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/CommunicableDisease/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/CommunicableDisease/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 48-72 hours later

Read the 1st TST

Visit #3 1-3 weeks after Visit 1

Place the 2nd TST

Visit #4 48-72 hours later

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/CommunicableDisease/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