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U.S. Department of Health and Human Services

  

Core Curriculum on Tuberculosis, 2000

Chapter 8
Infection Control in Health Care Settings

Administrative Controls

The first level of the hierarchy, the use of administrative controls, is the primary strategy for infection control. Administrative controls are measures intended primarily to reduce the risk of exposing uninfected persons to persons who have infectious TB. These measures include

  • Developing and implementing effective written policies and protocols to ensure the rapid identification, isolation, diagnostic evaluation, and treatment of persons likely to have TB;
  • Implementing effective work practices among health care workers (HCWs);
  • Educating, training, and counseling HCWs about TB;
  • Screening HCWs for TB infection and disease.

All health care facilities or settings must have guidelines for the prompt detection of suspected TB cases. These guidelines should include assigning supervisory responsibility for TB control.

In general, clinicians should suspect TB in any patient who has a persistent cough (i.e., a cough lasting for ³ 3 weeks), bloody sputum, night sweats, fever, weight loss, or loss of appetite. The index of suspicion should be very high in areas or among groups of patients in which the prevalence of TB is high. In ambulatory and inpatient settings, designated personnel should develop a protocol for the early detection of persons with infectious TB, basing it on the prevalence and characteristics of TB in the population served.

Risk Assessment
TB infection-control measures should be based on the assessment of the risk for transmission of TB in that particular setting. Classification of risk for a facility, for a specific area, and for a specific occupational group should be based on

  • The profile of TB in the community;
  • The number of infectious TB patients admitted to the area or ward, or the estimated number of infectious TB patients to whom HCWs in an occupational group may be exposed; and
  • The results of analysis of HCW skin test conversions (where applicable) and possible person-to-person transmission of M. tuberculosis.

All TB infection-control programs should include periodic reassessments of risk. The frequency of repeat risk assessments should be based on the results of the most recent risk assessment.

Regardless of risk level, the management of patients with known or suspected infectious TB should not vary. However, the index of suspicion for infectious TB among patients, the frequency of HCW skin testing programs, the number of TB isolation rooms, and other factors will depend on whether the risk for transmission of M. tuberculosis in the facility, area, or occupational group is high, intermediate, low, very low, or minimal.

Inpatient Settings. The risk assessment should be conducted for the entire facility and for specific areas within the facility (e.g., medical, TB, pulmonary, or HIV wards; HIV, infectious disease, or pulmonary clinics; and emergency departments or other areas where TB patients might receive care or where cough-inducing procedures are performed). In addition, risk assessments should be conducted for groups of HCWs who work throughout the facility rather than in a specific area (e.g., respiratory therapists; bronchoscopists; environmental services, dietary, and maintenance personnel; and students, interns, residents, and fellows).

Outpatient Settings. In outpatient settings, such as medical offices, a risk assessment should be conducted periodically and TB control policies should be developed.

Managing Suspected and Confirmed Cases of TB
Inpatient Settings
. In hospitals and other inpatient settings, such as hospices and emergency rooms, patients known to have TB or suspected of having TB should be placed in a TB isolation room right away. All TB isolation rooms must have negative pressure relative to other parts of the facility (air flow from the corridors into the isolation room) and must be checked daily while in use to ensure proper air flow.

Patients who are placed in isolation rooms should be educated about the transmission of TB, the reasons for isolation, and the importance of staying in their rooms. Every effort should be made to help the patient follow the isolation policy ó including the use of incentives, such as providing telephones or televisions or allowing special dietary requests. As few persons as possible should enter the TB isolation room, and anyone entering the room should wear respiratory protection (see Personal Respiratory Protection).

If patients who may have infectious TB must be transported outside their isolation rooms for medically essential procedures that cannot be performed in the isolation rooms, they should wear surgical masks that cover the mouth and nose during transport. Persons transporting the patients do not need to wear respiratory protection outside TB isolation rooms. Procedures for these patients should be scheduled at times when they can be performed rapidly and when waiting areas are less crowded.

Because TB is transmitted through the air rather than by fomites or direct contact, the sterilization of personal items or eating utensils and the cleaning of walls are unnecessary.

Outpatient Settings. In an outpatient setting (e.g, medical offices, clinics), patients who have signs or symptoms of TB should be moved to an area away from other patients (preferably into a TB isolation room) and promptly given a diagnostic evaluation. These patients should be given a surgical mask and instructed to keep it on. They should also be given tissues and asked to cover the nose and mouth when coughing or sneezing to contain droplet nuclei before they are expelled into the air.

When EMS personnel must transport patients who are suspected or confirmed cases of TB, a surgical mask should be placed over the patientís nose and mouth.

After a thorough and timely diagnostic evaluation (see Diagnosis of TB), patients in whom TB has been confirmed or is suspected should start appropriate therapy at once. TB should be considered in HIV-positive patients with undiagnosed pulmonary disease. If TB is suspected, appropriate precautions to prevent airborne transmission should be taken unless infectious TB is ruled out.

TB Skin Testing and Prevention Program for Health Care Workers
The risk assessment should identify which HCWs have the potential for exposure to TB and the frequency with which the exposure may occur. This information can then be used to determine which HCWs to include in the skin-testing program and the frequency with which they should be tested. Health care workers, including home health nurses and emergency medical technicians, should be included in a TB testing and prevention program if the risk assessment indicates that they are at risk for exposure. This means tuberculin skin testing for HCWS upon employment and at repeated intervals determined by their risk of exposure thereafter. Any worker who develops symptoms of TB disease or whose tuberculin skin test result converts to positive should be evaluated promptly. In addition, all health care workers should be educated about the basic concepts of TB transmission and pathogenesis, including information concerning the difference between latent TB infection and active TB disease, infection control practices, the signs and symptoms of TB, and the importance of participating in the employee skin testing program.

Discharge Planning
Health care facilities should work closely with the health department to report all confirmed or suspected cases of TB, to ensure that contact investigations are carried out for all cases, and to develop an appropriate discharge plan, including arrangements for DOT and follow-up care, for TB patients or persons suspected of having TB. Patients who are suspected of having infectious TB may be discharged to their home after starting TB therapy, even though they may still be infectious. It is important to note that after treatment has started, persons who have TB are less likely to transmit the disease to members of their household. However, before the patient is discharged to home, clinicians and discharge planners should consider whether any household members were previously exposed or are at very high risk for TB disease if infected (e.g., HIV-positive or otherwise severely immunocompromised persons or children £ 4 years of age). If the household does include such persons, arrangements should be made to prevent them from being exposed to the TB patient until a determination has been made that the patient is noninfectious.

 


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination - http://www.cdc.gov/tb

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