Preventing Tuberculosis (TB) Transmission in Ambulatory Surgery Centers Heidi Behm, RN, MPH TB Controller HIV/STD/TB Program
Topics of Discussion TB Overview Epidemiology of TB in Oregon Annual Facility Risk Assessment Employee Screening Developing an Infection Control Plan Questions?
Why do we have to this? It s an Oregon Administrative Rule OSHA requires it. It s a CDC Guideline AND it s the right thing to do! Number of TB cases has dropped dramatically since 1993 due to infection control. During 90s outbreaks in medical settings were common. Still common in other countries.
Latent TB Infection vs. Active TB Latent TB Infection (LTBI) -Positive TB skin test or IGRA -No symptoms of TB -Normal CXR -Not contagious Active TB Disease (pulmonary, typical) -Maybe positive TB skin test or IGRA -Abnormal CXR -Symptoms of TB (cough, hemoptysis, fever, weight loss) -Contagious if pulmonary
Epidemiology of TB in Oregon 2011-74 cases of active TB disease 68% Portland Metro: Multnomah, Washington, Clackamas All counties in OR are low incidence by CDC definition Cases of TB disease continue to decline in Oregon and nationally!
Why is epidemiology important? Need for annual risk assessment Indicates facility s chance of encountering patient with active TB Your community profile is at: http://public.health.oregon.gov/diseasesconditions/communicabled isease/tuberculosis/documents/data/commriskassess.pdf
Annual Facility Risk Assessment Document and complete annually Looks complex-but is easy! Needed to plan your TB Infection Control Program Helps you determine what your employee screening program should be Found online at: http://public.health.oregon.gov/diseasesconditions/communicabledis ease/tuberculosis/documents/tbriskassessment.pdf
Employee Screening and Risk Assessment Annual risk assessment needed to determine risk level Most Oregon facilities are low risk For outpatient settings low risk = < 3 patients for the preceding year
Employee Screening- low risk facility New hires must have symptom screen, risk assessment and two step TB skin test, or IGRA or chest x-ray. Employee annual screening not required! GOOD contact investigation needed if exposure.
Two Step Testing Detects past TB infection if diminished skin test reactivity. First TST may not be positive, but helps body remember TB. Second TST evokes positive response because body now identifies and reacts to PPD. If employee has documentation of negative TST within last year, only one TST needed!
Procedure Two Step Test Visit #1 Day 0 Place the 1st TST Visit #2 Visit #3 Visit #4 48-72 hours later 1-3 weeks after Visit 1 48-72 hours later Read the 1st TST Place the 2nd TST Read the 2nd TST
Cut off for Positive TST For HCWs 10mm is cut off unless other risk factors Other risk factors HIV/AIDS, on TNF alpha inhibitor (Humira, Enbrel, Remicade), etc. If an employee has NEVER worked in healthcare can use 15 mm
Interferon Gamma Release Assay A blood test for LTBI QuantiFERON Gold and T SPOT More specific than TST- won t react to BCG vaccine and most non-tuberculosis mycobacterium Single visit needed If HCW has an IGRA from another facility that was done within the last year, do not need to repeat it
Employee Positive Tests: Evaluation and Treatment Newly positive need symptom check and CXR If employee is previously positive, documented normal CXR within past 6 months acceptable (this may change) If > 6 months or no documentation repeat CXR needed Refer to PCP for further evaluation and possible LTBI treatment
TB Infection Control Plan Each facility should have a documented TB Infection Control Plan Review it annually Make someone responsible for the plan The plan should be written and specific to your location Employees should know where it is If a patient is not triaged appropriately or there s evidence of HCW infection, an investigation should take place and your plan changed if appropriate
Plan Element 1 1. Defines employees who are at risk All employees with direct patient contact are at risk for TB exposure.
Plan Element 2 2. Screens employees for TB All new employees with direct patient contact will be screened for TB symptoms and risk factors upon hire. A QuantiFERON test will be given within 2 weeks of start date for previously negative employees. This facility is determined to be low risk so annual testing is not required.
Plan Element 3 3. Conducts follow-up of employees exposed Specify name of person responsible TB symptom screen and baseline TB test will be administered within 1 week of exposure. If post exposure baseline is negative, a second test will be given 8-10 weeks after last exposure.
Plan Element 4 4. Provides employees with TB training -Employees will be given TB training upon hire and annually thereafter. -Employee will sign a record at session end acknowledging understanding. -Training will include: -where to get copy of TB IC Plan -groups at TB risk esp. immunocompromise -mode of transmission and s/s - methods to prevent transmission and procedure for isolating
Plan Elements 5-7 5. Identifies suspected or confirmed TB cases 6. Isolates or controls exposures when an infectious TB patient is identified 7. Alerts employees to hazards Coughing patients will be given a surgical mask and taken to room 1B for further assessment. A sign will be placed on the door alerting staff to use proper precautions.
May be needed in plan Protects employees during high-risk procedures bronchoscopy, sputum induction, suctioning, Uses environmental controls to reduce the likelihood of TB exposure brief comment on rooms and waiting area Maintains environmental controls Uses respirators (a written respiratory protection program is also required)
Summary LTBI is not contagious. Active pulmonary TB is airborne and contagious. Both should be treated. Each facility should conduct an Annual Risk Assessment. Most facilities will be low risk -new hire: two step (TST) or single IGRA, no annual Each facility should have a TB Infection Control Plan that is specific to your facility. Staff should know where it is.
Resources Annual Risk Assessment: http://public.health.oregon.gov/diseasesconditions/communicablediseas e/tuberculosis/documents/tbriskassessment.pdf Community TB Profile for Annual Risk http://public.health.oregon.gov/diseasesconditions/communicablediseas e/tuberculosis/documents/data/commriskassess.pdf CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. http://www.cdc.gov/tb/publications/guidelines/infectioncontrol.htm Tuberculosis Infection Control: A Practical Manual for Preventing TB, Curry International TB Center http://www.currytbcenter.ucsf.edu/products/product_details.cfm?productid =WPT-12CD
Questions? Heidi Behm, RN, MPH 971-673-0169, heidi.behm@state.or.us Local Health Department Contact information at: http://www.oregon.gov/dhs/ph/lhd/lhd.shtml