In this issue...
A Big Thank you!
Timing of Tuberculosis Testing and Smallpox Vaccination
Administration of Crushed Tablets in Solids and Liquids
Update on Recent Legislation Affecting TB Control Activities
DTC sincerely thanks you for completing the recent surveys on funding issues and other associated problems related to providing anti-TB medications to TB cases in your districts. The survey data have been extremely helpful in assisting DTC to prepare information for the VDH Commissioner on the myriad of issues you encounter assuring the completion of treatment among Virginia's TB cases. All thirty-five districts participated in this effort, completing survey questions for both the district and individual patients. Out of the over 400 cases for whom information was requested, only 15 surveys remain unanswered. Pat yourselves on the back! DTC will distribute the survey analysis at the TB, refugee and immigrant health nurse training program in October 2003.
Questions have been raised by many on the timing of the administration of the tuberculin skin test and the smallpox vaccine. According to a recent MMWR Recommendations and Reports (MMWR 2003; 52 (No.RR-7) (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5207a1.htm):
"Suppression of tuberculin skin test (purified protein derivative [PPD]) reactivity has been demonstrated after administration of smallpox vaccine, as has been observed after administration of other parenteral live-virus vaccines. Health-care workers scheduled to receive an annual PPD skin test should not receive the skin test for 1 month after smallpox vaccination to prevent possible false-negative reactions."
Please contact DTC if you have additional questions.
DTC has received several queries, since the 2003 publication of the ATS/CDC/IDSA Treatment for TB disease, on the administration of medications, particularly INH, in foods and liquids. Several studies have evaluated the effects of food on the bioavailability of INH. A description of these studies and findings can be found in the following article:
Self, T.H., Chrisman, C.R., Baciewicz, A.M., & Bronze, M.S. (1999). Isoniazid Drug and Food Interactions. American Journal of Medical Science, 317(5), 304-11.
The following table summarizes INH-food interactions.
Food TypeInteractions |
Recommendations |
Regular mealsDelays and decreases absorption of INH. Can occur with any meal, but especially with carbohydrates |
Take INH on an empty stomach or at least 1.5 hours before a meal. |
Foods high in tyramineAdverse-type reaction |
Monitor patients for flushing, palpitations, headache, itching, nausea and vomiting. Avoid foods high in tyramine, such as Swiss, Cheshire, Gruyere cheeses or red wine. |
Foods high in histamineAdverse-type reaction |
Monitor patients for flushing, palpitations, headache, itching, nausea and vomiting. Avoid foods with high histamine content, such as tuna and skipjack fish. |
The following guidance was communicated by Dr. Ram Koppaka (CDC) in consultation with Charles Peloquin at the National Jewish Center for Immunology and Respiratory Medicine in Denver offers some practical guidance.
"Certain sugars (sucrose, glucose, fructose) are reactive, particularly when mixed with certain other reactive substances such as INH. What happens when the two come into contact is that the sugar reacts with the INH, rendering the latter inert and not effective. These reactions, however, take some time so the anti-TB drugs should not be stored in sugary solutions. The reaction is slowed by the thickness of the substance that is being used to deliver the medication. Pudding and applesauce are superior to juice or sugar water. The bottom line is do what you have to do to get the drug into the person, but choose the thickest substance that is usable, mix, and administer immediately. The conventional wisdom is that you don't want to store the drug in these juices or foods, but dissolving and then giving it rather quickly should be fine."
The above communication combined with the results of the study referenced suggest that in cases when food must be used in administering medications or to control gastric upset, it is prudent to use the smallest amount of food possible.
A 2003 legislation, passed and signed by Governor Warner, authorized registered nurses acting as agents of the Department of Health to possess and administer - at their discretion - tuberculin purified protein derivative (PPD) to persons in whom TB skin tests are indicated (according to policies, protocols and standards of care established by the Virginia Department of Health). This legislation also allowed registered nurses, and licensed practical nurses under the supervision of registered nurses, to administer PPD with written, verbal, or standing orders issued by a health professional licensed to prescribe medications in Virginia.
PPD is listed as a Schedule VI drug, which means that it requires an individual prescription for each dose of PPD administered. However, the 2003 legislation now permits pubic health nurses to continue carrying out activities such as contact investigations that have traditionally been performed without specific orders. The new legislation essentially gives PHNs limited prescriptive authority for this PPD agent. In addition, nurses in occupational health settings can now carry out these types of activities using standing agency policies and protocols, without specific prescriptions for each dose of PPD administered. The full text of this 2003 legislation is available at http://leg1.state.va.us/cgi-bin/legp504.exe?031+ful+CHAP0514
The VDH policy and recommendations for screening for latent TB infection is being revised and will available online in the near future.
In 2003, a second bill was passed and signed by Governor Warner. This bill authorizes public health nurses, when acting according to the guidelines and recommendations of the Department of Health, to collect sputum samples and submit the samples to a public health laboratory without a specific physician order. Current sputum collection guidelines was published in the September 2002 AcidFast Blast (http://vdhweb/std/afbsept.asp#Sputum). The full text of this legislation is available at http://leg1.state.va.us/cgi-bin/legp504.exe?031+ful+CHAP0515