TUBERCULOSIS CONTROL IN NHS EMPLOYEES
Version
5
Name of responsible (ratifying) committee
Health and Safety Committee
Date ratified
05th November 2014
Document Manager (job title)
Consultant Occupational Health Physician
Date issued
24th November 2014
Review date
23rd November 2016
Electronic location
Health and Safety policies
Related Procedural Documents
Immunisation of Healthcare and Laboratory Staff
Key Words (to aid with searching)
Work Health Assessment; TB screening
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
5
05.11.14
Interpretation of Mantoux test; draft updated NICE
guidance. (Page 7).
Dr S Harvey
Title of Policy: Tuberculosis Control in NHS Employees. Issue Number 5 Issue Date 24/11/2014
(Review date: 23/11/2016 (unless requirements change)
Page 1 of 9
CONTENTS
Quick Reference Guide……………………………………………………………page 3
Introduction………………………………………………………………………….page 4
Purpose………………………………………………………………………………page 4
Scope…………………………………………………………………………………page 4
Definitions……………………………………………………………………………page 4
Duties and responsibilities………………………………………………………….page 5
Process……………………………………………………………………………….page 5-7
Training requirements……………………………………………………………….page 7
References and Associated Documentation……………………………………..page 7
Equality and Diversity Statement…………………………………………………..page 8
Monitoring Compliance with and the effectiveness of procedural documents…page 9
Title of Policy: Tuberculosis Control in NHS Employees. Issue Number 5 Issue Date 24/11/2014
(Review date: 23/11/2016 (unless requirements change)
2
QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy. The quick reference can take the form of a list or a flow chart, if the latter would more easily
explain the key issues within the body of the document
1. Employees in certain occupational groups are more likely than the general population to come
into contact with tuberculosis (TB), for example, healthcare workers who have contact with
patients or clinical materials; or laboratory staff who have contact with patients, clinical
material or derived isolates.
2. Relevant healthcare workers include doctors, nurses, physiotherapists, radiographers and
occupational therapists. It is particularly important to test and immunize staff working within
maternity and paediatric departments and departments in which patients are likely to be
immunocompromised e.g. transplant and oncology units.
3. Employees who may be exposed to TB must undergo pre-placement health screening and
BCG immunisation where indicated and attend for screening (and treatment where required)
after contact or exposure to patients or clinical materials with infectious respiratory TB.
4. Employees must attend the TB clinic where requested for further investigation and treatment
when positive screening tests are obtained.
5. Employees who refuse appropriate screening, immunisation or treatment of Latent
Tuberculosis infection (LTBI) will be assessed by the occupational health physician and may
be restricted in their work location and role.
6. Employees who are known to be HIV positive will be assessed by the occupational health
physician to determine their risk of TB and whether any workplace restrictions are required.
Title of Policy: Tuberculosis Control in NHS Employees. Issue Number 5 Issue Date 24/11/2014
(Review date: 23/11/2016 (unless requirements change)
3
1. INTRODUCTION
Human tuberculosis (TB) is caused by infection with bacteria of the Mycobacterium tuberculosis
complex and may affect almost any part of the body. The most common form is pulmonary TB,
which accounts for almost 60% of all cases in the UK. Pulmonary TB typically causes a
persistent productive cough which may be accompanied by blood-streaked sputum or, more
rarely, frank haemoptysis. Almost all cases of TB in the UK are acquired through the respiratory
route, by breathing in infected respiratory droplets from a person with infectious respiratory TB.
Transmission is most likely when the index case has sputum that is smear positive for the
bacillus on microscopy, and often after prolonged close contact such as living in the same
household. The initial infection may be eliminated; may remain latent (the individual has no
symptoms but the TB bacteria remain in the body); or progress to active TB over the following
weeks or months.
Latent TB infection may reactivate in later life; particularly if an individual’s immune system has
become weakened, for example by disease (e.g. HIV), certain medical treatments (e.g. cancer
chemotherapy, corticosteroids) or in old age.
Individuals in certain occupational groups are more likely than the general population to come
into contact with someone with TB. For example:
 Healthcare workers who will have contact with patients or clinical materials
 Laboratory staff who will have contact with patients, clinical material or derived isolates
 Staff of care homes for the elderly
 Prison staff working directly with prisoners
 Staff of hostels for homeless people and facilities accommodating refugees and asylum
seekers.
Employees in these groups must undergo pre-placement health screening and immunisation
where indicated; and screening (and treatment where required) after contact or exposure to
patients or clinical materials with infectious respiratory TB in the workplace, as set out in this
policy.
2. PURPOSE
The purpose of the policy is to outline the measures that must be taken to prevent and control
the development of TB in health care workers and thereby to protect the health of patients and
other staff.
3. SCOPE
The policy applies to all clinical staff who have the potential for contact with patients or clinical
specimens that may carry TB.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
4. DEFINITIONS
TB: Tuberculosis
LTBI: Latent Tuberculosis Infection
NHS: National Health Service
HCW: Health Care Worker
OHD: Occupational Health Department
NICE: National Institute Clinical Guidance
Title of Policy: Tuberculosis Control in NHS Employees. Issue Number 5 Issue Date 24/11/2014
(Review date: 23/11/2016 (unless requirements change)
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5. DUTIES AND RESPONSIBILITIES
Occupational Health Department


Carry out pre-placement health screening as set out in section 6 of this policy.
Perform BCG vaccination where indicated (after individual risk assessments for HIV
infection).
Inform employees who refuse appropriate screening or immunisation the consequences
with regard to risk and continuation of work in high risk areas or departments.
Refer staff with evidence of latent or active TB to the respiratory department for further
investigation and treatment where indicated.
Ensure, as far as possible, that clinical students, agency/locum staff and contract
ancillary workers are screened for TB to the same standard as new NHS employees.
Suitable documentary evidence from locum agencies and contractors who carry out
their own screening may suffice.
Assess the risks of TB for HIV-positive staff and advise on work exposure modifications
where necessary.
Provide information on TB and TB screening to new staff at general Trust and junior
doctor inductions.
Provide information to staff about TB symptoms and reporting after exposure to
infectious cases or material in the workplace.
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

Managers

Ensure employees have attended all appropriate occupational health screening,
immunisations and referrals where indicated.
Ensure staff attend respiratory clinics where requested to do so.
Ensure employees are aware of action to take in the presence of possible TB
symptoms.
Ensure staff have appropriate contact tracing on notification by the respiratory
department or occupational health department that this is indicated.
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Healthcare workers
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Comply with OH procedures for screening of TB as set out in this policy.
Report symptoms of TB they may be experiencing to OH.
Be aware that BCG does not confer complete protection and TB cases still occur in
vaccinated HCW.
Comply in full with all Trust policies relating to relevant and appropriate infection
control measures.
.
6. PROCESS
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Employees new to the NHS who will be working with patients or clinical specimens
should not start work until they have completed a TB screen or health check, or
documentary evidence is provided of such screening having taken place within the
preceding 12 months.
Relevant healthcare workers include doctors, nurses, physiotherapists, radiographers
and occupational therapists. It is particularly important to test and immunize staff
working within maternity and paediatric departments and departments in which patients
are likely to be immunocompromised e.g. transplant and oncology units.
Employees new to the NHS who will not have patient or clinical specimen contact
should not start work if they have signs or symptoms of TB.
Health checks for employees new to the NHS who will have contact with patients or
clinical materials should include:
1. Assessment of personal or family history of TB or whether come directly from, or
recently worked in or visited for more than 1 month, a country of high TB
incidence (using questionnaire).
Title of Policy: Tuberculosis Control in NHS Employees. Issue Number 5 Issue Date 24/11/2014
(Review date: 23/11/2016 (unless requirements change)
5
2. Symptom and sign enquiry, by questionnaire (including items on chest
symptoms such as cough for more than 3 weeks, haemoptysis or unexplained
fever or weight loss in the previous 12 months).
3. Documentary evidence of Tuberculin skin testing (or interferon-gamma testing)
and/or BCG scar check by an occupational health professional, not relying on
the applicant’s personal assessment. Determining a reliable history of BCG
vaccination may be complicated by: absent or limited documentary evidence;
unreliable recall of information; absence of a scar in some individuals vaccinated
intradermally; absence of a scar in a high proportion of individuals vaccinated
percutaneously; use of non-standard vaccination sites. The final decision
whether to offer BCG, where there is a possible history of vaccination but no
proof, must balance the risk of possible revaccination against the potential
benefit of vaccination and risk of exposure to TB.
4. Mantoux result within the last 5 years, if available.
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Offer a Mantoux test to new NHS employees, who are not new entrants from high incidence
countries, and have not had BCG vaccination (e.g. they are without scar, other documentation
or reliable history). If the Mantoux is negative offer BCG immunisation (see below). If the
Mantoux is positive (6mm or more), offer an interferon-gamma test (IGRA).
Employees of any age who are new to the NHS and are from countries of high TB incidence
(>40/100,000) or who have had contact with patients in settings with a high TB prevalence
should have an interferon-gamma test. If negative, offer BCG vaccination, after appropriate
assessment. If positive, the person should be referred to the TB clinic for clinical assessment
and possible treatment of latent infection or active disease.
If a new employee from the UK or other low-incidence setting, without prior BCG vaccination,
has a positive Mantoux and a positive interferon-gamma test, they should be referred to the
respiratory department for further investigation and consideration of TB treatment where
indicated.
Healthcare workers who are immunocompromised should proceed straight to interferongamma test, rather than a Mantoux test.
Employees new to the NHS will be offered BCG vaccination, whatever their age, if they will
have contact with patients and/or clinical specimens, are Mantoux negative (less than 6mm)
and have not been previously vaccinated (and are not known to be or suspected to be HIV
positive, as this is a contraindication to BCG vaccination.). There are no data on the
protection afforded by BCG vaccine when it is given to adults aged 35 years or over but for
those at risk by way of their employment use of BCG should be considered (Green Book).
Employees who will be working with patients or clinical specimens and who are Mantoux
negative (less than 6mmm) and/or interferon-gamma test negative, will have an individual risk
assessment for HIV infection before BCG vaccination is given.
If a prospective or current health care worker who is Mantoux negative (less than 6mmm)
and/or interferon-gamma test negative declines BCG vaccination, the risks will be explained.
If the person still declines BCG vaccination the employer will need to consider each case
individually, taking account of employment and heath and safety obligations and whether
restrictions on work location are required.
The risk of TB for employees who are known to be HIV-positive will be assessed by the
occupational health physician and modification of work exposures will be considered.
BCG must not be given to previously vaccinated individuals as there is an increased risk of
adverse reactions and no evidence of additional protection.
In Summary
To all new NHS employees:
 Offer Mantoux if not from high incidence countries and not had BCG vaccination
o If Mantoux is negative give BCG
o If Mantoux is positive perform interferon-gamma test e.g. IGRA

But, if recent arrival from high incident country (>40/1000, 000) or had contact with
patients where TB is prevalent, perform interferon-gamma test e.g. IGRA.
Title of Policy: Tuberculosis Control in NHS Employees. Issue Number 5 Issue Date 24/11/2014
(Review date: 23/11/2016 (unless requirements change)
6
Interpretation of the Mantoux test (from the Green Book):
Less than 6mm: negative result- no significant hypersensitivity to tuberculin protein; implies
previously unvaccinated individual who may be given BCG provided there are no
contraindications.
6mm or greater, but less than 15mm: positive result- hypersensitivity to tuberculin protein.
Should not be given BCG. May be due to previous TB infection or BCG vaccination or exposure
to non-tuberculous mycobacterium. (But, see below for NICE evidence on Mantoux of larger than
10mm).
15mm and above: strongly positive result-strongly hypersensitive to tuberculin protein. Suggests
tuberculosis infection or disease and should be referred for further investigation. Arrange
interferon-gamma test first in OHD.
NICE guidance on 10mm Mantoux
There is evidence that a Mantoux greater than 10mm is more sensitive for detecting Latent
Tuberculosis Infection (LTBI). There is good evidence for treating LTBI in high risk groups
to prevent the development of active TB. Employees with a Mantoux of 10mm or above
should have an IGRA test in OHD and be referred to the TB service for further
investigation. NICE written guidance is currently under review.
Factors affecting the result of the tuberculin test: the reaction to tuberculin protein may be
suppressed by the following: glandular fever; viral infections in general, including those of the
upper respiratory tract; live viral vaccines (tuberculin testing should not be carried out within four
weeks of having received a live viral vaccine); sarcoidosis; corticosteroid therapy;
immunosupression due to disease or treatment, including HIV infection. Individuals who have a
negative test but who may have had an upper respiratory tract or other viral infection at the time
of reading should be re-tested two to three weeks after clinical recovery. If a second tuberculin
test is necessary it should be carried out on the other arm.
7. TRAINING REQUIREMENTS
There are no specific training requirements for Trust staff. Pre-placement health screening is
undertaken by the Occupational Health Department. Information about TB and TB screening is
provided to all new staff at either the general staff inductions or junior doctor inductions.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
1. Tuberculosis. Clinical diagnosis and management of tuberculosis, and measures for its
prevention and control. National Institute for Health and Clinical Excellence. March 2011
2. Stopping Tuberculosis in England. An Action Plan from the Chief Medical Officer.2004.
3. Health Clearance for Serious Communicable Diseases: New Health Care Workers.
Department of Health. 2007
4. Control and prevention of tuberculosis in the United Kingdom; Code of practice 2000. Joint
Tuberculosis Committee of the British Thoracic Society
5. The Green Book. Immunisation against Infectious Diseases HMSO.1996
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly.
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace. Our Values
were developed after listening to our staff. They bring the Trust closer to its vision to be the
best hospital, providing the best care by the best people and ensure that our patients are at the
Title of Policy: Tuberculosis Control in NHS Employees. Issue Number 5 Issue Date 24/11/2014
(Review date: 23/11/2016 (unless requirements change)
7
centre of all we do. We are committed to promoting a culture founded on these values which
form the ‘heart’ of our Trust:
Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all times.
Title of Policy: Tuberculosis Control in NHS Employees. Issue Number 5 Issue Date 24/11/2014
(Review date: 23/11/2016 (unless requirements change)
8
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Minimum requirement to
be monitored
Lead
TB screening in occupational
health department
Consultant OH
physician
Tool
Annual audit
Frequency of Report
of Compliance
Annual
Reporting arrangements
Lead(s) for acting on
Recommendations
Policy audit report to:

Health and Safety Committee
OH department
manager
clinical
This document will be monitored to ensure it is effective and to assurance compliance.
The effectiveness in practice of all procedural documents should be routinely monitored (audited) to ensure the document objectives are being
achieved. The process for how the monitoring will be performed should be included in the procedural document, using the template above.
The details of the monitoring to be considered include:

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The aspects of the procedural document to be monitored: identify standards or key performance indicators (KPIs);
The lead for ensuring the audit is undertaken
The tool to be used for monitoring e.g. spot checks, observation audit, data collection;
Frequency of the monitoring e.g. quarterly, annually;
The reporting arrangements i.e. the committee or group who will be responsible for receiving the results and taking action as required.
In most circumstances this will be the committee which ratified the document. The template for the policy audit report can be found on
the Trust Intranet Trust Intranet -> Policies -> Policy Documentation
The lead(s) for acting on any recommendations necessary.
Title of Policy: Tuberculosis Control in NHS Employees. Issue Number 5 Issue Date 24/11/2014
requirements change)
(Review date: 23/11/2016 (unless
9