Maria Dalbey RN. BSN, MA, MBA March 17 th, 2015

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1 Maria Dalbey RN. BSN, MA, MBA March 17 th, 2015

2 2 Objectives Participants will be able to : Understand the Pathogenesis of Tuberculosis (TB) Identify the Goals of Public Health for TB Identify Hierarchy of infection prevention Administrative Controls Environmental controls Personal respiratory protection Identify infection control strategies to prevent the transmission of TB in the healthcare setting

prevention Administrative Controls Environmental controls Personal respiratory

3 3 Goals of Public Health for TB Find and assure the cure of all cases of active TB Identify those infected with TB who are at the greatest risk of developing active TB disease Reduce morbidity and mortality to the patient as well as reduce spread to the community

greatest risk of developing active TB disease Reduce morbidity

4 Tuberculosis (TB) About 80 active TB cases per year in Kentucky Caused by Mycobacterium tuberculosis Airborne transmission, usually by droplet nuclei Symptoms of lung TB: persistent cough, weight loss, night sweats Tests: Tuberculosis Skin Test (TST) or Blood Assay for MTB (BAMT) Report suspected and confirmed cases to Local Health Departments Image Source: Human Biology, Starr and McMillan 4

cough, weight loss, night sweats Tests: Tuberculosis Skin Test (TST) or Blood Assay for MTB (BAMT)

5 Pathogenesis of TB Infection and Disease Droplet nuclei containing tubercle bacilli are inhaled, enter the lungs, and travel to the alveoli. Tubercle bacilli multiply in the alveoli. A small number of tubercle bacilli enter the bloodstream and spread throughout the body. The bacilli may reach any part of the body, including areas where TB disease is more likely to develop (such as the lungs, kidneys, brain, or bone). 5

A small number of tubercle bacilli enter the bloodstream and spread throughout the body.

6 Pathogenesis of TB Infection and Disease Within 2-10 weeks, the immune system produces special immune cells called macrophages that surround the tubercle bacilli. The cells form a hard shell that keeps the bacilli contained and under control (TB infection) If the immune system cannot keep the bacilli under control, the bacilli begin to multiply rapidly (TB disease). This process can occur in different places in the body, such as the lungs, kidneys, brain, or bone (see diagram in box 3). 6

The cells form a hard shell that keeps the bacilli contained and under control (TB infection) If the immune system cannot keep the

7 7 TB Disease Signs and Symptoms ( S/S) often of long duration Fatigue, malaise Profound weight loss Fever, night sweats Pulmonary: Prolonged cough / coughing up blood Extrapulmonary: Depends on site and whether there is pulmonary involvement

sweats Pulmonary: Prolonged cough / coughing up blood

8 8 TB Disease Spread by droplet nuclei Most people exposed do not become infected Close contacts are at high risk of acquiring infection 10% of infected persons will develop TB disease Cavitary or smear positive patients are more infectious than noncavitary or smear negative patients

10% of infected persons will develop TB disease Cavitary or smear

9 Risk Factors For Developing Latent Tuberculosis Infection (LTBI) if HIV Diabetes Exposed Immunosuppressed Silicosis Chronic Renal Disease Cancer Low Body Weight 9

10 Administrative Hierarchy of Controls: Develop and implement written policies and protocols: Rapid identification of TB disease- this starts in your the Emergency room Isolation of patients with possible TB (suspect) Rapid diagnostic evaluation Three sputum s should be collected before starting treatment in medically stable patient Reflex to NAAT or Gene X-Pert PCR DNA testing for Tuberculosis Working with experts to confirm a TB diagnosis 10

(suspect) Rapid diagnostic evaluation Three sputum s should be collected before starting treatment in medically

11 11 Administrative Tuberculosis Risk Assessment Should include signs and symptoms of Tuberculosis Should contain risk factors that will effect your cut point to read the TST. Should contain any history of past TB exposure Should contain any history of travel to a country with high incidence rates

12 12 Administrative Staggered testing TST or BAMT testing should be spread out through the year. Depending on how many employees you may have you can do monthly, quarterly or semiannually

13 Administrative Testing of staff on hire an annually All HCW s listed in your TB Infection Control Plan should receive a skin test or a BAMT TST interpreting and recording test correctly This includes cut points related to employees risks factors BAMT T-SPOT QuantiFERON Questions about BAMT s? 13

interpreting and recording test correctly This includes cut points

14 Two Step Testing 14

15 MMWR Guidelines for Preventing the Transmission of MTB in Healthcare setting, /30/

16 A decision to test is a decision to treat. TST must be read 48 hr to 72 hrs past placement. Make sure the client can come back within that time, or schedule another time for placement. Positive test can be read up to one week per CDC Documentation is important. If not documented not done. Includes reading. 1) TST measurement 2) Interpretation of TST TST may be placed the same day as a live vaccine is given. However, if live vaccine given earlier must wait 1 month before TST. Circumstances when you use both TST 16 and BAMT

Positive test can be read up to one week per CDC Documentation is important. If not documented not done. Includes reading.

17 Administrative Educate, train, and network about Tuberculosis Annual TB training in your facility Testing Isolation Collect Three sputum and do a PCR test for TB Understand the difference between TB infection and TB disease TB disease Latent TB Infection 17

Three sputum and do a PCR test for TB Understand the difference

18 18 Factors Associated with Transmission Person factors The infectiousness of the case Time factors The duration and frequency of exposure Place factors The characteristics of the environment

19 Environmental Do you know the air exchanges in your facility? 12 air exchanges per hour or greater is recommended Do you have negative pressure rooms? Are these rooms tested monthly? How are these rooms tested? If they fail do you know who to contact? What do you do if you do not have a negative pressure room? 19

pressure rooms? Are these rooms tested monthly? How are these rooms tested?

20 Ventilation & TB Transmission Minimum of 12 Air Changes per Hour (ACH) recommended for TB isolation & procedure rooms Based on models of particle clearance rates 1 ACH clears 67% of contaminants in an hour 7 ACH clears 99.9% of contaminants in an hour 20

on models of particle clearance rates 1 ACH clears 67% of

21 Personal respiratory protection Respirators What type is recommended Surgical masks When should a surgical mask be worn Fit testing When to do fit testing for staff 21

22 Personal respiratory protection Respirators What type of respirator is recommended for health care workers? N95 masks There are several name brands There are two types Duck bill (orange and white) Full coverage (blue) Tight fit PAPR 22

23 N95 Mask 23

24 Personal respiratory protection Surgical masks Who should were a surgical mask? Staff or patient? When should a surgical mask be worn? When a patient is in isolated for TB and requires testing in another department what mask should be worn? Other questions about surgical masks? 24

25 Personal respiratory protection Fit testing Who do you fit test? When do you fit test? What if they can not wear a mask? Would you ever fit test family or visitors? Questions about fit testing? 25

26 26 Case presentation Female employee Needs annual test for TB You realize that upon hire she did not receive a two step. What would you do? Risk assessment, TST or both?

27 27 Risk Assessment then TST She has no risk so her cut off reading is 10 mm induration Results First TST 0 mm induration Two step TST 22 mm induration What would you do?

28 28 Send for a chest X-ray Results of Chest films Chest X-ray results are abnormal and consistent with questionable pneumonia What would you do?

29 Send for a Medical Evaluation Results of evaluation: She states she has had a cough for three weeks, has had some fever with chills but, states she thought she has the flu but her doctor told her it is pneumonia and gave her a Z-Pack. Upon further questioning she is a diabetic She admits to having travel to Mexico two months ago known TB in the family. What would you do? 29

30 30 Isolate Patient should be isolated in her home and the Health Department should be notified within 24 hours Collect three sputum's Send to state lab for a Gene-Xpert What should be done next?

31 31 Sputum results: Sputum smears are 3+, 2+ and 3+ Gene Xpert is positive for MTB but Rifampin sensitive Pt is seen by Infectious disease and started on 4 drug therapy. What are her DST s What is your responsibility at this time?

32 32 Working with the Health Department The Health Department will do the contact investigation outside the work place. They will provide you with an infectious period to guide you for your contact investigation at the facility. They will provide strict DOT with case management They will monitor sputum for smear and culture conversion

33 33 Contact investigation What is her infectious period? Determine who was exposed to the index case Look where time was spent- work station, medication room and or break room. You will do TST or BAMT initially than again in 8 weeks this will be determined by infectious period Will you need to expand Any one with S/S and or positive test need isolation, evaluation and chest films These are reported to the Health Department within 24 hours

34 When can she return to work? What do we treat the contacts with? 34

35 35

36 Thank you

37 Maria Dalbey TB Nurse Consultant ext 4292

38 References nes/default.htm Up-dated April

39 39 References Updated Guidelines for Using Interferon Gamma Release Assays to Detect MTB Guidelines for Preventing the Transmission of MTB in the Health-Care Setting

Tuberculosis Exposure Control Plan for Low Risk Dental Offices

Tuberculosis Exposure Control Plan for Low Risk Dental Offices A. BACKGROUND According to the CDC, approximately one-third of the world s population, almost two billion people, are infected with tuberculosis.