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Infection Control: New CDC Guidelines

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Guidelines for Preventing the Transmission of M. tuberculosis in Health-Care ... Organ transplantation. Immune reconstitution inflammatory syndrome (IRIS) ... – PowerPoint PPT presentation

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Title: Infection Control: New CDC Guidelines


1
Infection ControlNew CDC Guidelines
  • Kevin Fennelly, MD, MPH
  • 2006 Northeast TB Controllers Meeting
  • Relapse? The State of TB Control in the Era of
    Declining Funds
  • October 24, 2006

2
New Terminology
  • Guidelines for Preventing the Transmission of M.
    tuberculosis in Health-Care Settings, 2005MMWR
    2005 54 (RR-17) 1-147
  • health-care-associated outbreaks
  • tuberculin skin tests
  • airborne infection isolation room
  • airborne precautions
  • BAMT Blood assay for M. tuberculosis
  • IGRA interferon gamma release assay
  • QFT-G QuantiFERON-TB Gold test
  • Guidelines for Preventing the Transmission of M.
    tuberculosis in Health-Care Facilities, 1994MMWR
    1994 43 (RR-13) 1-132
  • nosocomial outbreaks
  • PPD (purified protein derivative)
  • respiratory isolation room
  • TB infection control

3
Whats New (1)
  • Change of risk classification and tuberculin skin
    test (TST) frequency
  • Expanded scope addressing lab, outpatient, and
    nontraditional settings
  • Expanded definitions of affected HCWs
  • TST instead of PPD

4
Change in Risk Classifications
  • Previous
  • Minimal
  • Very low
  • Low
  • Intermediate
  • High
  • New
  • Low
  • Medium
  • Potential ongoing transmission

Please refer to excellent presentation by Philip
LoBue at Medical Consultants Meeting, September
20, 2006. -KF
5
Whats New (2)
  • QuantiFERON-TB Gold test (QFT-G)
  • QFT-G is a type of blood assay for M.
    tuberculosis (BAMT)
  • Measures the patients immune system reaction to
    M. tuberculosis
  • Blood samples must be processed within 12 hours
  • Interpretation of QFT-G results is influenced by
    the patients risk for infection with M.
    tuberculosis
  • An alternative to TST

6
TSTs vs. BAMTs for Surveillance of Exposure to
Mtb
  • TSTs inexpensive assay
  • Two visits
  • Cost-effective?
  • Falses (NTM BCG)
  • Allow for historical comparisons
  • Two products stable
  • Quantitative
  • BAMTs expensive NIMB
  • One visit
  • Cost-effective?
  • Eliminates falses
  • Uncertainty re comparing to TST data
  • Newer versions will compete confuse
  • Not quantitative /-
  • Lack of technical experience and new problems
  • Notice regarding indeterminate results with the
    QuantiFERON-TB Gold Test CDC website, Oct 11,
    2006

7
Whats New (3)
  • Term airborne infection isolation (AII)
  • Criteria for initiating and discontinuing AII
    precautions
  • Respirator fit testing and training voluntary
    use of respirators by visitors
  • Additional information on ultraviolet germicidal
    irradiation (UVGI)
  • Frequently asked questions (FAQs)

8
Prompt TriageThink TB!
  • Primary TB risk to HCWs is patient with
    undiagnosed or unrecognized infectious TB
  • Promptly initiate AII precautions and manage or
    transfer patients with suspected or confirmed TB
  • Ask about and evaluate for TB
  • Check for signs and symptoms
  • Mask symptomatic patients
  • Separate immunocompromised patients

This is the Most Important Slide !!!
-KF
9
New Risk Factors for TB Risk of Transmission ?
  • Treatment with immune modulators
  • Well-documented with TNF-alpha inhibitors
  • For rheumatoid arthritis other collagen
    vascular diseases, Crohns disease, others
  • Organ transplantation
  • Immune reconstitution inflammatory syndrome (IRIS)

10
Frequency of Sputum Collection for Patients with
Suspected TB Disease
  • Three negative sputum smears
  • At least 8 hours apart
  • At least one collected during early morning
  • In most cases, patients with negative sputum
    smear results may be released from AII in 2 days

Use sputum induction with history of no or scant
sputum production ! -- KF
11
Criteria for Discontinuing AII Precautions
  • Infectious TB is unlikely and another diagnosis
    is made that explains the syndrome
  • Or
  • Patient has 3 consecutive negative AFB sputum
    smear results, and
  • Patient has received standard antituberculosis
    treatment (minimum of 2 weeks), and
  • Patient has demonstrated clinical improvement

12
Discharge to Home
  • Patient can be discharged without 3 negative
    sputum smears if
  • Follow-up plan has been made with local TB
    program
  • Patient is on standard treatment and directly
    observed therapy (DOT) is arranged
  • And clinically improving with microbiological
    response (e.g., sputa AFB 4 to 2 ) low
    suspicion of MDR-KF
  • No person in home lt4 years old or
    immunocompromised Recommend home visit!-KF
  • All in household previously exposed
  • Patient willing to stay home until sputum results
    negative
  • Do not release if high-risk persons will be
    exposed

13
IC Observations from a Consultant
  • Admin Clinical suspicion for TB among primary
    care practitioners and specialists is highly
    variable.
  • Environ Nursing staff need training know who
    and when to call, esp in low-use settings.
  • PRP Annual fit-testing is unsupported by data,
    onerous, costly detracts from other efforts.
  • Need coordination within settings lack of N95s
    to which HCWs are fit-tested.
  • Shortages of N95s due to SARS expect with
    influenza.

14
Summary
  • High index of suspicion remains most important TB
    IC measure.
  • Second most important is effective treatment
    micro lab is critical part of IC.
  • Environ and PRP controls only work if infectious
    patients are identified
  • And if used properly!!
  • Key control measure in era of declining funds
    EDUCATION!

15
CDC Tuberculosis GuidelinesHighlights and
Controversies 2000-2006 (excerpts related the
Guidelines for Preventing the Transmission of
Mycobacterium tuberculosis in Health-Care
Settings, 2005 )
  • Philip LoBue, MD
  • Centers for Disease Control and Prevention
  • Division of Tuberculosis Elimination
  • September 20, 2006

16
Guidelines for Preventing the Transmission of
Mycobacterium tuberculosis in Health-Care
Settings, 2005
  • Published in 2005
  • Broadening of scope
  • Revision of risk assessment
  • Screening of healthcare workers
  • Allows use of QFT-G in place of TST

17
Broadening of Scope
  • The scope of settings in which the guidelines
    apply has been broadened to include laboratories
    and additional outpatient and nontraditional
    facility-based settings
  • Examples
  • Dentists office
  • Home-based healthcare
  • Emergency medical services

18
Health-care Setting Risk Assessment
  • Classifications ongoing transmission, medium
    risk, low risk

19
Ongoing Transmission
  • Evidence of transmission of M. tuberculosis
    between patients and/or HCW, occurring in the
    setting during the preceding year
  • Evidence of person-to-person transmission
    includes
  • Increased rates or clusters of TST or QFT-G
    conversions
  • HCW with confirmed TB disease
  • Unrecognized TB disease in patients or HCWs
  • Recognition of an identical strain of M.
    tuberculosis in patients or HCWs with TB disease
    identified by DNA fingerprinting

20
Medium and Low Risk
  • Medium risk
  • Inpatient, at least 200 beds 6 or more TB
    patients per year
  • Inpatient, less than 200 beds outpatient
    outreach or home-based healthcare 3 or more TB
    patients per year
  • Otherwise low risk

21
TB Screening Procedures for SettingsClassified
as Potential Ongoing Transmission
  • Testing for infection with M. tuberculosis might
    need to be performed every 810 weeks until
    lapses in infection control have been corrected
  • Ongoing transmission should be used as a
    temporary classification only
  • Warrants immediate investigation and corrective
    steps
  • After a determination that ongoing transmission
    has ceased, the setting should be reclassified as
    medium risk for at least 1 year

22
TB Screening Procedures for Settings Classified
as Low Risk
  • All HCWs should receive baseline two-step TST or
    a single QFT-G upon hire
  • After baseline testing, additional TB screening
    is not necessary unless an exposure occurs
  • HCWs with a baseline positive or newly positive
    test or documentation of treatment for LTBI or TB
    disease should receive a CXR to exclude TB
    disease
  • Routine repeat CXRs are not needed

23
TB Screening Procedures for Settings Classified
as Medium Risk
  • All HCWs should receive baseline two-step TST or
    a single QFT-G upon hire
  • After baseline testing, HCWs should receive TB
    screening annually
  • Symptom screen for all HCWs
  • Single TST or QFT-G for HCWs with baseline
    negative test results
  • HCWs with a baseline positive or newly positive
    test or documentation of treatment for LTBI or TB
    disease should receive a CXR to exclude TB
    disease
  • Routine repeat CXRs are not needed

24
Prevention and Control of Tuberculosis in
Correctional and Detention Facilities
  • Published in 2006
  • Risk assessment different from health-care
    settings
  • Screening

25
Risk Assessment
  • A facility has minimal TB risk if
  • No cases of infectious TB have occurred in the
    facility in the last year
  • The facility does not house substantial numbers
    of inmates with risk factors for TB (e.g., HIV
    infection and injection-drug use)
  • The facility does not house substantial numbers
    of new immigrants (i.e., persons arriving in the
    US within the previous 5 years) from areas of the
    world with high rates of TB
  • Employees of the facility are not otherwise at
    risk for TB
  • Any facility that does not meet these criteria
    should be categorized as a nonminimal TB risk
    facility

26
Screening Minimal Risk Facilities
  • All inmates and detainees at intake screening
    for symptoms and risk factors for TB
  • If no symptoms or risk factors, no further
    screening required
  • If risk factors present TST or QFT-G or CXR
    within 7 days of arrival
  • If HIV-infected, HIV status unknown with risk
    factors for HIV, or other severe
    immunosuppression CXR

27
Screening Nonminimal Risk Facilities
  • All inmates and detainees at intake screening
    for symptoms AND TST or QFT-G or CXR within 7
    days of arrival
  • If HIV-infected, HIV status unknown with risk
    factors for HIV, or other severe
    immunosuppression CXR

28
Additional Evaluation
  • If symptoms or abnormal CXR evaluate for disease
  • If TST or QFT-G positive CXR and evaluate for
    LTBI treatment once TB disease has been excluded
    and if completion of treatment is likely
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