Guidelines for Preventing Transmission of TB in the Health-Care Setting

The following policy is based on a low risk TB assessment and was derived from the Center for Disease Control's:  
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, which were 
released in December of 2005. For the full article please see
The term 'tuberculin skin tests' (TSTs) is used instead of purified protein derivative (PPD). 
The frequency of TB screening for Health Care Workers (HCW)s 
has been decreased in various settings, and the criteria for 
determination of screening frequency have been changed. 
The scope of settings in which the guidelines apply has been 
broadened to include laboratories and additional outpatient 
and nontraditional facility based settings. 
Criteria for serial testing for M. tuberculosis infection of 
HCWs are more clearly defined. In certain settings, this 
change will decrease the number of HCWs who need serial TB 
These recommendations usually apply to an entire health-care 
setting rather than areas within a setting. 
New terms, airborne infection precautions (airborne 
precautions) and airborne infection isolation room (AII 
room), are introduced. 

Recommendations for annual respirator training, initial respirator fit testing, and periodic respirator fit testing 
have been added. The evidence of the need for respirator fit testing is summarized. 
Information on ultraviolet germicidal irradiation (UVGI) and room-air recirculation units has been expanded. 
Additional information regarding MDR TB and HIV infection has been included. 
Outpatient settings include TB treatment facilities, medical offices, ambulatory-care settings, dialysis units, and 
dental-care settings. 
HCWs Who Should Be Included in a TB Surveillance Program 
HCWs refer to all paid and unpaid persons working in 
health-care settings who have the potential for exposure to 
M. tuberculosis through air space shared with persons with 
infectious TB disease. Part time, temporary, contract, and 
full-time HCWs should be included in TB screening programs. 
All HCWs who have duties that involve face to-face contact 
with patients with suspected or confirmed TB disease 
(including transport staff) should be included in a TB 
screening program. 
In addition to close contacts, the following persons are also 
at higher risk for exposure to and infection with M. 
tuberculosis. Persons listed who are also close contacts 
should be top priority. 
Foreign-born persons, including children, especially those 
who have arrived to the United States within 5 years after 
moving from geographic areas with a high incidence of TB 
disease (e.g., Africa, Asia, Eastern Europe, Latin America, 
and Russia) or who frequently travel to countries with a high 
prevalence of TB disease. 
Residents and employees of congregate settings that are high 
risk (e.g., correctional facilities, long-term--care 
facilities [LTCFs], and homeless shelters). 
HCWs who serve patients who are at high risk. 
HCWs with unprotected exposure to a patient with TB disease 
before the identification and correct airborne precautions of 
the patient. 
Certain populations who are medically underserved and who 
have low income, as defined locally. 
Populations at high risk who are defined locally as having an 
increased incidence of TB disease. 
Infants, children, and adolescents exposed to adults in 
high-risk categories. 
Fundamentals of TB Infection Control 
One of the most critical risks for health-care--associated 
transmission of M. tuberculosis in health-care settings is 
from patients with unrecognized TB disease who are not 
promptly handled with appropriate airborne precautions. 
All health-care settings need a TB infection control program 
designed to ensure prompt detection, airborne precautions, 
and treatment of persons who have suspected or confirmed TB 
disease (or prompt referral of persons who have suspected TB 
disease for settings in which persons with TB disease are not 
expected to be encountered). 

TB Infection-Control Program 
Every health-care setting should have a TB infection control 
plan that is part of an overall infection control program. 
The specific details of the TB infection control program will 
differ, depending on whether patients with suspected or 
confirmed TB disease might be encountered in the setting or 
whether patients with suspected or confirmed TB disease will 
be transferred to another health-care setting. Staff charged 
with making this distinction should obtain medical and 
epidemiologic consultation from state and local health 
TB Infection-Control Program for Settings in Which Patients 
with Suspected or Confirmed TB Disease Are Not Expected To Be 
TB Risk Assessment 
Every health-care setting should conduct initial and ongoing 
evaluations of the risk for transmission of M. tuberculosis, 
regardless of whether or not patients with suspected or 
confirmed TB disease are expected to be encountered in the 
setting. The TB risk assessment determines the types of 
administrative, environmental, and respiratory protection 
controls needed for a setting and serves as an ongoing 
evaluation tool of the quality of TB infection control and 
for the identification of needed improvements in infection 
control measures. 
TB Risk Assessment for Settings in Which Patients with 
Suspected or Confirmed TB Disease Are Not Expected To Be 

The initial and ongoing risk assessment for these settings 
should consist of the following steps: 
1. Review the community profile of TB disease in 
   collaboration with the local or state health department. 
2. Consult the local or state TB control program to obtain 
   epidemiologic surveillance data necessary to conduct a TB 
   risk assessment for the health-care setting. 
3. Determine if persons with unrecognized TB disease were 
   encountered in the setting during the previous 5 years. 
4. Determine if any HCWs need to be included in the TB 
   screening program. 
5. Determine the types of environmental controls that are 
   currently in place, and determine if any are needed in 
   the setting (see Environmental Controls; Appendices A and 
6. Document procedures that ensure the prompt recognition
   and evaluation of suspected episodes of health-care--
   associated transmission of M. tuberculosis. 
7. Conduct periodic reassessments (annually, if possible) to 
   ensure 1) proper implementation of the TB 
   infectioncontrol plan; 2) prompt detection and evaluation 
   of suspected TB cases; 3) prompt initiation of airborne   
   precautions of suspected infectious TB cases before 
   transfer; 4) prompt transfer of suspected infectious TB 
   cases; 5) proper functioning of environmental controls,
   as applicable; and 6) ongoing TB training and education 
   for HCWs. 
8. Recognize and correct lapses in infection control. 
   Use of Risk Classification to Determine Need for TB 
   Screening and Frequency of Screening HCWs 
Risk classification should be used as part of the risk 

assessment to determine the need for a TB screening program 
for HCWs and the frequency of screening
TB Screening Risk Classifications 
The three TB screening risk classifications are low risk, 
medium risk, and potential ongoing transmission. The 
classification of low risk should be applied to settings in 
which persons with TB disease are not expected to be 
encountered, and, therefore, exposure to M. tuberculosis is 
unlikely. This classification should also be applied to HCWs 
who will never be exposed to persons with TB disease or to 
clinical specimens that might contain M. tuberculosis. 
The classification of medium risk should be applied to 
settings in which the risk assessment has determined that 
HCWs will or will possibly be exposed to persons with TB 
disease or to clinical specimens that might contain M. 
The classification of potential ongoing transmission should 
be temporarily applied to any setting (or group of HCWs) if 
evidence suggestive of personto-person (e.g., 
patient-to-patient, patient-to-HCW, HCWto-patient, or 
HCWto-HCW) transmission of M. tuberculosis has occurred in 
the setting during the preceding year. Evidence of 
personto-person transmission of M. tuberculosis includes 1) 
clusters of TST or BAMT conversions, 2) HCW with confirmed TB 
disease, 3) increased rates of TST (tuberculin skin test) or 
BAMT (blood assay for M. tuberculosis)conversions, 4) 
unrecognized TB disease in patients or HCWs, or 5) 
recognition of an identical strain of M. tuberculosis in 
patients or HCWs with TB disease identified by 
deoxyribonucleic acid (DNA) fingerprinting. 

If uncertainty exists regarding whether to classify a setting 
as low risk or medium risk, the setting typically should be 
classified as medium risk.  
TB Screening Procedures for Settings (or HCWs) Classified as 
Low Risk 
All HCWs should receive baseline TB screening upon hire, 
using two-step TST or a single BAMT to test for infection 
with M. tuberculosis. After baseline testing for infection 
with M. tuberculosis, additional TB screening is not 
necessary unless an exposure to M. tuberculosis occurs. 
HCWs with a baseline positive or newly positive test result 
for M. tuberculosis infection (i.e., TST or BAMT) or 
documentation of treatment for LTBI or TB disease should 
receive one chest radiograph result to exclude TB disease (or 
an interpretable copy within a reasonable time frame, such as 
6 months). Repeat radiographs are not needed unless symptoms 
or signs of TB disease develop or unless recommended by a 
Although this organization classifies itself as a low risk 
for TB, should a case every be discovered in this setting the 
following will occur:
1. Perform an investigation in collaboration with the local 
   or state health department if health-care--associated 
   transmission of the M. tuberculosis case. 
2. Collaborate with the local or state health department to
   develop administrative controls consisting of the risk 
   assessment and the written TB infection control plan. 

Approved By Governing Board    
Control #340.0