Lisa Bridwell Robinson, DNP, CCRN, CNE, NP-C

40,000 to 710,000 of those infected and is the cause of death for 12,000 to 56,000 Americans annually.

The annual disease burden is dependent on several factors, including the efficacy of a vaccine, the number of individuals receiving the vaccine, the timing of influenza, and the characteristics of the virus.

An estimated 9.2 million to 35.6 million Americans are infected with influenza annually.

The only way to prevent infection is to get an annual flu vaccine.

The flu typically presents with a sudden onset of symptoms, including fever, chills, cough, sore throat, stuffy nose, body aches, headache, and fatigue.

Some cases may include vomiting and diarrhea.

A person with the flu can be contagious from 1 day prior to the onset of symptoms to up to 7 days after the start of symptoms.

The period from 3 to 4 days after the illness begins is when patients are most contagious.

After a person is exposed, the onset of symptoms usually occurs within 1 to 4 days.

Complications related to the flu are more frequently seen in individuals with chronic health conditions, the young, and those over age 65 years.

Primary prevention of the flu is through an annual flu vaccine. It is also recommended that those who are infected stay home to avoid spreading the virus and that healthy individuals avoid contact with those who are sick or appear to be sick.

Flu diagnosis can be made with many available rapid diagnostic tests.

Although false positives are rare, false negatives are a possibility,

so, some providers may diagnose flu based on the patient’s presentation of symptoms. State public health laboratories and some hospitals have more accurate and sensitive flu tests, with results available within a few hours.

Eli, a 19-year-old college freshman, presents to the clinic complaining of fever, malaise, and nausea. He says he came in because he feels too weak to go to class. Additionally, he reports having no appetite. For symptom relief, Eli has taken ibuprofen.

What additional information would you want to know about Eli’s history and current presentation?

except that he was told that as a small child, he had reactive airway disease. He works part time while attending college. His only sibling is alive and well. Both parents are alive, and Eli’s father takes medication for hypertension. Eli lives in a college dorm with 1 roommate, and his dorm houses about 150 students.

What additional questions related to Eli’s symptoms are relevant?

He denies having a cough. Additionally, Eli says that his throat is slightly sore, but he is not sure whether it is because he has been vomiting. He also says that his nose is somewhat stuffy. Eli says that he does not know of anyone around who is ill but that he takes classes in lecture halls with about 100 other students several days a week.

His temperature in the office is 101.2°F. Eli’s ears are clear upon examination, and his throat is mildly red. His blood pressure is within the normal range, his pulse rate is 104, and his respiratory rate is 20. Eli’s lungs are clear to auscultation. A rapid flu test is completed with a nasal swab. The flu test is positive.

What are the follow-up recommendations for Eli?

With his onset of symptoms being less than 24 hours, Eli is prescribed oseltamivir to be taken twice daily for 5 days.

Additionally, he should continue to take OTC medications for body aches and fever. He is also advised to avoid contact with others for the next several days.

Health care providers need to highlight prevention. An annual flu vaccination is the primary way to prevent contracting influenza.

Anyone over 6 months can get a yearly flu vaccine. The vaccine is especially important for individuals at a higher risk of complications, such as those with compromised immune systems and elderly individuals. Vaccination of health care providers is also encouraged, because they are more likely to be exposed to infected individuals and could also spread the virus.

The timing of the vaccine should occur prior to the onset of the typical flu season. The CDC recommends that everyone receive a vaccine by the end of October each year.

, is a family nurse practitioner and certified nurse educator who practices as a work-site health coach. She has practiced in a convenience care clinic and a family medical practice. Dr. Robinson also serves as

a faculty member for graduate nursing students in both master’s and doctoral programs.

1.     Disease burden of influenza. CDC website. cdc.gov/flu/about/disease/burden.htm. Updated May 16, 2017. Accessed November 1, 2017.

2.     Key facts about influenza (flu). CDC website.

. Updated October 3, 2017. Accessed November 1, 2017.

3.     Diagnosing flu. CDC website. cdc.gov/flu/about/qa/testing.htm. Updated October 3, 2017. Accessed November 1, 2017.

4.     What you should know about flu antiviral drugs. CDC website. cdc.gov/flu/antivirals/whatyoushould.htm. Updated January 5, 2017. Accessed November 1, 2017.

5.     Preventive steps. CDC website. cdc.gov/flu/consumer/prevention.htm. Updated September 12, 2017. Accessed November 1, 2017.

Articles

An estimated 9.2 million to 35.6 million Americans are infected with influenza annually. 

Case Studies: Influenza

Melanoma is the fifth most common cancer in men and the seventh most common cancer in women and accounts for most skin cancer deaths. The annual cost of melanoma treatment in the United States exceeds $3 billion, and about 9000 deaths each year are attributed to this form of cancer.

Risk factors for melanoma are both genetic and environmental. About 10% of melanoma patients have a first- or second-degree relative with the disease.

Familial cases of melanoma have been linked to 2 identifiable genes. Other factors that increase the risk of melanoma include blond, light brown, or red hair. Blue eye color and a high freckle density are also indicated as risk factors. Increased numbers of nevi (birthmarks/moles) present also indicate a proportional increase in risk for melanoma.

Skin cell damage from ultraviolet exposure is the recognized cause of more than 90% of melanoma cases.

Indoor tanning is a significant modifiable risk factor. Sun exposure should be minimized with the use of sunscreen with a sun protection factor (SPF) of 15 or higher and by seeking shade and wearing sunglasses, protective clothing, and hats. Additionally, scheduling outdoor activities early or later in the day is recommended.

Patients should be encouraged to report any observed changes in their skin, especially new growth, changes in old growth, or skin that will not heal.

Dermoscopy, a handheld light magnifier, can aid diagnosis based on lesion appearance.An early diagnosis with excisional biopsy can improve prognosis and survival.

An acronym called the A-B-C-D-E’s of melanoma can assist in assessing an area of concern on the skin. The A is for asymmetrical, as an irregular shape can be a sign of melanoma. Border is the B, as irregular or jagged borders of moles are also more concerning. C is for color, as uneven color of the lesion may indicate the need for further evaluation. Diameter is the D, as moles or spots larger than a pea are more concerning; and E is for evolving, meaning the patient has seen changes in the past 1 to 2 months.

Judith Ann, a 49-year-old Caucasian female who works part-time and is in good health, presented to her primary care physician with a new-onset enlarged submandibular lymph node. She reported noticing that the node had been present for about 2 weeks and seemed to be getting larger. Judith denies fever, chills, rashes, weight gain, or recent illness. She does not smoke or drink alcohol.

: What additional information would you want to know about Judith Ann’s history and presentation?

: Her parents are both deceased, her father from lung cancer with a tobacco history, and her mother from ovarian cancer. Her only sibling is alive and well. Physical exam findings are unremarkable, and she is up-to-date with her mammogram. She does say that she saw an ophthalmologist 2 months ago because of what she described as a sty that wouldn’t go away and had to be removed.

: What additional questions related to the removal of a lesion from her eyelid are relevant?

: She said that she thought the lesion was asymmetrical, had changed color, and was growing. At the time of removal, it was not sent for a pathology exam. She reported not using sunscreen as a child and remembers having several severe sunburns. She has light brown hair, blue eyes, and a very light skin tone. Referral for further evaluation was made. A biopsy on the lymph node the next week was positive for melanoma. The lesion removed from Judith Ann’s eyelid was likely the primary melanoma site.

: What are the follow-up recommendations for Judith Ann?

: After diagnosis and treatment at an oncology center, it is important to provide her with information on how to monitor for recurrence or secondary skin cancers. She should be seen at least once a year for a full skin exam and lymph node assessment. More frequent evaluation may be needed for some cases.

The use of sunscreen and sun-protective clothing, hats, and sunglasses should become part of her daily routine. Also, education on self-exams can promote early detection, improving mortality.

Health care providers need to highlight prevention. In communities, increased access to shade at public playgrounds and schools can promote sun protection. Education about the harmful effects of sun exposure, including indoor tanning, is needed. Avoiding sun exposure from 10 am to 4 pm is also recommended. Although Caucasians have a high risk of melanoma, those who are not white are also at risk for the disease. Communicating the dangers of sun exposure and the importance of wearing hats, sunglasses, protective clothing, and sunscreen with at least an SPF of 15 is vital.

Lisa Bridwell Robinson, DNP, CCRN, CNE, NP-C, is a family nurse practitioner and certified nurse educator who practices as a work site health coach. Dr. Robinson also serves as a faculty member for graduate nursing students in both master’s and doctoral programs of study. This case study is written in honor of her mother-in-law, a cherished nurse, wife, and mother who courageously battled melanoma.

Melanoma is the fifth most common cancer in men and the seventh most common cancer in women and accounts for most skin cancer deaths. 

Melanoma: An Overview

The leading preventable cause of death and disease in the United States is the use of tobacco.

Annually, 480,000 Americans die as a result of cigarette smoking. Each year, smoking-related illness costs the United States more than $300 billion.

An estimated 15% of adults, or 36 million people, in the United States are current cigarette smokers.

Nicotine from a cigarette reaches the brain of a smoker in less than 10 seconds. A sensation of pleasure results from an immediate release of dopamine and norepinephrine, and when the euphoria is gone the brain craves more.

Without a continuous release of these chemicals, the brain initiates symptoms of withdrawal. These withdrawal symptoms can include headache, nausea, diaphoresis, anxiety, tremors, irritability, and tachycardia.

The addiction to nicotine can be equal to the addiction of heroin. Continued exposure to nicotine increases tolerance, resulting in the smoker’s increasing usage to achieve the same effect. This results in an automatic, inevitable addiction.

The negative impact of smoking is far reaching. Cigarette smoke is composed of more than 7000 chemicals, many of which are toxic and some of which cause cancer. Physical consequences of smoking include the smell of smoke lingering on the clothes, hair, and breath. Gingivitis, yellowing of teeth, and eventually tooth decay can result.

Respiratory symptoms can include coughing, wheezing, and productive sputum.

In the long term, smoking can lead to lung scarring, chronic obstructive pulmonary disease (COPD), and asthma.

Cardiovascular complications of smoking can include myocardial infarction, stroke, and peripheral vascular disease.

Also in the long term, smoking tobacco has been associated with cancers of the lung, mouth, esophagus, larynx, colon, bladder, uterus, cervix, and kidneys.

Smoking cessation, at any time, decreases the risk of these serious conditions.

Nicotine replacement therapies (NRTs) are the first-line medications to assist with smoking cessation.

Using NRT, in any form, increases the likelihood of smoking cessation by 50% to 70%.

Although NRTs administer nicotine to the body, they do not contain the carcinogenic and toxic substances found in tobacco smoke.

The available forms of NRT include nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, and the nicotine patch. These medications do not have significant adverse effects.

NRTs should be used for at least 12 weeks, and can be used for up to 9 months. Nicotine patches are available in 21, 14, and 7 mg doses. The patch releases a small, continuous amount of nicotine, and the user decreases the dose over time.

Providing quicker absorption than the patch, the nicotine lozenge and nicotine gum allow nicotine to be absorbed through the oral mucosa. Gum and lozenges are available in both a 2 and 4 mg dose. Deciding on which dose to use is based on when the patient’s first cigarette is smoked: if within the first 30 minutes of waking, then the 4 mg strength should be used; if the first cigarette is smoked more than 30 minutes after waking, then the 2 mg dose should be used. Available only by prescription, the nicotine inhaler and nicotine nasal spray are less frequently used options. Of the NRT options, the patch is the slowest acting. Patients should be cautioned that using NRT while continuing to smoke can lead to angina or an myocardial infarction.

In none of the NRT options is nicotine absorbed as quickly as the nicotine in cigarettes.

To increase the likelihood of a successful cessation attempt, NRTs can be combined. The use of a nicotine patch and oral NRTs, especially with a heavy smoking history, can increase the chances of success.

Adherence to the use of NRTs has been found to be low. It is important for health care providers to encourage adherence by providing clear verbal and written instructions on the use of these therapies.

Non-nicotinic medication options to consider are varenicline (Chantix) and bupropion sustained-release (Zyban).

Both of these medications have been found to reduce cravings and withdrawal symptoms. Bupropion may also help with the mood changes associated with withdrawal symptoms.

A concern with these medications is the increased risk for depression and suicidal ideation.

Initial and ongoing assessment of mental illness and its symptoms is essential.

Varenicline should not be taken with NRTs because it is a nicotine receptor partial agonist, which means it blocks the brain's pleasure response from nicotine.

It should be started one week prior to quitting smoking for optimal results. The usual dose is 1 mg, twice per day.

One adverse effect of varenicline is nausea, so patients should be instructed to take the medication after a meal and with a full glass of water. Additional adverse effects can include constipation, headaches, sleep disturbance, and bizarre dreams.

The FDA has issued a black box warning related to psychiatric events while taking varenicline. Patients are advised, via the package insert, that if they experience any such events they should stop the medication and contact a health care provider.

Bupropion, an antidepressant, is usually prescribed for up to 12 weeks but can be used for a longer timeframe depending on individual need. Initiation of bupropion should begin 2 weeks prior to stopping smoking. Dosing is typically 150 mg once per day for a week, then increasing to 150 mg twice per day. It works by stabilizing levels of dopamine and norepinephrine. A history of seizures, anorexia, or bulimia is a contraindication for the use of this drug. Adverse effects of bupropion include insomnia, bizarre dreams, and dry mouth.

The FDA has also added a black box warning to bupropion, and patients should be monitored for depression, suicidal ideation, and suicide attempts. This package insert also alerts patients to immediately contact a health care provider if these symp- toms are noticed.

A treatment plan for smoking cessation could include the use of NRTs, like the nicotine patch, in combination with the non-nicotine medication bupropion.

Additional interventions are available to assist with smoking cessation success. Encouragement and advice from health care providers, along with referrals for counseling, should be considered.

Behavioral therapy, either individual or group-based, especially in the early weeks of smoking cessation, has proven to be beneficial. With ongoing behavioral support, smokers are 4 times more likely to quit.

In behavioral therapy, smokers receive advice, information, support, and encouragement. This allows the smoker to address issues like motivation to remain abstinent from smoking, discovering behavior change techniques, and developing coping skills.

Smokers can also identify triggers such as stress and develop coping strategies to overcome stressful situations. Relaxation techniques and stress reduction strategies further promote the likelihood of successful smoking cessation. Behavioral interventions can also include encouraging the smoker to set a quit date, to share their plans to quit with family and friends, and to prepare their homes for smoking cessation by removing items such as cigarette lighters and ash trays.

Support programs for smoking cessation are also available online and via telephone quit lines.

These options offer easily accessible support for smokers trying to quit. Online resources are available day and night and can provide information and interaction to support cessation attempts at times convenient to the patient.

Exercise and physical activity can also reduce nicotine cravings and withdrawal symptoms.

Additionally, exercise can offset the weight gain sometimes associated with smoking cessation. Symptoms of stress, anxiety, and depression experienced during smoking cessation can also be minimalized by daily exercise.

Recommended activities should be based on the patient’s abilities and interests. Walking, cycling, and swimming offer great aerobic benefit and should be considered.

Electronic cigarettes (ECs), also known as e-cigarettes and electronic nicotine delivery systems, are devices that heat a liquid for inhalation.

Sale and use of these devices has continued to increase in recent years. The liquid used in these devices varies widely and may or may not contain nicotine. Some of the liquid also have added flavoring. Concerns related to the safety of ECs are based on a lack of regulation for the liquids used in the devices.

A large variety of ECs are available for purchase, and research on the safety of their use is limited. Other concerns related to the use of ECs include the risk of poisoning in children and adults who handle the nicotine-containing cartridges used in the devices.

Currently, clinicians are advised to recommend other smoking cessation therapies until more is known about the safety of ECs.

Discussion with smokers about smoking cessation should always include education on the harmful effects of tobacco. Health care providers should also obtaining a detailed smoking history, including prior cessation attempts and discussions on the benefits of available pharmacotherapies.

Combination therapy of NRTs, such as the nicotine patch with nicotine gum or lozenges, has been found to be more successful with patients who have a longer and heavier smoking history.

Considering the use of non-nicotinic medications with or without NRT and addressing behavioral therapy interventions all increase the chances of success in a smoking cessation attempt. An individualized plan for smoking cessation should be tailored to each patient’s situation and needs and could include combining medication, behavioral therapy, support, and follow-up.

Providing patients with available resources and support, especially in the early weeks of a smoking cessation attempt, increases the likelihood of success.

, is a doctorally prepared family nurse practitioner

educator who practices in a retail clinic and as a worksite health coach. Dr. Robinson also serves as a faculty member,

for graduate nursing students in both masters and doctoral programs of study.

Burden of tobacco use in the U.S. CDC website. cdc.gov/tobacco/campaign/tips/resources/data/cigarette-smoking-in-united-states.html Updated February 2, 2017. Accessed February 25, 2017.

Porter A. The role of the advanced practice nurse in promoting smoking cessation in the adult population.

Channey S, Sheriff S. Evidence-based treatments for smoking cessation.

2012;37(4):24-31. doi: 10.1097/01.NPR.0000412892.27557.e8.

Siddiqui F, Huque R, Dogar O. Updated evidence-based guide to smoking cessation therapies.

2016;21(12):609-611. doi: http://dx.doi.org/10.12968/bjcn.2016.21.12.607.

Phillips A. Supporting smoking cessation in older patients: a continuing challenge for community nurses.

2016;21(9):457-461. doi: 10.12968/bjcn.2016.21.9.457.

Papandonatos G, Erar B, Stanton CA, Graham AL. Online community use predicts abstinence in combined internet/phone intervention for smoking cessation.

2016;84(7):633-644. doi:10.1037/ccp0000099.

Siu AL; US Preventive Services Task Force. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. preventive services task force recommendation statement.

2015;163(8):622-634. doi: 10.7326/M15-2023.

The leading preventable cause of death and disease in the United States is the use of tobacco. 

Smoking Cessation

Annual screening for tuberculosis (TB) has become a familiar process for many. Anyone working or volunteering in the health care industry or who may come in contact with high-risk populations has a risk of exposure and may be required to have periodic testing. Even college students are often expected to receive TB screening prior to beginning classes.

The history of TB can be traced back to the Middle Ages.

Over time, it has been known by various names, including phthisis pulmonalis, Pott’s disease, scrofula, the white plague—based on the pallor seen among infected patients&mdash;and consumption because it appears to consume the patient, causing profound weight loss.

Archeolo- gists have found TB in relics from ancient Egypt, India, and China.

TB develops after exposure to the organism

It is airborne, spreading from one patient to another when an infected patient sneezes, coughs, speaks, sings, or laughs.

Individuals in close proximity can breathe the TB bacteria into their lungs, and this exposure may lead directly to an active TB infection. Some individuals who are exposed and breathe in the bacteria do not immediately develop the disease, however. While the bacteria live in their body, they do not feel sick, do not have symptoms, and cannot spread the disease to others; this is called latent TB infection (LTBI).

One-third of the world's population is estimated to have LTBI, the persistent immune system response from exposure to the TB organism.

Over time, LTBI may develop into TB disease through the process of TB reactivation. The risk of reactivation in a healthy individual is estimated to be less than 10% and typically occurs within 5 years of becoming infected. Risk of reactivation is higher in children and in patients who have other predisposing factors, like HIV.

Reactivation of LTBI accounts for approximately 80% of TB cases.

Progression from LTBI to the disease of TB occurs only if the bacteria overcome the natural defense of our body’s immune system.

This progression can occur soon after infection, or it may happen later in response to a weakened immune system. Symptoms may include unexplained weight loss, loss of appetite, night sweats, fever, fatigue, and chills. A cough lasting longer than 3 weeks, hemoptysis, and chest pain are also frequently seen with the disease. Additional symptoms may be reported if the infection is affecting areas of the body other than the lungs.

An increased risk of progression to TB from LTBI is seen in specific populations. This is especially a concern in HIV-infected individuals. According to the World Health Organization, in 2015, globally, 55% of patients with TB had documented HIV test results.

Efforts to control TB around the world have focused heavily on detection and prevention of TB infection in this group. Additional factors that increase the risk of progression from LTBI to TB include individuals with chronic renal failure or those on hemodialysis; patients with diabetes, gastrectomy, jejunoileal bypass, organ transplant, and head or neck cancer

; and individuals who inject illegal drugs.

Even having a low body weight (more than 10% below ideal levels) increases the risk of progression from LTBI to active TB disease. Age can also be a factor. Elderly patients, babies, and young children 8 are considered at increased risk.

Testing for TB should focus on those who are at higher risk for becoming infected with the bacteria. The risk is greatest for individuals who have spent time with someone who has TB disease. This includes living or working in high-risk settings, such as correctional facilities, long-term care facilities, nursing homes, and homeless shelters.

Additionally, screening should be considered for anyone living among high concentrations of people, like refugee camps, mental health institutions, incoming college students from high incident countries, and military personal.

Anyone working or volunteering in the health care system may come in contact with those who have the disease and should be screened, too.

Scheduled TB screening of health care workers is an important part of an infection control plan and is required by law in some states. Concerns of transmission have also prompted screening of people from countries where TB is more common. This includes most countries in Latin America, Africa, Asia, and Eastern Europe.

Screening should also be considered for those who have any of the known risk factors for TB, including HIV or a weakened immune system.

Two screening test options are available to determine if a person is infected with the TB bacteria: the tuberculin skin test (TST) and the TB blood test.

Development of the TST began with Clemens von Pirquet, an Austrian-born scientist and physician who began using a small amount of isolated TB bacteria and scratching it into the skin to observe for a reaction. Expanding on the work of von Pirquet, Charles Mantoux developed the TST, which has remained, the standardized screening test for TB since 1907. The TST has also been called the Pirquet skin test, the Mantoux skin test, and the tuberculin sensitivity test.

TST can be administered the same day as live virus vaccinations. If not completed on the same day, the testing should be completed 4 to 6 weeks after live virus vaccine administration.

The standardized procedure for TST includes using a 27-gauge tuberculin syringe, bevel facing upward, to inject 0.1 ml of purified protein derivative on the inner aspect of the forearm. This intradermal injection, when placed correctly, produces a wheal (a pale ele- vation of the skin) 6 to 10 mm in diameter (Figure 1).13 The test must be read between 48 and 72 hours after placement; if not read within this timeframe, the test must be repeated. The second test can be given immediately because there is no contraindication to repeat testing.

Reading the TST and interrupting the results include measuring the induration and assessing the patient’s risk of TB infection. The reaction or induration should be measured in millimeters. Induration is defined as the hardened, palpable, raised area only and should not include measuring of erythema (redness) (Figure 2).

A measurement of 5 mm or more is read as a positive TST in the following populations:

• Those with recent contact with an individual who has TB

• Patients who have had organ transplants

•Those with known immunosuppression (eg, taking long-term, high-dose steroids)

An induration of 10 mm or more is read as a positive TST in these populations:

•Migrants from high-prevalence countries within the last 5 years

• Individuals who live or work in high-risk settings

• Patients with a diagnosis of conditions from high-risk categories

• Infants, children, and adolescents who have had exposure to adults from high-risk categories

All reactions with an induration of 15 mm or more are considered positive, even if no risk factors exist.

Some false-positive TST reactions have been documented. These reactions may be attributed to individuals’ being infected with nontuberculosis mycobacteria, having a history of bacillus Calmette-Guérin (BCG) vaccination, or receiving improper TST placement or interpretation.

Individuals infected with TB may not react to the TST and have a false-negative reaction. Possible explanations for false-negative results include recent TB infection (within the first 10 weeks of exposure), remote past history of TB infection, recent live virus vaccinations, or improper TST placement or interpretation.

A 2-step TST is now commonly used for health care workers. After the ini- tial TST is negative, a second TST is administered between 1 and 3 weeks later. The first TST may boost or stimulate a reaction to the second TST. This more comprehensive testing could reveal LTBI from exposures years earlier. These 2-step tests are typically used as initial or baseline screening only, mostly for new hires. Thereafter, routine annual TST screening of health care employees is recommended (Figure 3).

Interferon-Gamma Release Assay (IGRA) is the blood test used to detect TB bacteria.

Currently, 2 approved versions of the test are available in the United States. Lab protocols for collection and handling requirements of the blood should be reviewed prior to conducting this test. In the lab, the blood is used to test the patient’s immune system reaction to the TB bacteria.

A positive IGRA test indicates the patient has LTBI or TB disease. A negative IGRA test indicates that the patient’s blood did not react to the test and infection with LTBI or TB disease is very unlikely.

Deciding which test to use, TST or IGRA, can depend upon reasons for testing, test availability, and cost. No contraindication exists for using the IGRA test, and use of this test is preferred if the patient has received the BCG vaccine.

This vaccine is not recommended in the United States, but it is given in some high-risk countries at birth to prevent TB infection.

Results of a TST may be positive if the vaccine has been previously given.

The only contraindication to the TST is a severe reaction to a previous TST. Severe reactions include blistering, ulcerations, necrosis, and anaphylactic shock. TST is safe for infants, children, and pregnant women.

Simultaneous testing with both TST and IGRA is not recommended.

Neither test can discriminate between LTBI, TB disease, and treated infections.

Neither negative TST nor IGRA indicates that the person did not react to the test and is unlikely to have TB. Positive TST or IGRA results indicate the patient is infected with TB bacteria and further evaluation is needed.

A complete medical history and chest radiography with anterior, posterior, and lateral views are the usual initial assessments.

Chest x-ray has a high sensitivity and is well suited for early detection of TB.

Next, sputum samples are examined for acid-fast bacilli and cultured for mycobacteria.

Additional lab tests may also be ordered. After testing, if the patient is found not to have TB disease, but has TB bacteria present in the body, the diagnosis of LTBI is then made.

Current treatment options for LTBI can reduce the risk of developing active TB by as much as 90%.

A concern related to these treatments is the risk of hepatotoxicity. Close clinical and laboratory monitoring is required with the use of these therapies. Decisions about the treatment of LTBI are usually based on the likelihood of developing TB disease considering overall health and risk factors.

Positive diagnosis of TB disease requires treatment with antituberculosis therapy, which consists of several medications, for a period of 6 to 12 months.

The CDC and Infectious Diseases Society of America have comprehensive treatment guidelines available for treatment planning.

These guidelines urge beginning treatment as quickly as possible to decrease the likelihood of additional exposures. Common medications used for treatment include ethambutol, isoniazid, pyrazinamide, and rifampin. Close monitoring of patients receiving treatment is essential to assess for complications, such as drug— drug interactions.

Many new TB cases are diagnosed in marginalized groups, where access to treatment can be more difficult, making adherence a greater issue.

However, adherence to the medication regimen is essential for a cure. Drug-resistant TB developed when patients did not take their medications as prescribed or stopped their medications too soon. Therefore, in some communities, health department staff meet regularly with patients who are receiving medications for the treatment of TB disease just to observe the patient taking their medications. This process of direct observational therapy helps prevent drug-resistant strains of TB.

Since 1993, the number of new TB cases in the United States has continued to decline. At present, incidence rates are the lowest ever seen, with only 3 cases per 100,000 individuals. Still, 9412 new TB cases were reported last year.

There is still work to be done: at the current rate of decline, achieving elimination of TB will take another 70 years.5 In addition, because more than 13 million individuals in the United States are infected with LTBI, yet elimination of TB is dependent on preventing new cases. This is best achieved by screening to detect LTBI and preventing reactivation.

Premature death and avoidable adverse experiences result from TB, a treatable disease with a cure. Strategies to screen high-risk groups and individuals must continue. Following up with newly diagnosed cases of TB quickly can decrease new exposures and increase the chances of cure.

Dr. Lisa Bridwell Robinson, DNP, CCRN, CNE, NP-C, is a family nurse practitioner and certified nurse educator who practices in a retail clinic and as a worksite health coach. Dr. Robinson also serves as a faculty member for graduate nursing students in both masters and doctoral programs of study.

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3.     Testing for tuberculosis. CDC website. cdc.gov/tb/publications/factsheets/testing/tb_testing.htm. Updated September 1, 2016. Accessed October 3, 2016.

4.     Latent tuberculosis infection: Scaling up programmatic management of LTBI, a critical action to achieve the WHO End TB Strategy targets. World Health Organization website. who.int/tb/publications/ltbi_factsheet_161014.pdf. Accessed September 28, 2016.

5.     Mancuso J, Diffenderfer J, Ghassemieh B, Horne D, Kao T. The prevalence of latent tuberculosis infection in the United States.

2016;194(4):501-508. doi: 10.1164/rccm.201508-1683OC

6.     Global tuberculosis report 2015. World Health Organization website. who.int/tb/publications/factsheet_global.pdf. Accessed November 15, 2016.

7.     TB elimination: targeted tuberculosis testing and interpreting tuberculin skin test results. CDC website. cdc.gov/tb/publications/factsheets/testing/skintestresults.pdf. Published December 2011. Accessed November 15, 2016.

8.     Tuberculosis (TB): who should be tested. CDC website. cdc.gov/tb/topic/testing/whobetested.htm. Updated September 8, 2016. Accessed November 15, 2016.

9.     Improving early detection of active TB through systematic screening. World Health Organization website. who.int/tb/publications/tbscreening_factsheet.pdf?ua=1. Published 2013. Accessed November 15, 2016.

10.  American College Health Association Guidelines. Tuberculosis screening and targeted testing of college and university students.

2011;59(7):670-677. doi: 10.1080/07448481.2011.596733.

11.  Linas BP, Wong AY, Freedberb KA, Horsburgh CR Jr. Priorities for screening and treatment of latent tuberculosis infection in the United States.

Annual screening for tuberculosis has become a familiar process for many. Anyone working or volunteering in the health care industry or who may come in contact with high-risk populations has a risk of exposure and may be required to have periodic testing.

Lisa Bridwell Robinson, DNP, CCRN, CNE, NP-C

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