EPIDEMIOLOGY FACT SHEET 1: Primary, Secondary, and

Tertiary Prevention Fact Sheet - TB Examples

INSTRUCTORS GUIDE VERSION 1.0
EPI Fact Sheet 1: Pr!ar"# Sec$%&ar"# a%& Tertar" Pre'e%t$% Fact Sheet (
T)*erc)+$,, E-a!.+e,
LEARNING O/0ECTIVES
After reviewing this Fact Sheet, participants should e ale to!
"istinguish among primary, secondary, and tertiary prevention activities
Provide examples of primary, secondary, and tertiary prevention activities related to
the prevention and control of M. tuberculosis
ASPH EPIDEMIOLOGY COMPETENCIES ADDRESSED
#$%$ Apply the asic terminology and definitions of epidemiology
#$&$ #ommunicate epidemiologic information to lay and professional audiences
ASPH INTERDISCIPLINARY/CROSS-CUTTING COMPETENCIES ADDRESSED
'$&$ (Pulic )ealth Biology* Apply iological principles to development and
implementation of disease prevention, control, or management programs
+$,$ (Systems Thin-ing* 'dentify characteristics of a system
P+ea,e e'a+)ate th, !atera+ *" c+c1%2 here: htt.:33444.5$$!era%2.c$!3S)r'e"36
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S)22e,te& ctat$%: Ne4 0er,e" Me&ca+ Sch$$+ G+$*a+ T)*erc)+$,, I%,tt)te. 3I%c$r.$rat%2
T)*erc)+$,, %t$ P)*+c Hea+th C$re C)rrc)+)!.3 900:: E.&e!$+$2" Fact Sheet 1: Pr!ar"#
Sec$%&ar"# a%& Tertar" Pre'e%t$% Fact Sheet > T/ E-a!.+e, INSTRUCTORS GUIDE Ver,$% 1.0.
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1
This material was developed y the staff at the 3loal Tuerculosis 'nstitute
43TB'5, one of four 6egional Training and .edical #onsultation #enters funded
y the #enters for "isease #ontrol and Prevention$ 't is pulished for learning
purposes only$ Permission to reprint excerpts from other sources was granted$
#ase study author4s5 name and position!
3eorge 7halil, .P) 4wor- done as .P) candidate5
.arian 6$ Passannante, Ph"
Associate Professor, 8niversity of .edicine 9 "entistry of /ew :ersey, /ew
:ersey .edical School and School of Pulic )ealth
Epidemiologist, /:.S, 3TB'
For further information please contact!
/ew :ersey .edical School 3loal Tuerculosis 'nstitute 43TB'5
00; <arren Street
P$=$ Box ,>12
/ewar-, /: 1>,1,-,>12
or y phone at 2>?-2>0-12>2
EPIDEMIOLOGY FACT SHEET 1: Primary, Secondary, and
Tertiary Prevention Fact Sheet - TB Examples
INSTRUCTORS GUIDE VERSION 1.0
I%tr$&)ct$%
Epidemiology is an important part of tuerculosis 4TB5 control efforts ecause the
information on patterns of infection and disease can assist in identifying people or groups of
people at ris- for TB, understanding how the disease is transmitted, prioriti@ing cases, and
planning appropriate use of staff and resources$
,

The oAectives of epidemiology are to!
'dentify the cause of disease or ris- for disease
"etermine the urden of disease in a community
Study the natural history and prognosis of disease
Evaluate oth existing and new preventive and therapeutic measures and modes of
health care delivery
Provide the foundation for developing pulic policy and regulatory decisions relating to
environmental prolems
0
'n a community or group with a high urden of disease, it is the responsiility of pulic health
officials, -nowing its cause and iologic implications, to put in place preventive measures to
alleviate the urden$ There are three prevention approaches that are crucial in decreasing
mortality and moridity of a disease! primary, secondary, and tertiary prevention$ These
levels of prevention were first descried y +eavell and #lar-
?
and continue to provide a
useful framewor- to descrie the spectrum of prevention activities$
Pr!ar" Pre'e%t$%
BPrimary prevention denotes action ta-en to prevent the development of a disease in a
person who is well and does not have the disease in CuestionD 4page %5$
0
These activities
include health promotion as well as disease prevention activities$ )ealth promotion activities
can e as simple as using appropriate hand washing techniCues or can e more
sophisticated such as vaccination to prevent disease occurrence$
,$ Eaccines
The only vaccination for TB on the mar-et is the acille #almette-3uFrin 4B#35 vaccineG
however, its use is rarely indicated in the 8nited States$ Before putting a vaccine on the
mar-et in the 8nited States, the #enters for "isease #ontrol and Prevention 4#"#5 along
with the 8S Food and "rug Administration and other government agencies, must evaluate
the vaccines efficacy, safety, contraindications, utility, and cost effectiveness$
Two controlled prospective community trials efore ,2;; and studies done in ,2H>, ,2;1,
and after ,2>; using different B#3 strains, found poor efficacy ranging from 1I to &1I$
H,;
'n
addition to poor efficacy, the B#3 vaccine is not indicated in the 8nited States ecause
secondary prevention techniCues are greatly hindered y the B#3 vaccine, which can
interfere with the management of persons who are possily infected with M. tuberculosis$
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EPIDEMIOLOGY FACT SHEET 1: Primary, Secondary, and
Tertiary Prevention Fact Sheet - TB Examples
INSTRUCTORS GUIDE VERSION 1.0
Safety is another concern when evaluating a vaccine$ )igh rates of local reaction and
infection often leave a permanent scar at the site of a B#3 vaccine$ Also, the estimated ris-
of a complication from a sucutaneous ascess is ?&> per , million vaccinations, 1$?2-1$&2
per , million from a musculos-eletal lesion, and 1$,2-,$;% per , million fatalities from
disseminated lesions$
%

Since the resurgence of TB in the early ,221s, the B#3 vaccine was again evaluated for use
in the 8nited States$ Since then, the #"# has made the following recommendations
%
! ,5
B#3 is considered for children in the 8nited States who have a negative tuerculin s-in test
4TST5 and are continually exposed to an untreated or ineffectively treated patient who has
infectious TB andJor drug-resistant TB and cannot e isolated from the patientG 05 B#3 is
also considered on a case-y-case asis for health care wor-ers in high-ris- settings$
#urrently, new vaccines for the prevention of TB are in the development phase$
>

0$ Environmental controls
Another form of primary prevention for TB is environmental control, such as ultraviolet lights
and ventilationG however, these measures are ta-en mostly at hospitals and cannot e
practically implemented at places where most TB transmission exists 4e$g$, nursing homes,
prisons, in the community, etc$5$
&
)owever, programs aimed at decreasing overcrowding can
also e considered primary prevention measures for TB$
Sec$%&ar" Pre'e%t$%
BSecondary prevention denotes the identification of people who have already developed a
disease, at an early stage in the diseaseKs natural history, through screening and early
intervention$D BThe rationale for secondary prevention is that if we can identify disease earlier
in its natural history, intervention measures will e more effective$ Perhaps we can prevent
mortality or complications of the disease and use less invasive or less costly treatment to do
soD$
0
4page %5
,$ "etection of latent TB infection 4+TB'5
The #"# recommends a strategy to identify those who have +TB' and, if indicated, the use of
chemotherapy to .re'e%t the +ate%t %?ect$% ?r$! .r$2re,,%2 t$ act'e T/ &,ea,e$
There are two tests that can e used to help detect +TB'$
a$ The Tuerculin S-in Test 4TST5
The first is a s-in test in which testing material, called tuerculin, is inAected intradermally
into the individual and in 0 to ? days, the patient returns to the health care wor-er who
chec-s to see if there is a reaction to the test$
&

$ LuantiFE6=/-TB 3old 4LFT-35
The second test used to identify +TB' is LFT-3, a lood test that measures how a
personKs system reacts to the acteria that causes TB$
2

As mentioned previously, secondary control methods for TB are greatly hindered y the B#3
vaccine$ Post-vaccination B#3-induced tuerculin reactivity ranges from no induration to an
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EPIDEMIOLOGY FACT SHEET 1: Primary, Secondary, and
Tertiary Prevention Fact Sheet - TB Examples
INSTRUCTORS GUIDE VERSION 1.0
induration of ,2 mm at the s-in-test site$ Tuerculin reactivity caused y B#3 vaccination
wanes with time and is unli-ely to persist M,1 years after vaccination in the asence of M.
tuberculosis exposure and infection$ 6ecent studies have suggested that the LFT-3 is more
sensitive than the TST$
,1
Another recent study that compared TST and LFT-3 found that the
LFT-3 test was highly specific and unaffected y B#3 vaccination status, a maAor cause of
false-positive TST responses$
,1
Since there is no gold standard for screening tests to
determine if someone has TB disease, other speciali@ed tests such as chest N-ray and a
sample of sputum may e needed$ Tale ' is a summary of evidence comparing TST to LFT-
3, a type of interferon-gamma assay$
/ahid P, Pai ., )opewell P#$J011%JAdvances in the diagnosis and treatment of tuerculosisJ
Proceedings of the American Thoracic Society/?!,1?-,,1$ =fficial :ournal of the American
Thoracic Society$ O American Thoracic Society$ 6eprinted with permission$
Secondary prevention of TB involves the identification and testing of targets groups of people
and communities with greater li-elihood of eing infected$ PTargeted tuerculin testing for
+TB' is a strategic component of tuerculosis 4TB5 control that identifies persons at high ris-
for developing TB who would enefit y treatment of +TB', if detectedD$
&
Some of these high ris- groups are!
)ealth care wor-ers who wor- with patients at ris- of TB
Those who have lived or traveled extensively in areas where TB is endemic
'mmunocompromised individuals
Those who have had a recent positive conversion of a s-in test
Persons who live in a congregant setting 4e$g$ Aails and nursing homes5
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EPIDEMIOLOGY FACT SHEET 1: Primary, Secondary, and
Tertiary Prevention Fact Sheet - TB Examples
INSTRUCTORS GUIDE VERSION 1.0
)omeless persons
Another type of secondary prevention measure is called a contact investigation$ "uring a
contact investigation a pulic health wor-er interviews patients with active TB disease in
order to identify BcontactsD or people who may have een exposed to that person$ =nce
identified the contacts will e evaluated for +TB' and TB disease and provided with
appropriate treatment, when necessary$
0$ Treatment of +TB'
Patients who are identified as eing infected with TB should e evaluated for active TB
disease, y receiving a chest N-ray, and a focused clinical evaluation$ =nce active disease is
excluded, one of the following treatments listed in Tale 0 is indicated$
Ta*+e: Dr)2 Re2!e%, ?$r the Treat!e%t $? LT/I
Dr)2, D)rat$%
@!$%th,A
I%ter'a+ M%!)!
&$,e,
'sonia@id 2 "aily 0>1
Twice
wee-lyQ
>%
'sonia@id % "aily ,&1
Twice
wee-lyQ
;0
6ifampin H "aily ,01
Q "irectly oserved therapy 4"=T5 is
mandatory for patients on twice wee-ly
4intermittent5 therapy
Tale source! modified version of #"# tale availale at!
http!JJwww$cdc$govJTBJpusJtfactsheetsJtreatment+TB'$htm$ Accessed .arch ,2, 011&$
#enters for "isease #ontrol and Prevention$ TB fact sheet$
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EPIDEMIOLOGY FACT SHEET 1: Primary, Secondary, and
Tertiary Prevention Fact Sheet - TB Examples
INSTRUCTORS GUIDE VERSION 1.0
"irectly oserved therapy 4"=T5 is suggested for patients with +TB' at high ris- of not
adhering to the prescried therapy, and mandatory for those on twice wee-ly regimens$ For
"=T, a health care wor-er or other trained person who is not a family memer watches as
the patient swallows antituerculosis medicines for at least the first 0 months of treatment$
"=T thus shifts the responsiility for cure from the patient to the health care system$
Tertar" Pre'e%t$%
11
The treatment of people who have already developed a disease is often descried as tertiary
prevention$ The final strategy used for preventing and controlling TB in the 8nited States is
identifying and treating patients with active TB$ Each person with infectious TB has the
potential to infect many othersG however, the site of the infection is important in determining
its capaility to spread$ For example, the lungs and larynx are two common organs where TB
may e highly infectious$ 'f instead, the TB infection is locali@ed to areas such as lymph
nodes or outside the lung, treatment is necessary, yet it is not transmissile and, therefore, is
not a maAor pulic health concern$
The treatments used for people with active TB will vary depending on whether the TB is
resistant to some of the standard TB medications$ Treatment can ta-e % months or longer$
Some of the most common drugs used to treat TB are!
isonia@id 4'/)5
rifampin 46'F5
ethamutol
pyra@inamide
"=T is used to e sure that patients who have active disease to rememer to ta-e their TB
medications$
8$r1, Cte&
,$ Passannante . and Ahamed /$ Basic Epidemiology for Tuberculosis Program Staff.
/ewar-, /:! /ew :ersey .edical School /ational Tuerculosis #enter$ 011;$
http!JJwww$umdnA$eduJntcweJproductsJasicepi$htm
0$ 3ordis +. Epidemiology: Second Edition. /ew Ror-, /R! <$B$ Saunders #o$ 0111$
?$ +eavel )6 and #lar- E3$ Preventive Medicine for the octor in !is "ommunity. /ew Ror-,
/R! .c3raw-)ill$ ,2%;$
H$ 6osenthal S6, +oewinsohn E and 3raham .+ et al$ B#3 vaccination against tuerculosis
in #hicago! a twenty year study statistically analy@ed. Pediatrics$ ,2%,G 0&! %00-%H,$
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EPIDEMIOLOGY FACT SHEET 1: Primary, Secondary, and
Tertiary Prevention Fact Sheet - TB Examples
INSTRUCTORS GUIDE VERSION 1.0
;$ 6osenthal S6, +oewinsohn E and 3raham .+ et al. B#3 vaccinations in tuerculosis
households. Am 6ev 6espir "is$ ,2%,G &H!%21->1H$
%$ #enters for "isease #ontrol and Prevention$ The role of B#3 Eaccine in the prevention
and control of Tuerculosis in the 8nited States! A Aoint statement y the Advisory #ouncil for
the Elimination of TB and the Advisory #ommittee on 'mmuni@ation Practices$ ..<6
6ecomm 6ep. ,22%G H; 466-H5!,-,&$
http!JJwww$cdc$govJmmwrJpreviewJmmwrhtmlJ111H,1H>$htm
>$ Brennan .:, Fruth 8, .ilstien :, Tiernan 6, de Andrade /ishio-a S, et al$ 4011>5
"evelopment of /ew Tuerculosis Eaccines! A 3loal Perspective on 6egulatory 'ssues$
P+oS .ed H4&5! e0;0 doi!,1$,?>,JAournal$pmed$11H10;0$
http!JJmedicine$plosAournals$orgJperlservJSreCuestTget-
document9doiT,1$,?>,JAournal$pmed$11H10;0
&$ Targeted tuerculin testing and treatment of latent tuerculosis infection. American
Thoracic Society. Am : 6espir #rit #are .ed$ 0111G,%,!S00,-0H>$
http!JJwww$thoracic$orgJsectionsJpulicationsJstatementsJpagesJmtpiJlatentt,-0>$html
2$ .adariaga .3, :alali U and Swindells S. #linical utility of interferon gamma assay in the
diagnosis of tuerculosis. : Am Board Fam .ed$ 011>G 01!;H1-;H>$
http!JJwww$Aafm$orgJcgiJcontentJfullJ01J%J;H1
,1$ "iel 6, +odden 7emper 6, .eywala <alter 7, /iemann S, /iehhaustt$ Predictive value of
a whole-lood 'F/-gamma assay for the development of TB disease$ Am : 6espir #rit #are
.ed. 011&G,>>!,,%H-,,>1$
,,$ Luestions and Answers Aout TB, 011> Accessed on the #"# wesite
http!JJwww$cdc$govJtJfaCsJCaVTB"isease$htmWActive, Accessed on Feruary 2, 0112$
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