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Tuberculosis: infection control in hospital and at home

Jarvis M (2010) Tuberculosis: infection control in hospital and at home. Nursing Standard. 25, 2, 41-47. Date of acceptance: June 17 2010.

Summary
This article examines infection control issues relating to tuberculosis (TB) in acute and community settings. Background information on TB is discussed briefly along with key challenges to global and national control. A programme to prevent infection composed of specific hierarchical levels is outlined, using national and international guidance, and suggestions are made for infection control in the community. The article will be useful for nurses involved in the care of patients with confirmed or suspected TB.

The aim of TB infection control is to minimise the risk of transmission between populations. It is a topic growing in significance as a result of the development of drug-resistant TB and the association of TB with human immunodeficiency virus (HIV) infection (WHO 2009b). This article examines the background to TB and the principles of TB infection control in healthcare settings and the home.

Author
Miles Jarvis, TB specialist nurse, Royal Bournemouth Hospital, Bournemouth. Email: miles.jarvis@rbch.nhs.uk

Global and national data

Global TB epidemiology is shown in Box 1. The numbers of reported cases of TB have been rising in the UK since the 1980s (Health Protection Agency (HPA) 2010). The HPA reported 8,655 cases of TB in the UK in 2008 (an incidence rate of 14.1 cases per 100,000 population). This figure may be increasing slowly each year; there was a 2.2% increase in the rate of TB in 2008 compared with the rate in 2007 (HPA 2009). The disease tends to cluster in major urban areas, for example London in the UK. An estimated 39% of cases (an incidence of 44.3 cases per 100,000 population) occurred in London in 2008 (HPA 2009). BOX 1 Global tuberculosis (TB) epidemiology 4Two billion people are infected with Mycobacterium
tuberculosis (latent TB) worldwide.

Keywords
Drug resistance, human immunodeficiency virus, public health, respiratory system and disorders, tuberculosis These keywords are based on subject headings from the British Nursing Index. All articles are subject to external double-blind peer review and checked for plagiarism using automated software. For author and research article guidelines visit the Nursing Standard home page at www.nursing-standard.co.uk. For related articles visit our online archive and search using the keywords.

ONE PERSON DIES from tuberculosis (TB) every day in the UK (British Thoracic Society et al 2009). TB has been described as the greatest killer in history, claiming more lives than any other infectious disease (Ryan 1992). Although curable in most cases, it continues to cause approximately two million deaths each year (World Health Organization (WHO) 2009a). It is recognised that in the healthcare setting, patients, visitors and healthcare workers may be exposed to known and unknown patients with active pulmonary TB (Curran et al 2006). There is also a higher risk of exposure to TB in congregate settings, for example prisons, and households with TB patients (WHO 2009b). Effective and appropriate infection control measures are therefore essential, and patients with TB should have a good understanding of the relevant measures that apply to them. NURSING STANDARD

4Around 5-10% of these individuals will develop

active TB disease.

4If an individual has both latent TB and human

immunodeficiency virus (HIV) infection, his or her risk of developing active TB is 50-fold higher compared with those who are HIV negative.

4A total of 9.27 million new cases (1.37 million of

them in HIV positive people) were reported in 2007.

4There were two million deaths worldwide and

4.1 million infectious cases in 2007.
(Adapted from World Health Organization 2009a)

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The increasing rates of TB in the UK over the last two decades have been accompanied by a significant change in its epidemiology (Anderson et al 2008). While in the past this condition tended to occur in the general population, it is now associated more strongly with high-risk groups (Department of Health (DH) 2004), as shown in Box 2. Large percentages (72%) of TB cases in the UK occur in non-UK born patients and in people aged between 15 and 44 years (61%) (HPA 2009). It is important for infection control, therefore, that any communication barriers, for example language, are overcome so that the risks of disease transmission are minimised both in the hospital and at home.

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Background to tuberculosis
In 1882, Robert Koch discovered that TB is caused by bacteria from the genus Mycobacterium (Grange 2008). The genus includes more than 100 species of rod-shaped acid-fast bacteria and the causative agent of TB in humans is termed the Mycobacterium tuberculosis complex (Pratt et al 2005). M. tuberculosis complex infection usually occurs as a result of inhalation (almost universally), ingestion and/or inoculation (Pratt et al 2005). TB can be spread when an individual with infectious TB coughs, talks, sneezes or shouts. This forces TB bacteria contained within respiratory droplets into the air; these then evaporate to leave droplet nuclei, which are only 1-5mm in diameter (1mm is 1,000 times smaller than a millimetre). These nuclei contain viable tuberculosis bacilli, which can drift in normal air currents for long periods (Curran et al 2006). BOX 2 High-risk groups for tuberculosis (TB) 4People entering the UK from countries where there
are high rates of TB.

4People with human immunodeficiency virus infection

or whose immune systems are suppressed.

4Intravenous and/or heavy drug users. 4Prisoners and homeless people. 4Refugees and people who have been displaced. 4Ethnic minorities and those with limited access
to health care.

If droplet nuclei are inhaled, they can be drawn deep into the individuals alveoli because of their small size (Gordon and Mwandumba 2008). This may then give rise to an initial site of infection, which may develop into primary TB. In most cases, this leads to latent TB, which may or may not develop into post primary TB at a future date. It is estimated that one-third of people worldwide carry latent TB infection (Pratt et al 2005). TB may be defined either as pulmonary (respiratory) or as extrapulmonary (non-respiratory), depending on the site of disease. Pulmonary and laryngeal TB are generally potentially infectious, while most extrapulmonary sites of disease are not. Patients with suspected pulmonary TB need to submit sputum specimens to determine infectiousness (National Institute for Health and Clinical Excellence (NICE) 2006). Sputum samples are examined by staining microscopy for the presence of acid fast bacilli; the presence of acid fast bacilli generally indicates Mycobacterium (Pratt et al 2005). Sputum samples are known as smears and are reported as smear positive (if acid fast bacilli are seen) or smear negative (if acid fast bacilli are not seen). A finding of smear positive acid fast bacilli does not confirm M. tuberculosis, but simply shows that bacteria are present. Further testing (culture) is required to determine the species of mycobacteria present in the sample. If subsequent culture shows M. tuberculosis, a positive smear suggests infectious respiratory TB. Microbiology request forms should therefore always request acid fast bacilli and culture. Patients who produce three negative sputum samples on consecutive days are generally regarded as non-infectious (NICE 2006). However, negative sputum smears do not rule out a diagnosis of TB; they simply demonstrate that bacteria are not observed in those particular samples. Smear negative samples may later become culture positive for M. tuberculosis, and treatment may commence while waiting for culture results if clinical suspicion is high (Schluger 2008). Samples are then processed further to identify the mycobacteria present. Depending on the culture media, identification of the mycobacteria and the relevant drug sensitivities will usually be available between two and 12 weeks.

Key challenges to tuberculosis control

Drug resistance This is an increasing problem both internationally and in the UK, and is now one of the key challenges to global TB control (Grant et al 2008). Some strains of TB are resistant to one or more of the drugs often used to treat TB (Pratt et al 2005). While such strains may be NURSING STANDARD

4Those at risk of occupational exposure.

(Adapted from Pratt et al 2005)

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resistant to one drug only, and are generally treatable with current drug regimens, other strains can be resistant to more than one drug. The term multi-drug resistance TB (MDR-TB) refers to strains that are resistant to rifampicin and isoniazid, two common first-line anti-TB drugs. MDR-TB strains of TB are costly and clinically difficult to treat: extensive treatment regimens are generally required. While patients who have MDR-TB are no more infectious than those with drug-sensitive TB (Grant et al 2008), patients must be isolated and nursed in a negative pressure room (NICE 2006), because of the complexities and difficulties associated with treatment of individuals with MDR-TB. There are further strains of TB, known as extensively drug resistant TB (XDR-TB); these are strains of MDR-TB that are resistant to most of the second-line anti-TB drugs, for example amikacin or moxifloxacin, used to treat MDR-TB (Grant et al 2008). Although only eight cases have been treated in the UK, five of these patients have died. (Abubakar et al 2009). Such patients should be isolated and their treatment commenced rapidly, following advice from expert clinicians regarding drug regimens. Risk factors for MDR-TB are listed in Box 3. HIV co-infection TB and HIV co-infection is a major public health problem worldwide (Pozniak 2008). Nine percent of all new adult TB cases may be attributable to HIV infection (WHO 2009a) and TB is a leading cause of HIV-related illness and deaths. It is estimated that 1.37 million new cases of TB occurred among HIV-infected people in 2007 and around 456,000 of these people died (WHO 2009a). TB and HIV have been dubbed a cursed duet because of the way each condition negatively affects the other (Chrtien 1990). Active TB accelerates HIV viral replication, while HIV infection significantly predisposes an individual to active TB (Collins et al 2002). The availability of highly active antiviral therapy has reduced the morbidity and mortality of patients with HIV, including those infected with TB (Pozniak 2008). As HIV infection is a risk factor for MDR-TB, patients with suspected TB and HIV infection should ideally be nursed in a negative pressure facility (NICE 2006).

BOX 3 Risk factors for multi-drug resistance tuberculosis (MDR-TB) 4Previous TB drug treatment. 4Previous TB treatment failure. 4Close prolonged contact with a known case
of MDR-TB.

4Residence in London. 4Human immunodeficiency virus infection. 4Age 25-44 years. 4Male gender.
(Adapted from National Institute for Health and Clinical Excellence 2006)

is important to know that they exist because they can assist the development of local infection control policy and risk assessments. The local risk assessment establishes a level of risk of TB exposure for the healthcare facility (Pratt 2009), based on a systematic assessment (and periodic re-assessment) of the risk of transmission of M. tuberculosis. This should be informed by the local epidemiological profile of M. tuberculosis and an assessment of hospital facilities, resources, personnel and expertise (Pratt 2009). Local TB policies should provide guidance on how to identify and treat TB and outline work practices that minimise the risk of exposure to TB in the healthcare setting. Control of TB in the healthcare setting has traditionally focused on three main strategies: administrative, environmental and personal protection (Pratt 2009). WHO (2009b) policy recommends that the healthcare facility should develop an infection control plan that ensures proper implementation of these three levels of control, which should be put into operation as a single, co-ordinated programme. However, the nurse should recognise that these three levels of control are hierarchical and are listed here in order of importance. 4Administrative controls for example, early recognition and treatment of TB. 4Environmental controls for example, use of an appropriately ventilated room. 4Personal respiratory protection for example, use of masks (Curran et al 2006). Administrative control Controls are needed to identify and investigate patients in hospital who have TB and to treat them promptly with effective drug therapy (Curran et al 2006). The aims are to reduce healthcare workers and patients exposure to TB and to ensure that treatment is commenced rapidly and appropriately. Patients with a history suggestive of pulmonary TB need to be september 15 :: vol 25 no 2 :: 2010 43

Local risk assessment and infection control

WHO (2009b) stresses the importance of national TB infection control activities that is, activities developed to ensure TB infection control in healthcare facilities, congregate settings (such as prisons, hostels and nursing homes) and households. It is not within the scope of this article to examine national infection control policies, but it NURSING STANDARD

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investigated urgently. This includes obtaining sputum specimens, which are reported on urgently by microbiology. Common symptoms indicative of active TB are listed in Box 4. Not all patients will present with the symptoms outlined in Box 4. Breen et al (2008) found that 25% of patients presented without fever, sweats or weight loss, but had active TB infection. It is imperative that patients are triaged rapidly and isolated appropriately on arrival to the healthcare facility. Training of clinical staff is vital so that potential TB patients can be promptly identified and isolated (WHO 2009b). Actions required if a patient is suspected of having pulmonary TB are summarised in Box 5. Once positive sputum microscopy results are available, appropriate treatment must be started urgently, preferably supervised by a physician who has had training in the specialist care of TB patients (NICE 2006). Most patients with TB in the UK will have fully sensitive disease (Curran et al 2006), and effective anti-TB treatment will generally result in a non-infectious status within two weeks, assuming full adherence to treatment and clinical improvement. Respiratory isolation can be discontinued if the patient submits three consecutive negative sputum smears (NICE 2006). Environmental control The aim of environmental control measures is to reduce the concentration of infectious airborne particles. This is achieved by placing the patient with suspected pulmonary TB either in a negative pressure isolation room or a single room with the door closed and air vented to the outside (Pratt 2009 ). NICE (2006) guidance recommends that all acid fast bacilli smear-positive TB patients should be nursed in a single room, with measures to prevent air flowing out to other patient areas. BOX 4 Signs and symptoms of active tuberculosis 4Cough for more than three weeks, with or without
sputum production.

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BOX 5 Action required if pulmonary tuberculosis (TB) is suspected 4Rapid identification of suspected TB patients
through early triage.

4Isolation in a cubicle with doors closed and on a

separate ward to human immunodeficiency virus positive patients or other patients who are immunocompromised.

4Obtain sputum samples and request urgent acid fast

bacilli staining/culture.

4Control spread of TB through cough etiquette and

respiratory hygiene, for example covering the mouth when coughing or sneezing or using tissues.

4Staff to wear particulate filter respirator masks

at filtration level P3, if risk factors for multi-drug resistance TB exist or if aerosol-generating procedures are performed, for example sputum induction, nebuliser treatment or cardiopulmonary resuscitation.

4Patients to wear ordinary surgical masks whenever

they leave their room until two weeks drug treatment has been completed, with good adherence.

4Patients should be urgently reviewed by a physician

with training in specialised care of patients with TB.
(Adapted from National Institute for Health and Clinical Excellence 2006, World Health Organization 2009b)

4Weight loss. 4Night sweats. 4Lethargy. 4Lymphadenopathy (abnormal enlargement of the

lymph nodes).

4Pyrexia of unknown origin. 4Haemoptysis.

(Adapted from Gordon and Mwandumba 2008)

Any patient with suspected or proven MDR-TB should be treated in a monitored negative pressure room (NICE 2006). These are constructed to strict criteria, and the criteria should be monitored fully while the equipment is in use. Effective ventilation is achieved when contaminated air is removed and replaced with air from outside or from a low-risk area. Recirculated air that has been treated to kill or remove tubercle bacilli with filters and ultraviolet light is one alternative to this system. Ventilation is measured as number of air changes in a room per hour (ACH). It is estimated that 12 ACH are required (WHO 2009b). Negative pressure rooms should contain a toilet and bathing facilities, as well as a telephone and television (Curran et al 2006). Current NICE (2006) guidance includes an algorithm of care for isolation decisions for patients with suspected pulmonary TB. Patients with suspected or proven MDR-TB should be transferred to another healthcare facility if negative pressure rooms are not available locally. Other environmental measures include the use of upper room ultraviolet irradiation and air filtration devices. Ultraviolet light is known to kill or inactivate M. tuberculosis (DH 1998), and upper room ultraviolet irradiation lamps are a useful adjunct to ventilation systems to kill NURSING STANDARD

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tubercle bacilli in the upper parts of rooms, while minimising radiation exposure to the lower part of the room (DH 1998). Air filtration devices are also used. High-efficiency particulate air filters remove particles as small as 0.3m. They are relatively expensive to install and maintain, and are used chiefly to clean air recirculated to other areas of a facility, or recirculated within a room, or for rooms where there is no ventilation system. Personal respiratory protection This type of protection comprises the use of respirators to minimise the risk to healthcare workers from M. tuberculosis (Pratt and Curran 2006). These are usually single-use filtration masks. Filtration is achieved when the wearer draws in breath and air is pulled through the filtering component part of the mask (Curran et al 2006). Respirators are graded according to their inward leakage (Pratt and Curran 2006). The Filtering Face Piece 3 mask (highest grade in this category of respirator) is recommended by NICE for use when caring for TB patients (NICE 2006). NICE (2006) guidelines recommend that masks do not need to be worn in the patients room unless MDR-TB is suspected or if aerosol-generating procedures, for example bronchoscopy, induced sputum, intubation, autopsy or surgical procedures or cardiopulmonary resuscitation are being performed. This section of the guidelines has been the subject of considerable debate. In contrast to UK guidance, which is comparable to recommendations from the Joint Tuberculosis Committee of the British Thoracic Society (2000), the US Centers for Disease Control and Prevention (CDC) suggest that all healthcare workers entering a TB patients isolation room should wear at least a N-95 respirator, which is equivalent to a FFP2 mask (Jensen et al 2005). WHO (2009b) also recommends that healthcare workers should use particulate respirators (masks) when caring for patients with confirmed infectious TB or those suspected of having infectious TB. Pratt and Curran (2006) suggest that the NICE (2006) guidelines should be reviewed, because administrative and environmental controls do not entirely reduce the risk of preventable exposure to TB. They argue that, given that drug-sensitive TB is no less infectious than MDR-TB, it is not clear why the two-tier approach exists (Pratt and Curran 2006). It is, however, conceded that there is no substantive evidence to show transmission of TB from identified patients to staff except when aerosol generating procedures are taking place (Curran et al 2006). Overall, it is up to individual hospitals to implement respiratory protection within the TB control plan. Fit testing is a vital aspect of using personal respiratory protection. Testing should attempt NURSING STANDARD

to ascertain that a particular type of mask can form a seal for an individual, and the results of the test should be clearly recorded. (Curran et al 2006). Fit testing equipment should include full instructions (Pratt 2009), which are normally available from personal respiratory protection equipment suppliers.

Infection control in the community

While there has been extensive guidance written on preventing TB infection in healthcare settings, less is written about the subject in congregate and community settings, such as prisons, shelters and nursing homes (WHO 2009b). Yet the incidence of TB infection and disease in congregate settings exceeds that in the general population. For example, rates of TB in UK prisoners have been recorded at 208 cases per 100,000 population (Story et al 2007). NICE (2006) provides guidance, including TB screening and treatment advice, for the care of prison populations. WHO (2009b) recommends that the same standards that apply to healthcare settings are also applied to congregate settings. This means that risk assessments need to take place where TB incidence is higher (for example, housing shelters) and action taken to protect other service users from potential exposure while providing direct care for the patient with TB. NICE (2006) also states that patients with suspected pulmonary TB should not be admitted to hospital unless there is clear clinical or socioeconomic need. This is supported by WHO (2009b) policy, which recommends that TB patients spend a minimal amount of time in healthcare settings. Thus, much of the care of the patient with TB takes place in the community setting. Advice needs to be given by healthcare providers to members of the household of a person diagnosed with pulmonary disease, as they are at high risk of infection and disease. Research suggests that the greatest risk of infection arises through exposure to the infectious case before diagnosis (WHO 2009b). Early recognition of potential TB cases is therefore central to reducing the risk of TB transmission in the household. The patient diagnosed with pulmonary TB requires education on his or her treatment regimen, the need for adherence to treatment and possible adverse reactions. This education should be provided in the appropriate language and media (NICE 2006). Patients should also be educated on cough etiquette and respiratory hygiene (that is, covering the nose and/or mouth when coughing or sneezing, and coughing into a tissue or piece of cloth, which is then properly disposed of). The aim is to minimise the spread of droplet nuclei; in addition, it will decrease september 15 :: vol 25 no 2 :: 2010 45

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transmission of larger droplets and therefore assist control of other respiratory infections. If tissues or a piece of cloth are not available, then good practice is to cover the nose and mouth with the elbow or hand, followed by immediate cleaning (WHO 2009b). These basic measures should be undertaken by healthcare workers, visitors and families and should form part of any educational campaign delivered to communities (WHO 2009b). Particular attention should be given to the quality of information and education provided to family members and contacts of the TB patient, to avoid any unintentional stigmatisation. The social stigma associated with TB has been recognised as a barrier to successful care of these patients. TB has been considered a dirty disease (Macq et al 2006). It is closely associated with poverty (Banavaliker 2008) and can leave people feeling ashamed and isolated (Karim et al 2007). This can have a potential negative effect on TB control through a delay in diagnosis and poor concordance with treatment, which can ultimately lead to a greater public health risk and the development of drug resistance (Macq et al 2006). It is therefore vital that education campaigns do not perpetuate this stigma. However, WHO (2009b) notes that even well conducted community awareness programmes do not remove the stigma associated with TB. It is recognised that further research is necessary to understand the negative effects of TB stigma and the interventions that can reduce this (Macq et al 2006). Sensitivity is therefore required when designing community awareness campaigns (WHO 2009b). The aim of prevention is to minimise the potential exposure of those who have not yet been exposed. Houses should be well ventilated (natural ventilation is sufficient), particularly in rooms where TB patients spend considerable amounts of time (WHO 2009b). While still smear positive, TB patients should sleep alone in separate, ventilated rooms, spend as much time outside as possible TB cannot be transmitted easily outside as the bacilli are killed by ultraviolet light and minimise any time in congregate settings or on public transport. It is accepted that patients with drug-sensitive TB are non-infectious after two weeks of uninterrupted, adequate, anti-TB medication (McNicol et al 1995). One study has suggested that TB patients may remain infectious for longer (Connell et al 2009), although these data were from a cohort of patients with high rates of 46 september 15 :: vol 25 no 2 :: 2010

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social dysfunction and advanced disease, and may not be reproducible across the wider TB patient population. As a general rule, in practice, patients with pulmonary TB are requested to isolate themselves at home until two weeks of treatment are complete. It usually takes longer for patients with MDR-TB to become non-infectious, compared with patients with drug-sensitive TB, perhaps because of the limited efficacy of available second-line drugs (WHO 2009b). Therefore, for patients with drug-resistant TB, even if their treatment is commenced in a timely manner, potential transmission in the household may be prolonged, and advice to patients and family should reflect this. WHO (2009b) recommends that healthcare providers should ideally wear personal respiratory protection when attending patients in enclosed spaces. Further, TB contact screening should be performed according to national guidelines (NICE 2006). Identifying any further active or latent cases of TB that require investigation and treatment is an important part of TB infection control measures (WHO 2009b). Any members of the family who are at risk of immunosuppression, for example those who are HIV positive, should be identified and should not provide care for or share living space with those who have pulmonary TB. This particularly applies to children, especially those under five years of age. WHO (2009b) recommends that in cases of XDR-TB, renovation of the patients home should be considered if ventilation needs to be improved. This might include the building of a separate bedroom or installation of windows if a patient is going to be on long-term treatment over many months or years and may remain infectious for a long period of time.

Conclusion
This article has discussed effective infection control for managing and preventing the spread of TB in healthcare and community settings. Relevant global and national epidemiology has been outlined, along with key clinical information providing the background context. It is important that local infection control policy is based on global and national guidance, to ensure both consistency of practice and policies based on best available evidence. The three levels of control that are recommended by WHO to form an effective TB infection control plan in the healthcare setting are, in order of importance, administrative controls (recognising, investigating and treating TB), environmental controls (isolation of NURSING STANDARD

the TB patient in an appropriately ventilated room) and personal respiratory protection (use of respirators). Little has been published on TB infection control in the community, despite the fact that most TB treatment takes place in this setting. Available global and national guidance has been discussed, noting the importance of patient education, isolation at home and identification of potential vulnerable contacts who may need to be screened for TB. It is crucial that national guidance gives clear direction in the management of patients with pulmonary TB and commitment from all those involved in the care of TB patients is required to implement an effective TB infection control plan NS

USEFUL RESOURCES 4British Thoracic Society:

www.brit-thoracic.org.uk

4Department of Health:

www.dh.gov.uk/en/index.htm www.hpa.org.uk

4Health Protection Agency: 4National Institute for Health and Clinical

Excellence tuberculosis guidelines: www.nice.org.uk/CG033

4World Health Organization information

on tuberculosis information: www.who.int/topics/tuberculosis/en (Last accessed: September 1 2010)

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