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/HPSC6.2 All patients with suspected or known pulmonary or laryngeal TB must have a risk assessment forMDR-TB (section 6.5).6.3 Patients with suspected or confirmed MDR-TB must be admitted to an airborne isolation room(negative pressure isolation room with an ante room or a neutral pressure design as outlined inHBN 04 supplement 1). (This may require transferring the patient to another institution where thefacilities, together with a physician experienced in the management of complex drug-resistant casesare available) (section 6.5).6.4 Healthcare Workers (HCWs) (including HCWs visiting a patient in their own home) should wearFFP2 masks when caring for patients with suspected or confirmed infectious TB where MDR-TB orXDR-TB is not suspected. These patients are usually non-infectious after a minimum of two weekstreatment. The supervising clinician should be consulted before the use of masks is discontinued(section 6.5).6.5 HCWs should wear FFP3 masks when undertaking cough-inducing procedures on all patients (fullysusceptible and resistant strains included) e.g. sputum induction, bronchoscopy, administrationof aerosolised medications, airway suctioning, endotracheal intubation, caring for patients onmechanical ventilation and during treatment of lesions/abscesses when aerosolisation of drainagefluid is anticipated (section 6.5).6.6 HCWs (including HCWs visiting a patient in their own home) should wear FFP3 masks when caringfor patients with suspected or confirmed infectious MDR-TB or XDR-TB. The supervising clinicianshould be consulted before the use of masks is discontinued (section 6.5).6.7 A respiratory protection programme should be provided for all HCWs who may be required touse respiratory masks during the course of their work. HCWs should be fit tested by a trainedprofessional as part of this programme. All HCWs should fit check each time a mask is donned(section 6.5).6.8 Patients should wear a surgical mask while they are infectious when they are outside their room e.g.visiting the X-ray /OPD departments (section 6.5).7 BCG Vaccination7.1 The continuation of a universal programme of neonatal BCG vaccination is recommended in Irelandat this time (section 7.2).7.2 When BCG is given to infants there is no need to delay the primary immunisations. No furtherimmunisation should be given in the arm used for BCG immunisation for at least three monthsbecause of the risk of regional lymphadenitis (section 7.3).7.3 Training for health professionals in the correct administration of BCG vaccine is recommended.Those administering vaccine should be aware of indications, contraindications, immunisation andadverse reactions associated with BCG (section 7.4).7.4 BCG should not be administered to an individual with a positive tuberculin (or interferon-gamma)test (section 7.10).8 Contact Tracing8.1 Contact tracing should be conducted according to the concentric circle approach, whereby contactswith greatest exposure to the index case are prioritised for screening (chapter 8).8.2 Infectious pulmonary and laryngeal cases are priorities for contact investigation. A precautionaryapproach should be taken with broncheoalveolar lavage (BAL) smear positive cases (section 8.1).-xiii-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSC8.3 Those BAL smear positive cases with cavitation on chest X-ray, MDR-TB or XDR-TB or wherecontacts are immunosuppressed or less than 5 years of age should be presumed infectious forcontact tracing purposes (section 8.1).8.4 The determination of infectivity of all other BAL smear positive patients should be considered on acase-by-case basis (clinical/microbiology/public health input) (section 8.1).8.5 Young children under 10 years of age with pulmonary disease are rarely infectious. Such contacttracing investigations should be focused on finding a source and co-primary cases (section 8.1).8.6 The recommended interval between first and second screening rounds (TST ± IGRA) in contactinvestigations is eight weeks. If the last contact with the infectious case exceeded an eight-weekperiod, one TST is sufficient (section 8.6).8.7 Contact tracing of infectious or potentially infectious TB cases on aircraft should be limited toflights which were ≥8 hours duration and took place during the previous three months. All cases ofrespiratory TB who are sputum smear positive and culture positive (if culture available) are deemedinfectious. All cases of respiratory TB who are sputum smear negative and culture positive aredeemed potentially infectious. The following criteria should also be used when determining theinfectiousness of a case at the time of travel: (i) presence of cavitations on chest X-ray, (ii) presence ofsymptoms at the time of the flight and (iii) documented transmission to close contacts (section 8.12).8.8 If the index case is a passenger, obtain contact details of passengers sitting in the same row andthe two rows ahead and behind (from one side of the aircraft to the other because of ventilationpatterns) the index patient. Inform contacts of possible exposure and advise screening of thesecontacts and of cabin crew who serviced the section in which the TB case was seated (section 8.12).8.9 If the index case is an aircraft crew member, contact tracing of passengers should not routinelytake place. Contact tracing of other members of staff is appropriate, in accordance with the usualprinciples for screening workplace colleagues (section 8.12).8.10 A multidisciplinary team approach to effectively manage TB contact tracing in prisons is required.The team should be led by the local public health department who will undertake contact tracing(section 8.13).8.11 DOT is recommended for all prisoners receiving treatment for active disease and should beconsidered for those receiving treatment for LTBI (section 8.13).8.12 Evaluation of all contact tracing activities is recommended. The following information should becollected: (a) number of contacts identified (b) number of cases of active disease and LTBI and (c)the number of persons who accepted and completed preventive therapy (section 8.16).9 Screening in Special Situations9.1 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)(section 9.1).9.2 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 and sputumexamination should be carried out. Such employees should not start work. If an employee has nosuspicious symptoms, completion of the pre-placement questionnaire should be followed by anappropriate medical evaluation (section 9.1).9.3 HCWs from countries of high TB incidence (≥ 40 cases of TB per 100,000 per year) with a positiveTST (Mantoux test) defined as ≥10mm (table 2.1) should be referred to a respiratory or infectious-xiv-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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