Tuberculosis Procedure ICPr016 Table of Contents Tuberculosis Procedure ICPr016... 1 What is Tuberculosis?... 2 Any required definitions/explanations... 2 NHFT... 2 Tuberculosis (TB)... 3 Latent TB... 3 Pulmonary TB... 3 Non-pulmonary TB... 3 Smear positive TB... 3 Smear negative TB... 3 Signs and Symptoms of Active Tuberculosis... 3 Diagnosis... 3 Notification... 4 Treatment... 4 Infection Prevention and Control Precautions for In-Patients... 5 Infection Prevention and Control Precautions for Patients Nursed in their own Homes... 5 For further information... 5 Equality considerations... 5 Reference Guide... 6 Page 1 of 6
What is Tuberculosis? Tuberculosis (TB) is the name of the disease caused by a bacterium called Mycobacterium tuberculosis. TB most commonly affects the lungs (pulmonary) but can affect any organ in the body (non-pulmonary), or more than one. Tuberculosis is passed from person to person via airborne droplets. People with pulmonary tuberculosis produce infected droplets particularly during coughing and sneezing. Laryngeal tuberculosis is usually highly contagious. Significant close contact is required to enable transmission, defined by the WHO as approximately 8 hours of sharing the air of an infectious case of TB. However, in non-pulmonary tuberculosis infections, the following clinical situations must be considered potentially open and infectious: Urinary tract tuberculosis in catheterised patients Patients with open/draining tuberculosis lesions All other non-pulmonary tuberculosis cases are not infectious unless opened by a surgical procedure. In most people who come into contact with an infectious case of TB, their immune system kills the bacteria that have been inhaled and they are removed from the body. In a small proportion of people, the bacteria remain in the body in a dormant or latent state, causing no illness or risk to others. This latent infection has a low risk (<10%) of developing into active disease in the future, commonly if the immune system is put under stress by illness or major life events. A smaller proportion of people will develop tuberculosis as a result of their recent exposure and require treatment. There are certain groups of people who are at increased risk of TB including people who: Have lived in areas of high TB incidence HIV-positive younger than 5 years excessive alcohol intake injecting drug users solid organ transplantation haematological malignancy having chemotherapy had a jejunoileal bypass diabetes chronic kidney disease or receive haemodialysis had a gastrectomy having treatment with anti-tumour necrosis factor-alpha or other biologic agents have silicosis. spending time in prison homeless Any required definitions/explanations NHFT Northamptonshire Healthcare NHS Foundation Trust Page 2 of 6
Tuberculosis (TB) This is the name of the disease caused by a bacterium called Mycobacterium tuberculosis. Latent TB This is an infection that occurs when someone is infected with TB but the disease is inactive and the patient is well. They are not infectious to others and will probably never develop active TB. Pulmonary TB This is when TB occurs in the lungs. Non-pulmonary TB This occurs outside the lungs eg joint, bladder, lymph node. Smear positive TB This refers to sputum samples submitted to the laboratory where there are sufficient numbers of mycobacteria present that they can be seen under the microscope. This indicates that the patient is infectious. Smear negative TB This refers to samples submitted where no mycobacteria were seen under the microscope, because numbers present were smaller, but the specimen may go on to grow TB in the laboratory. Signs and Symptoms of Active Tuberculosis The common signs and symptoms include Cough lasting 3 weeks or longer, dry or productive Unexplained weight loss Increased fatigue Fever and night sweats Pain or swelling - in cases of non-pulmonary TB TB infections do not respond to standard antibiotic therapy. If the patient fails to improve following a course of antibiotics TB should be considered. Diagnosis Early diagnosis is of vital importance in order to reduce the risks of infection to others and to improve treatment outcomes. Advice should be sought from the Northants TB Nursing Service based at Isebrook Hospital on 01933 235848. Diagnosis of TB, regardless of site of infection, is made from microbiological culture of specimens. Patients with respiratory symptoms will be asked to undergo a chest X-ray and submit 3 sputum samples for TB as soon as possible. Specimens (patients with suspected TB that is not in the lungs will need to submit specimens from which ever part of the body is affected and advice should be sought from the TB Nursing service or from the TB clinicians at the appropriate Acute Hospital Trust) should be taken once daily, preferably on consecutive mornings. They will be sent to the Microbiology department at the appropriate Acute Hospital Trust. Investigation for TB must be specified on the request form as this is not a routine test. These specimens can confirm a diagnosis of TB and also the organism s drug sensitivities so Page 3 of 6
that correct treatment can be prescribed. The organism is very slow to culture and results may not be available for 6 weeks. People with suspected or confirmed TB do not need to be admitted to hospital unless there is a clear clinical or socio-economic need. All necessary tests can be carried out as an outpatient. Referrals to Acute Units for patients with possible TB are exempt from the Choose and Book process and are accepted by faxed letter in the interest of early assessment. TB treatment is complex. All TB, regardless of site of disease, are required to be managed by a chest physician or a paediatrician with experience of tuberculosis (NICE 2011). The TB Nurses work closely with these teams and with the patients through the diagnosis and treatment processes. The TB Nursing Service runs open-access TB Screening clinic at each end of the County. Patients do not need referral. Northampton - Chest Clinic, NGH every Wednesday Kettering - Northfield House, KGH on the 2 nd and 4 th Tuesdays of the month The clinics run from 0900 to 1030hrs. No appointment is needed. Notification Tuberculosis, whether infectious or not, is a notifiable disease. It is a statutory requirement in England, Wales and Northern Ireland for the diagnosing clinician to notify all cases of clinically diagnosed TB, whether confirmed by microbiological culture or not. Notification is made by the TB nurses using the enhanced TB Surveillance system. Treatment Treatment involves a course of specific antibiotics for at least 6 months, supervised by a TB Specialist Respiratory or Paediatric Consultant. In cases involving the central nervous system treatment is prolonged to 12 months. All TB, no matter the site of disease is managed in by a respiratory consultant in conjunction with any other specialist consultant. If the patient has a drug resistant infection or if they are unable to tolerate one of the drugs, the treatment will be amended and also prolonged. Directly Observed Treatment Rarely, a patient may prove themselves unreliable or unable to self-medicate. It may become necessary, in order to prevent the development of drug resistance in that individual, with all the attendant risks for the community, to manage that patient more closely. This is a substantial resource commitment involving home visits at least three times a week to administer the medication for the duration of treatment. Infectious Status Patients are considered to be infectious if they have smear positive pulmonary or laryngeal disease. The smear is positive when sufficient numbers of mycobacteria are present in the sputum so that they can be seen on direct microscopic examination in the laboratory. Following 2 weeks of effective treatment and clinical improvement, patients are considered non-infectious as long as treatment is continued. Page 4 of 6
Pulmonary cases in which no mycobacteria are seen on direct microscopy (smear negative) are considered to be less infectious than smear positive cases. Non-pulmonary and latent TB cases are not infectious. Infection Prevention and Control Precautions for In-Patients Patients with suspected pulmonary TB will be cared for in a single room with the door closed until the diagnosis is made. If sputum samples are reported as smear positive, the patient will stay in a single room until they have had 2 weeks of effective treatment and shown clinical improvement, as decided in consultation with the TB specialist treating clinician, consultant Microbiologist and TB Specialist Nurse. Health care workers do not need to wear personal protective equipment (PPE) when caring for patients with suspected TB unless multi-drug resistance (MDR-TB) is suspected or aerosol - generating procedures, such as nebuliser therapy, are being performed. When PPE is being used, the reason should be explained to the patient and their family/carers (NICE 2016). Those family members who have had close contact prior to admission do not need to use PPE. Screening of close contacts will be arranged by the TB Nursing Service. Inpatients with smear-positive respiratory TB should be asked (with explanation) a surgical mask whenever they leave their room until they have had 2 weeks' drug treatment. to wear Crockery and cutlery are not associated with the transmission of TB. Disposable equipment is not necessary. There is no need to isolate patients with non-infectious TB such as in a bone or lymph node. Standard precautions and effective hand decontamination practices will be adhered to at all times. There is no need to keep patients in hospital while the diagnosis is being made unless there is clear clinical or socio-economic need. Infection Prevention and Control Precautions for Patients Nursed in their own Homes The majority of patients with TB are treated at home. It is not necessary to isolate an infectious person on treatment from others with whom they have had regular contact prior to their diagnosis. Patients should be encouraged to minimise aerosol production by covering mouth and nose with a tissue when coughing. The tissue is discarded as domestic waste and the patient encouraged to wash their hands. Staff will ensure effective hand decontamination procedures are adhered to at all times. There is no need for staff to use PPE. Waste is disposed of as normal domestic waste. For further information Please contact the TB Specialist Nurse for Northamptonshire Equality considerations The author has considered the needs of the protected characteristics in relation to the operation of this protocol to align with the outcomes with IP&C Assurance Framework. We Page 5 of 6
have identified that ensuring that communication reaches all vulnerable groups. The service has been designed to ensure communication relevant to any healthcare associated infection reaches all sections of the community. This includes taking into consideration communication barriers relating to language or specific needs to reach the whole population. The Infection Prevention & Control team work closely with multi agency groups and community partners where appropriate we will undertake engagement and outreach activity with targeted action to relevant groups to follow NHS Improvements communication framework. Some groups are particularly vulnerable in relation to their protected characteristics, e.g. age, ethnic minority communities and disability and where we identify that, the expectation is that staff will meet the needs appropriately. Reference Guide Tuberculosis Clinical Diagnosis and Management of Tuberculosis for its Prevention and Control. NICE 2016 The Health Act 2008: Code of Practice on the prevention and control of infections and related guidance The Health and Social Care Act (2008) 2015 Public Health (Control of Disease) Act 1984 DH British Thoracic Society. Control and Prevention of Tuberculosis in the United Kingdom: Code of Practice 2000 (Thorax 2000; 55:887-90) Version No. Date Ratified/ Amended Date of Implementation Next Review Date Reason for Change (e.g. full rewrite, amendment to reflect new legislation, updated flowchart, minor amendments, etc.) 4.0 01.09.2015 02.09.2015 01.09.2017 New governance of trust policies template. 5.0 09/2017 09/2017 09/2019 Updated guidance 6.0 01/18 29/06/2018 31/01/2020 Changed from policy to procedure Page 6 of 6