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1 Introduction to TB Nurse Case Management Online February 4, 11, 18 and 25, 2015 TB Infectiousness and TB Isolation/Segregation Presented by Jenelle Leighton RN, BSN February 11, 2015 Jenelle Leighton RN, BSN has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity 1

2 Objectives Determine TB patient infectiousness Isolation versus segregation Assess when a patient with active TB may return to work/school/community Infectiousness (1) Infectiousness is directly related to number of tubercle bacilli TB patients expel into the air TB patients generally expel more tubercle bacilli if their cough produces a lot of sputum Only people with TB of the lungs, airway or larynx are infectious 2

3 Infectiousness (2) Infectiousness appears to decline rapidly after adequate treatment is started; however: How quickly infectiousness declines varies from patient to patient Patients with drug-resistance TB may not respond to initial drug regimen Treatment with both Rifampin and Isoniazid is associated with a more rapid conversion of smears and cultures to negative Infectiousness (3) Children are less likely than adults to be infectious Children generally do not produce a lot of sputum when they cough 3

4 Characteristics of Infectiousness Infectiousness is related to: Cough > 3 weeks Cavitation on chest radiograph Positive sputum smears (bacteria load) 4

5 2005 MMWR Guidelines for the Investigation of Contacts of Person with Infectious Tuberculosis Why is the infectiousness status of an active case of tuberculosis important to understand? What impact may it have on your case management? 5

6 Isolation Isolation is the separation of ill persons who have a communicable disease (TB) from those who are healthy in a place and under conditions that will prevent the transmission of infection. This often includes restriction of their movement from the designated place of isolation to stop the spread of that disease or illness. Segregation To separate or set apart from others or from the main body or group; 6

7 Discharge from the Hospital Confirm residency Check with your agencies protocol Assure medications are available Household contact < 5 years of age evaluated Extra-pulmonary 2006 Summary of Changes for Correctional Facilities Placement of all inmates and detainees with suspected TB in airborne infection isolation (AII) immediately is emphasized Interferon Gamma Release Assays (IGRAs) have been added to testing recommendations Recommendations for ventilation have been added CDC Tuberculosis Module Training MMWR Article Volume 55, No. RR July 7, 2006 Prevention and Control of Tuberculosis in Correctional and Detention Facilities: Recommendations from CDC 7

8 Screening Methods Symptom Screening Symptoms suggestive of TB disease History of inadequate treatment for TB disease Place immediately in an AII room until patient has undergone a thorough medical evaluation Noninfectious May be released from AII 1. If TB diagnosis excluded OR 2. After patient is improving on multidrug anti-tb treatment if suspicion for TB diagnosis remains Infectious Should remain in isolation until treatment has rendered patient noninfectious (see Discontinuation of Airborne Precautions) Home Isolation/Segregation No work No school No public transportation No one comes over to your house No shopping, no movies, no church, no restaurants Decrease exposure time to household members 8

9 Isolation Requirements Patients with confirmed pulmonary TB disease should remain on isolation and are considered infectious until they have had ALL of the following: 3 consecutive negative AFB sputum-smear results collected 8 24 hours apart, with at least 1 being an early morning specimen AND Standard 4 drug anti-tb treatment for minimum of 2 weeks AND Demonstrated clinical improvement AND Demonstrate compliance with DOT Sputum Smears 3 consecutive negative smears Sometimes a patient will have two negative sputum smears followed by a positive sputum smear..what do you do? 9

10 Contract I,, understand I have been diagnosed with active or suspect pulmonary tuberculosis and that I have the following responsibilities in regards to my condition and treatment. That I must remain on home isolation until authorized by the St. Louis County Department of Health. What is required of you: Do not go to work or school Stay away from public gatherings Do not go to movies, theaters, malls, stores or restaurants Do not travel by public transportation Do not go to church or social clubs Do not have visitors in your home or visit other person s homes Do not have workers in your home for cleaning or repairs What you can do: Cover your nose and mouth with a tissue when you cough or sneeze Move about in your home Open the windows to let fresh air into your room Ride in the family car to your doctor s appointment Wear a mask when riding in the car with other people Upon entering the clinic or doctor s office, wear a mask Sit or walk outside in the fresh air, open air away from people That I will be placed on tuberculosis medications for the next several months and that this medication must be taken exactly as the doctor has instructed me to take it. That while on these medications I will be participating in Directly Observed Therapy (DOT) and must be available to the health care worker at the time and place we agreed upon, during St. Louis County DOH business hours, to receive my medications. That while taking these medications I must inform the doctor and nurse all other medications that I am taking. No alcoholic beverages while taking these medications. 10

11 That while taking these medications I will report any side effects to my doctor, outreach worker, or nurse. If serious side effects occur go to the emergency room. Side effects include but not limited to: Loss of Appetite Nausea Vomiting Yellowish Skin or Eyes Fever for 3 or More Days Abdominal Pain Tingling fingers or Toes Skin Rash Tingling or Numbness around the mouth Easy Bruising Blurred Vision Ringing in the Ears Hearing Loss Dizziness Aching Joints Easy Bleeding That I must keep all scheduled appointments. I understand that my failure to comply with these responsibilities could result in prolonging my illness and pose a health risk to myself. Failure to comply could increase the possibility of the tuberculosis reactivating and become transmissible. By my signature below I certify that my responsibilities in regards to my treatment for tuberculosis and the consequences of not meeting my responsibilities have been explained to me and that I understand these responsibilities. I further certify that my failure to meet these responsibilities could result in my involuntary hospitalization pursuant to of the Missouri Revised Statues. (Signature of Patient) (Date Signed) (Witnessed By) (Date Signed) I was present when the above was read to (Witnessed By) (Date Signed) 11

12 Jenelle Leighton RN, BSN St. Louis County Department of Health Division of Communicable Disease Control Services Phone Fax References MMWR: Guidelines for Preventing the Transmission of M. tuberculosis in Health-Care Settings, 2005 MMWR: Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosis, 2005 Heartland National Tuberculosis Center CDC Tuberculosis Module Training MMWR Article Volume 55, No. RR July 7, 2006 Prevention and Control of Tuberculosis in Correctional and Detention Facilities: Recommendations from CDC 12

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