AcidFast Blast - January 2005

Vol. 4, No. 1

In this issue...
Tuberculosis in Children

Tips for Administering Medication to Children and Adults Who Cannot Swallow Pills
[Click here for a printer-friendly, pdf file of this article.]

Interjurisdictional Referrals

References Cited in This Issue

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Tuberculosis in Children

Over the last several years, Virginia has experienced an increase in the number of pediatric tuberculosis cases. This is troublesome, because for the most part this represents recent and sometimes ongoing transmission within our communities. Several recent studies emphasize the value of contact investigation in the identification of children with TB disease and latent TB infection (LTBI) (Lobato, Mohle-Boetani, & Royce, 2000; Marks et. al, 2000; Lobato, Mohle-Boetani, & Royce, 2003). These studies also emphasize the importance of home visits in identifying children who are contacts. One study compared the outcomes of contact investigations resulting from 1,080 cases of infectious TB in adults. The home visits made in this study to identify contacts yielded 6.7 close contacts; whereas, only 4.7 contacts were identified when home visits were not done (Marks et. al, 2000). Sadly, all too often these "missed" contacts are children.

Children, especially those under 6 years of age, who are identified as contacts of a patient with known or suspected tuberculosis disease must receive medical evaluation promptly for TB disease or LTBI. This evaluation must include an immediate tuberculin skin test, chest x-ray and a physical examination (within 7 days from identification as a contact). The signs and symptoms of TB disease may be subtle in young children and differ to some extent from those present in adults and adolescents. Symptoms of TB disease in children can include cough, wheezing, fever, weight loss, failure to thrive, anorexia, decreased activity, playfulness or enerty, hemoptysis, musculoskeletal pain, lymph node swelling, and personaly changes. ("Targeted tuberculin skin testing," 2004)

Children with active TB disease must receive appropriate therapy (i.e. standard 4 drug regimen unless the source case is known and is pan-sensitive) and close supervision of treatment administered using direct observed therapy. Family members may administer the medication under the supervision of a healthcare worker, however, they cannot be relied upon to provide adequate supervision of the overall treatment.

All children with LTBI (i.e. positive TST, normal chest x-ray and without signs/symptoms of active TB) should be started on an appropriate treatment regimen for LTBI once active disease is ruled out.

Children < 4 years of age who are close contacts to an active TB case should receive treatment for LTBI, regardless of the TST result; and, this treatment should start as soon as active TB has been excluded (confirming the absence of symptoms and verification that the chest radiograph is normal). If the initial TST is negative, the TST should be administered again three (3) months after the contact is broken. If the repeat test is negative, treatment and follow-up can be discontinued for persons who are asymptomatic. If the repeat test is positive, treatment for LTBI should be continued for the full, recommended preventive course.

For infants under 6 months of age, the prophylaxis treatment (window treatment) for LTBI should be continued until the following the following two events have occurred:
a) ATB skin test can be administered and repeated when the infant is over six months of age, AND;
b) 12 weeks have elapsed since the infant's last exposure to the infectious TB patient.

Tips on Administering Medication to Children & Adults Unable to Swallow Pills
(San Diego County, 1995; Charles P. Felton, 2004)

Administering TB medications to persons who are unable to swallow pills and capsules can be a challenge. The following recommendations and guidelines will enable nurses and outreach workers to overcome this challenge. Hopefully, these guidelines will ensure that the medications will more likelybe ingested by the patient than worn by the health care worker.

General Recommendations

• All standard anti-tuberculosis drugs can be crushed - INH, ethambutol, pyrazinamide - or opened - Rifampin - and mixed with a small amount of food.
• Do not crush medications too far in advance, because they might absorb the moisture in the air. Medications should be crushed immediately before mixing with the given food.
• When mixing medications with food, use the smallest quantity of food possible. Again, mix the crushed/opened medication with food immediately before administering the medication.
• Pyrazinamide, ethambutol, isoniazid and rifampin can be given together, i.e., mixed together the same small amount of food. However, keep in mind that a large amount of medication mixed into a small amount of food may not be well accepted by the patient. Therefore, it might be necessary to mix each medicine with a small amount of food (foods and flavors may vary), and administer each medicine separately. All medications should be administered at the same time, using directly observed therapy (DOT).
• If the medication is not administered within 30 minutes after crushing/opening, discard it and prepare a new dose.
• INH is the only anti-tuberculosis drug available in a commercially prepared liquid form. Do not use locally prepared syrups or suspensions of other anti-tuberculosis medications, because their stability cannot be assured.

Infants (<1 year of age)

• Liquid medications should be measured and given to an infant using a dropper or a syringe without a needle. Liquid medication can also be administered using just nipple of a baby's bottle.
• Medication can be mixed with a small amount of juice or other liquid (<1 ounce) and administered in a baby's bottle. Make sure that the entire content of the bottle are swallowed. Note: INH is not stable in sugary liquid. Therefore, the use of sugary liquids is not recommended. Again, medication should be administered as soon as it is mixed with food, otherwise it will become unstable.

Young Children

• Both liquid and pill forms of TB medications can be used with young children. For young children receiving treatment for active TB disease, crushed tablets administered with a small amount of food is preferred over the liquid forms of medications. Liquid forms of anti-tuberculosis drugs other than INH are unstable.
• Liquid INH causes abdominal pain and cramping in more than half of the children receiving this medication. For this reason, crushed pills should be used whenever possible.
• Pills can either be swallowed or crushed.
• If a child cannot swallow pills, crush the pills and mix (or layer) with one or two spoonfuls of a non-sugary liquid or soft food (pudding, jelly, applesauce or another food the child likes). Red-flavored applesauce works well for administering rifampin. Medicated food should be followed by ingestion of food without medications.
• Medication should be administered as soon as it is mixed, otherwise will become unstable.

Adolescents and adults

• Encourage children, adolescents and adults who are unable to swallow pills to practice swallowing a candy similar in size to the TB pills; this practice will teach this population how to swallow pills and capsules.
• Tablets tend to SINK; so, instruct the patient to tilt the head UP to swallow pills.
• Capsules tend to FLOAT, so instruct the patient to tilt the head DOWN to swallow capsules.

Troubleshooting

• If the patient vomits within 30 minutes after ingesting a medication, the dose should be repeated as soon as the patient is able to take it.
• If the vomiting episode occurs more than 30 minutes after ingesting the medicine, presume that medication absorption has occurred; so, the dose should not be repeated.
• Treatment should continue even if patient has a minor illness such as a cold, ear or throat infection. If the patient has a gastrointestinal virus, treatment should resume as soon as the patient is able to tolerate the medication.

Available Preparations of Standard Anti-tuberculosis Medications

Isoniazid (INH)

• Available in tablet and syrup form
  50, 100, and 300 mg tablets
  50 mg/5 ml in 70% sorbitol syrup
• Syrup may be preferred form for children < 1 year of age. Sorbitol may cause diarrhea. The syrup form of INH is unlikely to be tolerated in amounts greater than 10- 15ml (100-150 mg INH).
• Although INH is best absorbed in an empty stomach, experience has shown that most patients are unable to tolerate INH without food, and can attain adequate drug levels even when it is taken with a small amount of food.
• If using INH in syrup form, use only a manufactured, USP standard preparation. Do not use locally prepared syrups, because the stability of INH in a liquid containing sugar cannot be assured.

Rifampin

• Available in 150 and 300 mg capsules
• Do not use locally prepared rifampin syrups or suspensions, because rifampin may not be stable in such solutions.

Ethambutol

• Available as 100 and 400 mg tablets
• Do not use locally prepared ethambutol syrups or suspensions.

Pyrazinamide

• Available as 500 mg tablets.
• Do not use locally prepared pyrazinamide syrups or suspensions.

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Tips for Administering TB Medication to Children and Adults Who are Unable to Swallow Pills

Administering TB medications to persons who are unable to swallow pills and capsules can be a challenge. The following recommendations and guidelines will enable nurses and outreach workers to overcome this challenge. (San Diego County, 1995; Charles P. Felton, 2004)

General Recommendations

• All standard anti-tuberculosis drugs can be crushed - INH, ethambutol, pyrazinamide - or opened - Rifampin - and mixed with a small amount of food.
• Do not crush medications too far in advance, because they might absorb the moisture in the air. Medications should be crushed immediately before mixing with the given food.
• When mixing medications with food, use the smallest quantity of food possible. Again, mix the crushed/opened medication with food immediately before administering the medication.
• Pyrazinamide, ethambutol, isoniazid and rifampin can be given together, i.e., mixed together the same small amount of food. However, keep in mind that a large amount of medication mixed into a small amount of food may not be well accepted by the patient. Therefore, it might be necessary to mix each medicine with a small amount of food (foods and flavors may vary), and administer each medicine separately. All medications should be administered at the same time, using directly observed therapy (DOT).
• If the medication is not administered within 30 minutes after crushing/opening, discard it and prepare a new dose.
• INH is the only anti-tuberculosis drug available in a commercially prepared liquid form. Do not use locally prepared syrups or suspensions of other anti-tuberculosis medications, because their stability cannot be assured.

Infants (<1 year of age)

• Liquid medications should be measured and given to an infant using a dropper or a syringe without a needle. Liquid medication can also be administered using just nipple of a baby's bottle.
• Medication can be mixed with a small amount of juice or other liquid (<1 ounce) and administered in a baby's bottle. Make sure that the entire content of the bottle are swallowed. Note: INH is not stable in sugary liquid. Therefore, the use of sugary liquids is not recommended. Again, medication should be administered as soon as it is mixed with food, otherwise it will become unstable.

Young Children

• Both liquid and pill forms of TB medications can be used with young children. For young children receiving treatment for active TB disease, crushed tablets administered with a small amount of food is preferred over the liquid forms of medications. Liquid forms of anti-tuberculosis drugs other than INH are unstable.
• Liquid INH causes abdominal pain and cramping in more than half of the children receiving this medication. For this reason, crushed pills should be used whenever possible.
• Pills can either be swallowed or crushed.
• If a child cannot swallow pills, crush the pills and mix (or layer) with one or two spoonfuls of a non-sugary liquid or soft food (pudding, jelly, applesauce or another food the child likes). Red-flavored applesauce works well for administering rifampin. Medicated food should be followed by ingestion of food without medications.
• Medication should be administered as soon as it is mixed, otherwise will become unstable.

Adolescents and adults

• Encourage children, adolescents and adults who are unable to swallow pills to practice swallowing a candy similar in size to the TB pills; this practice will teach this population how to swallow pills and capsules.
• Tablets tend to SINK; therefore, instruct patients to tilt their heads up to swallow pills.
• Capsules tend to FLOAT; therfore, instruct patients to tilt their head DOWN to swallow capsules.

Troubleshooting

• If the patient vomits within 30 minutes after ingesting a medication, the dose should be repeated as soon as the patient is able to take it.
• If the vomiting episode occurs more than 30 minutes after ingesting the medicine, presume that medication absorption has occurred; so, the dose should not be repeated.
• Treatment should continue even if patient has a minor illness such as a cold, ear or throat infection. If the patient has a gastrointestinal virus, treatment should resume as soon as the patient is able to tolerate the medication.

Available Preparations of Standard Anti-tuberculosis Medications
(Lobato, Mohle-Boetani, & Royce, 2000; Marks et al., 2003)

Isoniazid (INH)

• Available in tablet and syrup form
  50, 100, and 300 mg tablets
  50 mg/5 ml in 70% sorbitol syrup
• Syrup may be preferred form for children < 1 year of age. Sorbitol may cause diarrhea. The syrup form of INH is unlikely to be tolerated in amounts greater than 10- 15ml (100-150 mg INH).
• Although INH is best absorbed in an empty stomach, experience has shown that most patients are unable to tolerate INH without food, and can attain adequate drug levels even when it is taken with a small amount of food.
• If using INH in syrup form, use only a manufactured, USP standard preparation. Do not use locally prepared syrups, because the stability of INH in a liquid containing sugar cannot be assured.

Rifampin

• Available in 150 and 300 mg capsules
• Do not use locally prepared rifampin syrups or suspensions, because rifampin may not be stable in such solutions.

Ethambutol

• Available as 100 and 400 mg tablets
• Do not use locally prepared ethambutol syrups or suspensions.

Pyrazinamide

• Available as 500 mg tablets.
• Do not use locally prepared pyrazinamide syrups or suspensions.

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Interjurisdictional Referrals

Periodically, the Division of TB Control (DTC) receives questions on the procedures for Interjurisdictional Referrals of TB cases, suspects, contacts, and patients on treatment for LTBI. There are several types of Interjurisdictional referrals and the procedures vary depending on the final relocation of the patient.

I. Intrastate Transfers (transfer of TB patient records between districts in Virginia)

The transfer of patients between districts and health departments within Virginia should be managed directly by the referring AND receiving jurisdictions. The health district from where the patient is transferring should provide all pertinent information about the patient (records, films, etc.) to the district/health department in the patient's new locale. If possible, the health district from where the patient is transferring should provide the patient with the contact information (addresses, names and phone numbers) of the health department in the locale to where the patient is relocating.

For cases of TB disease only, health departments referring a patient to another Virginia health department should notify Bill White (DTC) or Tim Epps (DTC) of the transfer. This referring jurisdiction should maintain an open record on the case until treatment is complete; and, it should follow-up with the receiving health department on completion of treatment information for all contact investigation referrals, including those contacts who are already on treatment.

Telephone DTC at 804-864-7906 for assistance in finding TB control contacts in the locale to where the patient is moving.

II. Interstate Transfers (transfer of TB patient records between states)

Without exception, DTC must process all interstate transfers of TB patient records; therefore, all interstate transfer forms must be sent to DTC. Referring health departments may initiate communication with the receiving jurisdiction when transferring these records, however, this communication must be in addition to notifying DTC.

The transferring patient's public health nurse (PHN) case manager should complete the Interjursidictional Referral Form (pdf file). Complete the form accurately and in its entirety. When submitting this referral form to DTC, send along pertinent patient records such as x-ray reports, bacteriology reports, DOT or medication sheets, and other relevant data.

The health department referring the patient should keep the case record open until the TB treatment is complete. Further, this referring jurisdiction should follow-up with the receiving US state for completion of treatment data on all contact investigation referrals, including those contacts already receiving treatment.

II. International Transfers (transfers between countries)

Without exception, DTC must process all international transfers of TB patient records; therefore, all international transfer forms must be submitted to DTC. Please note that most countries will only follow-up on active cases and suspects. The PHN case manager should complete the International Notification form (pdf). Complete the form accurately and in its entirety. When submitting the referral form to DTC, send along pertinent patient records such as x-ray reports, bacteriology reports, DOT or medication sheets, and other relevant data.

Please note that with most international referrals, DTC seldom receives feedback on the patient. Further, the country to where the patient is relocating is not required to maintain an open record on the case unless the patient is expected to return to Virginia before completing TB treatment.

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References

Lobato, M.N., Mohle-Boetani, J.C., & Royce, S.E. (2000). Missed opportunities for preventing tuberculosis among children younger than five years of age. Pediatrics, 106(6).

Marks, S.M., Taylor, Z., Qualis, N.L, Shrestha-Kuwahara, R.J., Wilce, M.A., & Nguyen, C.H. (2000). Outcomes of contact investigations of infectious tuberculosis patients. American Journal of Critical Care Medicine, 162, 2033-38.

Lobato, M.N., Royce, S.E., & Mohle-Boetani, J.C. (2003). Yield of source-case and contact investigations in identifying previously undiagnosed childhood tuberculosis. International Journal of Tuberculosis and Lung Disease, 7, S391-S396.

Targeted tuberculin skin testing and treatment of latent tuberculosis infection in children and adolescents. (2004). Pediatrics, 114(4).

San Diego County. (1995). How to Get TB Medicine in the Child and Not on You! [Brochure]. Lancaster, E: Author.

Charles P. Felton National Tuberculosis Center. (2004). Improving Completion Rates for Treatment of Latent TB Infection in Children and Adolescents. New York: Author.

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