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TUBERCULOSIS (TB) SCREENING, TESTING AND
EXPOSURE PROTOCOL
Policy Number: CLIN. 48
Goal:
To educate staff regarding TB exposure risks and methods for prevention of transmission
of TB; provide routine, periodic screening of staff for active and latent TB; provide for
early identification, evaluation and treatment of patients who may have infectious TB; and
ensure appropriate use of engineering controls to decrease the incidence of transmission
of TB.
Scope:
This protocol applies to all HDI sites.
Responsibility:
Background:
All HDI clinical staff
TB is a communicable disease caused by Mycobacterium tuberculosis, or the tubercle
bacillus. It is spread primarily by tiny airborne particles (droplet nuclei) expelled by a
person who has infectious TB. If another person inhales air containing these droplet
nuclei, transmission may occur. Although the majority of TB cases are pulmonary, TB
can occur in almost any anatomical site. TB can cause disability and/or death if not
detected and treated appropriately.
Targeted High-Risk Groups for TB Screening:
•
Close contacts of persons with active TB
•
Foreign-born persons from areas where TB is common
•
Residents and workers in high-risk congregate settings
•
Health care workers who serve high-risk clients
•
Medically under-served, low-income populations
•
Persons with certain medical conditions, such as HIV infection, diabetes, cancer, etc.
•
Children exposed to adults in high-risk categories
•
Persons who inject illicit drugs
•
High-risk racial or ethnic minority populations defined locally as having an increased prevalence
of TB
Signs and Symptoms of TB:
Pulmonary:
Productive, prolonged cough (3 weeks)
Chest pain
Hemoptysis
Systemic:
Fever
Chills
Night sweats
Loss of appetite
Weight loss
Becomes easily fatigued
Active TB Disease and Latent TB Infection:
Persons who are infected with tuberculosis, but who do not have TB disease cannot spread the infection
to other people. TB infection in a person who does not have TB disease is not considered a case of TB
and is often referred to as having latent TB infection (LTBI).
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In some people, the TB bacilli overcome the defenses of the immune system and begin to multiply,
resulting in the progression from TB infection to TB disease. This process may occur soon after or many
years after infection. In the United States, unless they are treated, approximately 5% of persons who
have been infected with tuberculosis will develop TB disease in the first year or two after infection and
another 5% will develop disease sometime later in life.
Protocol:
1.
All employees at patient care sites in the following job classifications have occupational exposure
to (TB):
Camp Health Aide
Migrant Services Director
Phlebotomist
Center Manager
Nurse Manager
Physician
Dentist
Nurse Midwife
Physician Assistant
Dental Assistant
Nurse Practitioner
Dental Hygienist
Nurse Supervisor
Radiology Technician/
Mammographer
Receptionist/Billing Clerk
Driver
Nutrition Services Director
MIHP Staff
Field Coordinator
Nutritionist
Staff Nurse
Fluoride Team Personnel
OB Nurse Manager
Triage Nurse
Housekeeping/Maintenance
OB Staff
WIC Staff
Medical Assistant /Clinical
Assistant
Pharmacist/Pharmacy Staff
Hearth Home Staff
2.
All employees at patient care sites in the following job classifications may have occupational
exposure to TB:
 Billing Staff
 Medical Records Staff
 Telephone Receptionist
3.
The Medical Director or designee will annually perform a TB risk assessment by site based on the
following elements:
 Community TB Profile
 Review of TB patients treated and drug susceptibility patterns
 Analysis of annual PPD-tuberculin skin test results of health care workers at each facility
 Review of infection control parameters and practices at patient care sites
4.
The most important factors in preventing transmission of TB are:
 Early identification of patients who may have infectious TB.
 Prompt implementation of TB precautions for such patients.
 Prompt initiation of effective treatment for those who are likely to have TB.
5.
Any patient strongly suspected of having active TB will be referred immediately to a facility
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equipped to handle such a patient safely. Any active TB patient is discouraged from re-entering
an HDI facility until considered non-infectious.
6.
Identifying patients who may have active TB:
 Triage will include vigorous efforts to promptly identify patients suspected of TB.
 A diagnosis of TB may be considered for any patient who has a persistent cough lasting > 3
weeks, bloody sputum, night sweats, weight loss, anorexia, or fever.
 Patients with signs or symptoms suggestive of TB should be evaluated promptly to minimize
the amount of time they are in ambulatory care areas.
 TB precautions include - placing these patients in a separate area apart from other patients
and not in open waiting areas, giving these patients surgical masks to wear and instructing
them to keep their masks on, and giving these patients tissues and instructing them to cover
their mouths and noses with the tissues when coughing or sneezing.
 Precautions should continue for patients who are known to have active TB and who have not
completed therapy until a determination has been made that they are non-infectious.
7.
Diagnostic evaluation for active TB:
 Obtain medical history and physical examination
 PPD skin test
 Chest x-ray
 Laboratory microscopic examination and culture of sputum or other appropriate specimens
8.
Initiation of treatment for suspected or confirmed TB:
 Patients who have confirmed active TB or who are considered highly likely to have active TB
should be started promptly on appropriate treatment in accordance with current guidelines.
 Patients with suspected or confirmed TB should be reported immediately (within 24 hours of
diagnosis) to the local public health department so that standard procedures for identifying
and evaluating TB contacts can be initiated.
9.
Persons with a history of a positive reaction to TB skin testing, should not be re-tested. Persons
with positive TB skin test results should have a chest x-ray as part of the initial evaluation of their
tuberculosis skin test, if negative, repeat chest x-rays are not needed unless symptoms develop
that could be attributed to TB. Persons with a history of positive TB skin testing who develop
signs and symptoms suggestive of TB should undergo a medical evaluation including a chest xray.
10.
Tuberculin skin testing is not contraindicated for BCG vaccinated persons.
11.
Education and training of health care workers:
All health care workers receive education regarding TB that is relevant to persons in their
particular occupational group. Training will be conducted before initial assignment and
updated annually.
12.
A. Employees listed in # 1 above must be screened/tested for personal exposure to TB annually.
B. Employees listed in # 2 above may be tested if they desire. Screening/testing is performed
per CDC guidelines at HDI expense.
C. New employees with a history of negative skins tests: If tested within the past year, do one
test. If no test within the past year, do two-step testing.
D. New employee with a history of a positive TB skin test: Complete a TB health questionnaire.
Obtain a chest x-ray if a current one is not available.
E. Employee with known exposure to TB: Test immediately and again in three months.
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13.
Any PPD test conversion or active TB in health care workers, any occurrence of possible personto-person transmission of TB and any situation in which patients or health care workers with
active TB were not promptly identified and isolated will be reported to the Safety Committee for
review and possible investigation.
14.
Any new conversion (induration  15 mm, or 10 mm in high risk patient, or  5 mm in HIV
positive patient) is treated as follows:
 TB questionnaire is completed by patient.
 AP Chest x-ray is done.
 If questionnaire suggests possible active TB, or Chest x-ray is suspicious for TB:
a)
employee is removed from active duty;
b)
3 sputum collections for AFB on consecutive mornings are evaluated;
c)
If negative, employee may return to work.
d)
If positive, employee is referred to the local Health Department and personal
physician for appropriate therapy and follow-up.
e)
After the employee is deemed non-infectious, they may return to work.


If TB questionnaire and Chest X-ray are not suggestive of active TB, prophylaxis is
recommended and the employee is referred to his/her primary care provider for evaluation.
Employees with history of positive PPD skin test, will have the TB Questionnaire
administered yearly and reviewed by the Infection Control Coordinator in lieu of annual PPD
testing.
15.
Elective dental treatment should be deferred until a physician confirms that the patient does not
have infectious TB or until the patient is no longer considered infectious. If urgent dental care
must be provided for a patient who has, or is strongly suspected of having infectious TB, such
care should be provided in facilities that can provide TB isolation.
16.
Engineering controls, personal protective equipment and decontamination procedures are
available or performed as described in the Infection Control Plan for HDI. We currently do not
have any isolation rooms with negative air pressure at any site.
17.
Resources available from the local health department include:
 TB medication for county residents
 Medical assessment and treatment
 Consultation advice
 MDCH TB Control Program (517) 335-8165
 www.cdc.gov/nchstp/tb/
18.
Standard TB Skin Testing: Mantoux (intradermal) injection of 0.l ml of Purified Protein Derivative
(PPD) administered into forearm by health care worker trained to perform this test.
19.
Reading TB Skin Test Results:
The reaction to the Mantoux test should be read by a trained health care worker 48 to 72 hours
after the injection. Patients should never be allowed to read their own tuberculin skin test results.
If a patient fails to show up for the scheduled reading, a positive reaction may still be measurable
up to 1 week after testing. However, if a patient who fails to return within 72 hours has a negative
test, tuberculin testing should be repeated.
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20.
Classifying the Tuberculin Reaction:
 5mm is classified as positive
in:
-HIV positive persons
-Recent contacts of a case of TB
-Persons with fibrotic changes on
chest radiograph consistent with
old healed TB
-Patients with organ transplants
and other immunosuppressed
patients
 10mm is classified as positive in (all
others):
-Recent arrivals from high-prevalence
countries
-Injection drug users
-Residents and employees of high-risk
congregate settings
-Mycobacteriology laboratory
personnel
-Persons with clinical conditions that
place them at high risk
-Children < 4 years of age, or children
and adolescents exposed to adults in
high-risk categories
 15mm is classified as
positive in:
-All others with no known
risk
Related Policies:
Infection Control Plan
CLIN. 10 - Protocol for Employee Health
Reviewed By:
Infection Control Coordinator, Medical Director, QI Committee
Effective Date:
December 4, 2000
Revised Date:
March 11, 2003; February 7, 2007; September 19, 2008
Review Date:
September 19, 2010
Approval:
________________________________________
Medical Director
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TB QUESTIONNAIRE
Name: __________________________________________
OSHA mandates that all Healthcare Workers be screened annually for TB. Because of
your known reaction to TB skin testing or history of BCG, please complete the following:
(Circle the appropriate answer)
1. Have you had exposure to a person with confirmed TB in the past year?
Yes
No
2. Have you had a chronic cough during the last year that lasted more than 3 weeks?
Yes
No
3. Have you had unexplained hemoptysis (blood in sputum) in the last year?
Yes
No
4. Have you had unexplained night sweats, fever, or weakness in the last year?
Yes
No
5. Have you had unexplained weight loss or decrease in appetite?
Yes
No
Please sign this form below and return the completed questionnaire to your department/
site manager. Thank you.
Signature: ________________________________________ Date: _______________
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TUBERCULOSIS RISK ASSESSMENT
Site: _____________________________________________
Date: ____________________________________________
Community TB Profile:
______________________________________________________________________
______________________________________________________________________
___________________________________________________________________
Number of TB patients treated: _____________
Drug susceptibility patterns:
______________________________________________________________________
______________________________________________________________________
___________________________________________________________________
Analysis of annual PPD-tuberculin skin test results:
# Performed ______________
# Negative _______________
# Positive/New conversions ______________
Action plan, if necessary:
______________________________________________________________________
______________________________________________________________________
___________________________________________________________________
Signature: __________________________
Medical Director
cc: Infection Control / Safety Committee
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Date: _______________