Infection Control: Managing Miasmas

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Infection ControlManaging Miasmas

• Introducing!
• Guidelines for the Assessment of Tuberculosis
  Patient Infectiousness and Placement into High
  and Lower Risk Settings

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The Workgroup

• Robert Benjamin
• Stephen Born
• Barbara Cole
• Charles Crane
• Lisa Gooze
• Steven Hwang
• Co-Chairs

• John Jereb (Ex-Officio)
• Kathleen Moser
• Annette Nitta
• Susan Sawley
• Gisela Schecter
• Rashmi Singh

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Charge to the Workgroup

• Revise 1997 CDHS/CTCA Guidelines for Placement or
  Return of TB Patients into High Risk Housing,
  Work, Correctional, or In-patient Settings
• Frequency and timing of sputum collection
• Criteria for placement of TB patients into high
  risk settings
• Criteria for placement of TB patients into lower
  risk settings
• Criteria for placement of patients with known or
  presumed MDR-TB into high and lower risk settings

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Methods

• Developed list of pertinent literature
• Developed tool for abstracting relevant articles
• Divided up the most important articles for review
  and abstraction
• Met monthly by phone to discuss research
• Developed the document, reviewed the document and
  reached consensus

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Frequency and Conditions of Sputum Collection

• CDC 2005 3 consecutive negative sputum AFB
  smear results from sputum collected gt 8 hours
  apart (with 1 specimen collected during the early
  morning) before being considered noninfectious
• Sputum specimen yield
• Early morning versus spot (8 articles)
• Induced versus spontaneous (8 articles)
• Post bronchoscopy

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Frequency and Conditions of Sputum Collection

• CTCA/CDPH Guideline Recommendation Proposed 2009
  3 consecutive respiratory specimens, including
  at least one early AM or induced sputum, or BAL,
  collected at least 8 hours apart, are AFB smear
  negative.
• If available, induced sputum is preferred.
• If bronchoscopy is done, a post-bronchoscopic
  sputum specimen obtained at least 8 hours post
  procedure should be one of the specimens.

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Risk Definitions Settings

• High Risk Setting
• A housing or work setting in which others will
  share air with the TB patient and which is
  characterized by one or more of the following
  factors
• A large number or high density of persons.
• The presence of persons at high risk of
  progression to active TB disease (see III.3.,
  below)
• The presence of persons who have not been
  previously exposed to the TB patient.

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Risk Definitions Settings

• Lower Risk Setting
• A residential setting not characterized as high
  risk, and
• No other persons will share the air with the TB
  patient OR
• Other persons who will share the air with the TB
  patient are not at increased risk for progression
  to TB disease if infected OR
• All persons at increased risk of progression to
  TB disease if infected, including all children
  under the age of 5 years, who will share the air
  with the TB patient, have been previously exposed
  to the TB patient, have had a complete medical
  evaluation and have been started on therapy,
  including window period treatment for presumed
  LTBI as appropriate.
• Determination of risk should be done by the
  local TB control program

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Risk Definitions Settings

• Lower Risk Setting
• A work setting not characterized as high risk,
  and in which no contacts are known or reasonably
  expected to be at increased risk of progression
  to TB disease if infected.
• Determination of risk should be done by the
  local TB control program

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Risk Definitions Increased Risk of Progression
to TB Disease if Infected

• Children lt 5 years of age
• Persons with medical conditions associated with
  an increased risk of progression to active TB
  disease, including
• HIV infection (including persons at increased
  risk for HIV infection who have not been tested)
• Diabetes mellitus, especially if insulin
  dependent or poorly controlled
• End-stage renal disease
• Injection drug use, even if HIV negative

• Cancer of the head and neck
• Immunosuppressive treatment, including chronic
  corticosteroids, anti TNF-a agents,
  post-transplant therapy and cancer chemotherapy
• Other diseases characterized by
  immunosuppression, such as lymphoma or leukemia
• Intestinal bypass or gastrectomy
• Low body weight (gt 10 below ideal body weight)
• Chronic malabsorption
• Malnutrition and clinical situations associated
  with rapid weight loss
• Silicosis

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Risk Definitions Increased Risk of MDR-TB

• Contact to an MDR TB case
• Current TB treatment (Rx) with evidence of
  treatment failure
• Prior TB treatment since 1970 (Exception relapse
  of disease following completion of adequate
  therapy by DOT for an episode of pan-susceptible
  disease)
• Immigration from or recent extended travel to, a
  country with a high incidence (gt 4) of MDR-TB
  among cases from that country diagnosed in the
  US. At the present time these countries are
• Russia and other former Soviet states
• Peru
• Other state or locally identified risk groups
  including
• Hmong refugees
• Persons of Tibetan origin

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General Considerations for Determining the Risk
of TB Transmission and Secondary TB cases

• The patients infectiousness
• The probability that exposed persons, if
  infected, will develop active TB
• The potential for transmission in the environment
• Drug resistance of the patients TB isolate

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Criteria for Infectiousness and Placement in High
and Lower Risk Settings
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Criteria for Infectiousness and Placement in High
and Lower Risk Settings
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Criteria for Infectiousness and Placement in High
and Lower Risk Settings
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Criteria for Infectiousness and Placement in High
and Lower Risk Settings
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Criteria for Infectiousness and Placement in High
and Lower Risk Settings
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Home Isolation

• Started on standard TB treatment
• No infants or children lt 5 or severely
  immunosuppressed present in household
• OR if present on appropriate LTBI or window
  period treatment
• Patient is willing to follow restrictions imposed
  by local TB control program

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