1. Lindsay Koranda
Rush University College of Nursing
EVIDENCE BASED PRACTICE PROTOCOL:
TUBERCULOSIS SCREENING AND TESTING
GUIDELINES FOR EVANSTON TOWNSHIP
HIGH SCHOOL HEALTH CENTER

2.  Lack of detailed tuberculosis screening and testing guidelines
at the school-based health center.
PROBLEM STATEMENT

3.  In 2010, an estimated 11,182 children were infected with
tuberculosis (TB) in the U.S. [ 1 ]
 One-third of the global population has latent TB. [ 2 ]
 For childhood TB alone, $80 million will be spent addressing
the problem, $40 million on treatment, and another $40
million will be put towards research globally. [ 3 ]
CLINICAL PRACTICE PROBLEM

4.  In the late 1980’s and early 1990’s, the AAP recommended
universal TB testing for all children, even if they had no risk
factors.
 In 1996, the recommendations were revised to focus on the
concept of risk factor screening.
 Based on the response from the risk assessment
questionnaire, children and adolescents with at least one
positive risk factor should be tested for TB. [ 1 ]
HISTORY OF GUIDELINES

5.  Evanston Township High School (ETHS) Health Center is
partnered with NorthShore University Healthsystem, serves
children and adolescents in kindergarten up to 12th grade,
ages 5 to 22 years old.
 District 202 & 65
 Students are seen at the clinic for a wide array of reasons,
from acute & chronic illnesses, to physicals and vaccinations.
 The healthcare providers play the role of a primary care
provider (PCP) or supplement to the students’ PCP. [ 1 ]
BACKGROUND

6. Worldwide plan developed by the World Health Organization in
2006.
 The vision is a TB-Free world.
 The goal is to dramatically reduce the global burden of TB by
2015.
 The targets are:
 To reduce prevalence and deaths due to TB by 50% compared with
baseline by 2015.
 To eliminate TB as a public health problem by 2050.
STOP TB STRATEGY

7.  Study 1: Practice policies for TB testing in CT
 Findings:
 60% of providers read AAP guidelines
 62% agreed to being knowledgeable on the TB testing policies for their
school district
 85% screened for TB prior to testing
 19% reported that a TST was required and 5% reported requiring neither [1]
 Study 2: Case study: Consequences of universal testing for
school entrance
 11 weeks into treatment with isoniazid (INH), a 4-year-old girl started
having symptoms, which eventually progressed into liver toxicity,
requiring a liver transplant. [2]
LITERATURE REVIEW CONCLUSIONS

8.  Study 3: Overall specificities and sensitivities of tuberculin skin
test (TST) and interferon-gamma release assay (IGRA)
 IGRAs were found to be slightly more specific, but equally as
sensitive, in comparison to TSTs [1]
 Study 4: Effectiveness of TB tests in pediatric population
 Findings were consistent with above study
 Further research is needed for IGRAs and children under 2 years old
[2]
 Study 5: Cost-effectiveness of TB testing
 38% of the schools required TSTs for admission into kindergarten
 $1.27 million in savings if universal testing were to be eliminated [3]
LITERATURE REVIEW CONCLUSIONS

9.  “Case rates of tuberculosis for all ages are higher in urban,
low-income areas and in nonwhite racial and ethnic groups;
80% of reported cases in the United States occur in Hispanic
and nonwhite people.” [ 1 ]
 Children 14 years and younger who were born outside of the
U.S. make up 25% of newly diagnosed TB cases. [ 2 ]
NEED FOR EBPP

10.  The H.S.-
 Comprised of:
 43.4% White, 30.9% Black, and 16.6% Hispanic [1]
 Current enrollment in the clinic is 1,899 students
 Out of those enrolled, 885 have All Kids
 Many international students coming from all parts of the world, many
are high-prevalent regions.
 Some students leave the country during the summer to go on mission
trips that typically last for 6 to 8 weeks.[2]
NEED FOR EBPP

11. WORLDWIDE TB INCIDENCE

12.  Evanston-
 1-3% have no health insurance and 2-6% are on Medicaid.
 In 2012, 17% of residents had an income of $25,000 or less and 23%
had an income of $25,000 to $50,000.
 Rated as a “middle-need” community when it comes to prevention
and access to health care. [1]
 In 2012-
 9,951 TB cases in the U.S.
 347 in Illinois
 146 in Chicago
 89 in Suburban Cook County [2]
 4 at ETHS Health Center [3]
NEED FOR EBPP

13.  Three categories:
 Structure
 Process
 Outcome
 All of these elements have an impact on each other
DONABEDIAN PARADIGM

14. 1. Annual risk assessment questionnaire
2. Targeted testing
 Only testing children with at least one risk factor
3. If one or more risk factors are present, choosing the most
appropriate test
 Tuberculin skin test (TST), also known as the Mantoux or PPD
 Interferon-gamma release assay (IGRA)
 Two branded in U.S.: QuatiFERON-TB Gold (QFT) and T-Spot (also known as the
Elispot)
EVIDENCE BASED PRACTICE PROTOCOL

15.  Risk Assessment Questionnaire
 New questions added
 Existing questions expanded
 Student as an individual
 EBPP
 Easy-to-read algorithm format
 Added detail
DIFFERENCE BETWEEN OLD & NEW

16. NO YES
1. Where you born
outside of the U.S.?
*If yes, what country?
2. Were any of your
family members born
outside of the U.S.?
3. Has a family
member or anyone that
you’ve been in close
contact with had
tuberculosis disease?
4. Has a family
member ever had a
positive TB skin test?
RISK ASSESSMENT QUESTIONNAIRE

17. NO YES
5. Have you traveled
outside of the country for
one week or more and had
contact with residents of
that country?
*If yes, what country
6. Have any of your family
members recently traveled
to another country?
7. Have you ever been
tested for HIV, with positive
results?
8. Have you ever used
illegal drugs?
9. Do you have regular
contact with an adult/s
who are: homeless, have
been in jail, use illegal
drugs, or have HIV? *Changes highlighted in
RED

18. EBPP
See handout

19.  Mission trip students should be tested upon return only if they
traveled to a country with high incidence of TB infection
 Testing should be at least 10 weeks after trip. [1]
 International students should be tested upon entrance into
school.
 Suggestions for adherence improvement include: incentives
for follow-up visits, confidentiality confirmation, and
reminders. [ 2 ]
EBPP IMPLEMENTATION

20. 1. 100% of staff (FNPs and pediatricians) will read the EBPP, as
evidenced by a sign off sheet.
2. All five staff members should be well educated on the new
protocol, as evidenced by passing (with a score of 80% or
higher) a quiz that will be taken one month after
implementation of the protocol.
3. All students will be screened upon admission to school
(starting in kindergarten), and annually thereafter.
4. Staff members will report that they feel more competent in
situations related to TB, as demonstrated by a discussion that
will take place two months after implementation of the new
protocol.
5. All students who are treated with medication for TB infection
will follow up monthly throughout their treatment course (DOT),
as evidenced by documentation in Epic.
6. TB positive patient visits will be properly coded with the ICD
system, as evidenced by documentation in Epic.
OUTCOME EVALUATIONS

21.  Risk assessment questionnaires
 Cost: paper & ink
 Salary of providers & support staff, medical supplies, and
funding from state all remain unchanged.
 TSTs done at SBHC
 Free
 QFTs for insured students
 $230 (before insurance) at NorthShore lab
 $323.40 (before insurance) at local Quest lab
 QFTs for uninsured students
 $30 (based on sliding scale) at Erie Family Health Center
 Free at Cook County Department of Public Health
COST IMPLICATIONS

22.  Ultimately, it is the APNs role to identify, evaluate, and
manage acute and chronic diseases.
 While there lacks a gold standard for tuberculosis testing,
APNs must still be competent in knowing what populations
are at greater risk, how to administer the risk assessment
survey, when to test and which test to choose.
 Continuing education to stay on top of latest research and
guidelines.
SIGNIFICANCE TO APN ROLE

23.  In the end, no matter which test is used, the most important
take home point is to look at the patient as a whole
 This means looking at risk factors, symptoms, and history of
exposure, rather than solely the test result.
 Emphasis is put on the growing change in management of
tuberculosis
 What used to be managed inpatient by specialists is now commonly
seen in the outpatient setting by primary care providers. [1]
PEARLS

24. THE END