LTBI and TB Basics: Symptoms and Treatment

By Tiffany Hirokawa

For Asian, Asian Americans (A/AAs), Native Hawaiians, and Pacific Islanders (NH/PIs), tuberculosis (TB) and latent TB infection (LTBI) disproportionately impacts these communities. A/AAs accounted for nearly 36% and NH/PIs accounted for nearly 2% of all U.S. TB cases in 2021. To address the disproportionate impact of LTBI/TB, community health centers (CHCs) play a pivotal role as essential safety net providers serving the frontlines of prevention and treatment for at-risk communities. However, CHCs face substantial barriers in implementing and conducting LTBI/TB screening, testing, and treatment for their patient populations often as a result of limited funding and staffing, unclear/non-applicable TB guidelines, provider and patient educational barriers, and sociocultural patient barriers.

The Tuberculosis Elimination Alliance’s limited blog series, “Addressing LTBI and TB at Community Health Centers Serving Asian, Asian Americans, Native Hawaiians, and Pacific Islanders,” aims to shed a light on the impact of LTBI and TB on A/AA and NH/PI communities and the community health center providers that serve them. Learn about TB/LTBI basics, the critical role CHCs play in community care, and the importance of providing resources and support to TB/LTBI providers.

Photos courtesy of Canva

What is TB disease? What does it look like? How is it transmitted? How is it treated?

Tuberculosis (TB) is a bacterial disease caused by mycobacterium tuberculosis. The bacteria is shown to typically impact the lungs, but if left untreated can spread and impact any part of the body including but not limited to the nervous system, kidney, and brain. Therefore, TB symptoms are dependent on which area of the body is affected. Common symptoms from TB in the lungs include a cough lasting 3 weeks or longer, chest pain, and coughing up blood or sputum. Additional symptoms include weakness, weight loss, fever, no appetite, chills, and night sweats. To this day, there continues to be many common misconceptions surrounding TB transmission, often posing a barrier to patient education and effective infectious disease management. TB is an airborne-transmitted disease and is spread from one person to another through coughing, singing, or talking. Therefore, TB disease is not transmitted through shaking hands, hugging, kissing, sharing food/drinks, or touching shared surfaces. Additionally, extrapulmonary TB (TB disease occurring outside of the lung) is *usually not infectious.

*This statement does not denote that extrapulmonary disease cannot be infectious

TB disease without proper treatment can become fatal; therefore, early screening and treatment interventions are key in preventing TB disease progression. TB treatment, its duration and drug regimes; however, varies from person-to-person. Depending on the individual’s co-existing conditions (e.g., HIV, diabetes mellitus), current medications, and whether the TB is multi-drug resistant or drug-susceptible, this will determine the regime and interventions used. Furthermore, the patient’s response to treatment will also influence their treatment duration and drug regimen. For example, adverse effects to treatment may interfere with patients’ ability to complete treatment. In turn, the CDC offers varied treatment recommendations for drug-susceptible TB to accommodate individual patient circumstances and preferences. Current regimes include the 6 or 9 month RIPE Drug regimen (Rifampin (RIF), isoniazid (INH), pyrazinamide (PZA), and ethambutol (EMB)) or the 4-month Rifapentine-moxifloxacin TB Treatment Regimen. To support TB treatment completion and prevent TB disease progression and mult-drug resistance, Directly Observed Therapy (DOT) either in-person or virtually or self-administered therapy (SAT) can be used. DOT involves support in treatment adherence by health workers, community volunteers or family members in which these individuals observe and record patients taking their TB dose.

Photo courtesy of Canva

Latent TB Infection (LTBI) faces additional barriers and misconceptions. Not all individuals infected with mycobacterium tuberculosis will develop TB and can instead have the dormant version of the disease–LTBI. Unlike TB, individuals with LTBI are asymptomatic, meaning they do not present any symptoms, and cannot transmit the disease. Although, without LTBI treatment, individuals with LTBI may develop active TB disease within their lifetime. According to the CDC’s Think, Test, Treat TB campaign, without treatment about 1 in 10 people with LTBI (inactive TB) will develop TB disease and become infectious to others (capable of transmission). At-risk populations, including those who are immunocompromised (e.g., HIV, diabetes mellitus, organ transplants, substance use, and cancer), recent and long-term immigrants from areas of high TB incidence, and individuals in close contact with areas at high-risk for TB transmission (e.g., congregate living settings, homeless shelters, prisons, and healthcare settings) are at increased risk for developing active TB disease. For example, according to the CDC’s 2021 report, the majority of tuberculosis (TB) cases for non-U.S.-born persons living in the United States for 20 years or longer before diagnosis are the result of reactivation of LTBI. Likewise, immunocompromised individuals (e.g., HIV, cancer, organ transplant recipients, autoimmune conditions) are at increased risk for developing active TB disease because of their weakened immune system’s lowered ability to fight the bacterial disease.

Accounting for the diversity of at-risk populations, there are several LTBI treatment regimes. In 2020, the CDC and National Tuberculosis Controllers Association and CDC updated LTBI treatment recommendations proposed multiple short-course regimes including the 3-month Isoniazid & Rifapentine (3HP), 4-month Rifampin (4R), 3-month Isoniazid & Rifampin (3HR), along with the longer-course 6-month Isoniazid (6H), or 9-month Isoniazid (9H) regimes. Shorter courses of treatment suggest higher treatment completion and minimizes adverse effects and risks for hepatotoxicity (toxic damage to the liver).

Source Image 1: CDC, [Think, Test, Treat TB Campaign]. (n.d). https://www.cdc.gov/tb/publications/letters/images/Consumer-graphic-protect-your-family-thumbnail.jpg?_=48438; Source Image 2: CDC, [LTBI Guide for Primary Caregivers]. (n.d). https://www.cdc.gov/tb/publications/ltbi/images/LTBI-booklet.jpg

With an estimated 13 million individuals living with LTBI in the United States, early screening and testing interventions are necessary to identify and prevent the progression of TB disease. Therefore, to stay updated on the latest LTBI and TB guidelines, please visit the Centers for Disease Control and Prevention’s (CDC) TB page. Here, you will find LTBI and TB guidelines, patient and provider education materials, and additional resources. For providers, in 2020, the CDC released the Latent Tuberculosis Infection: A Guide for Primary Health Care Providers to provide primary care providers with updated and actionable guidelines for LTBI screening, testing, and treatment. In furthering the call for TB eradication, check out the CDC’s latest Think, Test, Treat TB campaign focusing on LTBI awareness and community interventions.

For additional LTBI and TB resources, please visit TEA’s updated resource page today! If you have any questions about the content above, please contact tea@aapcho.org or visit the TEA website for more information.

Want to get involved? Become a local TEA partner today! We invite state and local TB control programs, community-based organizations, and community health centers to consider becoming a TEA partner today.

We also encourage you to apply to our upcoming mini-grant cycle. For the 2022–2023 TEA Mini-Grant Program, TEA will be offering up to fifteen (15) Mini-Grants to organizations serving A/AA- and NH/PI-communities to enhance LTBI/TB community engagement and education, provider education, and quality improvement. Deadline to apply is Friday, August 5 by 5:00pm local time. Learn more from the RFP: https://bit.ly/TEA22RFP

For more information, please visit www.tbeliminationalliance.org and contact tea@aapcho.org today!

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AAPCHO

AAPCHO

The Association of Asian Pacific Community Health Organizations — dedicated to promoting advocacy, collaboration and leadership to improve AA and NHPI health.