PRACTICE POINTER: How to minimise risk of acquiring tuberculosis when working in a

high prevalence setting: a guide for healthcare workers

Author(s): Tara Harrop, James Aird and Guy Thwaites
Source: BMJ: British Medical Journal, Vol. 342, No. 7801 (9 April 2011), pp. 818-821
Published by: BMJ
Stable URL: http://www.jstor.org/stable/41150859
Accessed: 23-05-2016 05:18 UTC
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P D A ^ T I f* p For the full versions of these articles see bmj.com

PRACTICE POINTER

How to minimise risk of acquiring tuberculosis when working

in a high prevalence setting: a guide for healthcare workers

Tara Harrop,1 James Aird,1 Guy Thwaites2 3

1Ngwetezane Hospital, KwazuluNatal, South Africa

imperial College, London, UK
3Hospital for Tropical Diseases,
University College Hospital London,
London,

UK

Correspondence to: T Harrop,

Sandground Cottage, Bristol

Travelling to areas of high tuberculosis

prevalence increases healthcare workers'

risk of infection. This article discusses
precautions that can be taken before,
during, and after exposure to minimise risk

BS39 4BZ.UK
taraharrop@hotmail.com
Gtehisas:SA4/201;342:dl544
doi:10.1136/bmj.d1544

discuss what workers should do before starting work; how

they should protect themselves when at work; how to detect
infection and what to do about it; and what needs to be done
when they return to work in an area with a low prevalence of

tuberculosis (box 1).

What should healthcare wooers do before travelling?
First determine whether tuberculosis is common in the rel-

Many healthcare workers spend time working or travelling in

evant country and hospital (fig 1). The greatest numbers of

areas with a high prevalence of tuberculosis, where rates of

people with tuberculosis are in Southern Asia and China, but

drug resistant disease are increasing. It is therefore increas-

sub-Saharan Africa has the highest incidence and prevalence

ingly important for them to be able to assess and reduce the

of active disease worldwide (fig I).1 Be aware that national

risk of acquiring tuberculosis.

averages will hide regional hotspots.

In regions with a high prevalence of tuberculosis patients

The incidence of multidrug resistant tuberculosis (resistant

with undiagnosed or untreated disease are concentrated in

to at least rifampicin and isoniazid) is increasing in many

hospitals, so healthcare workers are regularly exposed to

countries. These strains are harder to treat and have higher

Mycobacterium tuberculosis. Few visiting healthcare work-

morbidity and mortality than drug sensitive strains,3 so to

ers appreciate this risk when working in such settings.

This article reviews the risk of healthcare workers con-

quantify risk more accurately, it is important to determine

tracting tuberculosis while working in areas of high risk. We

the incidence of drug resistant tuberculosis.

It will be easier to determine tuberculosis status on return if
tests for tuberculosis and HIV infection are performed before

Box 1 1 Precautions to take before, during, and after potential exposure to tuberculosis

departure. Tests should include a chest radiograph, a tuber-

Before leaving

culin skin test or interferon y release assay, and an HIV test.

Determine the likely prevalence of tuberculosis in the work place, including the risk of

Current UK guidelines recommend vaccinating healthcare

contact with multidrug resistant strains

workers of any age with BCG if they have not been vaccinated

Undergo baseline chest radiography, tuberculin skin test or interferon y release assay, and
an HIV test

before, their skin test is negative, and they are HIV negative,4

Have a BCG vaccination if not previously vaccinated and HIV negative

when given to people over 35. 5 Indeed, some countries (such

Purchase supply of N95 or FFP2 masks after fit testing

as the United States) rarely use BCG.6 Repeated BCG vaccination is not recommended even if the tuberculin skin test is

While abroad

non-reactive.5 6 Documentary evidence of vaccinations and

Maximise natural ventilation

Encourage patients with a cough or those known to be infectious to wear surgical masks
Wear a mask, especially when performing high risk procedures, such as intubation
Have chest radiography and tuberculin skin testing every three to six months and keep
records of all tests

Report to occupational health before starting work explaining the nature and extent of your
exposure
A positive tuberculin skin test or interferon y'release assay may indicate active or latent

infection. Thorough investigation (computed tomography or bronchoscopy) may be needed:

consult with a tuberculosis specialist
The benefits of treating latent infection are greatest for recent exposure or in the presence of
risk factors for reactivation

APRIL

exposed to M tuberculosis. A prospective study of medical stu-

dents and interns from Peru reported a 10-15 times greater

risk of developing active M tuberculosis infection compared

with the general population: 5% developed active disease

and 17% acquired latent infection over one year.7 The risk
of infection is particularly high for those involved in aerosol

inducing procedures, such as induced sputum collection,

bronchoscopy, intubation, and autopsy. Patients are infec-

Current advice for latent multidrug resistant infection is close monitoring

should be kept because they will be needed on return to work

in a low prevalence setting.

Healthcare workers may be frequently and repeatedly

On return

BMj

results of the tuberculin skin test and interferon release assay

How can workers reduce their risk of getting tuberculosis?

Remain attentive to symptoms of active disease

818

although there is little evidence that BCG provides protection

tious if acid fast bacilli are seen in sputum by microscopy

2011

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342

PRACTICE

Current UK guidelines recommend that staff wear face

masks only if a patient has suspected or confirmed multidrug

resistant disease or during aerosol generating procedures.5 In

the US, however, the Centers for Drug Control and Prevention

advises wearing N95 masks during contact with any patients

with suspected tuberculosis.15
Modelling studies carried out after the outbreak of exten-

sively drug resistant tuberculosis in South Africa concluded

that transmission could be reduced by increasing ventilation,
decreasing admissions of infectious patients or reducing their

time spent as inpatients, staff wearing high efficiency particulate air filter masks, coughing patients wearing surgical
masks, and more rapid testing and diagnosis.10 16
How do workers know they are infected?
Fig 1 1 Estimated tuberculosis incidence rates by country, 2007. Reproduced, with permission,
from WHO. Global Tuberculosis Control2

Inhalation of M tuberculosis leads to one of three possible

outcomes. Firstly, the bacteria may be killed by the innate
immune response and persistent infection avoided. Secondly,

before the start of treatment. Laryngeal tuberculosis is con-

the bacteria may survive and replicate but infection is control-

sidered the most infectious form of disease, but patients with

unsuspected pulmonary tuberculosis pose the greatest risk

led by the adaptive immune response: bacterial replication

and dissemination are arrested, but viable bacteria remain

because without treatment they can remain infectious for a

that can later reactivate to cause disease (box 2). Thirdly, nei-

prolonged period.
Reducing exposure to tuberculosis in settings with few

ther the innate nor the adaptive immune response controls

the infection and bacteria multiply in the lungs and may dis-

resources is challenging, but several simple measures can

seminate to other organs. Only then do symptoms develop,

reduce transmission. Opening windows and doors to improve

but this occurs in less than 1% of people exposed. Therefore,

ventilation substantially reduces transmission in clinics and

most people will not know they are infected unless specific

wards.8 9 Such methods are most effective in older hospitals

tests are performed.

with large open wards, big windows, and high ceilings. In

Asymptomatic or "latent" infection is traditionally diag-

addition, reports suggest that patients with suspected pul-

nosed with a skin test- the intradermal injection of tuber-

monary tuberculosis should be encouraged to cough hygi-

culin purified protein derivative (Mantoux or Heaf test). The

enically, dispose of tissue and sputum safely, and wear a

response, read after 48-72 hours, is the measured diameter of

surgical mask.10 n Patients with drug susceptible tuberculo-

induration, not just erythema, and the results are expressed

sis should be considered infectious until they have completed

in millimetres or as a grade (fig 2). The test should be per-

two weeks of appropriate antituberculosis drugs. Those with

formed at least 6-10 weeks after potential exposure to M

muldrug resistant disease may be infectious for many weeks

and should be considered so until bacteria are neither seen
nor cultured from sputum.5

Masks and respirators are effective at preventing infections,12 although visiting doctors may be reluctant to wear

Box 2 1 Reactivation of latent tuberculosis infection17

Factors that increase risk of reactivation
HIV infection

Exposure within one year

them if they are not freely available to other staff, and some

Repeated and close exposure

local staff may think that they contribute to the stigmatisation

Age <16 years

of patients with tuberculosis. They are also expensive and

workers may need to take their own supplies. Surgical masks

are reported to decrease the risk of contracting tuberculosis 2.4-fold (although they provide protection only for a few
hours or until they get wet)13; high efficiency paniculate air

filter masks (FFP 2/3 or N95) by 17.5-fold; a cartridge respirator 45.5-fold; and powered air purifying respirators (which

need electricity for charging and regular maintenance) 238-

Diabetes
Cigarette smoking

Systemic corticosteroids
Treatment with anti-tumour necrosis factor

Malnourishment
Chronic renal failure

Malignancy or chemotherapy

fold. FFP 2/3 and N95 masks are the most widely used and

Pulmonary silicosis

cost between 1 (1.16; $1.6) and 3 per mask. They must

Gastrectomy

be the correct size and be tightly fitted to be effective. Facial

Common symptoms

hair can interfere with fitting, and it is advisable to fit test

Persistent, severe cough, with or without haemoptysis

them before departure.14 Masks can be uncomfortably hot in

Chest pain

tropical settings and become ineffective if damaged or wet.14

Night sweats or fevers

There are no explicit guidelines on how long an N95 mask

Unexplained weight loss

is effective, although if necessary they can be reused (short

Back or joint pains

term) if handled carefully (not creased or torn and the poten-

tial for contamination by contact with the external surface is

minimised).14

Diarrhoea or abdominal pain

Enlarged lymph nodes-large, firm, and matted

819

BMj 1 9 APRIL 2011 1 VOLUME 342

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PRACTICE

hg 2 i Guidelines for

screeningfor latent

the likelihood of infection with drug resistant bacteria. Active

Tuberculin skin tost (TST) (6-10 weeks after exposure) j

disease is diagnosed by a review of symptoms (box 2), careful

TST taken to be positive if:

tuberculosis infection in

clinical examination, and comparison of chest radiographs

>6 mm without BCG

asymptomatic healthcare

>15 mm with BCG

workers' 18 19 20

before and after exposure. If active disease is suspected,

If TST is likely to be unreliable

"'

appropriate specimens (such as induced sputum or bronchial

Positive 1 Negative
t Positive t

alveolar lavage) should be taken for mycobacterial smear and

culture before starting treatment with four antituberculosis

Interferon ratoast assay " j Repeat TST

drugs. Alternative agents may be needed if the risk of multi-

Positive | Negative boosting phenomenon

drug resistance is high.22 In the UK, latent M tuberculosis

Investigations for and increases sensitivity

active tuberculosis j " ^T^7^

Such as chest radiograph, ?

infection is treated with six months of isoniazid monotherapy

or three months of rifampicin and isoniazid,5 on the basis of

computed tomography, I |

the findings of two large Cochrane reviews.23 24 Treatment is

bronchoscopy, ; If not previously

sputum culture i vaccinated J

also effective in people infected with HIV-reducing the risk

of developing active tuberculosis by around 60%- although

Positive 1 Negative I

three months of rifampicin and isoniazid is not currently rec-

Active tuberculosis | Latent tuberculosis Repeat screening

ommended for this group because of adverse reactions.

Start full j Treat for latent Every 3-12 months

tuberculosis | tuberculosis depending on

In HIV negative people, treatment of latent infection

prevents one in every 35 people treated from progressing

treatment j ""

to active tuberculosis, but about one in 200 people on isotuberculosis,18 and the results require careful interpretation.

niazid monotherapy experiences serious liver toxicity.23 The

Previous BCG vaccination or exposure to environmental

best management of latent infection with multidrug resistant

mycobacteria (widespread in tropical countries) can result

bacteria is unclear.25 The use of second line antituberculosis

in false positive responses, and false negative tests can occur

drugs for prophylaxis is discouraged.25 At present, health-

in immunosuppressed patients (such as those with advanced

care workers whose test results become positive after expo-

HIV infection) and in those with active tuberculosis.

sure to multidrug resistant strains are given information on

The limitations of skin tests led to the development of inter-

feron y release assays. Two commercial assays are currently

the symptoms and signs of tuberculosis (box 2) and are followed up with serial chest radiographs for two years.3 5 25 26

available in the UK: the QuantiFERON-TB Gold and T-SPOT.

specific M tuberculosis antigens. They have the advantage

What should workers do before starting work again in

low risk settings?

. These blood tests assess T cell mediated immunity to

that previous BCG vaccination does not cause a falsely posi-

UK guidelines recommend that all those who have worked

tive result, but they cannot differentiate latent from active

in a country with a high incidence of tuberculosis (>40

symptomatic infection.

cases/ 100 000 population) for more than three months

UK guidelines currently recommend a two step screen-

should not start work in the NHS until they have been

ing strategy for latent infection in asymptomatic healthcare

reviewed by occupational health.5 Previous BCG status

workers (fig 2). All those who have worked in high incidence

(either a scar or written evidence of vaccination) and the

areas are advised to be screened on return.5 If away for a long

results of pre-exposure tuberculin skin test or interferon y

period, some guidelines suggest regular screening (as often

release assay (or both) should be available and the tests

as every 8-10 weeks19), particularly when performing high

repeated if they were previously negative. If the person is

risk procedures. However, because tuberculin is unavailable

symptomatic or the test results have become positive, chest

in many resource poor settings, this may be impractical. US

radiography should be performed alongside a careful clinical examination for active disease.

guidelines recommend using an interferon y release assay

in people who have had BCG,21 but this policy has not been

universally adopted elsewhere. In the United Kingdom, the

Summary

National Institute for Health and Clinical Excellence recom-

The risk of healthcare workers contracting tuberculosis while

mends that all positive tuberculin skin tests should be con-

working in a high incidence area is real; all workers must be

firmed by interferon yrelease assays, and it is reviewing the

aware of the precautions needed to minimise risk.

use of these assays to diagnose latent and active tuberculosis;

Consider the tuberculosis profile of both the hospital and

the results are expected in March 201 1.

the country before accepting a position. Baseline investiga-

What should workers do if their tests become positive?

HIV testing, and a tuberculin skin test skin test or interferon

tions before departure should include chest radiography,

820

Healthy people who become infected with M tuberculosis

y release assay. It may be appropriate to take a supply of N95

have a 10% lifetime risk of developing active tuberculosis.

masks to wear, particularly if involvement in aerosol gener-

The risk is highest within the first year of exposure and is

ating procedures is expected or the prevalence of multidrug

increased if exposure is prolonged and extensive. Other risk

resistant tuberculosis is high. Masks require fit testing and

factors also increase the likelihood of developing active dis-

this is best done before travelling. When at work, encourag-

ease (box 2); HIV infection is the most important.

ing patients who are known to be infectious to wear masks

Current UK guidelines recommend that all healthcare

and optimising natural ventilation may reduce the risk

workers whose skin or interferon assays convert from nega-

of transmission. Six monthly chest radiography and skin

tive to positive should be treated. The treatment regimen

tests or interferon assays should be performed if working

depends on whether active or latent disease is diagnosed and

for more than 12 months. If tests become positive, consider

APRIL

2011

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342

Response on bmj.com

treatment for latent or active infection, depending on the

"Childhood tuberculosis

clinical picture.

(TB) has been generally

Return to work in a low tuberculosis prevalence setting

neglected because TB

should not begin before an occupational health review to

infected children are

determine whether the exposure has led to infection or dis-

less contagious than

adults and thus do not

ease. This will require review of all previous investigations

significantly contribute
to disease transmission."
Edwin A Dias, KVG

Medical College, India

and vaccinations, repeat chest radiography and skin test or

12 Qian Y, Willeke K, Grinshpun SA, DonnellyJ, CoffeyCC. Performance of

N95 respirators: filtration efficiency for airborne microbialand inert

partdes. Am IndHygAssoc J1998;59:128-32.

13 Balazy A, Toivola M, Adhikari A, Sivasubramani SK, Reponen T, Grinshpun
SA. Do N95 respirators provide 95% protection level against airborne
viruses, and how adequate are surgical masks? Am J Infect Control

2006;34:51-7.
14 Yassi A, Bryce E, Moore D. Protecting the faces of health care workers:

interferon y release assay. If tests are positive further investi-

knowledge gaps and research priorities for effective protection against

gations may be needed to exclude active disease.

occupationally-acquired respiratory infectious diseases. 2004. www.

cher.ubc.ca/PDFs/Protecting Faces Final ReDortndf.

Contributors: TH, JA, and GT jointly wrote the article and all are guarantors.

Competing interests: All authors have completed the Unified Competing

Interest form at www.icmje.org/coLdisclosure.pdf (available on request from

O To respond to an article

the corresponding author) and declare: no support from any organisation for the

on bmj.com, click on

submitted work; no financial relationships with any organisations that might have

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Accepted: 20 February 2011

10-MINUTE CONSULTATION

Frequent exacerbations in chronic obstructive

pulmonary disease
Christina George,1 Will Zermansky,2 John R Hurst1

Academic Unit of Respiratory

Medicine, University College
London Medical School, London
NW32PF.UK

2Highgate Group Practice, London,

UK

A 62 year old smoker with confirmed chronic obstructive

have frequent exacerbations have a more rapid decline in

pulmonary disease (COPD) has received his third course

lung function, poorer quality of life, and greater mortality.

of steroids and antibiotics for apparent exacerbations in a

Preventing exacerbations is therefore a key goal of COPD

year. He is anxious about the frequent flare ups and addi-

management.

tional treatment he is being prescribed.

Consider:

Are the episodes of deteriorating symptoms

Correspondence to: JR Hurst

j.hurst@medsch.ucl.ac.uk

What you should cover

Cite this as: 8M/2Gll;M2:dl434

COPD is characterised by poorly reversible airflow obstruc-

really exacerbations of COPD, or are there other

explanations?
Have all available interventions to reduce

fbrs ts part f a series of

occasionai articles on common

tion and progressive symptoms. Exacerbation of COPD

is a clinical diagnosis of exclusion and there are many
causes of worsening symptoms in a patient with under-

Is the patient taking prescribed medication as

problems k' primary care. The BMJ

lying COPD that should be considered. The frequency of

doi:10.1136/bmj.d1434

welcomes cowtf fbtfrtons from Ps

exacerbations varies between patients, and the best predictor is a patient's history of exacerbations. Patients who

exacerbations been recommended (box)?

directed?

Does the patient understand the impact of

exacerbations and the importance of early treatment?
821

SW 1 9 APRIL 2011 1 VOLUME 342

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