PREVENTING

TUBERCULOSIS TRANSMISSION

IN NURSING HOMES

Heidi Behm, RN, MPH

TB Controller

HIV/STD/TB Program

Topics of Discussion • Definition of long-term care facility

(LTCF)

• Tuberculosis (TB) Overview

• Epidemiology of TB in Oregon

• Annual Facility Risk Assessment

• Employee and Resident Screening

• Developing an Infection Control Plan

• Questions?

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Why Do We Have to do This? • It’s an Oregon Administrative Rule

• The Occupational Safety and Health Administration (OSHA) requires it

• It’s a Centers for Disease Control (CDC) Guideline

• AND…it’s the right thing to do!

• Number of TB cases has dropped dramatically since 1993 due to infection control. During the 90s, outbreaks in medical settings were common, and are still common in other countries

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What Types of Facilities Need to Screen? • https://public.health.oregon.gov/DiseasesConditions/Commu

nicableDisease/Tuberculosis/Documents/tbtestrecs.pdf

INCLUDES:

• Long-term care = skilled nursing facility or “nursing home”

• Hospice facility

• Rehabilitation facility

NOT Included:

• Assisted living or residential facility

• Group homes

QUESTIONS?

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A Summary of What’s Required Tuberculosis Screening for Long-Term Care Facilities in Oregon

Summary of Key Points and Recommendations

https://public.health.oregon.gov/DiseasesConditions/CommunicableDisease/Tuberculosis/Documents/ltcsummaryrecs.pdf

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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 interferon gamma release

assay (IGRA)

• Abnormal CXR

• Symptoms of TB cough, hemoptysis, fever, weight loss)

• Contagious if pulmonary

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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!

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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

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Annual Facility Risk Assessment

• Document and complete annually

• Looks complex-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

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Employee/Resident Screening and Risk Assessment

• Annual risk assessment needed to determine risk level

• Most Oregon facilities are “low risk”

• Low risk = < 3 patients for the preceding year with TB

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Employee Screening

Low Risk Facility • New hires must have symptom screen,

risk assessment and two-step TB skin test,

or an interferon gamma release assay

(IGRA) or chest x-ray

• Employee annual screening not required!

• GOOD contact investigation needed if

exposure

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Resident Screening

Low Risk Facility • New residents must have symptom screen, risk

assessment and two step TB skin test, or IGRA

or chest x-ray

• UNLESS…the resident is being transferred from

another low risk facility and has a documented

history of negative tests. Than only symptom

screening needed

• Annual screening not required!

• GOOD contact investigation needed if exposure

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Two-Step Testing (TST)

• 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 purified protein derivative (PPD)

• If employee/resident has documentation of negative TST within last year, only one TST needed!

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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

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“Cut off” for Positive TST

• 10 mm 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

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Interferon Gamma Release Assay

• A blood test for Latent TB Infection (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 A healthcare worker (HCW) or resident has an IGRA from another facility that was done within the last year, do not need to repeat it 16

Positive Tests: Evaluation and Treatment

• Newly positive need symptom check and CXR

• If previously positive, documented normal CXR within past 6 months acceptable (this may change)

• If > 6 months or no documentation repeat CXR needed

• For EMPLOYEES –refer to patient care provider (PCP) for further evaluation and possible LTBI treatment

• For RESIDENTS- what is currently done?

Individualize…risk vs. benefit

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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 a HCW infection, an investigation should take place and your plan changed if appropriate

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Plan Element 1 1. Defines employees and residents who are at

risk

“All employees with direct patient contact are at risk for TB exposure.”

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Plan Element 2

2. Screens employees and residents 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.”

“All new residents will be…”

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Plan Element 3

3. Conducts follow-up of employees or residents exposed to TB

Specify name of person responsible

“TB symptom screen and baseline TB test will be administered within one week of exposure

If post exposure baseline is negative, a second test will be given 8-10 weeks after last exposure”

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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

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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 further assessed. A sign will be placed on the door alerting staff to use proper precautions.”

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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) 24

Summary

LTBI is not contagious. Active pulmonary TB is airborne and contagious

Each facility should conduct an Annual Risk Assessment

Most facilities will be low risk

New hire/resident: two step TST or single IGRA, no annual unless documented previously positive

Have a TB Infection Control Plan specific to your facility. Staff should know where it is

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Resources

• Annual Risk Assessment:

http://public.health.oregon.gov/DiseasesConditions/CommunicableDisease/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

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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

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Commission’s Upcoming Events

• November 30, 2012 , Staying Ahead of the Curve: Strategies for Preventing, Measuring and Reducing Infections in Nursing Homes, Eugene, OR

• January 9, 2013 Norovirus Webinar

• February 5-7, 2013 Fundamentals of Infection Prevention: A Comprehensive Training Course for Infection Prevention Professionals, Portland, OR

Stay updated about these free events and register for our newsletter by visiting our website:

www.oregonpatientsafety.org

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