|





 



  
  


 






  
  
 



December 2006
note: Slide #123 has been edited.
 Ô rpose of 2005 G idelines
ƥ Update and replace 1994 Mycobacteri

t berc losis infection control (IC) g idelines
ƥ F rther red ce threat to health-care workers
(HCWs)
ƥ Expand g idelines to nontraditional settings
ƥ Si
plify proced res for assessing risk
ƥ Ôro
ote vigilance and expertise needed to avert
another TB res rgence
 Whatƞs New (1)
ƥ Change of risk classification and t berc lin
skin test (TST) freq ency
ƥ Expanded scope addressing lab,
o tpatient, and nontraditional settings
ƥ Expanded definitions of affected HCWs
ƥ ƠTSTơ instead of ƠÔÔDơ
 Whatƞs New (2)
ƥ Q antiFERON-TB Gold test (QFT-G)
ƥ QFT-G is a type of blood assay for M.
t berc losis (BAMT)
ƛ Meas res the patientƞs imm ne system reaction to
M. t berc losis
ƛ Blood samples m st be processed within 12 ho rs
ƛ Interpretation of QFT-G res lts is infl enced by the
patientƞs risk for infection with M. t berc losis
ƛ An alternative to TST
 Whatƞs New (3)
ƥ Term Ơairborne infection isolationơ (AII)
ƥ Criteria for initiating and discontin ing AII
preca tions
ƥ Respirator fit testing and training; vol ntary se
of respirators by visitors
ƥ Additional information on ltraviolet germicidal
irradiation (UVGI)
ƥ Freq ently asked q estions (FAQs)
Change in Risk Classifications
Ôrevio s New
ƥ Minimal ƥ Low
ƥ Very low ƥ Medi m
ƥ Low ƥ Ôotential ongoing
transmission
ƥ Intermediate
ƥ High
 HCWs Who May Be Incl ded in a
TB Testing Ôrogram
ƥ Ôaid and npaid persons working in health-
care settings who have potential for expos re
to M. t berc losis thro gh shared air space
with infectio s patient
ƥ Incl des part-time, f ll-time, temporary, and
contract staff
ƥ All HCWs whose d ties involve face-to-face
contact with s spected or confirmed TB
sho ld be in a TB screening program
 Transmission of M. tuberculosis
ƥ Spread by airborne route; droplet nuclei
ƥ Transmission affected by
ƛ Infectiousness of patient
ƛ Environmental conditions
ƛ Duration of exposure

ƥ Most exposed persons do not become

infected
 TB Ôathogenesis (1)
Latent TB Infection
ƥ Once inhaled, bacteria travel to l ng
alveoli and establish infection
ƥ 2Ã12 wks after infection, imm ne
response limits activity; infection is
detectable
ƥ Some bacteria s rvive and remain
dormant b t viable for years (latent TB
infection, or LTBI)
 TB Ôathogenesis (2)
Latent TB Infection
ƥ Ôersons with LTBI are
ƛ Asymptomatic
ƛ Not infectio s

ƥ LTBI formerly diagnosed only with TST

ƥ Now QFT-G can be sed
 TB Ôathogenesis (3)
Active TB Disease
LTBI progresses to TB disease in
ƥ Small n mber of persons soon after
infection
ƥ 5%ƛ10% of persons with ntreated LTBI
sometime d ring lifetime
ƥ Abo t 10% of persons with HIV and
ntreated LTBI per year
 Ôersons at Higher Risk for Expos re to
and Infection with M. t berc osis (1)
ƥ Cose contacts
ƥ Foreign-born persons from or areas with high
TB incidence
ƥ Residents and staff of high-risk congregate
settings
ƥ Heath-care workers who serve high-risk
cients
Ôersons at Higher Risk for Expos re to
and Infection with M. t berc osis (2)

ƥ HCWs nknowing exposed to TB patient

ƥ Low-income, medica nderserved
gro ps
ƥ Loca defined high-risk gro ps
ƥ Yo ng persons exposed to high-risk ad ts
 Ôersons at High Risk for LTBI
Ôrogressing to TB Disease
ƥ Ôersons coinfected with HIV and M. tubercuosis
(highest risk)
ƥ Those with recent M. tubercuosis infection
(within 2 ears)
ƥ Chidren under 4 ears of age
ƥ Ôersons with certain cinica conditions or other
conditions of compromised immunit
ƥ Those with a histor of untreated or poor
treated TB
 TB Ôatient Characteristics That
Increase Risk for Infectio sness (1)

ƥ Co ghing
ƥ Undergoing co gh-ind cing or aerosol-
generating proced re
ƥ Failing to cover co gh
ƥ Having cavitation on chest radiograph
 TB Ôatient Characteristics That
Increase Risk for Infectio sness (2)
ƥ Ôositive acid-fast bacilli (AFB) sp t m
smear res lt
ƥ Disease of respirator tract and larnx
ƥ Disease of respirator tract and l ng
or ple ra
ƥ Inadeq ate TB treatment
 Environmental Factors That Increase
Risk for Transmission
ƥ Expos re in small, enclosed spaces
ƥ Inadeq ate ventilation
ƥ Recirc lating air containing infectio s
droplets
ƥ Inadeq ate cleaning and disinfection of
eq ipment
ƥ Improper specimen-handling proced res
 Risk for Health-careƛAssociated
Transmission of M. tuberculosis (1)
Risk varies b
ƥ TB prevalence in health-care setting
ƥ TB prevalence in communit
ƥ Ôatient population served
ƥ Health-care worker occupational group
ƥ Effectiveness of infection control measures
 Risk for Health-careƛAssociated
Transmission of M. tuberculosis (2)
Linked to close contact with infectious TB
patients during procedures generating aerosols
ƥ Bronchoscop
ƥ Endotracheal intubation or suctioning
ƥ Open abscess irrigation
ƥ Autops
ƥ Sputum induction
ƥ Aerosol treatments
 Ôrevio s Health-careƛAssociated
Transmission of M. t berc losis (1)
In hospital TB o tbreaks, 1980sƛ1990s
ƥ MDR TB spread to patients and HCWs
ƥ Man patients, some HIV-infected HCWs
ƥ Rapid progression from new infection to disease
ƥ Factors
ƛ Delaed diagnosis
ƛ Lapses in AII preca tions
ƛ Lapses in respirator protection
 Ôrevio s Health-careƛAssociated
Transmission of M. t berc losis (2)
Follow- p
ƥ Transmission m ch decreased or ceased in a
setting when recommended infection control
interventions implemented
ƥ However, effectiveness of each intervention
co ld not be determined
F ndamentals of Infection Control (1)
Hierarch of Infection Control

Administrative Controls

Environmental Controls

Respirator Ôrotection
 F ndamentals of Infection Control (2)
Hierarch of Infection Control
ƥ m



 
! red ce risk of
expos re via effective IC program
ƥ 

  
! prevent
spread and red ce concentration of
droplet n clei
ƥ "#


$#

 
!
f rther red ce risk of expos re in special
areas and circ mstances
 Administrative Controls (1)
Most Important
ƥ Assign responsibilit for TB infection
control (IC)
ƥ Work with health department to cond ct
TB risk assessment and develop written
TB IC plan, incl ding AII preca tions
ƥ Ens re timel lab processing and reporting
ƥ Implement effective work practices for
managing TB patients
 Administrative Controls (2)
ƥ Test and eval ate HCWs at risk for TB or
for expos re to M. t berc losis
ƥ Train HCWs abo t TB infection control
ƥ Ens re proper cleaning of eq ipment
ƥ Use appropriate signage advising co gh
etiq ette and respirator hgiene
 Environmental Controls

ƥ Control so rce of infection

ƥ Dil te and remove contaminated air
ƥ Control airflow (clean air to less-
clean air)
Respirator Ôrotection (RÔ) Controls

ƥ Implement RÔ program
ƥ Train HCWs in RÔ
ƥ Train patients in respirator hgiene
 Relevance to Biologic
Terrorism Ôreparedness
ƥ M ltidr g-resistant M. t berc losis is
classified as a categor C agent of biologic
terrorism
ƥ Implementing g idelines in this doc ment
is essential to preventing the transmission
of M. t berc losis in health-care settings
" 





 
  






 


Develop an Infection Control (IC) Ôrogram

ƥ Ôerform TB risk assessments in all settings

ƥ Develop TB IC program as part of overall
IC program
ƥ Base IC program on risk assessment
ƥ Determine details of IC program b
likelihood that persons with TB will be
enco ntered in that setting or transferred
to another setting
 Infection Control Ôrogram (1)
Settings Expecting to Enco nter TB Ôatients
ƥ Assign and train TB IC program manager
ƥ Collaborate with local health department to
develop administrative controls, incl ding
ƛ Risk assessment
ƛ Written TB IC plan, incl ding protocols for
identifing, eval ating, managing infectio s TB
patients
ƛ Testing and eval ation of HCWs
ƛ Training and ed cation of HCWs
ƛ Ôroblem eval ation and contact investigation
ƛ Coordination of discharge
 Infection Control Ôrogram (2)
Settings Expecting to Enco nter TB Ôatients

ƥ Develop plan for accepting TB patients or

s spects transferred from another setting
ƥ Implement and maintain environmental
controls, incl ding AII rooms
ƥ Implement RÔ program
ƥ Ôrovide ongoing training and ed cation of
HCWs
 Infection Control Ôrogram (3)
Settings  Expecting to Enco nter
TB Ôatients

ƥ Assign responsibilit for TB IC program

ƥ Collaborate with local health department to
develop administrative controls, incl ding
ƛ Risk assessment
ƛ Written TB IC plan that o tlines protocol for
triage and transfer of TB patients to another
health-care setting
ƛ Ôroblem eval ation and contact investigation
 TB Risk Assessment (1)
Settings Expecting to Enco nter TB Ôatients
ƥ Collaborate with health department to review
comm nit TB profile, obtain epidemiologic data
for risk assessment
ƥ Review n mber of TB patients enco ntered
ƥ Determine
ƛ HCWs to be incl ded in TB testing and in RÔ program
ƛ Instances of nrecognized TB
ƛ N mber of AII rooms needed
ƛ Tpes of environmental controls needed
 TB Risk Assessment (2)
Settings Expecting to Enco nter TB Ôatients

ƥ Identif and address areas with increased

transmission risk
ƥ Ens re prompt recognition and eval ation
of M. t berc losis transmission in setting
ƥ Cond ct periodic reassessments
ƥ Correct lapses in IC
 TB Risk Assessment (3)
Settings  Expecting to Enco nter
TB Ôatients

ƥ Collaborate with health department to

review comm nit TB profile; obtain
epidemiologic data for risk assessment
ƥ Determine
ƛ If an HCWs need to be incl ded in TB
screening program
ƛ If nrecognized TB occ rred in last 5 ears
ƛ Tpes of controls in place, tpes needed
 TB Risk Assessment (4)
Settings  Expecting to Enco nter
TB Ôatients

ƥ Doc ment steps for prompt recognition

and eval ation of s spected M.
t berc losis transmission
ƥ Cond ct periodic reassessments
ƥ Correct an lapses in IC
 TB Risk Classifications (1)
All settings sho ld perform risk classification
as part of risk assessment to determine
need for and freq enc of an HCW testing
program, regardless of likelihood of
enco ntering persons with TB disease.
 TB Risk Classifications (2)
ƥ Low risk ƛ Ôersons with TB disease not
expected to be enco ntered; expos re
nlikel
ƥ Medi m risk ƛ HCWs will or might be
exposed to persons with TB disease
ƥ Ôotential ongoing transmission ƛ
Temporar classification for an settings
with evidence of person-to-person
transmission of M. t berc losis
 TB Risk Classifications (3)

 

V#
 
% & 
 '








<3 TB >3 TB
<200 beds
patients/r patients/r
Evidence of ongoing
transmission,
regardless of setting
<6 TB >6 TB
ƿ200 beds
patients/r patients/r
 TB Risk Classifications (4)

 

' #
 
% & 
 '








TB treatment
Evidence of
facilities,
ongoing
medical <3 TB >3 TB
transmission,
offices, patients/r patients/r
regardless of
amb lator
setting
care settings
 TB Risk Classifications (5)
 


  

(

$ % & 
 '


 




Emergenc medical Onl patients Settings Evidence of ongoing

service (EMS), medical with LTBI where TB transmission
settings in correctional treated patients are regardless of setting
facilities, o treach expected to
No co gh-
care, long-term care be
ind cing
facilities enco ntered
proced res
are performed
in setting
Sstem to
detect/triage
persons with
TB smptoms
 TB Risk Classification Example
Small Hospital
ƥ 150-bed hospital in small cit
ƥ 2 TB patients admitted in past ear
ƛ 1 placed directl in AII room
ƛ 1 staed on medical ward 2 das before AII
placement
ƥ Contact investigation showed no evidence of
transmission

"
)


! Low
 Risk Classification Example
Ô blic Health Clinic

ƥ Amb lator-care setting where TB clinic is

held 2 das/week
ƥ In past ear, 6 TB patients and 50 LTBI
patients treated
ƥ No evidence of transmission

"
)


! Medi m
 Risk Classification Example
Ô blic Hospital
ƥ Large p blic hospital in big cit
ƛ Average of 150 TB patients/ear (35% of cit b rden)
ƛ Strong IC program; man AII rooms
ƛ Ann al TST conversion rate among HCWs of 0.5%
ƥ Hospital has strong links with health department
ƥ No evidence of transmission

"
)


! Medi m, with close ongoing

s rveillance for episodes of transmission
 Risk Classification Example
Ôrison Setting
ƥ Inpatient area of a correctional facilit
ƥ Some inmates are from TB-prevalent
co ntries
ƥ In past ear, 2 cases of TB diagnosed in
inmates

"
)


! Medi m
 Risk Classification Example
Large Hospital
ƥ Big-cit hospital with 35 TB patients/ear
ƥ TST conversion rate among HCWs of 1.0%
ƥ At ann al testing, 3/20 (15%) respirator
therapists (RTs) had TST conversions
ƥ Ôroblem eval ation
ƛ The 3 RTs who converted spent time in lab where ind ced sp t m
specimens were collected, and lab venting was inadeq ate

"
)


!
1. Ôotential ongoing transmission for the RTs
2. Medi m risk for the rest of the setting
 Risk Classification Example
Health Maintenance Organization (HMO) Clinic
ƥ Amb lator-care center associated with a large HMO
where TB rates are highest in the state
ƥ In past ear, 1 TB patient presented
ƥ At first visit patient was
ƛ Recognized as having TB
ƛ Sent to an emergenc department with an AII room
ƛ Held separatel and asked to wear a mask before triage
ƥ Contact investigation showed no evidence of
transmission

"
)


! Low
 Risk Classification Example
HIV-Care Clinic
ƥ Hospital-affiliated HIV clinic serving 2,000 patients
ƥ Has AII room and a TB IC program
ƥ All patients screened for TB at enrollment
ƛ Those with respirator complaints placed in AII
ƥ In past ear, 7 patients fo nd to have TB
ƛ All 7 promptl p t in an AII room
ƛ No contact investigation done
ƛ Ann al conversion rate of 0.3% (same as rate in hosp)

"
)


! Medi m (beca se of

HIV-infected persons)
 Risk Classification Example
Home Care Agenc
ƥ Home health-care agenc serving a poor area
with TB rates higher than overall comm nit
ƥ Has 125 emploees
ƛ Abo t 30% of workers are foreign-born (FB), man
immigrated within past 5 ears
ƛ Ôrovide n rsing, phsical therap, basic home care
ƛ On baseline 2-step testing, 4 had (+) initial res lt; 2
had (+) second res lt (3 of 4 are FB); no TB disease.
ƥ In past ear, agenc had no TB patients
"
)


! Low. Co ld be medi m if FB workers
are from TB-prevalent co ntries, or large n mber of clients
are HIV infected.
 TB Testing Freq enc
"
)


 (
* $
Low Baseline on hire; f rther
testing not needed
nless expos re occ rs
Medi m Baseline, then ann all
Ôotential ongoing Baseline, then ever 8ƛ
transmission 10 wks ntil evidence of
transmission has ceased
 Testing HCWs Who Transfer
ƥ All HCWs sho ld receive baseline TB
testing
ƥ In IC plans, address HCWs who transfer to
another setting
ƥ Keep all historic testing res lts; in f t re,
might need to interpret res lts of TST vs.
QFT-G
 TB Testing Freq enc
for HCWs Who Transfer
"
)



Low or Med ´
Ôotential


 Low´Low Low´Med Ongoing
Transmission
]
 Yes Yes Yes
"
 No Ever 12 As needed in

 months investigation
m 
 Yes, and if TST negative, 8ƛ10 wks after last
+# 
 potential expos re to M. t berc losis
 Eval ating TB IC Ôroced res and
Identifing Ôroblems (1)

ƥ Ann all eval ate TB IC plan

ƥ Review medical records of a sample of
patients with s spected or confirmed TB
disease to find possible problems in TB IC
ƥ Use data from risk assessment worksheet
in cond cting review
 Eval ating TB IC Ôroced res and
Identifing Ôroblems (2)
Factors to consider in TB IC eval ation
ƥ Time intervals for all related activities
ƥ D ration of AII preca tions
ƥ Extent of meeting criteria for discontin ing AII preca tions
ƥ Ôatient histor of previo s admissions
ƥ Adeq ac of TB treatment regimens
ƥ Adeq ac of sp t m collection proced res
ƥ Adeq ac of discharge planning
ƥ N mber of visits to o tpatient setting
 Eval ating Environmental Controls (1)

ƥ Determine if recommended environmental

controls are in place b reviewing recent
environmental eval ation
ƥ Review environmental control maintenance
proced res and logs
ƥ Use g idelines from American Instit te of
Architects (AIA) to review environmental control
design specifications
ƥ Eval ate performance of installed sstem
 Eval ating Environmental Controls (2)

ƥ Assess n mber and tpe of aerosol-

generating proced res performed in the
setting
ƥ Determine if the n mber of AII rooms is
adeq ate for the setting based on AIA
g idelines and the risk assessment
 S ggested Components of Initial TB
Training and Ed cation for HCWs
ƥ Clinical information
ƥ Epidemiolog of TB: local, U.S., global
ƥ Recommended IC practices
ƥ TB and conditions of compromised
imm nit
ƥ Role of p blic health in TB control
R
]

 !|

" 

 Ôrompt Triage
Think TB!
ƥ Ôrimar TB risk to HCWs is patient with
ndiagnosed or nrecognized infectio s TB
ƥ Ôromptl initiate AII preca tions and manage or
transfer patients with s spected or confirmed TB
ƛ Ask abo t and eval ate for TB
ƛ Check for signs and smptoms
ƛ Mask smptomatic patients
ƛ Separate imm nocompromised patients
Criteria for Initiating AII Ôreca tions
ƥ Ôatient has smptoms or signs of TB
disease
'

ƥ Ôatient has doc mented infectio s TB

disease and has not completed anti-TB
treatment
 Criteria for Discontin ing
AII Ôreca tions
ƥ Infectio s TB is nlikel and another diagnosis is
made that explains the sndrome
'

ƥ Ôatient has 3 consec tive negative AFB sp t m

smear res lts, and
ƥ Ôatient has received standard antit berc losis
treatment (minim m of 2 weeks), and
ƥ Ôatient has demonstrated clinical improvement
Freq enc of Sp t m Collection for
Ôatients with S spected TB Disease
ƥ Three negative sp t m smears
ƥ At least 8 ho rs apart
ƥ At least one collected d ring earl
morning
ƥ In most cases, patients with negative
sp t m smear res lts ma be released
from AII in 2 das
 AII Ôolicies and Ôractices (1)
ƥ AII rooms sho ld be single-patient rooms with
a private bathroom
ƥ Environmental factors and entr of visitors and
HCWs sho ld be controlled to minimize
transmission of M. t berc losis
ƥ HCWs who enter sho ld wear at least N95
disposable respirators
ƥ Visitors to AII rooms can be offered respirator
protection and sho ld be instr cted in
respirator se
 AII Ôolicies and Ôractices (2)
ƥ Diagnose and treat in the AII room
ƥ Ens re patient adheres to AII preca tions
ƥ Separate patients with s spected or confirmed
infectio s TB disease from HCWs and other patients
ƥ Sched le patients with s spected or confirmed
infectio s TB disease for proced res when a
minim m n mber of HCWs and other patients are
present
ƥ Ôrovide a s rgical or proced re mask for s spected
or confirmed infectio s TB patients d ring transport,
in waiting areas, and when others are present
 AII Room Ôolicies and Ôractices
ƥ Keep doors closed as m ch as possible
ƥ Maintain adeq ate n mber of AII rooms
ƥ Check room for negative press re dail
when in se
ƥ Gro p AII rooms together
 Clinical Diagnosis
ƥ Obtain medical histor and phsical exam
ƥ Ôlace patients with s spected or known
infectio s TB disease nder AII preca tions
ntil determined to be noninfectio s
ƥ Eval ate persons with extrap lmonar TB for
conc rrent p lmonar TB disease
ƥ Altho gh normall not infectio s, children
sho ld be eval ated for infectio sness
 Laborator Diagnosis
ƥ Ens re lab personnel are skilled in all aspects of
specimen processing
ƥ Staff sho ld have access to most rapid methods
available and add others as available
ƥ Labs sho ld report positive res lts to clinicians
with 24 ho rs of obtaining res lt
ƥ Ens re that labs report dr g s sceptibilit res lts
on M. t berc losis isolates as soon as the are
available, and that the res lts are sent to the
local or state health department promptl
 AII Ôreca tions for Settings Not
Expecting to Enco nter TB Ôatients

 m



 

  "#


$
 
  
 


 

Triage Written plan for As needed in As needed for
onl triage holding areas for HCWs who
s spected/ attend patients
Separate holding
confirmed TB d ring transfer;
area
patients offer s rgical
mask to patient
if no holding
room
 AII Ôreca tions for Settings Expecting
to Enco nter TB Ôatients

 m



 

  "#


$
 
  
 


 


Ôatient Written AII ƿ1 inpatient AII For anone

rooms policies room entering room of
patient with
Ôersons with Air cleaning to
s spected/
s spected/ increase air
confirmed
confirmed TB changes/ ho r
infectio s TB
placed in AII room (ACH)
 AII Ôreca tions for Inpatient Settings
Emergenc Department/Medical
Office/Amb lator-Care Setting

m



 

  "#


$
 
  
 

 


Ôromptl detect, ƿ1 AII room for settings At least N95 RÔ for

eval ate, and with high vol me of
separate patients s spected or confirmed
with s spected or TB patients, or effectivel
confirmed TB. vented room + air
cleaning
anone entering AII
rooms of persons
with s spected or
confirmed infectio s
TB
 AII Ôreca tions for Inpatient Settings
Intensive Care Units
m





 


 "#



$
 

  

 



 


Ôlace patient with ƿ1 AII room for settings At least N95 RÔ for
s spected or with high vol me of anone who enters
confirmed TB in s spected or confirmed AII rooms of persons
AII room, if TB patients. with s spected or
possible. confirmed infectio s
To prevent contamination
TB.
risk, place bacterial filter
on vented patientƞs
endotracheal t be.
 AII Ôreca tions for Inpatient Settings
S rgical S ites or Operating Rooms (OR)
m





 


 "#



$
 

  

 



 



Ôostpone non- rgent OR anteroom sho ld be Use RÔ with a

proced res on either positive press re valveless filtering
s spected/confirmed relative to both OR and facepiece, e.g., N95
TB patients ntil corridor, or negative disposable.
known to be non- relative to both OR and
infectio s. corridor. If no
anteroom, keep OR
Do proced re at end of
door closed, minimize
da and d ring low
traffic.
traffic times.
Ôrovide sterile field
while preventing
contamination with M.
t berc losis.
 AII Ôreca tions for Inpatient Settings
Laboratories
m



 

  "#


$
 
  
 


 

Lab-specific risk Handle specimens Lab specific based
assessment and IC s spected to contain M. on risk assessment
plan t berc losis and
At least N95. Use if
aerosol-prod cing
Biosafet level (BSL) 2 aerosol-prod cing
proced res in class I or
for non-aerosol- proced res
II biological safet
prod cing proced res performed o tside
cabinet (BSC).
BSC
Ann al HCW M.
t berc losis testing in
med. and high-risk
settings
 AII Ôreca tions for Inpatient Settings
Bronchoscop S ites

m



 

  "#


$
 
  
 

 

Avoid bronchoscop AII room or one that At least N95 respirator
on s spected or meets AII ventilation protection for HCWs
confirmed TB patients req irements. In present for
or postpone ntil mechanicall ventilated bronchoscop
noninfectio s. When patients, keep circ itr proced res on patients
sp t m collection is closed. with s spected or
not possible, se confirmed TB
sp t m ind ction.
 AII Ôreca tions for Inpatient Settings
Sp t m Ind ction and Inhalation Therap Rooms

m



 

  "#


$
 
  
 

 


Use if sp t m Local exha st At least N95 disposable

collection is ventilation (e.g., RÔ for HCWs
inadeq ate. speciall vented booth) performing these
or room that meets or proced res on a patient
Use appropriate
exceeds AII with s spected or
preca tions if patient
req irements confirmed TB
has s spected or
confirmed TB.
 AII Ôreca tions for Inpatient Settings
A tops S ites/Embalming Rooms
m



 

  "#


$
 
  
 

 


In case of bod Meet or exceed At least N95 disposable

with s spected or req irements for AII respirator protection
confirmed TB, room. for HCWs performing
ens re AII a topsies on bodies
Exha st air to o tside.
preca tions and with s spected or
protection for those confirmed infectio s TB
performing disease
a topsies.
Coordinate between
attending HCWs
and pathologists to
ens re proper IC.
 AII Ôreca tions for O tpatient Settings
TB Treatment Facilities (TB Clinics)
m



 

  "#


$
 
  
 

 


Ôromptl detect, Based on risk Implement

eval ate, and separate assessment, ƿ1 AII respirator protection
to AII room patients room for patients with program for HCWs
with s spected or s spected or confirmed who share space with
confirmed TB. TB s spected or
confirmed TB
Ens re separation from Ôroced res that
patients.
HIV-infected patients. prod ce co ghs,
Screen HCWs for M. aerosols sho ld be
t berc losis infection. performed in booth or
Sched le treatment of AII room.
TB patients for certain
times or areas awa
from HIV patients.
 AII Ôreca tions for O tpatient Settings
Dialsis Units
m



 

  "#


$
 
  
 

 


Written plan for treatment AII room or holding At least N95

or referral of s spected or area for disposable RÔ for
confirmed TB patients hemodialsis HCWs entering AII
patients with rooms of patients with
Ôatients with end-stage
s spected or s spected or
renal disease sho ld be
confirmed TB confirmed TB
tested for M. t berc losis
infection.
Separate imm no-
compromised dialsis
patients from s spected
or confirmed TB patients.
AII Ôreca tions for O tpatient Settings
Dental Care Settings
m



 

  "#


$
 
  
 

 

Develop written IC AII setting to treat At least N95 disposable
polic based on patients with RÔ for HCWs attending
comm nit risk s spected or patients with s spected
assessment. confirmed infectio s or confirmed TB.
TB.
Ôostpone non- rgent Instr ct TB patients to
treatment of TB In settings with high cover co gh, wear
patients. vol me of s spected s rgical mask.
or confirmed TB
patients, se HEÔA
nits or ltraviolet
germicidal irradiation
(UVGI).
 AII Ôreca tions for Nontraditional Settings
Emergenc Medical Services (EMS)

m



 

  "#


$
 
  
 

 

Written IC plan Amb lance vent Consider s rgical or
sstem sho ld be non- proced re masks for
Incl de an exposed
recirc lating. s spected or
EMS staff in contact
confirmed TB patients
investigation of TB Use all available
and N95 RÔ for EMS
patients. environmental controls
staff.
to increase n mber of
air changes per ho r
(ACH). Air sho ld flow
from front to back and
o t.
 AII Ôreca tions for Nontraditional Settings
Medical Settings in Correctional Facilities
m



 

  "#


$
 
  
 

 

Develop setting-specific ƿ1 AII room based on Implement RÔ program.
IC plan. risk assessment
Give s rgical mask to
Test staff for TB Ôlace inmates with inmates who m st leave
ann all. s spected or confirmed AII room.
TB in AII or transfer to
Test inmates for TB and Consider N95 RÔ for staff
AII setting.
maintain tracking transporting inmates with
sstem. Collect sp t m in infectio s TB.
booth, AII room, or
Collaborate with local
o tside; not in cell.
health department on TB
contact investigations,
discharge planning, and
training/ed cation of
staff and inmates.
 AII Ôreca tions for Nontraditional Settings
Home Health Care

m



 

  "#


$
 
  
 

 


Train patients, famil No co gh-ind cing Consider N95 RÔ for staff

re: meds, co gh proced res nless transporting persons with
etiq ette, medical infection controls in infectio s TB.
eval ation. place
Ôostpone travel ntil
not infectio s.
 AII Ôreca tions for Nontraditional Settings
Long Term Care/Hospice

m



 

Ôatients with s spected or confirmed TB sho ld not be
managed or treated nless proper administrative,
environmental, and respirator protection controls in place.
 Training and Ed cating HCWs
ƥ Initial TB training and ed cation
ƛ Ôrovide initial TB training to all HCWs, incl ding
phsicians, and doc ment training

ƥ Follow- p TB training and ed cation

ƛ Ann all eval ate the need for follow- p training for
HCWs
ƛ Ôrovide retraining if expos re occ rs
ƛ Ôrovide ann al respirator protection training for
HCWs who se respirators
 TB Infection Control S rveillance
TB screening programs provide critical info and
consist of
ƥ Baseline testing for M. t berc losis infection
(new hires)*
ƥ Serial testing for M. t berc losis infection
ƥ Serial screening for smptoms or signs
ƛ Clinical eval ation
ƛ Chest radiograph
ƥ TB training and ed cation

* And other persons who will be tested periodicall (i.e., residents and
staff of long termƛcare facilities and correctional settings).
 Eval ating Ôroblems
ƥ Cond ct a contact investigation for problems
s ch as
ƛ Conversion in TST or BAMT res lt in HCW
ƛ TB disease diagnosis in HCW
ƛ S spected person-to-person transmission of M.
t berc losis
ƛ IC lapses that expose HCWs to M. t berc losis
ƛ Ôossible TB o tbreaks identified sing a tomated
laborator sstems
 Ôroblem Eval ation
Contact Investigation (1)

Objectives of contact investigation:

ƥ Determine likelihood that M. t berc losis
transmission occ rred
ƥ Determine extent of M. t berc losis
transmission
ƥ Identif persons exposed and, if possible,
so rce of potential transmission
 Ôroblem Eval ation
Contact Investigation (2)
ƥ Identif factors that co ld have
contrib ted to transmission
ƥ Implement interventions
ƥ Eval ate effectiveness of interventions
ƥ Ens re that expos re to M. t berc losis
has been terminated and conditions
leading to expos re have been eliminated
Collaborate with Health Department
ƥ Seek state or local TB program assistance
in planning and implementing TB control
activities.
ƥ State or local health department m st be
notified abo t s spected or confirmed TB
disease s ch that follow- p, comm nit
contact investigation, and completion of
therap can be ens red.
 Environmental Controls (1)
ƥ After administrative controls, second line
of defense in TB IC program
ƥ Ôrevent spread, red ce concentration of
infectio s droplet n clei
ƥ In AII rooms, these sstems control
airflow direction to minimize spread of
infectio s droplet n clei to adjacent areas
 Environmental Controls (2)
ƥ Technologies for removing or inactivating
M. tuberculosis consist of
ƛ Local exhaust ventilation
ƛ General ventilation
ƛ Air-cleaning methods, e.g., high-efficienc
particulate air (HEÔA) filtration, ultraviolet
germicidal irradiation (UVGI)
 Local Exha st Ventilation (1)
ƥ So rce-control method for capt ring
airborne contaminants
ƛ Enclosing device: so rce f ll or partiall
enclosed; incl de tents, booths, and biologic
safet cabinets (BSCs)
ƛ External device: so rce near b t o tside
enclos re
 Local Exha st Ventilation (2)
ƥ Sho ld remove at least 99% of particles
before next patient or HCW enters
ƥ Use for co gh-ind cing and aerosol-
prod cing proced res
 General Ventilation
ƥ Sstems that dil te and remove
contaminated air and control airflow patterns
in a room
ƥ Single-pass sstem preferred for AII rooms
ƥ Maintain AII rooms nder negative press re
ƛ Existing settings: ƿ6 air changes/hr (ACH)
ƛ New or renovated settings: ƿ12 ACH
 Air-Cleaning Methods
HEÔA filters
ƥ Use as s pplement to ventilation
ƥ Used to filter infectio s droplet n clei from
the air
ƥ M st be sed
ƛ When discharging air from local exha st ventilation
booths directl into s rro nding room
ƛ When discharging air from an AII room into the general
ventilation sstem

ƥ Can be sed to clean air that is exha sted

to o tside
 Air-Cleaning Methods
UVGI
ƥ Kills or inactivates M. tuberculosis
ƥ Use as supplement to ventilation
ƥ Not substitute for negative pressure
ƥ Not substitute for HEÔA filtration when air
recirculated from AII room into other areas
ƥ Emphasis on safet and maintenance
ƥ Occupational exposure limits
ƛ Overexposure can cause damage to skin, ees
ƛ UVGI sstems must be properl installed and maintained
 Respirator Ôrotection
General
ƥ Third level in the IC hierarch
ƥ Sho ld be sed b persons
ƛ Entering rooms of s spected/confirmed TB
patients
ƛ Aro nd co gh- or aerosol-prod cing proced res
ƛ In settings where administrative and
environmental controls will not prevent the
inhalation of infectio s droplet n clei
ƥ Decision on se of respirator protection (RÔ) in
labs sho ld be made on case-b-case basis
Respirator Ôrotection Ôrogram (1)
ƥ Settings where HCWs se RÔ to prevent
M. t berc osis infection sho d deveop,
impement, and maintain an RÔ program;
inc de a HCWs who se RÔ
ƥ Ôrovide HCWs ann a training on TB
contro, IC, and RÔ
ƥ Give HCWs time to become proficient and
comfortabe with respirators
Respirator Ôrotection Ôrogram (2)
ƥ Settings with no AII rooms, no co gh- or
aerosol-prod cing proced res, or no
expectations of patients with s spected or
confirmed TB do not need an RÔ program
ƛ Have written protocols for recognizing signs
or smptoms of TB and referring or
transferring patients to a setting where the
can be managed
 Considerations for
Selecting Respirators (1)
ƥ Minim m respirator protection is a
filtering facepiece respirator (nonpowered,
air-p rifing, half-facepiece, s ch as N95
disposable).
ƥ In high-risk sit ations (co gh- or aerosol-
prod cing activities), additional protection
ma be needed
 Considerations for
Selecting Respirators (2)
ƥ Use respirators that also protect HCWs
against m co s membrane expos re to
bloodborne pathogens as appropriate
ƥ Use respirators witho t exhalation valve
d ring proced res req iring sterile field
ƥ Consider offering respirators (e.g., N95
disposable) to visitors to AII rooms
 Considerations for
Selecting Respirators (3)
ƥ In certain settings (e.g., AII rooms,
vehicles carring infectio s patients),
administrative and environmental controls
ma not be eno gh to protect HCWs
ƥ Respirator sage reg lated b OSHAƞs
general ind str standard
 Respirator Ôrotection
Ôerformance Criteria
ƥ The following can be sed for protection
against M. t berc losis
ƛ Nonpowered partic late filter respirators
certified b CDC/NIOSH: N-, R-, or Ô-95, 99,
or 100), incl ding disposable respirators, or
powered air-p rifing respirators (ÔAÔR) with
high-efficienc filters
ƥ Respirators sho ld fit different face sizes
and feat res of HCWs
 Respirator Ôrotection
Ôerformance Criteria
ƥ Respirators m st be CDC/NIOSH approved
nder 42 CFR, Ôart 84
ƥ Tpes of Respirator Ôrotection
ƛ Nonpowered air-p rifing respirators
ƛ Ôowered air-p rifing respirators (ÔAÔRs)
ƛ S pplied-air respirators
 Nonpowered Air-Ô rifing
Respirators
Filter Efficiencies
Resistance to
Degradation 95 (95%)* 99 (99%)* 100 (99.97%)*

N (not resistant to oil) N95 N99 N100

R (resistant to oil) R95 R99 R100

Ô (oil proof) Ô95 Ô99 Ô100

* The percentages in parentheses indicate the minim m

allowable laborator filter efficienc val e when challenged with
0.3 Õm particles
 Effectiveness of Respirator
Ôrotection Devices
ƥ Face seal fit determines protective abilit
ƥ Filter efficienc depends on
ƛ Filtration characteristics
ƛ Size distrib tion of droplets in the aerosol
ƛ Velocit thro gh the filter
ƛ Filter loading
ƛ Electrostatic charges on the filter
 Implementing a Respirator
Ôrotection Ôrogram
ƥ Assign responsibilit
ƥ Train HCWs ann all
ƥ Cond ct fit testing of HCWs
ƛ D ring initial RÔ program training
ƛ Ôeriodicall thereafter

ƥ Inspect and maintain respirators

ƥ Eval ate program periodicall
 Co gh- and Aerosol-Ôrod cing
Ôroced res Req iring Use of RÔ
ƥ Co gh-prod cing proced res
ƛ Endotracheal int bation, s ctioning,
diagnostic sp t m ind ction, aerosol
treatments, bronchoscop, larngoscop
ƛ Gastric aspiration and nasogastric int bation
can ind ce co gh in some patients

ƥ Aerosol-prod cing proced res:

ƛ Irrigating TB abscesses, homogenizing or
lophilizing tiss e, performing a topsies
 


V


 
 Characteristics of Infectio sness
(1)
Infectio sness related to
ƛ Co gh >3 weeks
ƛ Cavitation on chest radiograph
ƛ Ôositive sp t m smear res lts
Characteristics of Infectio sness
(2)
ƛ Respirator tract disease involving l ng,
airwa, or larnx
ƛ Fail re to cover mo th and nose when
co ghing
ƛ Inadeq ate treatment
ƛ Undergoing co gh- or aerosol-prod cing
proced res
 Discharge to Home
ƥ Ôatient can be discharged witho t 3 negative
sp t m smears if
ƛ Follow- p plan has been made with local TB program
ƛ Ôatient is on standard treatment and directl
observed therap (DOT) is arranged
ƛ No person in home <4 ears old or
imm nocompromised
ƛ All in ho sehold previo sl exposed
ƛ Ôatient willing to sta home ntil sp t m res lts
negative
ƥ Do not release if high-risk persons will be
exposed
 Dr g-Resistant Disease
ƥ Consider AII preca tions for MDR TB
patients ntil discharge or c lt re
conversion
ƛ Transmission from MDR TB patients ma be
extensive

ƥ Risk for transmission not increased in

TB/HIV coinfected patients vs. TB patients

 





%  ]V

]

 Diagnosis of Latent TB Infection
ƥ Ôersons with LTBI
ƛ Are asmptomatic
ƛ Do not feel sick
ƛ Cannot spread TB to others

ƥ Diagnostic proced res

ƛ Ôositive TST with medical eval ation to excl de TB
ƥ Eval ation incl des assessing smptoms and signs,
x-ra, and sp t m tests
ƛ Blood assa for M. t berc losis (BAMT) now available
 T berc lin Skin Test (1)
ƥ TST is most sed test for M. t berc losis
infection in U.S.
ƥ Improve variable res lts b HCW training
and attention to detail
ƥ Improve HCW adherence to serial TST b
revising operational policies and HCW
training
 T berc lin Skin Test (2)
ƥ Need based on assessment of
ƛ HCW recent expos re
ƛ Clinical conditions increasing risk for TB
ƛ If setting can treat if HCW infected
ƥ Use recommended Manto x method
ƛ Training materials available from CDC website:
http://www.cdc.gov/nchstp/tb/p bs/pem.htm
ƛ M ltip nct re (e.g., tine) tests not as reliable
ƛ Contact HD for additional TST reso rces
 Administering the TST
ƥ Inject 0.1 mL ÔÔD
intradermall
ƥ Sho ld prod ce wheal of
6ƛ10 mm
ƥ Do not recap, bend,
break, remove needles
from sringes
ƥ Follow standard IC
preca tions
 Reading TST Res lt
ƥ Read 48ƛ72 hrs after placement
ƛ If HCW ret rns after >72 hrs, place
and read another TST*
ƛ Do not let HCWs read their own
res lts

ƥ Find and meas re ind ration

ƛ Meas re diameter of ind ration across
the arm
ƛ Do not meas re redness

* If the TST reaction is read as ƿ15 mm p to 7 das after

placement, the res lt can be considered positive.
 Interpreting TST Res lt (1)
ƥ Ôrobabilit of positive TST res lt acc rac
depends on M. t berc losis prevalence in
comm nit
ƛ Low prevalence: low probabilit of acc rac
ƛ High prevalence: high probabilit of acc rac
 Interpreting TST Res lt (2)
Different c t points sed depending on
ƥ Ôatientƞs risk for having LTBI

ƥ Size of ind ration

>5 mm highest risk

>10 mm other risk factors

>15 mm no known risk factors

 Interpreting TST for HCWs
1. Baseline ƿ10 mm = positive
(ƿ5 if HCW has HIV)
2. Serial testing Increase of ƿ10 mm =
positive (TST conversion)
3. Known expos re ƿ5 mm = positive when
(contact investigation) baseline res lt is 0 mm;
increase of ƿ10 mm =
positive when baseline
or previo s follow- p
TST res lt is >0mm, b t
<10mm
 Special Considerations in TST
ƥ Anerg
ƥ Antiretroviral therap for HIV infection
ƥ Ôregnanc
ƥ TST boosting
ƥ Use of two-step TST
ƥ BCG vaccination
ƥ Differences in ÔÔD preparations
 Anerg
ƥ Anerg is the imm ne sstemƞs fail re to
respond to injected reagents or antigens
ƥ Ôersons with compromised imm nit ma not
react to t berc lin
ƥ A few persons with normal imm nit also do
not react
ƥ Th s, absence of TST reaction does not r le
o t LTBI or TB disease
ƥ Anerg testing not recommended as adj nct
to TST, beca se TST res lts alone cannot
g ide clinical decision making
HIV Ôatients with Reconstit ted Delaed-
Tpe Hpersensitivit (DTH) Response
ƥ HIV patients with initial negative TST res lt
can convert to positive after starting highl
active antiretroviral therap (HAART)
beca se of improved imm nit
ƥ Sho ld repeat testing for M. t berc losis
infection in HIV-infected patients with
previo s negative M. t berc losis res lt
after starting HAART
 Ôregnanc
ƥ No change in g idelines
ƥ No evidence that TST has an adverse
effects on pregnant mother or fet s
ƥ Ôregnant HCWs sho ld be incl ded in
serial skin testing; no contraindications
ƥ Ôostponing diagnosis of M. t berc losis
infection d ring pregnanc is nacceptable
 TST Boosting
ƥ Some with LTBI have a negative TST
reaction when tested ears after infection
ƥ Initial TST ma stim late (boost) abilit to
react
ƥ Ôositive reactions to s bseq ent TSTs
co ld be misinterpreted as indicating
recent infection
 TST Two-Step Testing
Used for initial baseline M. tuberculosis testing for
those who will be given TST periodicall
ƥ No previous TST: do two-step test
ƥ First test positive: consider TB infected
ƥ First test negative: retest in 1ƛ3 wks (after first
TST result was read)
ƥ Second test positive: consider TB infected
ƥ Second test negative: consider not infected
 BCG Vaccination
ƥ Not ro tinel recommended in U.S.
ƥ BCG vaccination not a contraindication to
TST
ƥ Can lead to boosting in baseline two-step
testing
ƛ Boosted reaction from previo s BCG (false
positive) is indisting ishable from M.
t berc losis reaction (tr e positive)
Differences in ÔÔD Ôreparations (1)
ƥ Two ÔÔD preparations available in U.S.
®
ƛ AÔLISOL
ƛ T bersol®

ƥ Compared to U.S. standard, no differences*

* Villarino ME, B rman W, Wang YC, L ndergan L, Catanzaro A, Bock N, Jones

C, Nolan C. Comparable specificit of 2 commercial t berc lin reagents in
persons at low risk for t berc losis infection. JAMA 1999:281(2):169-71.
Differences in ÔÔD Ôreparations (2)
®
ƥ Compared to each other, AÔLISOL
prod ces larger reactions
ƥ Altho gh difference is slight, might affect
positivit rate in large instit tional settings
ƥ Recommend sing one prod ct
consistentl
 Use of BAMT S rveillance
and LTBI Testing
ƥ LTBI traditionall diagnosed with TST
ƥ Blood assa for M. t berc losis (BAMT)
available: QFT-Gold
ƥ QFT-G was approved b FDA in 2005 and can be
sed to detect LTBI
ƛ Meas res interferon (IFN)-gamma released in blood
when inc bated overnight with vario s reagents,
incl ding antigens specific for M. t berc losis
ƛ Lmphoctes from persons with LTBI react to these
proteins b releasing IFN-gamma
 Use of BAMT
Benefits of QFT-Gold over TST
ƥ Req ires onl one patient visit
ƥ Assesses responsiveness to M.
t berc losis antigens
ƥ Does not boost previo s responses
ƥ Interpretation less s bjective than for TST
ƥ Ôrobabl less affected b BCG vaccination
 Use of BAMT
Baseline and Serial Testing
ƥ Baseline testing with BAMT
ƛ Establish baseline with single negative BAMT
res lt
ƛ HCWs with positive BAMT res lt sho ld be
referred for medical and diagnostic eval ation

ƥ Serial testing for infection control

ƛ A conversion is a change from negative to
positive
 Special Considerations
ƥ QFT-Gold has not been eval ated in
persons aged <17 or pregnant women
ƥ The BAMT is not affected b the booster
phenomenon as is the TST
ƥ BCG vaccination is not a contraindication
to having a BAMT and does not infl ence
BAMT res lts
 Diagnosing TB Disease
ƥ Chest radiograph
ƥ Eval ation of sp t m samples
ƛ Smear
ƛ C lt re
ƛ Dr g s sceptibilit testing

ƥ Recommend against sing bronchoscop

beca se of risk of contamination or
transmission

  



%]V
]

 Treatment for LTBI
ƥ Treating LTBI red ces the risk that M.
t berc osis infection wi deveop into TB
disease
ƥ Certain gro ps have higher risk for deveoping
TB disease after infection; sho d be treated
ƥ Before beginning treatment for LTBI
ƛ Exc de diagnosis of TB
ƛ Ens re patient has no histor of adverse reactions
res ting from prior LTBI treatment
 Candidates for Treatment for LTBI
If M. tubercuosis Test
Give LTBI Treatment to
Resut Is
Highest risk groups ƿ5 mm
ƥ Immunocompromised
ƥ Recent contacts
ƥ X-ra indicates previous TB

Other high-risk groups ƿ10 mm

Ôatients with no risks ƿ15 mm

The frequenc of TB testing for HCWs wi be determined b the risk

cassification for the setting.
 Treatment Regiments for LTBI
R    R

 

 V 



  
Dail 270
INH 9*
2x wkl 76
Dail 180
INH 6
2x wkl 52
RIF 4 Dail 120

*Ôreferred
INH=isoniazid; RIF=rifampin
 Treatment for TB Disease (1)
ƥ TB treatment regimens m st contain
m ltiple dr gs to which M. t berc losis is
s sceptible
ƥ Treating TB disease with a single dr g can
lead to resistance
ƥ Also, adding a single dr g to a failing
regimen can lead to dr g resistance
 Treatment for TB Disease (2)
ƥ Ôreferred regimen
ƛ Initial phase: 2 months isoniazid (INH), rifampin
(RIF), prazinamide (ÔA), and ethamb tol
ƛ Contin ation phase: 4 months INH and RIF
ƥ In patients with cavitar p lmonar TB and
positive c lt re res lts at end of initiation phase,
contin ation phase sho ld be 7 months
ƥ TB patients with HIV who are taking anti-
retrovirals (ARVs) sho ld be managed b TB/HIV
disease experts
ƛ TB treatment regimens might need to be altered
 Cleaning, Disinfecting, and
Sterilizing Ôatient Rooms (1)
ƥ Three categories of medical eq ipment:
critical, semicritical, and noncritical
ƥ Critical: Instr ments introd ced directl into
bloodstream or other normall sterile areas
(e.g., needles, s rgical instr ments) sho ld
be sterile at time of se
 Cleaning, Disinfecting, and
Sterilizing Ôatient Rooms (2)
ƥ Semicritical: Do not penetrate bod
s rfaces b t might come into contact with
m co s membranes; clean with high-level
disinfectant
ƥ Noncritical: Do not to ch patient, or onl
to ch skin; not associated with
transmission
 References
ƥ Centers for Disease Control and Ôrevention.
G idelines for preventing the transmission of
Mycobacteri m t berc losis in health-care settings,
2005. MMWR 2005; 54 (No. RR-17): 1ƛ141.
http://www.cdc.gov/nchstp/tb/p bs/mmwrhtml/
Maj_g ide/infectioncontrol.htm

ƥ Errata (A g st 2006) available online

http://www.cdc.gov/nchstp/tb/p bs/mmwrhtml/
Errata_table.pdf
 Contin ing Ed cation Credits (1)
ƥ Contin ing ed cation credits will be available ntil
December 30, 2008
ƥ Ôarticipants will receive one of the following:
ƛ 3.5 ho rs contin ing medical ed cation (CME) credit
ƛ 0.35 contin ing ed cation nits (CEUs)
ƛ 4.0 contact ho rs contin ing n rsing ed cation (CNE)
credit
ƛ 3.5 contact ho rs National Commission for Health
Ed cation Credentialing (NCHEC) credit
ƥ Ôarticipants are req ired to read and st d the
g idelines, take a test, and complete an eval ation
 Contin ing Ed cation Credits (2)
ƥ If o ret rn the form electronicall, o will
receive ed cational credit immediatel.
ƥ If o mail the form, o will receive ed cational
credit in approximatel 30 das.
ƥ No fees are charged for participating in this
contin ing ed cation activit.
ƥ MMWR CE Credit:
http://www.cdc/gov/mmwr/cme/conted.html
 Additional Reso rces
For additional information on TB, visit
the CDC Division of T berc losis
Elimination website at
http://www.cdc.gov/tb
 Additional TB G idelines
ƥ CDC. Ôrevention and Control of T berc losis in Correctional and Detention
Facilities: Recommendations from CDC.MMWR 2006; 55 (No. RR-09): 1ƛ44.
ƥ CDC. G idelines for the investigation of contacts of persons with infectio s
t berc losis: recommendations from the National T berc losis Controllers
Association and CDC. MMWR 2005; 54 (No. RR-15): 1-37.
ƥ CDC. G idelines for sing the Q antiFERON-TB Gold Test for detecting
Mycobacteri m t berc losis infection, United States. MMWR 2005; 54 (No.
RR-15): 49-55.
ƥ CDC. Controlling t berc losis in the United States: recommendations from the
American Thoracic Society, CDC, and the Infectio s Diseases Society of
America. MMWR 2005; 54 (No. RR-12): 1-81.
ƥ CDC. G idelines for infection control in dental health-care settingsƜ2003.
MMWR 2003; 52 (No. RR-17).
ƥ CDC. Treatment of t berc losis. American Thoracic Society, CDC, and
Infectio s Diseases Society of America. MMWR 2003; 52 (No. RR-11).
ƥ CDC. G idelines for environmental infection control in health-care facilities:
recommendations of CDC and the Healthcare Infection Control Ôractices
Advisory Committee (HICÔAC).MMWR 2003; 52 (No. RR-10).