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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