Tuberculosis transmission and control
- Kimon C Zachary, MD
Kimon C Zachary, MD
- Assistant Professor of Medicine
- Harvard Medical School
The transmission of tuberculosis (TB) in healthcare facilities is an important public health concern; careful infection control measures are required to reduce healthcare-associated transmission [1,2].
Issues related to control of TB transmission will be reviewed here. Other issues related to TB are discussed in detail separately. (See related topics.)
Person-to-person transmission of tuberculosis (TB) occurs via inhalation of droplet nuclei (airborne particles 1 to 5 microns in diameter). Coughing and singing facilitate formation of droplet nuclei [3-7]. (See "Natural history, microbiology, and pathogenesis of tuberculosis".)
Factors associated with risk for TB transmission via droplet nuclei include [8,9]:
●Presence of active untreated pulmonary or laryngeal TB
- Jensen PA, Lambert LA, Iademarco MF, et al. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep 2005; 54:1.
- Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clin Infect Dis 2017; 64:e1.
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- Tostmann A, Kik SV, Kalisvaart NA, et al. Tuberculosis transmission by patients with smear-negative pulmonary tuberculosis in a large cohort in the Netherlands. Clin Infect Dis 2008; 47:1135.
- O'Shea MK, Koh GC, Munang M, et al. Time-to-detection in culture predicts risk of Mycobacterium tuberculosis transmission: a cohort study. Clin Infect Dis 2014; 59:177.
- Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee (HICPAC): Glossary. https://www.cdc.gov/hicpac/2007IP/2007ip_glossary.html (Accessed on February 16, 2017).
- Ninomura P, Bartley J. New Ventilation Guidelines For Health-Care Facilities. ASHRAE J 2001; 43:29.
- Dharmadhikari AS, Mphahlele M, Stoltz A, et al. Surgical face masks worn by patients with multidrug-resistant tuberculosis: impact on infectivity of air on a hospital ward. Am J Respir Crit Care Med 2012; 185:1104.
- United States Department of Labor. Occupational Safety and Health Standards: Appendix A to § 1910.134: Fit Testing Procedures (Mandatory). https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=9780 (Accessed on February 16, 2017).
- Welbel SF, French AL, Bush P, et al. Protecting health care workers from tuberculosis: a 10-year experience. Am J Infect Control 2009; 37:668.
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- Young KH, Ehman M, Reves R, et al. Tuberculosis Contact Investigations--United States, 2003-2012. MMWR Morb Mortal Wkly Rep 2016; 64:1369.
- Tokars JI, McKinley GF, Otten J, et al. Use and efficacy of tuberculosis infection control practices at hospitals with previous outbreaks of multidrug-resistant tuberculosis. Infect Control Hosp Epidemiol 2001; 22:449.
- Sutton PM, Nicas M, Harrison RJ. Tuberculosis isolation: comparison of written procedures and actual practices in three California hospitals. Infect Control Hosp Epidemiol 2000; 21:28.
- Dorman SE, Belknap R, Graviss EA, et al. Interferon-γ release assays and tuberculin skin testing for diagnosis of latent tuberculosis infection in healthcare workers in the United States. Am J Respir Crit Care Med 2014; 189:77.
- Zwerling A, Benedetti A, Cojocariu M, et al. Repeat IGRA testing in Canadian health workers: conversions or unexplained variability? PLoS One 2013; 8:e54748.
- Chaisson LH, Roemer M, Cantu D, et al. Impact of GeneXpert MTB/RIF assay on triage of respiratory isolation rooms for inpatients with presumed tuberculosis: a hypothetical trial. Clin Infect Dis 2014; 59:1353.
- Lippincott CK, Miller MB, Popowitch EB, et al. Xpert MTB/RIF assay shortens airborne isolation for hospitalized patients with presumptive tuberculosis in the United States. Clin Infect Dis 2014; 59:186.
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- Moran GJ, Barrett TW, Mower WR, et al. Decision instrument for the isolation of pneumonia patients with suspected pulmonary tuberculosis admitted through US emergency departments. Ann Emerg Med 2009; 53:625.
- Centers for Disease Control and Prevention: Tuberculosis (TB) http://www.cdc.gov/tb/amplification_tests/amplification_tests.pdf (Accessed on January 20, 2008).
- Consensus statement on the use of Cepheid Xpert MTB/RIF® assay in making decisions to discontinue airborne infection isolation in healthcare settings. NTCA APHL, April 2016. http://www.tbcontrollers.org/docs/resources/NTCA_APHL_GeneXpert_Consensus_Statement_Final.pdf (Accessed on April 27, 2016).
- Cowan JF, Chandler AS, Kracen E, et al. Clinical Impact and Cost-effectiveness of Xpert MTB/RIF Testing in Hospitalized Patients With Presumptive Pulmonary Tuberculosis in the United States. Clin Infect Dis 2017; 64:482.
- Centers for Disease Control and Prevention (CDC). Updated guidelines for the use of nucleic acid amplification tests in the diagnosis of tuberculosis. MMWR Morb Mortal Wkly Rep 2009; 58:7.
- US Food and Drug Administration. New data shows test can help physicians remove patients with suspected TB from isolation earlier. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm434226.htm (Accessed on February 19, 2015).
- Revised Device Labeling for the Cepheid Xpert MTB/RIF Assay for Detecting Mycobacterium tuberculosis. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6407a8.htm?s_cid=mm6407a8_e (Accessed on February 26, 2015).
- Luetkemeyer AF, Firnhaber C, Kendall MA, et al. Evaluation of Xpert MTB/RIF Versus AFB Smear and Culture to Identify Pulmonary Tuberculosis in Patients With Suspected Tuberculosis From Low and Higher Prevalence Settings. Clin Infect Dis 2016; 62:1081.
- Campos M, Quartin A, Mendes E, et al. Feasibility of shortening respiratory isolation with a single sputum nucleic acid amplification test. Am J Respir Crit Care Med 2008; 178:300.
- Fløe A, Hilberg O, Thomsen VØ, et al. Shortening Isolation of Patients With Suspected Tuberculosis by Using Polymerase Chain Reaction Analysis: A Nationwide Cross-sectional Study. Clin Infect Dis 2015; 61:1365.
- Cepheid. Xpert MTB/RIF assay [package insert]. Cepheid, Sunnyvale, CA 2015. www.cepheid.com/mtbrif-pi (Accessed on June 13, 2016).
- Division of Microbiology Devices, Office of In Vitro Diagnostics and Radiological Health, Center for Devices and Radiological Health, Food and Drug Administration, Centers for Disease Control and Prevention (CDC). Revised device labeling for the Cepheid Xpert MTB/RIF assay for detecting Mycobacterium tuberculosis. MMWR Morb Mortal Wkly Rep 2015; 64:193.
- TB TRANSMISSION
- COMPONENTS OF TB INFECTION CONTROL
- Airborne infection isolation
- Use of masks
- - Healthcare workers
- - Patients
- - Visitors
- Contact investigation
- Assessing compliance
- CLINICAL APPROACH
- Assessing risk for TB
- Diagnostic evaluation
- Clinical triaging
- - Outpatient management
- - Inpatient management
- Initiating airborne precautions
- Discontinuing airborne precautions
- Discharge planning
- INFORMATION FOR PATIENTS