Guidelines on the Prevention and Control of Tuberculosis in Ireland

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<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSC9. Screening in Special SituationsScreening is the practice of identifying a condition or illness, which could benefit from early diagnosis,preventative or curative intervention. 318 Screening should only be undertaken where an illness is sufficientlyprevalent, has a known natural history and appropriate and agreed diagnostic techniques and treatment(s)are available. Illnesses being screened for may not cause symptoms that would lead a patient to seekmedical care of his/her own volition. In addition, there should be an agreed policy on whom to treat andthe cost of screening should be economically balanced.Screening for TB should be focused (‘targeted screening’) on groups or individuals with a greater risk orincidence of TB than the general population, and should be undertaken with the following aims:• To detect and treat active disease, thereby reducing the possibility of transmission to susceptibleindividuals• To identify those with LTBI and offer treatment and counselling as appropriate• To obtain baseline data on TST status for comparison with data from routine surveillance tofacilitate reassessment of levels of risk in high-risk groups.Targeted screening should be conducted depending on local epidemiology and resource availability. It isimportant to be aware that high risk groups for screening may change over time. The committee agreedthat in Ireland, priority groups for screening at this time include:• HCWs• New entrants to Ireland• Prisoners• Homeless individuals and• Persons with HIV infection (chapter 10).9.1 Healthcare WorkersEstimates of the risk of infection in HCWs vary according to time, geographical location, exposure intensityand duration (depending on type of hospital and job category). 319-321 In low-incidence countries, activedisease among HCWs is often associated with non-occupational exposures. 322 Two UK studies reportedthat the risk of active disease in HCWs was two to three times higher than in the general population whenmatched for employment and socioeconomic status. 323;324 A questionnaire-survey of incidents involvingpotential transmission from HCWs found 105 incidents occurred in 2005, which mainly included non-UKborn doctors and nurses, despite occupational screening at employment. Infection is thought to have beenacquired in the past in their country of origin. 325 In 2006, HCWs were found to comprise 5% of all notifiedcases of TB in the United Kingdom, and were more likely to be non-UK born (89%) and female (67%). 14 InIreland, the proportion of annual TB cases reported in HCWs has increased slightly from 5.7% in 2002 to7.3% in 2006 (personal communication, HPSC). Between 2002 and 2006, 68.4% of HCW cases were agedbetween 20 and 40 years of age. Forty-two percent were Irish born individuals with the majority of non-Irish born HCWs originating from India (34.6%), Pakistan (15.4%) and the Philippines (12.8%).Recommendation:A pre-placement screen is recommended for all clinical staff working with patients or clinicalspecimens (this may also be applicable to ancillary staff as determined by a risk assessment).Health questionnaireAll new HCWs should initially complete a pre-placement health declaration undertaken by occupationalhealth which includes screening questions for active TB, details of previous immune status investigationsand BCG status.-113-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCThe following information should be recorded:• Suggestive symptoms• History of BCG (scar check by health professional or documentary evidence of date or ageadministered)• Previous history of TB disease (dates or age, duration and type of treatment, name and address oftreating physician) including family history• Previous TST and result within the previous 5 years if available (documentary evidence of date/age,type of test and result, name and address of treating physician) and• History and details of contact with known cases of TB (date/age, relationship to the case/s, degreeof infectivity of the case). 326Recommendation:If an employee has unexplained and suggestive symptoms such as cough lasting three or moreweeks that is unresponsive to usual interventions and weight loss or fever, a chest X-ray andsputum examination should be carried out. Such employees should not start work. If an employeehas no suspicious symptoms, completion of the pre-placement questionnaire should be followedby an appropriate medical evaluation.Medical evaluationIn the US, CDC recommend that baseline testing for TB is performed for all new healthcare workers,regardless of their occupational risk of exposure to TB. 229 It is the view of this committee that in Ireland,screening of new employees (undertaken by occupational medicine) by TST (2TU Mantoux) should beprioritised as follows:• High priority**** 1HCWs arriving in Ireland (or returning to Ireland) from countries with a high incidence of TB (≥40/100,000 TB cases notified per year).11F Such individuals require a chest X-ray (provided theyare not pregnant) to rule out active TB in addition to a TST (2TU Mantoux test) to detect LTBIregardless of BCG vaccination status (section 9.2). 326• Intermediate priority † † † † ‡ ‡ ‡ ‡ 23HCWs (regardless of BCG status and not in the high priority group ) working in units managingand treating patients with MDR-TB or XDR-TB and patients who are immunocompromised,physiotherapists, laboratory, 327 mortuary, 275 endoscopy and bronchoscopy staff 229,278,328 should allhave a TST (2TU Mantoux test) to rule out LTBI or active TB.• Low priorityIn this group, TST is only offered to those who have no (or inconclusive) evidence of prior BCGvaccine. 326 This group constitutes the vast majority of HCWs. The Mantoux test is undertaken in thissituation to obtain a baseline in case of future exposure in the healthcare setting and to offer BCGvaccine if necessary.1 ****This prioritisation is based both on the increased likelihood of the HCW having TB due to country of origin and because of this theincreased risk of transmission to patients if TB is undetected.2 † † † † This prioritisation is based on both the procedures undertaken by the HCW which increases their risk of contracting TB and alsoon the risk of transmission to immunocompromised patients if the HCW has TB.3 ‡ ‡ ‡ ‡ Healthcare associated transmission of M. tuberculosis has been linked to close contact with persons with TB disease duringaerosol-generating or aerosol-producing procedures including bronchoscopy, autopsy, sputum induction, endotrachealintubation and open abscess irrigation.-114-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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