484 - Tuberculosis Update, HSV-2 Screening, Time to “Yz-up”!

From the CDC and the Virginia Department of Health

1)  Refresher on TB Testing and Latent TB Infection Reporting

Tuberculosis (TB) is a disease that flies under the radar for many of us, but deserves our constant vigilance given that it is still the second leading infectious cause of death in the world (after COVID-19). Here’s a quick refresher on the basics of TB testing and reporting of latent tuberculosis infection (LTBI).

The US Preventive Services Task Force recommends screening the following patients:

·       Patients at high risk of acquiring TB

o   Exposure to TB

o   Residence in or frequent travel to countries with endemic TB

o   Healthcare workers exposed to TB

o   Residents or employees of large group institutions/workplaces

·       Patients at high risk of developing active disease if infected with TB:

o   Immunosuppressed

o   HIV infection

o   Diabetes mellitus and other medical conditions (renal failure, silicosis, s/p ileostomy/jejunostomy, leukemia or certain cancers, etc.)

o   Very old or very young patients

o   Recent TB infection (within 2 years), etc.

o   Substance use disorder

Screening and testing can be done by tuberculin skin test (TST), or by blood test (interferon-gamma release assays, IGRA). Importantly, these tests work the same way to diagnose TB – they both can be indicative of infection at some time in the past, but neither can differentiate active TB from LTBI.

A positive TB skin test depends on the patient’s risk factors:

·       high risk – HIV positive, immunosuppressed, recent contacts - 5 mm of skin induration

·       moderate risk – healthcare workers, drug abuse, congregate living situations, diabetes, residence in or travel to endemic areas, etc. – 10 mm induration

·       low risk – 15 mm induration, but generally, low risk folks should not be tested.

An IGRA test is reported as positive, negative, or indeterminate. Indeterminate tests. Indeterminate tests can result from immunosuppressant medications and other immune conditions and should be repeated. Consult infectious disease for a question about these results if needed.

If a TB test (blood or skin) is positive, the priority is to check for symptoms (fever, weight loss, night sweats, cough) and perform a chest x-ray. If either of those tests is positive, the patient should be evaluated for active tuberculosis. Contact your friendly health department or infectious disease consultant if needed.

If the patient has no symptoms and a negative chest x-ray the patient has LTBI. In a patient without immune compromise or other risk factors, there is a roughly 10% risk of conversion to active TB (5% in the first 2 years, and 5% over the remainder of their lifetime).  Treatment for LTBI can reduce that risk to <1%.  Treatment includes some combination of isoniazid and rifamycin-based antibiotics (INH + rifapentine for 3 months and INH + rifampin for 3 months are preferred options – but see the TB Core Curriculum document referenced below for complete information).

Since 2018 in Virginia (and increasingly in all states), LTBI is a reportable infectious disease. As such it must be reported by the testing clinician, and the health department needs the clinical information to go with that report, so it is not something that can be “left to the lab” to do.  The Virginia Department of Health has tried to make this easier with a one-page fillable PDF form that can be emailed or faxed (see Reference 2 below), or the report can be initiated by phone to your local health department.

John’s Comments:

There is a list of all reportable diseases available at the VDH TB page listed below. Reporting diseases like this is nobody’s favorite part of being a clinician but is an important professional responsibility. Doing a little preparation on the front end by bookmarking sites, saving phone numbers, and training your staff can make this a less burdensome process.

References:

·       Virginia Department of Health. Disease Regulations Update. Published online November 16, 2018. Accessed January 31, 2023. Link

·       Virginia Department of Health. TB Infection (LTBI). Tuberculosis. Accessed January 31, 2023. Link

·       Centers for Disease Control and Prevention, Division of Tuberculosis Elimination (DTBE). Core Curriculum on Tuberculosis: What the Clinician Should Know. 7th ed.; 2021. Link

From the USPSTF

 2)  Guidance on Routine Screening for Genital Herpes

Genital herpes is a common sexually transmitted infection (STI) caused by 2 related viruses, herpes simplex type 1 (HSV-1) and herpes simplex type 2 (HSV-2).  HSV-1 causes both orofacial and anogenital infection; HSV-2 rarely presents outside of the anogenital area.  While antiviral medications may provide clinical benefits to symptomatic persons, infection is lifelong.  Transmission of HSV can also occur from mother to infant during delivery when genital lesions or prodromal symptoms are present. 

While the precise prevalence of asymptomatic HSV-2 infection is difficult to determine, it is estimated that over the past 20 years HSV-1 and HSV-2 seroprevalence has steadily declined, yet specific populations remain disproportionately affected.  The 2015-2016 National Health and Nutrition Examination Survey of persons aged 14-49 estimates seroprevalence of HSV-1 to be highest in Mexican American (72%) and non-Hispanic Black (59%) persons compared with the general US population (48%).  Estimated seroprevalence of HSV-2 in US non-Hispanic Black adolescents and adults (35%) is nearly 3 times that in the general US population (12%).   During pregnancy, an estimated 22% of the US population may be seropositive for HSV-2. 

Currently, routine serologic screening for genital herpes is limited by the low predictive value of the widely available serologic screening tests and the expected high rate of false-positive results likely to occur with routine screening of asymptomatic persons.  In this context, the USPSTF recently published an update of their 2016 recommendation regarding screening of asymptomatic persons for HSV-2 infection.  In line with their previous recommendation, they concluded with moderate certainty that the harms outweigh the benefits for population-based screening for genital HSV infection in asymptomatic adolescents and adults, including pregnant persons and recommend against such screening (D recommendation).  

 Mark’s Comments:

This recommendation provides another important reminder regarding why both disease prevalence and the characteristics of a screening test are both important when determining whether to use it for population-based screening.  Specifically, the most concerning potential harm of screening for HSV-2 would be the considerable anxiety and disruption of personal relationships that a positive test could cause, particularly knowing that almost half of the positive screening tests would likely be false positive given the prevalence of disease and the limitations (low specificity) of the existing testing process.  Thus, the wisdom of the “D” recommendation.

 References:

US Preventive Services Task Force. Serologic Screening for Genital Herpes Infection: USPSTF Reaffirmation Recommendation Statement. JAMA 14 February 2023; 329(6):502-507. doi:10.1001/jama.2023.0057.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  It’s Time to “Yz-up”! 

“Why is it important to swim with a buddy?”  Our local YMCA swim instructor

One of the inspirations for the PeerRxMed process is the YMCA youth swimming program – specifically their “buddy system” for swimmers.  I learned to swim at the “Y”, and prior to the pandemic, was a regular fixture at our local branch.   Before a children’s swimming class gets in the pool, the instructor always asks, “Why is it important to swim with a buddy.”  The most common answer is an enthusiastic “So somebody is watching out for you!”, often followed closely by “So you don’t drown!” and “Because it’s more fun!”  There is great wisdom in all three of these answers.

On January 27^th, Medscape released the results of their annual “Physician Burnout and Depression Report.”   The results were sobering, as was the quote included as part of the title:  “I cry but no one cares.”   The tragically high prevalence of professional burnout (53% overall – up from 47% a year ago) has been ongoing for so long now and the proportional response seemingly so anemic that it would be understandable if many colleagues are feeling forgotten.  However, what really caught my attention were some additional data that are quite notable and very relevant to the PeerRxMed movement.   For instance, the question, “How do you cope with burnout?” had almost as many colleagues answering “spend time alone/isolate myself” (40%) as “Talk with family or friends” (45%), and almost a quarter of respondents indicated they use alcohol to cope.  

It gets worse.  For the question “Has burnout had a negative effect on your relationships?”, 65% of our colleagues answered “Yes” (and I would contend the other 35% haven’t asked), yet only 13% have sought professional help and more than a third indicated they would not consider seeking help.   In addition, 23% said they felt depressed and 6% indicated they were experiencing clinical depression, yet over half shared they would not seek help because “depression says something negative about me.”    

So once again we must ask the annual follow-up question, “What’s up with this behavior!?”  We all know the healthcare system is dysfunctional and it requires extreme daily effort on the part of clinicians to try and navigate it.  And yet, in the midst of these challenges, instead of learning from our swim class teachers and supporting each other, we too often lean into our professional bias toward independence, isolation, and aversion to help-seeking to get through the day.  Indeed, such an approach is built into the culture of medicine – it’s what we’re selected to do, trained to do, socialized to do, programmed to do, and expected to do.  In many ways, it’s our “badge of honor.”  Somehow, we’ve come to believe that as long as we emotionally “armor-up” we are magically invulnerable to the tragedy and suffering we’re surrounded by each day as well as the often-overwhelming patient care demands, regulatory burdens, administrative hassles, technological inefficiencies, structural challenges, and organizational dysfunction.

PeerRxMed was created to help break down the many barriers the culture of medicine has created which interfere with our fundamental human need to connect with and support each other.  The past 3 years have only brough into finer focus this need that existed before the pandemic and will be here after.  So let’s learn an important lesson from the local swimming class and be sure to regularly check in with our colleagues to ensure that none of us are trying to “swim” without a buddy.   Doing so in the face of the statistics above is just reckless … and lonely.  It’s time to “Yz-up” and help each other do the same.  No one should care alone … ever.

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org