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4/27/2011
1
TB in CorrectionsPhoenix, ArizonaMarch 24 2011March 24, 2011
Infection Control Michael Kelley, MD, MPH
March 24, 2011
Michael Kelly, MD has the followingdisclosures to make:
• No conflict of interests
• No relevant financial relationships with• No relevant financial relationships with any commercial companies pertaining to this educational activity
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TB INFECTION CONTROLIN CORRECTIONAL FACILITIESMichael Kelley, M.D., M.P.H.
Medical Director, Communicable Disease Unit
Austin-Travis County Health and Human Services Department
Tuberculosis Transmission
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Interrupting Tuberculosis Transmission
ActiveDi
INHEarly
Identification, Disease
InfectedWell (LTBI)
Identification,Isolation andTreatment
UninfectedSusceptible
Vaccine?
Facets of an Infection Control Program
Administrative Controls Screening Screening
Early diagnosis and treatment
Isolation of contagious cases
Environmental Controls Ventilation, filtration, UV lights
Airborne Infection Isolation
Personal Protective Attire Respiratory Protection Program
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Correctional Facility Risk
Minimal Risk FacilitiesN i f i TB i No infectious TB cases in past year
No substantial numbers of inmates with risk factors for TB (e.g., HIV or injection drug use)
No substantial numbers of recent (within 5 years) immigrants from high TB prevalence countries.
Employees not otherwise at risk for TB Employees not otherwise at risk for TB
Nonminimal Risk Facilities Do not meet above criteria
CDC. MMWR 2006; 55(RR-9)
Screening for TB
Screening for active diseaseP i il i k Primarily at intake
Screening for Latent TB Infection At intake and periodically
Periodic screening of staff
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Screening for Active Disease
HistoryC i di i f TB Current or previous diagnosis or treatment of TB
Risk factors for TB
Symptoms Cough>3 weeks, hemoptysis, chest pain
Fever, weight loss, night sweats
Observation
Chest X-ray
Screening for LTBI
PPD
A f IGRA – Quantiferon Gold or T-spot TB
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Effect of TB Screening
Cases/100,000 for intakesJail screening law went into effect in Sept 1993
Intake screenings
Symptom screening on intake C b d b ti l t ff if di l t ff t Can be done by correctional staff if medical staff not
available.
Should use checklist
CXR or PPD/IGRA within 7 days Minimal risk facilities - detainees with risk factors for TB
exposure or progression, or history of prior TBp p g , y p
Non-minimal risk facilities – all detainees
CXR on immunocompromised even if PPD/IGRA is negative
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If symptom or CXR screening is positive
Put a mask on the patient until they are in respirator isolationrespiratory isolation Surgical mask is okay
Put them in a respiratory isolation room On site
Off site
Keep them in isolation until they are deemed non-contagious
Factors associated with greater infectiousness
Frequency and strength of cough
Positive sputum smear
Laryngeal TB
Cavitary TB
Smaller volume shared airspace
Greater duration of exposure Greater duration of exposure
Untreated or just starting treatment
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Transport of infectious patient
Mask and segregate until transportation is arrangedarranged
Ambulance should have their own airborne precaution protocols
Facility transportation vehicle No other patients transported at the same time Patient in back, staff in front Patient in back, staff in front Ventilation on high, recirculation off Staff wear N95 mask
Sputum Collection
Must be done in Airborne Infection Isolation Room or sp t m collection boothsputum collection booth
If no suitable room available, collect sputums outside
Attendant must wear particulate respirator
3 sputum specimens should be collected at least 8 hours apart with one an early morning specimen
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When can a patient be released from respiratory isolation?
When TB is considered unlikely andA h di i h l i h i lik l Another diagnosis that explains the symptoms is likely, or
Sputum smears x3 are negative
Patient is on standard multidrug TB treatment Has been on treatment at least 2 weeks
Shows clinical improvement on treatment
Has 3 consecutive negative sputum smears
Keeping TB patients non-infectious
Make sure treatment matches drug susceptibility st diesstudies
Use DOT Not pill line or KOP
React when patient does not show up for DOT
Treatment refusals
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Screening for LTBI
PPD or IGRA
St ff i Staff screening
Inmate screening
Baseline and periodic
If screening test is positive Evaluate to R/O active TB
C id i h Consider preventive therapy
Screening for LTBI is a useful monitor of the effectiveness of your infection control program
Environmental Controls
Ventilation
Filtration
UV lights
Local controls vs facility controls
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Local Environmental Controls
Ventilation
Air Changes/Hour (ACH)D i b Down time between room uses
Positive Pressure
Negative Pressure
Correctional Guidelines adapted from Control of Tuberculosis in Healthcare Facilities Guidelines (MMWR 12/30/2005;54(RR17))
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Examples of recommended ventilation levels for new construction or renovation
Setting Minimum ACH Direction of air flow (pressure)flow (pressure)
Housing 6 In (negative)
Respiratory Isolation*
12 In (negative)
Day rooms, dining, i it ti
6 Out (positive)visitationKitchen* 6-10 In (negative)
Laundry* 10-12 In (negative)
* Exhaust to outside CDC. MMWR 2006; 55(RR-9)
Air Washout Times
TABLE 1. Air changes per hour (ACH) and time required forremoval of airborne contaminants, by efficiency percentageremoval of airborne contaminants, by efficiency percentage
Minutes required for removal
ACH 99.0% efficiency 99.9% efficiency
2 138 207
4 69 104
6 46 69
12 23 35
15 18 28
20 7 14
50 3 6
CDC. MMWR 2006; 55(RR-9):12
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Filtration
Exhaust to outside preferred
f If air is recirculated Must be filtered
Only recirculate to same general area
Filters must be changed according to maintenance schedule
UV lights
Installation in air ducts or upper room space
f Line of sight activity
Effectiveness reduced by high humidity
Risk of excessive UV light exposure Skin burns, eye irritation
Maintenance Maintenance Dusting
Bulb changes
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Respiratory Isolation (AII) Rooms
Negative Pressure > 12 ACH 12 ACH Continuous reading manometers and alarms
recommended Daily functional test while in use, monthly if not in use
Tissue (flutter) test Smoke tube
Quantitative testing Quantitative testing Whenever the functional test is not passed After building renovations or modifications to HVAC system Periodic quantitative testing
Airborne Infection Isolation Room
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Functional test of AII room
Respiratory Protection
Particulate respirator masks – N95 Use when administrative and environmental controls Use when administrative and environmental controls
cannot adequately reduce risk of transmission Entering respiratory isolation room Transporting a contagious patient Performing cough inducing procedures
Respiratory protection program Required in facilities covered by OSHAq y Responsible party assigned Covered staff receive training, medical evaluation and fit
testing
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Making your work safer
Consider brief symptom screening before inmate/detainee enters facilitinmate/detainee enters facility
Immediately place a mask on inmate suspected to have TB, even before intake screening is completed
Pay attention to air flow in the screening site (i.e., from staff towards inmate to exhaust)
Use local environmental control supplementation if available