Course Book : #114 - Tuberculosis Update

Course # 114

Two Contact Hours

Author: Monica Oram, RN, BSN and parts given credit to

Virginia Olesak, RN (Marion County Health Dept. )

 

This course is intended for the reader to be able to achieve the following goals:

  1. Define tuberculosis and list common symptoms.

  2. Learn the difference between TB infection and TB disease

  3. Understand how a person becomes infected with Tb

  4. Learn how to reduce the chances of being exposed to TB

  5. Understand PPE, and Isolation procedures.

 

Defining Tuberculosis

 

Tuberculosis is an airborne infectious disease carried on mucous droplets suspended in the air and released by an infected person through talking, laughing, singing, yelling, breathing, and any activity that causes droplets from the mouth or nose.

 

Tuberculosis (TB) is a disease that is caused by a germ that gets into the lungs. TB is not spread through casual contact. It is when the contact takes place in confined spaces and in poorly ventilated areas that increases the risk of exposure.

Symptoms of TB may also be present in people who are not infected. These people can be a “carrier’ but not be infectious. These individuals do not exhibit signs and symptoms, but will test positive on a TB skin test.

 

About Tuberculosis

 

Just when it seemed we have won the war against tuberculosis, it has become a serious health threat again. Before the 1940’s TB was quite common. Fortunately, a cure was found and TB was dramatically reduced in the United States. During the mid 1980’s cases began to increase. This trend seems to have been related to the spread of HIV infection. New drug resistant strains have arisen also. Healthcare workers are often on the front lines. This is why it is crucial for everyone who works in healthcare to understand TB ( it’s symptoms and precautions) to prevent getting or giving the disease, and avoiding undue alarm by basing attitude on facts- not fear.

TB is a serious disease caused by a tiny germ, called mycobacterium tuberculosis.

 

(following reprinted respectfully with permission from

Virginia Olesak, RN)

Before the introduction of anti-tuberculosis chemotherapy in the late 1940’s, TB was the leading case of death in the United States, accounting for one death in every seven. Improved living standards, public health measures, and more effective drugs have resulted in a markedly lower disease rate in the United States. In under developed countries, public health officials report more deaths from tuberculosis than from any other bacterial disease. The World Health Organization estimates 1.7 billion people are infected with tuberculosis.

 

While the disease previously infected mainly children, it is now more common among older people, especially males, foreign borne individuals and individuals co-infected with HIV.

 

In 2001, 1,145 cases of TB were reported in Florida, ranking 4th in the United States. TB in individuals born outside the United States comprised 43% of the 2001 cases. This is an increase of 15% from 28% in 1995.

 

23% of the reported Florida TB cases were co-infected with HIV in 2001.

The TB skin test can screen for infection before disease occurs.

 

The CDC reports that an estimated 10-15 million people in the United States are infected with TB. The possibility of TB must always be ruled out if the patient presents with respiratory symptoms, especially if the patient has had an increased risk for exposure to TB. The patient’s general health is also an important determinant of risk.

 

The CDC and prevention center consider the following individuals at high risk for TB and recommend a TB skin test for the following:

  • Persons with signs or symptoms suggestive of tuberculosis

  • Persons with contact to a person with active TB

  • Persons with an abnormal chest X-Ray compatible with past TB

  • Persons who inject drugs

  • Persons with medical conditions that increase the risk for tuberculosis

  • Groups at high risk of recent infection of Tb (e.g. recent immigration from countries with high rates of TB, personnel and residents of nursing homes, hospitals, prisons, and mental institutions.

 

The tuberculin test that gives the most accurate result is the mantoux test- the intracutaneous injection of PPD ( purified protein derivative)

The PPD is not 100% sensitive or 100% specific and both false positive and false negatives may occur. To date, however, no better diagnostic test is available. By administering the test only to those at high risk, the number of individuals with a false positive test unnecessarily being placed on preventative therapy will be reduced. This skin test, often referred to as a PPD or mantoux test, is a screening tool and is the traditional method of diagnosing individuals infected with mycobacterium tuberculosis.

 

It should only be administered to identify infected people at high risk for disease who would benefit from preventative therapy and those with tuberculosis disease who need treatment.

 

 

Information regarding individuals from foreign countries

 

Individuals in foreign countries may have been vaccinated with BCG. BCG is a vaccination for TB. This vaccination is not widely used in the United States, but is often given to infants and small children in foreign countries where TB is high. BCG does not always protect the individual from TB.

 

If a person was vaccinated with BCG, they will most often test POSITIVE on a PPD. Therefore, a PPD should not be given to these individuals. The positive result could be from the BCG vaccine, or from latent TB infection.

 

FYI: BCG vaccine was named after the French scientists named Calmette and Guerin, With the B indicating Bacillus.

 

Symptoms of Tuberculosis

 

Just because a person has a cough or is fatigued, does not mean the individual has TB. Only when symptoms are present for longer than 3 weeks, the person has had a recent “positive” PPD, or the person has had recent exposure to TB, do we suspect the individual is infected with TB.

Other diseases such as HIV/AIDS and Malaria have similar symptoms to TB.

 

When do we suspect Tuberculosis Disease?

When a person has respiratory symptoms lasting more than three weeks and exhibits other symptoms such as:

  • Fatigue

  • Malaise ( general discomfort)

  • Loss of appetite

  • Weight Loss

  • Fever

  • Night Sweats

  • Prolonged Coughing

  • Coughing Up Blood

  • Chest Pain

 

Difference between TB Infection and TB Disease

 

There are two kinds of TB exposures.

  1. TB Infection- also called latent TB, or inactive TB

  2. TB Disease- also called active TB

 

TB Infection- (latent TB) This means that the person carries the TB germ, but does not look or feel sick and cannot infect others. A TB skin test will reveal evidence of TB germs in the person’s system. Preventative treatment is recommended for some individuals.

With TB infection:

  • The person has the TB infection in their system

  • The person does not look or feel sick

  • The person is NOT contagious to others

  • The person tests POSITIVE on a PPD skin test

  • The person requires one drug therapy

  • One drug therapy usually lasts 6 months, but may last up to a year.

 

TB Disease- (AKA Active TB) In this case, signs of illness are usually present. The person may have a cough for 3 weeks or more, feel weak, have a fever, have weight loss, loss of appetite, night sweats, cough up blood or have chest pains while coughing. The person can infect others unless he or she is taking TB medications as directed by a physician.

With TB Disease:

  • The person shows signs of illness

  • The person is infectious if not treated

  • The person requires more than one drug therapy

  • The drug therapy generally lasts six to twelve months

  • After one to three weeks of drug therapy, if symptoms improve, the person is no longer considered contagious.

 

Without treatment, the disease will become worse. If TB disease is in the lungs, it may produce phlegm, mucous, and/or blood. TB can get into other parts of the body as well, including the liver, kidneys, spine, bones, abdominal cavity.. To name a few. TB disease in other parts of the body have different symptoms than with TB in the lungs.

 

Tests can show if you have TB disease. A chest X-Ray may show damage to the lungs. Phlegm can be tested to see if there is TB bacilli present.

If TB bacilli are present in the lungs or throat, they can be exhaled into the air and breathed by others. For this reason, they will need to be isolated.

(more on this later)

 

Failure to take medication as ordered is a big problem, Non-compliance leads to multi-drug resistant TB. The TB bacilli are still alive and become even stronger in non- compliant patients in medication treatment. They will then require stronger drugs to kill the TB Bacilli.

 

How a person becomes infected with TB

 

Inside the lungs are many alveolar clusters. It is in these clusters our blood gets oxygen and gets rid of carbon dioxide. The organism, mycobacterium tuberculosis, also known as the tubercle bacillus. This bacteria is carried on drops of moisture in the air. When the TB germs (droplets) are inhaled, it travels to the alveolar clusters. The TB germs are breathed in to the lungs and begin to multiply. Some TB germs may travel to other parts of the body, such as the kidneys, bones, and brain. The person now has TB INFECTION.

The immune system traps TB bacilli with special “germ fighter”, the White Blood Cells, They help to keep the person from becoming sick.

 

The body fights back but usually cannot kill all the germs. Some people may get very sick at this point, but most do not. The body builds defenses, like a wall, referred to as “capsules” around the germ. These germs go into a “sleeping stage” and the person feels fine. Then the germ “wakes up” by breaking out of their capsules. The TB bacilli begin to multiply again. This may happen in a year, or years, later. It usually happens when the body is weak from fighting other infections such as HIV/AIDS, diabetes, kidney disease, pneumonia, or cancer. When the TB germs break out of their capsule, the person has TB DISEASE.

 

You can be exposed to TB if you have spent time around someone who is infected, by breathing infectious TB droplets. You can only get TB by breathing these droplets. You cannot get TB by touching the person with TB, drinking glasses, clothing, handshakes, or toilet seats. Untreated people can become sick and may die if not treated.

 

A skin test is the best way to know if one has been exposed. Certain people should have the test. We have already explored some of those who should be tested, however, it is important to keep in mind that those who are in the following categories should also be tested:

  • Infected with HIV

  • Live or work in a correctional institution

  • Live or work in a nursing home or mental institution

  • Work in a health care setting

  • Live with or are in contact with those who have TB

  • Persons showing any signs of TB

  • Come to the US from a country where a lot of people have TB

  • Any one who is an IV drug user

  • Babies, young children and the elderly who may have has a potential exposure

  • People who were not properly treated in the past

 

Medication Treatment

 

The type of treatment the individual will receive will depend on whether they have TB infection, or TB disease.

  • TB Infection is usually treated with a drug called “INH”. Also known as isoniazid. Its functional class is anti- tubercular and its chemical class is Isonicotinic acid. The action of INH is that it is a bactericidal interference with lipid, nucleic acid biosynthesis. If a person has an overdose of INH, the drug pridoxine is then used to counteract the over dose. INH kills the bacteria that are in the body. If the person takes this medication as prescribed, treatment for latent TB will generally keep then from getting TB disease. Treatment is 6-12 months. Side effects include loss of appetite, nausea, vomiting, yellowish eyes or skin, fever over 3 days, abdominal pain, and tingling in hands or feet. Alcohol can increase the side effects and can contribute to hepatic problems with these drugs.

 

Multi drug therapy is required for TB disease and can include the use of rifampin.

Side effects of rifampin can turn urine orange, it may even turn tears or saliva orange. If the patient has contacts, he or she will not be able to wear them until rifampin treatment is completed, due the fact that they will become stained from the drug. Rifampin also causes sensitivity to the sun. These individuals will need to use a good sunscreen when outside.

Rifampin also decreases significantly the effectiveness of birth control pills. The patient on birth control pills will need to know to use another method of birth control while on rifampin therapy.

 

 

  • TB Disease is usually treated with INH, plus other drugs in a combination therapy regime. Most people can be treated in a doctor’s office, or clinic rather that requiring hospitalization.

 

Other drugs used include rifampin, pyrazinamide, and ethambutol. Streptomycin may also be given by injection.

 

Since many of the drugs used have multiple side effects, non-compliance becomes a serious problem. When the individual stops taking the medication as directed, they build up a resistance for the drug to be effective, requiring stronger medication in higher doses.

 

 

Why healthcare workers need to be concerned

 

Without consistent prevention efforts, contagious diseases like TB can spread quickly. TB is preventable. TB had almost been eliminated. We know now that TB is on the rise, and prevention is the only way to control this disease.

As a healthcare provider, the risk of transmission includes the increased possibility of coming in contact with someone who has the disease.

The closeness and the duration of contact also increases the healthcare workers risk of exposure.

Exposure Control Plan

A written exposure control plan addresses policies and procedures in your facility. The topics included in this plan are as follows:

In accordance with OSHA guidelines, the policy must include:

  • Early identification of those with suspected or actual TB

  • Initiating isolation of individuals with suspected or actual TB

  • Referring individuals with suspected or known TB to facilities with isolation capabilities, if yours does not have isolation rooms available.

  • Evaluation and management of employees with positive PPD’s.

  • Training of all healthcare workers to reduce their chances of exposure to TB

In order to protect yourself you must understand all of the following:

  • Understand how TB is transmitted

  • Get tested for TB infection

  • Know and follow your facility’s policies and procedures for infection control

  • Wear person al protective equipment (PPE) when performing high hazard procedures involving people with known or suspected TB.

  • Pay special attention when caring for anyone on TB isolation

  • Report to your supervisor any possible exposure to TB

  • Participate in annual PPD screening tests

 

PPE and Isolation precautions

PPE should be worn according to your facility’s specific policy when caring for anyone with TB. The policy and procedures should cover the use of gloves, gowns, masks, as well as the proper disposal of these items.

 

The mask you will be required to use for an individual with TB is different from the general type of masks used. A TB mask is called a respirator mask. They are a special type of particulate respirator that will not allow the tiny TB particles to enter. They have a specially designed filter on them, and are referred to as an N95 mask.

 

 

 

Isolation procedures include:

An acid fast bacillus ( AFB) isolation card should be present, instructing the healthcare worker to wear a mask, wear a gown, and to use gloves for touching the patient or any infected article. Good hand washing is essential. One should consider any item in the isolation room to be contaminated. There should be an isolation cart outside the room with proper PPE available for immediate use.

 

Keep in mind that the air we breathe is a positive air pressure environment. A person with TB needs to be placed in a negative air pressurized room. Negative air pressure means air flows INTO the room from the outside. The air is cycled through at least six times an hour. The air is also filtered back to the outside, passing through specially designed filters. Remember to open doors SLOWLY to prevent air from flowing back into the building. The door must always remain closed. Wear a respirator mask when entering the room that has known or suspected TB.

 

*** IMPORTANT TO REMEMBER****

 

If you must take the patient out of the room for any essential purpose, the patient is to wear a REGULAR SURGICAL MASK, NOT A RESPIRATOR TYPE N95, LIKE YOU WEAR TO ENTER THE ROOM!!!

This is because the respirator mask ONLY filters INHALED air, NOT EXHALED AIR.

 

Summary

 

TB is a disease that is spread from person to person through the air, and is particularly dangerous to those with a weakened immune system. TB is the leading cause of death among HIV infected people, accounting for about one in every three people infected with HIV.

TB is preventable, and recognition with a TB skin test is essential to begin proper treatment quickly to prevent transmission and even death.

It is important fort he healthcare worker to understand how TB is spread and take all necessary precautions to prevent coming in contact with this disease.

 

 

 

References:

 

Center For Disease Control

www.cdc.gov

1600 Clifton Road

Atlanta, Georgia 30333

1-800331-3435

World Health Organization

www.who.org

 

HIV Positive web site

www.hivpositive.com

 

Department of Health and Human Services

www.hhs.gov

200 Independence Avenue, SW

Washington, DC 20201

1-877-696-6775

 

 

Special Thanks To Virginia Olesak, RN

Marion County Health Dept.

Ocala, Florida

Course # 114

Two Contact Hours

Author: Monica Oram, RN, BSN and parts given credit to

Virginia Olesak, RN (Marion County Health Dept. )

 

This course is intended for the reader to be able to achieve the following goals:

  1. Define tuberculosis and list common symptoms.

  2. Learn the difference between TB infection and TB disease

  3. Understand how a person becomes infected with Tb

  4. Learn how to reduce the chances of being exposed to TB

  5. Understand PPE, and Isolation procedures.

 

Defining Tuberculosis

 

Tuberculosis is an airborne infectious disease carried on mucous droplets suspended in the air and released by an infected person through talking, laughing, singing, yelling, breathing, and any activity that causes droplets from the mouth or nose.

 

Tuberculosis (TB) is a disease that is caused by a germ that gets into the lungs. TB is not spread through casual contact. It is when the contact takes place in confined spaces and in poorly ventilated areas that increases the risk of exposure.

Symptoms of TB may also be present in people who are not infected. These people can be a “carrier’ but not be infectious. These individuals do not exhibit signs and symptoms, but will test positive on a TB skin test.

 

About Tuberculosis

 

Just when it seemed we have won the war against tuberculosis, it has become a serious health threat again. Before the 1940’s TB was quite common. Fortunately, a cure was found and TB was dramatically reduced in the United States. During the mid 1980’s cases began to increase. This trend seems to have been related to the spread of HIV infection. New drug resistant strains have arisen also. Healthcare workers are often on the front lines. This is why it is crucial for everyone who works in healthcare to understand TB ( it’s symptoms and precautions) to prevent getting or giving the disease, and avoiding undue alarm by basing attitude on facts- not fear.

TB is a serious disease caused by a tiny germ, called mycobacterium tuberculosis.

 

(following reprinted respectfully with permission from

Virginia Olesak, RN)

Before the introduction of anti-tuberculosis chemotherapy in the late 1940’s, TB was the leading case of death in the United States, accounting for one death in every seven. Improved living standards, public health measures, and more effective drugs have resulted in a markedly lower disease rate in the United States. In under developed countries, public health officials report more deaths from tuberculosis than from any other bacterial disease. The World Health Organization estimates 1.7 billion people are infected with tuberculosis.

 

While the disease previously infected mainly children, it is now more common among older people, especially males, foreign borne individuals and individuals co-infected with HIV.

 

In 2001, 1,145 cases of TB were reported in Florida, ranking 4th in the United States. TB in individuals born outside the United States comprised 43% of the 2001 cases. This is an increase of 15% from 28% in 1995.

 

23% of the reported Florida TB cases were co-infected with HIV in 2001.

The TB skin test can screen for infection before disease occurs.

 

The CDC reports that an estimated 10-15 million people in the United States are infected with TB. The possibility of TB must always be ruled out if the patient presents with respiratory symptoms, especially if the patient has had an increased risk for exposure to TB. The patient’s general health is also an important determinant of risk.

 

The CDC and prevention center consider the following individuals at high risk for TB and recommend a TB skin test for the following:

  • Persons with signs or symptoms suggestive of tuberculosis

  • Persons with contact to a person with active TB

  • Persons with an abnormal chest X-Ray compatible with past TB

  • Persons who inject drugs

  • Persons with medical conditions that increase the risk for tuberculosis

  • Groups at high risk of recent infection of Tb (e.g. recent immigration from countries with high rates of TB, personnel and residents of nursing homes, hospitals, prisons, and mental institutions.

 

The tuberculin test that gives the most accurate result is the mantoux test- the intracutaneous injection of PPD ( purified protein derivative)

The PPD is not 100% sensitive or 100% specific and both false positive and false negatives may occur. To date, however, no better diagnostic test is available. By administering the test only to those at high risk, the number of individuals with a false positive test unnecessarily being placed on preventative therapy will be reduced. This skin test, often referred to as a PPD or mantoux test, is a screening tool and is the traditional method of diagnosing individuals infected with mycobacterium tuberculosis.

 

It should only be administered to identify infected people at high risk for disease who would benefit from preventative therapy and those with tuberculosis disease who need treatment.

 

 

Information regarding individuals from foreign countries

 

Individuals in foreign countries may have been vaccinated with BCG. BCG is a vaccination for TB. This vaccination is not widely used in the United States, but is often given to infants and small children in foreign countries where TB is high. BCG does not always protect the individual from TB.

 

If a person was vaccinated with BCG, they will most often test POSITIVE on a PPD. Therefore, a PPD should not be given to these individuals. The positive result could be from the BCG vaccine, or from latent TB infection.

 

FYI: BCG vaccine was named after the French scientists named Calmette and Guerin, With the B indicating Bacillus.

 

Symptoms of Tuberculosis

 

Just because a person has a cough or is fatigued, does not mean the individual has TB. Only when symptoms are present for longer than 3 weeks, the person has had a recent “positive” PPD, or the person has had recent exposure to TB, do we suspect the individual is infected with TB.

Other diseases such as HIV/AIDS and Malaria have similar symptoms to TB.

 

When do we suspect Tuberculosis Disease?

When a person has respiratory symptoms lasting more than three weeks and exhibits other symptoms such as:

  • Fatigue

  • Malaise ( general discomfort)

  • Loss of appetite

  • Weight Loss

  • Fever

  • Night Sweats

  • Prolonged Coughing

  • Coughing Up Blood

  • Chest Pain

 

Difference between TB Infection and TB Disease

 

There are two kinds of TB exposures.

  1. TB Infection- also called latent TB, or inactive TB

  2. TB Disease- also called active TB

 

TB Infection- (latent TB) This means that the person carries the TB germ, but does not look or feel sick and cannot infect others. A TB skin test will reveal evidence of TB germs in the person’s system. Preventative treatment is recommended for some individuals.

With TB infection:

  • The person has the TB infection in their system

  • The person does not look or feel sick

  • The person is NOT contagious to others

  • The person tests POSITIVE on a PPD skin test

  • The person requires one drug therapy

  • One drug therapy usually lasts 6 months, but may last up to a year.

 

TB Disease- (AKA Active TB) In this case, signs of illness are usually present. The person may have a cough for 3 weeks or more, feel weak, have a fever, have weight loss, loss of appetite, night sweats, cough up blood or have chest pains while coughing. The person can infect others unless he or she is taking TB medications as directed by a physician.

With TB Disease:

  • The person shows signs of illness

  • The person is infectious if not treated

  • The person requires more than one drug therapy

  • The drug therapy generally lasts six to twelve months

  • After one to three weeks of drug therapy, if symptoms improve, the person is no longer considered contagious.

 

Without treatment, the disease will become worse. If TB disease is in the lungs, it may produce phlegm, mucous, and/or blood. TB can get into other parts of the body as well, including the liver, kidneys, spine, bones, abdominal cavity.. To name a few. TB disease in other parts of the body have different symptoms than with TB in the lungs.

 

Tests can show if you have TB disease. A chest X-Ray may show damage to the lungs. Phlegm can be tested to see if there is TB bacilli present.

If TB bacilli are present in the lungs or throat, they can be exhaled into the air and breathed by others. For this reason, they will need to be isolated.

(more on this later)

 

Failure to take medication as ordered is a big problem, Non-compliance leads to multi-drug resistant TB. The TB bacilli are still alive and become even stronger in non- compliant patients in medication treatment. They will then require stronger drugs to kill the TB Bacilli.

 

How a person becomes infected with TB

 

Inside the lungs are many alveolar clusters. It is in these clusters our blood gets oxygen and gets rid of carbon dioxide. The organism, mycobacterium tuberculosis, also known as the tubercle bacillus. This bacteria is carried on drops of moisture in the air. When the TB germs (droplets) are inhaled, it travels to the alveolar clusters. The TB germs are breathed in to the lungs and begin to multiply. Some TB germs may travel to other parts of the body, such as the kidneys, bones, and brain. The person now has TB INFECTION.

The immune system traps TB bacilli with special “germ fighter”, the White Blood Cells, They help to keep the person from becoming sick.

 

The body fights back but usually cannot kill all the germs. Some people may get very sick at this point, but most do not. The body builds defenses, like a wall, referred to as “capsules” around the germ. These germs go into a “sleeping stage” and the person feels fine. Then the germ “wakes up” by breaking out of their capsules. The TB bacilli begin to multiply again. This may happen in a year, or years, later. It usually happens when the body is weak from fighting other infections such as HIV/AIDS, diabetes, kidney disease, pneumonia, or cancer. When the TB germs break out of their capsule, the person has TB DISEASE.

 

You can be exposed to TB if you have spent time around someone who is infected, by breathing infectious TB droplets. You can only get TB by breathing these droplets. You cannot get TB by touching the person with TB, drinking glasses, clothing, handshakes, or toilet seats. Untreated people can become sick and may die if not treated.

 

A skin test is the best way to know if one has been exposed. Certain people should have the test. We have already explored some of those who should be tested, however, it is important to keep in mind that those who are in the following categories should also be tested:

  • Infected with HIV

  • Live or work in a correctional institution

  • Live or work in a nursing home or mental institution

  • Work in a health care setting

  • Live with or are in contact with those who have TB

  • Persons showing any signs of TB

  • Come to the US from a country where a lot of people have TB

  • Any one who is an IV drug user

  • Babies, young children and the elderly who may have has a potential exposure

  • People who were not properly treated in the past

 

Medication Treatment

 

The type of treatment the individual will receive will depend on whether they have TB infection, or TB disease.

  • TB Infection is usually treated with a drug called “INH”. Also known as isoniazid. Its functional class is anti- tubercular and its chemical class is Isonicotinic acid. The action of INH is that it is a bactericidal interference with lipid, nucleic acid biosynthesis. If a person has an overdose of INH, the drug pridoxine is then used to counteract the over dose. INH kills the bacteria that are in the body. If the person takes this medication as prescribed, treatment for latent TB will generally keep then from getting TB disease. Treatment is 6-12 months. Side effects include loss of appetite, nausea, vomiting, yellowish eyes or skin, fever over 3 days, abdominal pain, and tingling in hands or feet. Alcohol can increase the side effects and can contribute to hepatic problems with these drugs.

 

Multi drug therapy is required for TB disease and can include the use of rifampin.

Side effects of rifampin can turn urine orange, it may even turn tears or saliva orange. If the patient has contacts, he or she will not be able to wear them until rifampin treatment is completed, due the fact that they will become stained from the drug. Rifampin also causes sensitivity to the sun. These individuals will need to use a good sunscreen when outside.

Rifampin also decreases significantly the effectiveness of birth control pills. The patient on birth control pills will need to know to use another method of birth control while on rifampin therapy.

 

 

  • TB Disease is usually treated with INH, plus other drugs in a combination therapy regime. Most people can be treated in a doctor’s office, or clinic rather that requiring hospitalization.

 

Other drugs used include rifampin, pyrazinamide, and ethambutol. Streptomycin may also be given by injection.

 

Since many of the drugs used have multiple side effects, non-compliance becomes a serious problem. When the individual stops taking the medication as directed, they build up a resistance for the drug to be effective, requiring stronger medication in higher doses.

 

 

Why healthcare workers need to be concerned

 

Without consistent prevention efforts, contagious diseases like TB can spread quickly. TB is preventable. TB had almost been eliminated. We know now that TB is on the rise, and prevention is the only way to control this disease.

As a healthcare provider, the risk of transmission includes the increased possibility of coming in contact with someone who has the disease.

The closeness and the duration of contact also increases the healthcare workers risk of exposure.

Exposure Control Plan

A written exposure control plan addresses policies and procedures in your facility. The topics included in this plan are as follows:

In accordance with OSHA guidelines, the policy must include:

  • Early identification of those with suspected or actual TB

  • Initiating isolation of individuals with suspected or actual TB

  • Referring individuals with suspected or known TB to facilities with isolation capabilities, if yours does not have isolation rooms available.

  • Evaluation and management of employees with positive PPD’s.

  • Training of all healthcare workers to reduce their chances of exposure to TB

In order to protect yourself you must understand all of the following:

  • Understand how TB is transmitted

  • Get tested for TB infection

  • Know and follow your facility’s policies and procedures for infection control

  • Wear person al protective equipment (PPE) when performing high hazard procedures involving people with known or suspected TB.

  • Pay special attention when caring for anyone on TB isolation

  • Report to your supervisor any possible exposure to TB

  • Participate in annual PPD screening tests

 

PPE and Isolation precautions

PPE should be worn according to your facility’s specific policy when caring for anyone with TB. The policy and procedures should cover the use of gloves, gowns, masks, as well as the proper disposal of these items.

 

The mask you will be required to use for an individual with TB is different from the general type of masks used. A TB mask is called a respirator mask. They are a special type of particulate respirator that will not allow the tiny TB particles to enter. They have a specially designed filter on them, and are referred to as an N95 mask.

 

 

 

Isolation procedures include:

An acid fast bacillus ( AFB) isolation card should be present, instructing the healthcare worker to wear a mask, wear a gown, and to use gloves for touching the patient or any infected article. Good hand washing is essential. One should consider any item in the isolation room to be contaminated. There should be an isolation cart outside the room with proper PPE available for immediate use.

 

Keep in mind that the air we breathe is a positive air pressure environment. A person with TB needs to be placed in a negative air pressurized room. Negative air pressure means air flows INTO the room from the outside. The air is cycled through at least six times an hour. The air is also filtered back to the outside, passing through specially designed filters. Remember to open doors SLOWLY to prevent air from flowing back into the building. The door must always remain closed. Wear a respirator mask when entering the room that has known or suspected TB.

 

*** IMPORTANT TO REMEMBER****

 

If you must take the patient out of the room for any essential purpose, the patient is to wear a REGULAR SURGICAL MASK, NOT A RESPIRATOR TYPE N95, LIKE YOU WEAR TO ENTER THE ROOM!!!

This is because the respirator mask ONLY filters INHALED air, NOT EXHALED AIR.

 

Summary

 

TB is a disease that is spread from person to person through the air, and is particularly dangerous to those with a weakened immune system. TB is the leading cause of death among HIV infected people, accounting for about one in every three people infected with HIV.

TB is preventable, and recognition with a TB skin test is essential to begin proper treatment quickly to prevent transmission and even death.

It is important fort he healthcare worker to understand how TB is spread and take all necessary precautions to prevent coming in contact with this disease.

 

 

 

References:

 

Center For Disease Control

www.cdc.gov

1600 Clifton Road

Atlanta, Georgia 30333

1-800331-3435

World Health Organization

www.who.org

 

HIV Positive web site

www.hivpositive.com

 

Department of Health and Human Services

www.hhs.gov

200 Independence Avenue, SW

Washington, DC 20201

1-877-696-6775

 

 

Special Thanks To Virginia Olesak, RN

Marion County Health Dept.

Ocala, Florida

Course # 114

Two Contact Hours

Author: Monica Oram, RN, BSN and parts given credit to

Virginia Olesak, RN (Marion County Health Dept. )

 

This course is intended for the reader to be able to achieve the following goals:

  1. Define tuberculosis and list common symptoms.

  2. Learn the difference between TB infection and TB disease

  3. Understand how a person becomes infected with Tb

  4. Learn how to reduce the chances of being exposed to TB

  5. Understand PPE, and Isolation procedures.

 

Defining Tuberculosis

 

Tuberculosis is an airborne infectious disease carried on mucous droplets suspended in the air and released by an infected person through talking, laughing, singing, yelling, breathing, and any activity that causes droplets from the mouth or nose.

 

Tuberculosis (TB) is a disease that is caused by a germ that gets into the lungs. TB is not spread through casual contact. It is when the contact takes place in confined spaces and in poorly ventilated areas that increases the risk of exposure.

Symptoms of TB may also be present in people who are not infected. These people can be a “carrier’ but not be infectious. These individuals do not exhibit signs and symptoms, but will test positive on a TB skin test.

 

About Tuberculosis

 

Just when it seemed we have won the war against tuberculosis, it has become a serious health threat again. Before the 1940’s TB was quite common. Fortunately, a cure was found and TB was dramatically reduced in the United States. During the mid 1980’s cases began to increase. This trend seems to have been related to the spread of HIV infection. New drug resistant strains have arisen also. Healthcare workers are often on the front lines. This is why it is crucial for everyone who works in healthcare to understand TB ( it’s symptoms and precautions) to prevent getting or giving the disease, and avoiding undue alarm by basing attitude on facts- not fear.

TB is a serious disease caused by a tiny germ, called mycobacterium tuberculosis.

 

(following reprinted respectfully with permission from

Virginia Olesak, RN)

Before the introduction of anti-tuberculosis chemotherapy in the late 1940’s, TB was the leading case of death in the United States, accounting for one death in every seven. Improved living standards, public health measures, and more effective drugs have resulted in a markedly lower disease rate in the United States. In under developed countries, public health officials report more deaths from tuberculosis than from any other bacterial disease. The World Health Organization estimates 1.7 billion people are infected with tuberculosis.

 

While the disease previously infected mainly children, it is now more common among older people, especially males, foreign borne individuals and individuals co-infected with HIV.

 

In 2001, 1,145 cases of TB were reported in Florida, ranking 4th in the United States. TB in individuals born outside the United States comprised 43% of the 2001 cases. This is an increase of 15% from 28% in 1995.

 

23% of the reported Florida TB cases were co-infected with HIV in 2001.

The TB skin test can screen for infection before disease occurs.

 

The CDC reports that an estimated 10-15 million people in the United States are infected with TB. The possibility of TB must always be ruled out if the patient presents with respiratory symptoms, especially if the patient has had an increased risk for exposure to TB. The patient’s general health is also an important determinant of risk.

 

The CDC and prevention center consider the following individuals at high risk for TB and recommend a TB skin test for the following:

  • Persons with signs or symptoms suggestive of tuberculosis

  • Persons with contact to a person with active TB

  • Persons with an abnormal chest X-Ray compatible with past TB

  • Persons who inject drugs

  • Persons with medical conditions that increase the risk for tuberculosis

  • Groups at high risk of recent infection of Tb (e.g. recent immigration from countries with high rates of TB, personnel and residents of nursing homes, hospitals, prisons, and mental institutions.

 

The tuberculin test that gives the most accurate result is the mantoux test- the intracutaneous injection of PPD ( purified protein derivative)

The PPD is not 100% sensitive or 100% specific and both false positive and false negatives may occur. To date, however, no better diagnostic test is available. By administering the test only to those at high risk, the number of individuals with a false positive test unnecessarily being placed on preventative therapy will be reduced. This skin test, often referred to as a PPD or mantoux test, is a screening tool and is the traditional method of diagnosing individuals infected with mycobacterium tuberculosis.

 

It should only be administered to identify infected people at high risk for disease who would benefit from preventative therapy and those with tuberculosis disease who need treatment.

 

 

Information regarding individuals from foreign countries

 

Individuals in foreign countries may have been vaccinated with BCG. BCG is a vaccination for TB. This vaccination is not widely used in the United States, but is often given to infants and small children in foreign countries where TB is high. BCG does not always protect the individual from TB.

 

If a person was vaccinated with BCG, they will most often test POSITIVE on a PPD. Therefore, a PPD should not be given to these individuals. The positive result could be from the BCG vaccine, or from latent TB infection.

 

FYI: BCG vaccine was named after the French scientists named Calmette and Guerin, With the B indicating Bacillus.

 

Symptoms of Tuberculosis

 

Just because a person has a cough or is fatigued, does not mean the individual has TB. Only when symptoms are present for longer than 3 weeks, the person has had a recent “positive” PPD, or the person has had recent exposure to TB, do we suspect the individual is infected with TB.

Other diseases such as HIV/AIDS and Malaria have similar symptoms to TB.

 

When do we suspect Tuberculosis Disease?

When a person has respiratory symptoms lasting more than three weeks and exhibits other symptoms such as:

  • Fatigue

  • Malaise ( general discomfort)

  • Loss of appetite

  • Weight Loss

  • Fever

  • Night Sweats

  • Prolonged Coughing

  • Coughing Up Blood

  • Chest Pain

 

Difference between TB Infection and TB Disease

 

There are two kinds of TB exposures.

  1. TB Infection- also called latent TB, or inactive TB

  2. TB Disease- also called active TB

 

TB Infection- (latent TB) This means that the person carries the TB germ, but does not look or feel sick and cannot infect others. A TB skin test will reveal evidence of TB germs in the person’s system. Preventative treatment is recommended for some individuals.

With TB infection:

  • The person has the TB infection in their system

  • The person does not look or feel sick

  • The person is NOT contagious to others

  • The person tests POSITIVE on a PPD skin test

  • The person requires one drug therapy

  • One drug therapy usually lasts 6 months, but may last up to a year.

 

TB Disease- (AKA Active TB) In this case, signs of illness are usually present. The person may have a cough for 3 weeks or more, feel weak, have a fever, have weight loss, loss of appetite, night sweats, cough up blood or have chest pains while coughing. The person can infect others unless he or she is taking TB medications as directed by a physician.

With TB Disease:

  • The person shows signs of illness

  • The person is infectious if not treated

  • The person requires more than one drug therapy

  • The drug therapy generally lasts six to twelve months

  • After one to three weeks of drug therapy, if symptoms improve, the person is no longer considered contagious.

 

Without treatment, the disease will become worse. If TB disease is in the lungs, it may produce phlegm, mucous, and/or blood. TB can get into other parts of the body as well, including the liver, kidneys, spine, bones, abdominal cavity.. To name a few. TB disease in other parts of the body have different symptoms than with TB in the lungs.

 

Tests can show if you have TB disease. A chest X-Ray may show damage to the lungs. Phlegm can be tested to see if there is TB bacilli present.

If TB bacilli are present in the lungs or throat, they can be exhaled into the air and breathed by others. For this reason, they will need to be isolated.

(more on this later)

 

Failure to take medication as ordered is a big problem, Non-compliance leads to multi-drug resistant TB. The TB bacilli are still alive and become even stronger in non- compliant patients in medication treatment. They will then require stronger drugs to kill the TB Bacilli.

 

How a person becomes infected with TB

 

Inside the lungs are many alveolar clusters. It is in these clusters our blood gets oxygen and gets rid of carbon dioxide. The organism, mycobacterium tuberculosis, also known as the tubercle bacillus. This bacteria is carried on drops of moisture in the air. When the TB germs (droplets) are inhaled, it travels to the alveolar clusters. The TB germs are breathed in to the lungs and begin to multiply. Some TB germs may travel to other parts of the body, such as the kidneys, bones, and brain. The person now has TB INFECTION.

The immune system traps TB bacilli with special “germ fighter”, the White Blood Cells, They help to keep the person from becoming sick.

 

The body fights back but usually cannot kill all the germs. Some people may get very sick at this point, but most do not. The body builds defenses, like a wall, referred to as “capsules” around the germ. These germs go into a “sleeping stage” and the person feels fine. Then the germ “wakes up” by breaking out of their capsules. The TB bacilli begin to multiply again. This may happen in a year, or years, later. It usually happens when the body is weak from fighting other infections such as HIV/AIDS, diabetes, kidney disease, pneumonia, or cancer. When the TB germs break out of their capsule, the person has TB DISEASE.

 

You can be exposed to TB if you have spent time around someone who is infected, by breathing infectious TB droplets. You can only get TB by breathing these droplets. You cannot get TB by touching the person with TB, drinking glasses, clothing, handshakes, or toilet seats. Untreated people can become sick and may die if not treated.

 

A skin test is the best way to know if one has been exposed. Certain people should have the test. We have already explored some of those who should be tested, however, it is important to keep in mind that those who are in the following categories should also be tested:

  • Infected with HIV

  • Live or work in a correctional institution

  • Live or work in a nursing home or mental institution

  • Work in a health care setting

  • Live with or are in contact with those who have TB

  • Persons showing any signs of TB

  • Come to the US from a country where a lot of people have TB

  • Any one who is an IV drug user

  • Babies, young children and the elderly who may have has a potential exposure

  • People who were not properly treated in the past

 

Medication Treatment

 

The type of treatment the individual will receive will depend on whether they have TB infection, or TB disease.

  • TB Infection is usually treated with a drug called “INH”. Also known as isoniazid. Its functional class is anti- tubercular and its chemical class is Isonicotinic acid. The action of INH is that it is a bactericidal interference with lipid, nucleic acid biosynthesis. If a person has an overdose of INH, the drug pridoxine is then used to counteract the over dose. INH kills the bacteria that are in the body. If the person takes this medication as prescribed, treatment for latent TB will generally keep then from getting TB disease. Treatment is 6-12 months. Side effects include loss of appetite, nausea, vomiting, yellowish eyes or skin, fever over 3 days, abdominal pain, and tingling in hands or feet. Alcohol can increase the side effects and can contribute to hepatic problems with these drugs.

 

Multi drug therapy is required for TB disease and can include the use of rifampin.

Side effects of rifampin can turn urine orange, it may even turn tears or saliva orange. If the patient has contacts, he or she will not be able to wear them until rifampin treatment is completed, due the fact that they will become stained from the drug. Rifampin also causes sensitivity to the sun. These individuals will need to use a good sunscreen when outside.

Rifampin also decreases significantly the effectiveness of birth control pills. The patient on birth control pills will need to know to use another method of birth control while on rifampin therapy.

 

 

  • TB Disease is usually treated with INH, plus other drugs in a combination therapy regime. Most people can be treated in a doctor’s office, or clinic rather that requiring hospitalization.

 

Other drugs used include rifampin, pyrazinamide, and ethambutol. Streptomycin may also be given by injection.

 

Since many of the drugs used have multiple side effects, non-compliance becomes a serious problem. When the individual stops taking the medication as directed, they build up a resistance for the drug to be effective, requiring stronger medication in higher doses.

 

 

Why healthcare workers need to be concerned

 

Without consistent prevention efforts, contagious diseases like TB can spread quickly. TB is preventable. TB had almost been eliminated. We know now that TB is on the rise, and prevention is the only way to control this disease.

As a healthcare provider, the risk of transmission includes the increased possibility of coming in contact with someone who has the disease.

The closeness and the duration of contact also increases the healthcare workers risk of exposure.

Exposure Control Plan

A written exposure control plan addresses policies and procedures in your facility. The topics included in this plan are as follows:

In accordance with OSHA guidelines, the policy must include:

  • Early identification of those with suspected or actual TB

  • Initiating isolation of individuals with suspected or actual TB

  • Referring individuals with suspected or known TB to facilities with isolation capabilities, if yours does not have isolation rooms available.

  • Evaluation and management of employees with positive PPD’s.

  • Training of all healthcare workers to reduce their chances of exposure to TB

In order to protect yourself you must understand all of the following:

  • Understand how TB is transmitted

  • Get tested for TB infection

  • Know and follow your facility’s policies and procedures for infection control

  • Wear person al protective equipment (PPE) when performing high hazard procedures involving people with known or suspected TB.

  • Pay special attention when caring for anyone on TB isolation

  • Report to your supervisor any possible exposure to TB

  • Participate in annual PPD screening tests

 

PPE and Isolation precautions

PPE should be worn according to your facility’s specific policy when caring for anyone with TB. The policy and procedures should cover the use of gloves, gowns, masks, as well as the proper disposal of these items.

 

The mask you will be required to use for an individual with TB is different from the general type of masks used. A TB mask is called a respirator mask. They are a special type of particulate respirator that will not allow the tiny TB particles to enter. They have a specially designed filter on them, and are referred to as an N95 mask.

 

 

 

Isolation procedures include:

An acid fast bacillus ( AFB) isolation card should be present, instructing the healthcare worker to wear a mask, wear a gown, and to use gloves for touching the patient or any infected article. Good hand washing is essential. One should consider any item in the isolation room to be contaminated. There should be an isolation cart outside the room with proper PPE available for immediate use.

 

Keep in mind that the air we breathe is a positive air pressure environment. A person with TB needs to be placed in a negative air pressurized room. Negative air pressure means air flows INTO the room from the outside. The air is cycled through at least six times an hour. The air is also filtered back to the outside, passing through specially designed filters. Remember to open doors SLOWLY to prevent air from flowing back into the building. The door must always remain closed. Wear a respirator mask when entering the room that has known or suspected TB.

 

*** IMPORTANT TO REMEMBER****

 

If you must take the patient out of the room for any essential purpose, the patient is to wear a REGULAR SURGICAL MASK, NOT A RESPIRATOR TYPE N95, LIKE YOU WEAR TO ENTER THE ROOM!!!

This is because the respirator mask ONLY filters INHALED air, NOT EXHALED AIR.

 

Summary

 

TB is a disease that is spread from person to person through the air, and is particularly dangerous to those with a weakened immune system. TB is the leading cause of death among HIV infected people, accounting for about one in every three people infected with HIV.

TB is preventable, and recognition with a TB skin test is essential to begin proper treatment quickly to prevent transmission and even death.

It is important fort he healthcare worker to understand how TB is spread and take all necessary precautions to prevent coming in contact with this disease.

 

 

 

References:

 

Center For Disease Control

www.cdc.gov

1600 Clifton Road

Atlanta, Georgia 30333

1-800331-3435

World Health Organization

www.who.org

 

HIV Positive web site

www.hivpositive.com

 

Department of Health and Human Services

www.hhs.gov

200 Independence Avenue, SW

Washington, DC 20201

1-877-696-6775

 

 

Special Thanks To Virginia Olesak, RN

Marion County Health Dept.

Ocala, Florida