What s New in TB Infection Control?

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1 What s New in TB Infection Control? Mark Lobato, MD Division of TB Elimination CDC / USPHS March 24, 2010 Providence, RI

2 Keeping the scourge at bay

3 Early disease prevention Modern cough etiquette

4 When I think of personal infection control

5 Really important levels of control Administrative Without, TB control fails Environmental Personal respiratory protection NOT the 1st level of control, training is critical

6 (Almost) everything you need to know about TB infection control in the health-care setting Morbidity and Mortality Weekly Report Recommendations and Reports December 30, 2005 Vol. 54 / No. RR-17 uidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings,

7 What s New? Broadens the scope of health-care settings Redefines TB risk assessment Changes TST frequency for HCWs Defines airborne infection isolation (AII) Summarizes respiratory fit testing Expands information on engineering controls

8

9 Risk is Variable Type of health-care facility Prevalence of TB in the community Patient population served HCW occupational group Area in the hospital Effectiveness of TB infection control

10 Changes in Risk Classifications and TST Frequency Screening

11 Risk Classifications Previous! Minimal! Very low! Low! Intermediate! High New! Low! Medium! Potential ongoing transmission

12 Risk Classifications for Hospitals Inpatient settings Low Medium Potential Ongoing Transmission <200 beds <3 TB patients/yr 3 TB patients/yr Evidence of ongoing transmission, 200 beds <6 TB patients/yr 6 TB patients/yr regardless of setting

13 Risk Classifications for Outpatient Settings Outpatient settings Low Medium Potential Ongoing Transmission medical offices, ambulatory care settings, TB treatment facilities <3 TB patients/yr 3 TB patients/yr Evidence of ongoing transmission, regardless of setting

14 Risk Classifications for Other Health-Care Settings ontraditional acility-based ettings Low Medium Potential Ongoing Transmissio MS, LTCFs, edical ettings in orrectional acilities, utreach care Only LTBI; system for detection of persons with TB symptoms Settings where persons with TB disease are treated Evidence of ongoing transmission regardless o setting

15 Example of Risk Classification (1) A 100 bed hospital Two TB patients admitted in the past year Contact investigation in exposed employees found no evidence of transmission Risk Classification: Low

16 Example of Risk Classification (2) Big city hospital admits 30 TB patients/ year TB test conversion rate of 1.0%; 3/20 (15%) respiratory therapists (RTs) converted Problem evaluation: The three who converted spent time where induced sputum specimens are collected Ventilation in this area is inadequate Risk Classification: 1. Potential ongoing transmission for RTs 2. Rest of facility: Medium

17 Example of Risk Classification (3) A home healthcare agency that serves a clientele w/ TB rates higher than community No patients with TB in past year 125 workers; 1/3 are foreign-born provide nursing, PT, basic home care at baseline two-step testing, 4 TST+; 2 TST+ on second-step; no cases Risk Classification: Low

18 TB Screening Frequency isk lassification ow edium otential ngoing ansmission Baseline; then further screening no necessary unless exposure occurs Baseline; then annually Baseline; then every 8 10 weeks until transmission interrupted

19 Airborne Infection Isolation (AII) in Specific Settings

20 Recommendations for AII Precautions iw tting spital oms Administrative controls Persons with suspected or confirmed TB placed in AII room Environment controls At least one inpatient AII room Air cleaning to ACH Respiratory protection Persons entering AII room of person with suspected/ confirmed T

21 Recommendations for AII Precautions 6hiw etting Administrative controls Environmental controls Respiratory protection D Prompt recognition/ triage of patients with suspected or confirmed TB At least 1 AII room for persons with suspected or confirmed TB in facilities with medium or higher risk For HCWs entering AII room of persons with suspected or confirmed TB

22 Recommendations for AII Precautions hiw etting Admininstrative controls Environment controls Respiratory protection ome ealthare Train patients and family about meds, cough etiquette, medical evaluation Postpone travel No coughinducing procedures unless appropriate infection controls are in place Consider when transporting patients w/ suspected or confirmed TB in an enclosed vehicle

23 riteria for Initiating AII Precaution Patient has signs or symptoms of infectious TB disease or Whenever patient has documented culture-positive pulmonary TB disease and is still infectious

24 Criteria for Discontinuing AII When infectious TB is unlikely and either 1) Another diagnosis is made that explains the clinical syndrome or 2) Patient has three consecutive negative AFB sputum smear results

25 Frequency of Sputum Collection for Patients with Suspected TB Disease Three negative sputum smears At least 8 hours apart At least one collected during early AM In many cases, patients with negative sputum smear results may be released from AII in 2 days

26 Who needs two-step testing? Situation New employee No previous TST Neg TST >12 months ago Neg TST <12 months ago Previous documented + TST Previous undocumented + TST Previous BCG Current employee with negative TST >12 months ago Recommendation Two-step test Two-step test 1 additional test No TST needed Two-step test Two-step test Single TST

27 Case Studies

28 Case 1: Stepping Out 22 year old student from India went to her private physician with complaints of chest pain and fatigue History of positive TST result and no Rx Sputum smear is positive for AFB Started on 4 drugs

29 Is this person infectious? Can she go to the store? Can she attend class with a mask?

30 Case 2: Long-term residence 42 year old female with some dementia cough x 3 wks 10 lb. weight loss No insurance

31 Chest radiograph

32 What s the Plan? Can this patient stay in the facility? If yes, What do you want to do? What do you want to know?

33 Case 3: In the E.D. 39 y/o Peruvian male in ED complains of cough for 3 months night sweats 18 lb. weight loss No known TB exposure TST 2 years ago was negative No travel since arriving in the U.S.

34 LUL cavitary process; bilateral apical opacities

35 Send home? Keep in ED? Admit to hospital? Triage

36 Key to good infection control Think TB! Follow administrative rules Start 4 drugs Patient education Directly Observed Therapy Monitor Discharge planning Respiratory protection

37 What happens when your best efforts fail?

38

39 Background On average there are 15 contacts identified for every respiratory TB case in the U.S. ~25% are infected with TB 1% of identified contacts are diagnosed with disease 10% of newly infected (immunocompetent) contacts will develop TB disease

40 Site of disease Pulmonary/ laryngeal/ pleural Pulmonary suspect (pending cultures) Non-pulmonary and laryngeal involvement ruled out AFB sputum smear positive AFB sputum smear negative or not performed Contact investigation not indicated Culture/ NAA positive or not performed Culture Negative Abnormal CXR consistent with TB Abnormal CXR not consistent with TB Always initiate Not indicated If sufficient resources In exceptional circumstances hen to initiate a Contact Investigation

41 Initial interview Conduct within 1 business day of report for infectious persons Within 3 days for noninfectious persons Re-interview 7-14 days post initial interview One interview should be in the living space of the patient Interviews

42 Prioritization of Contacts (1) Patient has pulmonary, laryngeal, or pleural AFB smear + TB Household contact Contact <5 years of age Contact with medical risk factor (e.g., HIV) Contact with exposure during medical procedure (e.g., sputum induction, bronchoscopy, autopsy) Contact in a congregate setting Contact exceeds duration/environment limits Contact is 5 years and 15 years of age High High High High High High Medium Any contact not classified as high or medium priority is assigned a low priority.

43 Prioritization of Contacts (2) Patient is a suspect or has confirmed pulmonary/pleural TB AFB smear negative, abnormal chest radiograph consistent with TB disease, may be NAA and/or culture positive Contact <5 years of age Contact with medical risk factor (e.g., HIV) Contact with exposure during medical procedure Household contact Contact exposed in congregate setting Contact exceeds duration/environment limits (limit per unit time established by the TB program) Any contact not classified as high or medium priority is assigned a low priority. High High High Medium Medium Medium

44 Estimating the Beginning of the Infectious Period TB symptoms Yes Yes Characteristic of Index Case AFB sputum smear positive No Yes Cavitary chest radiograph No Yes Likely period of infectiousness 3 months before symptom onset or 1 st positive finding consistent with TB disease, whichever longer 3 months before symptom onset or 1 st positive finding consistent with TB disease, whichever longer No No No Yes Yes SOURCE: California Department of Health Services Tuberculosis Control Branch; California TB Controllers Association. Contact Investigation Guidelines. Berkley, CA; 1998 No 4 weeks before date of suspected diagnosis 3 months before positive finding consistent with TB

45 Infectious Period Starts Start of the infectious period: 3 months before the diagnosis if no respiratory symptoms Or 3 months before the onset of symptoms, whichever is longer Start End e in months 3 3/ /25 3 8/ /6 Beginning of infectious period Onset of symptoms Beginning of infectious period Diagnosis of pulmonary TB Infectious Period

46 Infectious Period Ends The infectious period ends when the patient is isolated Or when all the following criteria are met: 1) effective treatment for >2 weeks (rule of thumb) 2) diminished respiratory symptoms 3) bacteriologic response as evidenced by the decrease in grade of smear positivity 11/6 Patient starts therapy 11/20 End of infectious period 2 weeks after start of meds me in weeks

47 Memory Aid Infectious Period Start Memorial Day Columbus Day End 3/25 Easter or Passover 4 th of July Labor Day 11/6

48 Prioritization Transmission probability assessment identifies contact tracing priorities based on the following characteristics person place time exposure

49 Person Characteristics linical data High likelihood Low likelihood of transmission of transmission isease location Laryngeal/pulmonary Extrapulmonary mear status Positive Negative mear source Spontaneous Induced or clinical XR Cavitary Non-cavitary ymptoms Cough No cough nti-tb drugs No Yes ( 2 weeks)

50 Place Characteristics Factor High likelihood Low likelihood of transmission of transmission Volume of air common Low High to the case/contacts Adequacy of ventilation Poor<10 Good>20 CFM/person CFM/person Recirculated air Yes No UV light Not present Present

51 Determining When to Expand a Contact Investigation onsider the following factors Achievement of program objectives with high and medium priority contacts Extent of recent transmission in identified contacts Unexpected high rate of positive TSTs, or Evidence of secondary cases, or Transmission to contacts aged <5, or Documented TST conversions, or Change in TST status from negative to positive

52 A Social Network with Place Bill Juan Rose Ted Mel s Bar Rita Ali Moe

53 Window Period Prophylaxis Decision to treat contacts with a negative skin test result should take the following factors into consideration The risk of the contact person for developing disease The frequency, duration, and intensity of exposure Corroborative evidence of transmission from the index patient

54 Thank you!

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