonstrated adherence to treatment
- English speaking or ability to effectively communicate with the health care worker
- No current alcohol or drug use
- Proficiency in using a smartphone or other technology
Respiratory Protection during PPE Shortages
CDC website: Strategies to Optimize the Supply of Personal Protective Equipment (PPE)
Wisconsin DHS website: Extended Use and Limited Reuse of N95 Respirators in Health Care Settings
Health care personnel (HCP) and caregivers should adhere to airborne precautions when caring for patients with infectious TB. Airborne precautions include the following respiratory protection:
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Respirators (for HCP and caregivers) are designed to protect health care personnel and other individuals from inhaling droplet nuclei. The minimum respiratory protection is a filtering face-piece respirator and must be selected from those approved by CDC/National Institute for Occupational Safety and Health (NIOSH) under Title 42 CFR, Part 84. It must meet one of the following specifications:
- Non-powered air-purifying respirators (N95, N99, N100, R95, R99, R100, P95, P99, and P100), including disposables
- Powered air-purifying respirators (PAPRs) with high-efficiency filters
- Supplied-air respirators
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Surgical masks (for patients with infectious TB) are designed to reduce the number of droplets being exhaled into the air by persons with infectious TB disease when they breathe, talk, cough, or sneeze. Persons suspected or confirmed to have infectious TB disease should be given, and encouraged to use, a surgical mask to minimize the risk of expelling droplet nuclei into the air.
Wisconsin Tuberculosis Program Contact information during the COVID-19 Response
As always, please contact the Wisconsin TB Program (WTBP) with any questions that you have. We may be working remotely, but we have continuous access to the secure WTBP voicemail and email inboxes. All faxes are received in the secure WTBP email inbox.
Main WTBP phone number: 608-261-6319
WTBP fax: 608-266-0049
WTBP group email: DHSWITBProgram@dhs.wisconsin.gov
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