INFECTIOUS CONTROL FOR MYOBACTERIUM
TUBERCULOSIS
Author
Policy Ratified by
Committee
Date
Classification
OSHEU
Date Issued
Area Applicable
University Wide
Review Date
Ref No:
Version No:
15/02/05
1
Disclaimer
When using this document please ensure that the version you are
using is the most up-to-date.
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IPCD Policy Number 7
CARDIFF AND VALE NHS TRUST
YMDDIRIEDOLAETH GIG
CAERDYDD A’R FRO
H/8
Policy on Infection Control for Mycobacterium Tuberculosis
This policy was approved by
Cardiff and Vale NHS Trust Board April 2002
Date of review – April 2004
Central Registration Number –
If the date at the time of reference to this Policy document is after the stated date
for review you must contact the author, or if absent, the Corporate Affairs Director,
to check that the content is current.
Out of date policies must not be relied on
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Contents
Page
1
2
3
4
5
6
7
Summary
Introduction
Notification of Tuberculosis
Ward Procedures
4.1
Confirmed or suspected smear positive pulmonary disease
4.2
Multiple drug resistant tuberculosis (MDR-TB)
4.3
Confirmed smear negative pulmonary disease
4.4
Non-pulmonary disease
4.5
Infants born to mothers with infectious tuberculosis
Transfer of Patients
5.1
Within the hospital
5.2
Visits to other departments and surgical operations
5.3
Transfer to other hospitals
5.4
Ambulance transportation
Health Care Personnel
6.1
Pre-employment
6.2
Routine screening
6.3
Contacts of smear positive pulmonary tuberculosis
6.4
Contacts of smear negative or non-pulmonary tuberculosis
References
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1. Summary
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All forms of tuberculosis are notifiable to the Consultant in Communicable Disease
Control by the doctor making or suspecting the diagnosis.
Notify the Infection Prevention and Control Department.
Adult patients with smear positive pulmonary disease should be transferred to a
negative pressure room on the Infectious Disease Unit whenever possible.
Respiratory isolation should be for two weeks after commencement of treatment for
drug susceptible tuberculosis.
Additional control measures are required for suspected or confirmed Multiple Drug
Resistant Tuberculosis. MDR-TB patients should be transferred to the Infectious
Disease Unit. Staff and visitors entering the room should wear specialised TB masks.
Smear negative pulmonary patients can be nursed on open ward unless there are
immunocompromised patients present.
Non-pulmonary Tuberculosis may be nursed on an open ward.
All new staff members including students and locums must have their Tuberculosis
status established by Occupational Health.
Follow up of staff contacts of smear positive pulmonary tuberculosis cases will be
carried out by Occupational Health.
2. Introduction
The Joint Tuberculosis Committee of the British Thoracic Society produced an updated
Code of Practice for the Control and Prevention of Tuberculosis in the United Kingdom in
20001. This Code of Practice takes into account evidence in relation to control of infection in
hospitals, protection of health care workers, contact tracing, multidrug-resistant disease
and the possible effects of HIV on tuberculosis. In 1998 the Interdepartmental Working
Group on Tuberculosis produced guidance on the control and transmission of HIV related
tuberculosis and multiple drug resistant tuberculosis2. The guidance given in this document
is taken from these two Codes of Practice.
Since the publication of the previous British Thoracic Society guidelines in 1994 the
epidemiology of tuberculosis in Britain has continued to change with increases in the
number of notifications, mostly in large urban areas. While the rates of tuberculosis in HIV
cases has continued to rise the rate for drug resistant tuberculosis has not risen but
resistance remains an important issue.
All forms of tuberculosis are notifiable to the Consultant in Communicable Disease
Control. This allows data collection to monitor epidemiological trends and to initiate
appropriate contact tracing. Failure to notify may mean that close contacts are not
screened and may result in appropriate chemoprophylaxis or BCG vaccination not being
given.
Notification must be on first awareness/suspicion of the possibility of tuberculosis. Failure
to comply can result in prosecution by the public health authority against the responsible
clinicians and the Trust.
3. Notification of Tuberculosis
All forms of tuberculosis are notifiable to the Consultant in Communicable Disease Control
(CCDC) by the doctor making or suspecting the diagnosis. This must be done initially by
phone (Cardiff 20 402478) and then by the official notification form. Failure to notify in some
circumstances could lead to action for medical negligence.
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The Infection Prevention and Control Department must also be notified by phone (see
Section 1). This will ensure that the appropriate infection control procedures are
implemented at ward level. Contact tracing and screening of staff members may
occasionally be necessary and when required will be done in conjunction with local Public
Health Officers and UHW Occupational Health Department.
4. Ward Procedures
The method of isolation/precautions used for patients with tuberculosis depends on the
type of disease diagnosed.
4.1 Confirmed or Suspected Smear Positive Pulmonary Disease
Patients with smear positive pulmonary disease require isolation in a room ventilated to the
outside or with mechanical ventilation extract system. Therefore, whenever possible,
patients with such disease should be transferred to the Infectious Diseases Unit (ward A7,
U.H.W.) for isolation and treatment. Isolation should be for a period of two weeks after the
commencement of treatment for drug susceptible tuberculosis.
Crockery and cutlery can be treated as for any other patient and no extra precautions are
required for linen etc. Infected material and other clinical waste should be disposed of by
incineration, in the usual manner.
If a patient on a general ward is diagnosed as having infectious tuberculosis after having
been there for several days the Infection Control Team should be contacted to make an
assessment of risk to other patients. Other patients must have their exposure documented
and the Consultant in Communicable Disease Control informed (CCDC).
a. Visitors
All visitors must report to the nurse-in-charge of the ward. Only visitors that have been
in close contact with the patient before diagnosis was made should be allowed to visit;
however individual risk assessments on potentially infective or susceptible visitors must
be made. Visitors of children with tuberculosis should be segregated from the rest of the
ward until they have been screened to exclude them as a source of infection.
b. Cleaning
Housekeepers cleaning the room are not at particular risk but should have had their
BCG/immune status established. Normal housekeeping procedures should be carried
out. Including terminal cleaning on discharge of the patient; see Cardiff and Vale
Decontamination Policy 2001.
c. Isolation
Transfer/admission to the Infectious Diseases Unit (A7, UHW) should be considered in
these cases.
 A single room should be used, if one is not available contact the IPCT.
 Visitors and members of staff from other departments must report to the Nurse-inCharge before entering the room.
 Patients should not leave the room to attend other departments without prior
arrangements.
 A respiratory isolation sign (pink) should be displayed on the door.
 The door of the room should be kept closed at all times unless the clinical need of
the patient dictates otherwise.
 Gloves should be worn if there is any risk from contamination with blood and body
fluids.
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Plastic aprons must be worn when soiling is likely.
Those who come into close contact with the patient should wear masks. Specialist
masks for tuberculosis should be used for contact with cases of smear positive TB.
(see below).
Face protection, e.g. visor, goggles or fluid shield face mask should be worn if there
is a risk of splashing from blood or body fluids and secretions.
Hands must be washed with soap and water and then disinfected with an approved
hand disinfectant (e.g. alcohol gel) before entering the room, after patient contact,
after contact with potentially infected materials, and after removal of disposable
gloves.
4.2 Multiple Drug Resistant Tuberculosis (MDR-TB)
Additional infection control procedures for patients with multiple drug resistance will be
decided by risk assessment on the units treating the patient. Whenever possible patients
with suspected or confirmed multiple drug resistant tuberculosis should be transferred to
the Infectious Diseases Unit (UHW).
Staff and visitors entering the room of a confirmed or suspected case of MDR-TB should
wear a specialised mask. The recommended mask for use in the Trust is the Tecnol PFR95
(ref no. 46727).
The patient should remain in isolation in a negative pressure room until assessed to be
non-infectious which ideally should be:
 the patient has had a minimum of two weeks of appropriate therapy
and
 three negative sputum microscopic smears on three separate occasions over at least a
fourteen day period
and
 shown tolerance to the prescribed treatment and ability and agreement to adhere to
treatment
and either
 a complete resolution of cough
or
 definite clinical improvement to treatment.
4.3 Confirmed Smear Negative Pulmonary Disease
The patient may be nursed on the open ward unless there are immunocomprimised
patients on the same ward in which case the patient should be placed in a side room. If
aerosol-generating procedures are to be performed (e.g. bronchoscopy) the patient should
be isolated during the procedure.
4.4 Non-Pulmonary Tuberculosis
The patient may be nursed on the open ward although aerosol-generating procedures (e.g.
abscess or wound irrigation) may necessitate patient isolation.
4.5 Infants Born to Mothers With Infectious Tuberculosis
Infants born to mothers who have infectious TB should receive chemoprophylaxis for six
weeks and then be tuberculin tested, if negative BCG must be given, if positive the
chemoprophylaxis should be continued. Specialist advice should be sought before starting
treatment.
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5. Transfer of Patients
As with other Infection Control matters, the Nurse-in-charge of the ward has the
responsibility to ensure that the necessary information regarding an infectious patient is
passed on to a senior member of the receiving ward/department, prior to transfer.
5.1 Within the Hospital
Patients with smear negative pulmonary and non-pulmonary tuberculosis do not present a
problem for the receiving ward. When transfers of this type take place the receiving ward
must be informed of the patient’s current status prior to transfer. Smear positive pulmonary
tuberculosis patients should be transferred, whenever possible, to the Infectious Diseases
Unit and should only be discharged from this unit to another ward in the hospital when the
consultant-in-charge of the patient is satisfied that they are no longer infectious. Immediate
clinical need may occasionally necessitate patient movement outside the Infectious
Diseases Unit; advice is available from the Infection Prevention and Control Department.
5.2 Visits to Other Departments and Surgical Operations
Visits of smear-negative pulmonary and non-pulmonary tuberculosis cases to other
departments should be kept to a minimum. When there is a need arrangements must be
made with the senior staff of the department concerned prior to transfer. Patients should be
seen at the end of the working session and should spend the minimum time in the
department.
Patients with smear-positive pulmonary tuberculosis must not visit other departments,
unless there is an important clinical need. If they do need to visit another department the
patient should wear a TB protective mask (see section 4.2).
Patients requiring a visit to the operating theatre must be regarded as infectious and
treated in accordingly.
5.3 Transfer to Other Hospitals
Smear positive pulmonary tuberculosis patients should only be transferred to units that
have ventilated rooms unless the consultant-in-charge of the patient is satisfied they are no
longer infectious. Prior arrangements will have to be made with the receiving ward and the
ambulance service for transfer of an infectious patient. No transfer should take place unless
all parties, especially in the case of MDR-TB, have agreed these arrangements. The
receiving ward must be informed of the current status of the patient. For smear-negative or
non-pulmonary tuberculosis transfer can take place much more readily; but the receiving
ward must be notified of the patients status prior to transfer.
5.4 Ambulance Transportation
The ambulance service must be notified prior to transfer of smear positive pulmonary
patients especially MDR-TB. Further information for the ambulance service can be obtained
from the Consultant in Communicable Disease Control (CCDC 029 20 402478).
6. Health Care Personnel
6.1 Pre-Employment
All new staff members including locums and students will be questioned by Occupational
Health to establish whether they have symptoms suggestive of tuberculosis. They will also
be required to show evidence of a BCG scar. Those without a definite scar must be Heaf
tested.
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Individuals with a negative or grade 1 reaction must receive BCG vaccination. The site of
vaccination should be inspected six weeks later. Those without a satisfactory reaction must
receive a further tuberculin test and if necessary a second BCG.
Staff members with suspicious symptoms will require chest radiography and clinical
assessment as directed by the Consultant Occupational Health Physician.
Asymptomatic individuals with grade 2, 3 or 4 Heaf tests do not require vaccination.
However a new staff member that comes from a geographical location where tuberculosis
is endemic must undergo clinical and radiographic examination as directed by the
Consultant Occupational Health Physician.
6.2 Routine Screening
Routine chest radiography is not required for any group of hospital staff.
6.3 Contacts of Smear Positive Pulmonary Tuberculosis
Initially a list of all staff members that have had contact with the infectious index patient will
be made. The Infection Prevention and Control Department and senior ward staff will do
this. The contact list will then be forwarded to the Occupational Health Department, and to
the Consultant in Communicable Disease Control.
Close contacts are defined as members of staff who carry out:
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mouth-to-mouth resuscitation
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prolonged care of a high dependency patient
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repeated chest physiotherapy
Close contacts will be notified to Occupational Health Department for Heaf testing and
follow up as directed by the Consultant Occupational Health Physician.
Casual contacts should only be examined if they are unusually susceptible or if they have
no history of BCG. They should be given a Heaf test and BCG if necessary.
6.4 Contacts of Smear Negative or Non-Pulmonary Tuberculosis
In these cases no action is necessary.
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7.
References
2.
The Prevention and Control of Tuberculosis in the United Kingdom: UK Guidance
on the Prevention and Control of Transmission of: 1. HIV-related Tuberculosis, 2.
Drug – resistant Including Multiple Drug – resistant, Tuberculosis. The
Interdepartmental Working Group on Tuberculosis (1998) Department of Health.
1.
Control and Prevention of tuberculosis in the United Kingdom: Code of Practice
2000. Joint Tuberculosis Committee of the British Thoracic Society. Thorax 2000;
55: 887 - 901
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