Core Curriculum on Tuberculosis, 2000
Infection Control in Health Care Settings
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
- 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.
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.
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
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
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.
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.