LATENT

TUBERCULOSIS
INFECTION
(LTBI)
Dr Wan Muhammad Farhan bin Wan Fauzi
UKKP HKT
CONTENT
Introduction​
LTBI in Adults
​Screening
Treatment
​Monitoring
LTBI 3

INTRODUCTION
LTBI is a state of persistent immune response to stimulation of M. tuberculosis
antigen without clinical evidence of active TB.

About a quarter of the world population (approximately 1.7 billion people) are
estimated to have LTBI. (2016)
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INTRODUCTION
A person with LTBI has 5 - 10% risk of developing active TB during his/her
lifetime, usually within the first five years after initial infection.

Identification and treatment of LTBI, the reservoir for M. tuberculosis, should be

an effective strategy to prevent and reduce further transmission, morbidity and
mortality of TB disease.
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LTBI IN ADULTS
LTBI treatment should be targeted to the group of affected people at highest risk
for progression to active TB, as the testing and treatment of LTBI entails costs
and/or risks.
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LTBI IN ADULTS
AT RISK GROUPS OTHER RISK GROUPS

• household/close contacts of • healthcare workers

bacteriologically confirmed PTB • immigrants for high TB burden
• PLHIV countries
• patients initiating anti-tumour necrosis • prisoners
factor (TNF) treatment • illicit drug users
• patients receiving dialysis
• patients preparing for
organ/haematological transplant
• patients with silicosis and other
associated occupational lung diseases
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SCREENING
• The at-risk groups that should be screened for LTBI should fulfil the following
criteria to be diagnosed with LTBI:
• Absence of any clinical features suggestive of active TB (cough, fever, night
sweats, weight loss)
• Normal chest x-ray or static x-ray findings
• A positive TST or IGRA test

SCREENING
TUBERCULIN SKIN TEST (TST)
• According to CDC and National
Tuberculosis Controller Association
(NTCA), the window period (duration
between infection and skin test
reactivity) is 8 - 10 weeks after
exposure.
• Bacille Calmette-Guérin (BCG) has
limited effect on the interpretation of
TST results later in life as it is given at
birth for most of the population in
Malaysia
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INTERFERON GAMMA RELEASE
ASSAY (IGRA)
• IGRAs are blood tests that detect cell-
mediated immune response. The test
measure T-cell release of interferon
gamma following stimulation by protein
antigens secreted by M. tuberculosis
and a few other mycobacteria. However
it does not detect Mycobacterium bovis,
BCG and most of the non-tuberculous
mycobacteria.
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TUBERCULIN SKIN TEST

TST CUT-OFF VALUE FOR DIFFERENT GROUPS
Positive (TST) Types of individual
reaction
≥5 mm • PLHIV
• Organ transplant recipient
• Persons who are immunosuppressed for other reasons (e.g.
those taking the equivalent of >15 mg/day prednisolone for ≥1
month or taking anti-TNF treatment)
≥10 mm All other high risk individuals including healthcare workers and
children (except newborns and infants
≥15 mm Individuals from countries with low incidence of TB

Source: Ministry of Health Malaysia. Management of Tuberculosis (Third Edition). Putrajaya: MoH Malaysia; 2012
(Source: Pekeliling KKM 600-29/4/33(79), 28 Julai 2020) 10
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TREATMENT
LTBI treatment is designed to prevent the progression of asymptomatic TB
infection to clinically active TB. Evidence has proven that treatment of LTBI can
prevent 60 - 90% of cases from developing TB.

The benefit of treating individuals with LTBI should outweigh its harm. This is
because safety is particularly important in LTBI treatment as the patients are
asymptomatic without active disease. To ensure compliance and success of
treatment, an effective, safe and short regimen is preferred for both adults and
children.
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TREATMENT
• In the treatment of all adults with latent tuberculosis infection (LTBI):
• 3HR or 3HP* regimens should be the first-line regimen unless
contraindicated
• 4R may be used for patients who cannot tolerate or are
contraindicated for INH based regimens
• 6H or 9H may be used for patients who cannot tolerate or are
contraindicated for rifamycin-based regimens
• In HIV-positive adults with LTBI, 1HP* may be considered for treatment

3HR=three months daily isoniazid + rifampicin, 3HP=three months daily isoniazid + weekly rifapentine,
4R=four months daily rifampicin, 6H=six months daily isoniazid, 9H=nine months daily isoniazid, 1HP=one
month daily isoniazid + rifapentine.
*rifapentine is not yet available in Malaysia
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TREATMENT
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MONITORING
Adherence to complete the full course of LTBI treatment is important to ensure
the effectiveness of the treatment in preventing active TB.

Individuals with LTBI who have completed treatment are advised to follow-up
regularly for two years. Adults who developed active TB while on LTBI
treatment or during follow-up should be referred to specialists experienced in
managing TB. TB drug resistance testing should be done to rule out acquired
drug resistance.
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MONITORING
THANK YOU
Mirjam Nilsson​
mirjam@contoso.com
www.contoso.com