Tuberculosis in the Workplace (2001) / Chapter Skim
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Appendix D Effects of CDC Guidelines on Tuberculosis Control in Health Care Facilities
Appendix D Effects of CDC Guidelines on Tuberculosis Control in Health Care Facilities
Pages 230-270
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From page 230... ...
SUMMARY In response to nosocomial outbreaks of tuberculosis among patients and health care workers, the Centers for Disease Control and Prevention (CDC) released tuberculosis control guidelines in 1990.
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The cost of implementation of the guidelines can be substantial, but many of these costs are one-time facility improvements. Although the ongoing costs of a tuberculosis control program can be substantial, these programs may be relatively cost-effective compared with the costs incurred in evaluating patients or healthcare workers exposed to a nonisolated tuberculosis patient.
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Finally, the guidelines discuss personal respiratory protection for health care workers who are likely to be exposed to tuberculosis aerosols (e.g., while in a tuberculosis isolation room)
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One important exception is that employee PPD test conversion rates will be discussed as a marker for the effectiveness of different tuberculosis control plans. Although the 1994 CDC guidelines are the most current, as summarized above, these guidelines are an extension and revision of the 1990 guidelines.
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without negative pressure were repaired, and the ventilation in the other rooms was made more consistent June · Aerosolized pentamidine administered only in isolation room September · Change from cup-type surgical mask to submicron mask for health care workers A review of admissions of HIV-positive patients with MDR tuberculosis was performed, covering three time periods: initial period (January 1990 to May 1990) , early follow-up (June 1990 to February 1991)
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However, the early implementation of administrative controls linked with beginning improvements in engineering controls led to a reduction in nosocomial transmission of MDR tuberculosis to other patients, as well as a reduction in PPD conversions in health care workers. Similarly, Maloney and colleagues (15)
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· Increased physician education · Window fans added to 90 rooms to provide negative pressure June 1 July 1 · Submicron masks used for personal respiratory protection · PPD testing done every 6 months now included nonemployee health care workers (e.g., attendings, house staff, medical students) · tuberculosis nurse epidemiologist hired To determine the effectiveness of these measures the authors reviewed tuberculosis exposure episodes (from July 1, 1991, to June 30, 1994)
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The author suggest that their data imply that the improvements in PPD conversion rates were primarily the result of improved administrative controls since changes mirrored improved isolation as a result of the new policies. They argue that since room negative pressure was demonstrated to be frequently suboptimal, engineering controls were not the major factor in the improvements.
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PPD conversion rates among house staff were as follows: June 1992, 10 percent (5.8/100 person-years) ; December 1992, 3 percent (5.1/100 personyears)
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The implementation of control measures and PPD conversion rates are shown in Table D-2. In an abstract presented at the 1994 Annual Conference of the Society for Occupational and Environmental Health Tuberculosis Control in the Workplace: Science, Implementation, and Prevention Policy, Koll and colleagues (20)
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Previously, an increase in health care worker PPD conversions had led to improvements in engineering controls, with 64 tuberculosis isolation rooms being made available. Over the 2 years, 253 tuberculosis patients were admitted, 85 percent of whom had pulmonary disease.
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therapy for latent tuberculosis infection was offered to everyone with a positive PPD test result. The air-handling system (which provided minimal air changes air was recirculated for economy of heating)
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The most significant impact on both high risk and other PPD conversions was whether the hospital admitted 26 tuberculosis patients (for non-high risk health care workers, PPD conversions of 1.2 percent in high-volume hospital versus 0.6 percent in low-volume hospitals; for high-risk health care workers, PPD conversion rates were 1.9 percent versus 0.2 percent)
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0.39 0.42 0.47 0.51 Respiratory protection provided Surgical mask 96.8 95.8 91.3 66.8 Submicron mask 2.5 3.4 6.8 19.0 Dust-mist respirator 0.3 0.5 1.1 10.9 Dust-mist-fume respirator 0 0 0.3 2.4 HEPA respirator 0 0 0.2 0.5 Slightly different than in the SHEA-CDC study, bronchoscopists at hospitals with one to five tuberculosis patients per year were more likely than other health care workers to convert their PPD test results. This was not true for hospitals with 26 tuberculosis patients per year.
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Patient B had a history of a positive PPD test result and so was masked and placed in an isolation room 50 yards from patient A Eight months later patient B developed pulmonary tuberculosis.
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health care workers with PPD conversions over the entire study period had no adult patient care responsibilities. The authors state that their hospital follows guidelines consistent with the CDC guidelines, although details are not provided.
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Of 11 roommates and 281 employees exposed, no PPD conversions or cases of active tuberculosis were found. In the discussion the authors note that if the five patients who should have been isolated by the algorithm had been isolated, the sensitivity would be 77 percent.
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There was no correlation between this ratio and the number of tuberculosis patients at the facility. Unfortunately there are no data presented on health care worker PPD conversion rates.
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were on tuberculosis isolation within 24 hours of admission. Only 33 had tuberculosis
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An increase in health care worker PPD conversion from 0.3 to 1.7 percent between lanuary and tune 1991 at the University of Louisville Hospital was attributed to a failure to follow 1990 CDC guidelines (35~. This led to the mandatory isolation of all patients presenting with community-acquired pneumonia (until two AFB smears were negative, or until tuberculosis was "ruled out on clinical grounds"~.
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conversions for other health care workers. A new ED facility with four tuberculosis isolation rooms, improved air flow throughout the ED, and Plexiglas shields and laminar air flow for registrars was opened in lanuary of the third testing (2-year follow-up)
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the door was kept closed at all times. Eighty-two percent of hospitals had only surgical masks available for health care workers.
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had some form of tuberculosis isolation available, and 54/129 (42 percent) had negative-pressure isolation rooms.
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The authors note that there was still room for improvement in having appropriate tuberculosis isolation rooms available, but noted that the high cost of construction would likely make this a slow process. They also noted a trend toward the adoption of more compliant personal respiratory protection consistent with the 1990 CDC guidelines.
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Survey Measure 1992 1996 Tuberculosis isolation rooms meet CDC guidelines 59/92 (64)
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Results of Maryland Hospital Survey Percent Measure 1992 1997 p Tuberculosis isolation rooms meeting CDC criteria 100 Tuberculosis rooms routinely checked 50 90 <0.01 EDs with tuberculosis isolation rooms available 50 90 <0.01 Compliant respirator used 24 100 <0.01 Protocol for identifying high-risk patient 49 At least annual PPD test for health care workers 50 98 <0.01
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This was done over 1 year (1994-1995, [exact dates not giving. All of the hospitals had written tuberculosis plans consistent with CDC guidelines, but none of the hospitals performed routine assessment of their tuberculosis control practices.
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or HEPA masks when out of room losis A total of 14 "clusters" of 22 PPD conversions among health care workers were reported from 11/191 (6 percent) hospitals, with one child PPD conversion reported.
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had isolation rooms in outpatient areas · All had an employee PPD program · 182/186 (98 percent) performed at least annual PPD testing for health care workers · 182/184 (99 percent)
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This hospital implemented tuberculosis control policies consistent with the 1990 CDC guidelines in 1992 (60~. Direct observations of health care worker behavior was made over a 14-week period (the year is not given)
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reported the results of a 1993 CDC survey of tuberculosis control practices in the ED. Written policies for managing patients with suspected tuberculosis in the triage and waiting areas were available at 159/282 (56.4 percent)
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Engineering controls are not required at that risk level, and none were specifically planned. Although no cases of tuberculosis were found by their chart review, given the high prevalence of tuberculosis in New York City during that time period and given the high rates of PPD conversions in students and faculty, a higher-level risk assessment would seem more appropriate.
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Also, the increased numbers of patients on isolation increased the perception that more tuberculosis patients were being admitted, increasing employee fear and anger. However, the concerns of health care workers did spark increased compliance with routine PPD testing.
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With 92 control patients for every tuberculosis patient, this led to a cost of $3,426 per case of tuberculosis diagnosed. The authors also estimated that 15 minutes/person of nurse epidemiologist time was spent tracing and contacting health care workers exposed to a case of tuberculosis, with an additional $6.00 to $11.00 per employee for PPD testing.
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as well. Although the authors did not calculate this, using their estimate of 30 contacts per case, the 14 nonisolated tuberculosis patients would have exposed 420 health care workers at a cost of 105 nurse epidemiologist hours ($2,100 at the $20/hour they estimated)
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A total of 13/115 patients for whom AFB tests were ordered and who were not placed on isolation actually met the criteria, and should have been isolated. One such patient with tuberculosis exposed 200 health care workers (no PPD conversions were found on follow-up)
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Resurgent tuberculosis in New York City. Human immunodeficiency virus, homelessness, and the decline of tuberculosis control programs.
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Boyle JF, Jarvis WR. Efficacy of control measures in preventing nosocomial transmission of multidrug-resistant tuberculosis to patients and health care workers.
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Effectiveness of a tuberculosis control plan in reducing PPD skin test conversions among health care workers. In: Anonymous.
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Reduction in tuberculin skin-test conversion rate after improved adherence to tuberculosis isolation. Infection Control and Hospital Epidemiology 1997;18:575-579.
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Knowledge of the transmission of tuberculosis and infection control measures for tuberculosis among healthcare workers. Infection Control and Hospital Epidemiology 1996;17:168-170.
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