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Tuberculosis Surveillance and Screening for
Long Term Care Facilities in Colorado

Developed by the Colorado Medical Directors Association and
the Colorado Department of Public Health and Environment

Purpose:

Tuberculosis is a serious infection that may affect all nursing home residents. It has been demonstrated that when an active case occurs in a nursing home, the disease is likely to spread among the residents. Nursing facilities provide an ideal environment for latent tuberculosis infection to develop into active disease because as people age they become more prone to impaired immune function and malnutrition. In addition, immune-suppressing medications are prescribed commonly. Furthermore, long term care residents live in a close environment and experience prolonged and repeated contact with other residents. As drug-resistant tubercle bacilli increase and spread, it is imperative that nursing facilities embark on a program to minimize risks and protect residents, staff and families from exposure.

In the United States, 50% of the new cases of tuberculosis occur in persons over the age of 55. In 1987, 27% of the tuberculosis cases occurred in persons over the age of 65, even though this group accounted for only 12% of the population. Among nursing home residents, the incidence of tuberculosis is estimated at 39.2 cases per 100,000 persons, compared to 21.5 cases per 100,000 elderly living in the community. Long term care residents who test positive with Mantoux skin testing (PPD) represent a reservoir of latent tuberculosis and are at risk of reactivation tuberculosis and those who test negative may be at risk for a primary tuberculosis infection.

Tuberculosis is spread from person to person by droplets that become airborne when a person with pulmonary or laryngeal tuberculosis coughs, sneezes, laughs, or sings. These aerosolized particles contain viable tubercle bacilli that may remain suspended and transmitted throughout a room or building. When inhaled by an uninfected person, the nuclei are small enough to reach the alveoli of the lungs and initiate an infection.

This protocol provides a basis to standardize tuberculosis surveillance and screening effects in nursing home facilities throughout Colorado.

Goals of this policy are:

  1. Early identification of active tuberculosis cases upon admission to the nursing home.
  2. Identification of the positive reactors without evidence of active disease and provision of chemoprophylaxis, as appropriate, for these persons.
  3. Monitoring for PPD conversion.
  4. Methodology to record and retrieve results.
  5. Education of staff regarding the nature of tuberculosis.

 


PROTOCOL for Residents of Long Term Care Facilities

 

1. PERFORMING AND READING TB SKIN TESTS. All new admissions to a long term care facility as well as all current residents who have not had a PPD skin test within one year and who do not fall into the exception category (No. 1J below) should receive a tuberculin test according to the following protocol:

A. Intradermal injection of 0.1 cc of intermediate strength purified protein derivative (PPD) of tuberculin containing 5 tuberculin units in the volar or hairless area of the forearm about 4 inches below the elbow, creating a wheal.

B. The skin test is read between 48-72 hours. Measure the area of INDURATION - swelling and hardness (erythema - redness - does not indicate a positive reaction). The number of millimeters of INDURATION is recorded.

C. If there is <5 mm of induration or no reaction at all, it is read as NEGATIVE.

D. A reaction of >5 mm is a positive reaction for high risk groups:

  1. Persons with HIV infection.
  2. Persons who have had close contact with an infectious tuberculosis case.

E. A reaction of >10 mm is classified as a POSITIVE reaction in persons who do not meet the above criteria but who have other risk factors for tuberculosis, including:

  1. Persons with:

    Silicosis
    Diabetes mellitus
    Prolonged steroid therapy or immuno-suppression
    Hematologic malignancies
    End stage renal disease

  2. Residents of high prevalence regions such as Africa, Asia, and Latin America
  3. Persons who have had chest x-rays with fibrotic lesions likely to represent healed tuberculosis
  4. Injecting drug abusers with unknown HIV status.
  5. Medically under-served low-income populations.
  6. Residents of LONG TERM CARE facilities.
  7. Health care workers

F. Skin induration of >15 mm is classified as a POSITIVE reaction in all other persons.

G. For new admissions and/or persons for whom a baseline skin test reaction is unknown or undocumented, steps A and B should be repeated one to two weeks following the initial skin test. This is the two-step method. The second test is performed and read in the same manner as the initial test.

H. All residents who initially test negative by the two step method and who are not included in one of the exceptions groupings (No. 1J) should be retested on an annual basis, using the single step Mantoux test. The booster response produced by the two-step methodology persists at least a year and obviates the need for annual two step testing.

I. Residents who have two successive skin tests which are negative and who are HIV positive should be tested with dermal control antigens (Candida, trichophyton, mumps) to determine if cutaneous anergy caused the negative skin test results.

J. Exceptions to skin testing should be limited to persons with:

  1. Known active tuberculosis.
  2. Previous documented positive tuberculin tests following the definition of "positive" provided in D, E, and F above.
  3. Documented severe hypersensitivity to PPD.

K. Past (>6 months previous) inoculation with BCG is not a contraindication to PPD skin testing and does not affect the skin reaction or interpretation.

L. Individuals who do not qualify for skin testing or who refuse skin testing, should receive a chest x-ray.

M. Do not use multiple puncture TB skin tests (tine tests).

 

2. EVALUATION OF POSITIVE REACTORS. A "REACTOR" is a person infected with TB at some point in the past, the date of infection being unknown.

A. Positive reactors should receive a chest x-ray to determine if there is evidence of active disease. If a portable chest x-ray is equivocal or of unsatisfactory quality, then a PA chest x-ray should be obtained.

B. Sputum samples for acid fast bacilli (AFB) smear and culture should be collected according to the laboratory's protocol for persons with any of the following:

i. Positive chest x-ray, or .
ii. Symptoms such as a productive or chronic cough, weight loss, hemoptysis, or unexplained fever, or
iii. Residents with unexplained pneumonia or bronchitis.

All sputum specimens should be sent to a laboratory that uses the BACTEC method. The State Lab will perform the culture with BACTEC at no charge.

C. If the physician suspects TB because of a chronic cough, fever or weight loss, sputum specimens should be obtained even if the PPD is negative,

D. For those with positive skin tests and without active tuberculosis, see 4A. After the initial chest x-ray has excluded active disease, further annual or follow-up chest x-rays are not recommended unless the person develops signs or symptoms suggestive of TB (such as productive cough, fever, weight loss).

 

3. EVALUATION OF TB SKIN TEST CONVERTERS. "CONVERSION" indicates new or recent infection and is defined as:

  1. change of induration of 15 mm within a 2 year period in a person >35 years.
  2. change of induration of 10 mm within a 2 year period in a person <35 years.

A. All new converters should be evaluated with a chest x-ray. Sputum for AFB smears and culture should be obtained if the chest x-ray suggests active disease or if the patient is symptomatic.

B. All new converters without evidence of active disease should be reported to the Attending Physician with a recommendation for preventive therapy (see No. 4 below).

C. Any new converters with culture or smear evidence of active disease must be reported within 24 hours to the county and/or state health departments as well as the attending physician. The directions of the county and/or state health department must be followed in managing a potential outbreak.


4. CHEMOPROPHYLAXIS to prevent development of active disease:


A. After active TB has been excluded, CHEMOPROPHYLAXIS should be considered, regardless of age, for residents with:

  1. Individuals with a positive PPD (> 10 mm) not previously treated and who have:

    Diabetes mellitus
    Silicosis or other chronic lung disease
    End-stage renal disease
    Malnutrition (<3.0 gm% serum albumin and <85% IBW; or weight loss >10% over the previous 6 months)
    Prolonged corticosteroid therapy (e.g. prednisone >15 mg for > two weeks).
    Other immunosuppressive therapy
    Hematogenous or reticuloendothelial malignancy (such as leukemia or Hodgkin's disease)

  2. Persons with a positive ppd (> 5mm) AIDS or HIV infection
  3. Documented close contact (e.g., room-mate, table-mate) by a resident with a person with infectious tuberculosis if the PPD measures > 5mm induration. Consultation with the state or local health department regarding the "closeness" of contact may be helpful.
  4. PPD skin test conversion (defined above in section No. 3--Evaluation of TB skin test converters).
  5. Persons with abnormal chest x-rays that show fibrotic lesions likely to represent old healed tuberculosis if the ppd is > 5 mm.

B. In the absence of one of the factors listed in 4A (above) that places a person at high risk for developing active disease, chemoprophylaxis should be offered and given to persons listed in 1E (2,4,5,6,and 7) if the person is <35 years of age.

C. Regimens for CHEMOPROPHYLAXIS for residents with positive PPD skin tests who are at high risk for development of active disease, as per 4A (above):

  1. If the chest x-ray is normal give INH 300 mg and pyridoxine (B6) 50 mg daily for a minimum of six months of continuous therapy.
  2. If the chest x-ray is abnormal, but stable, thereby consistent with past tuberculosis or if the resident has HIV infection, 12 months of therapy is recommended.
  3. To identify morbidity associated with the chemoprophylaxis, baseline CBC and liver function tests are recommended, followed by clinical monitoring during the treatment period and liver function test measurements at intervals of 1 month, 3 months, and 6 months.

 

5. SUSPECTED OR CONFIRMED ACTIVE TUBERCULOSIS


IF ACTIVE TUBERCULOSIS IS SUSPECTED, THEN IT MUST BE REPORTED TO THE COUNTY AND/OR STATE HEALTH DEPARTMENT WITHIN 24 HOURS. For consultation, the state health department telephone in Denver during regular working hours is 1-303-692-2700 and after hours is 303-370-9395. It is acceptable to leave the report as a message on a toll-free reporting machine 1-800-866-2759.

A. Regarding persons with suspected active tuberculosis (positive chest x-ray and/or sputum cultures or smears), the facility should comply with all recommendations of the state health department as regards management of active cases and screening of the remainder of the facility population.

B. It is recommended that all residents who develop active tuberculosis in the nursing home also be evaluated for HIV risk factors regardless of age. HIV antibody testing is strongly recommended, even if there are no risk factors present.

C. Treatment of active tuberculosis is changing rapidly because of the emergence of multi-drug resistant tuberculosis and development of new drugs. The county and/or state health department is an excellent resource for advice and help in managing tuberculosis.

 

6. ISOLATION OF RESIDENTS WITH SUSPECTED OR CONFIRMED ACTIVE TUBERCULOSIS:

Any resident with a positive chest x-ray, positive sputum smears, or positive sputum cultures should be placed in a respiratory isolation room that has negative airflow and exhausts to the outside. Standard surgical masks worn by employees are not effective protection against infection by Mycobacterium tuberculosis. The CDC recommends the use of particulate respirators by health care workers and environmental engineering modifications for rooms in which health care workers may be exposed to bursts or aerosolized infectious particles.

Most long-term care facilities will not be equipped to provide this degree of respiratory isolation. UNLESS THE FACILITY CAN PROVIDE RESPIRATORY ISOLATION, ACCORDING TO CURRENT FEDERAL GUIDELINES, THE PATIENT MUST BE TRANSFERRED TO A HOSPITAL OR FACILITY THAT HAS APPROPRIATE RESPIRATORY ISOLATION CAPACITY.

In general, a patient with active TB should be considered potentially contagious until sputum smears become negative on three consecutive exams and there is clinical improvement while on appropriate anti-TB medications.

The most recent guidelines of CDC/NIOSH should be followed and may be obtained from the State Health Department TB Program (303-692-2700).

 

7. DOCUMENTATION: A complete and detailed system of record keeping is essential for tracking and assessing the status of residents and staff with tuberculosis.

A. A master card file (or computerized equivalent) should be maintained for the facility documenting the dates of testing, the nature of the reaction, and treatment rendered.

B. The file should be maintained to make the following data easily accessible:

  1. At risk residents who have tested negative to tuberculin.
  2. Residents who have tested positive and may not be at risk in the event of an outbreak.
  3. Any resident who has received treatment for tuberculous infections.
  4. A listing of all staff PPD or chest x-ray status.

C. The following format is recommended:

  1. Resident or employee name.
  2. Age and sex.
  3. Medical conditions date of admission (or employment).
  4. Dates PPD administered and results.
  5. Dates and results of other diagnostic tests (such as chest x-ray, sputum smear and culture).
  6. Treatment and dates.
  7. Name and telephone number of treating physician.

This data should be readily available to the county or state health department for surveillance or for assistance in the event of an outbreak. Upon transfer to a hospital or another long-term care facility, their PPD status must be documented in transfer records.

 

8. EDUCATION: It is recommended that at least once a year, an in-service is held for all staff to review tuberculosis. The content of the in-service should address the demographics, risk factors, manifestations of tuberculosis, management, screening, and nursing care in tuberculosis. It is recognized that staff education is the single most important aspect of any infection control program. A teaching video for PPD interpretation is available through the state health department.



PROTOCOL for HEALTH CARE WORKERS including employees, volunteers, and practitioners working in Long Term Care Facilities:


ALL Health Care Workers and Providers should be screened with a two-step Mantoux test within 10 days of beginning employment and annually thereafter with a single step Mantoux test. If a documented negative single step Mantoux test has been done within the prior 12 months, only a single step test would be needed upon employment. A chest x-ray should be substituted if the employee falls into the exception grouping (No. 1J above) or otherwise cannot be skin tested. Positive skin test has been defined earlier in this protocol.

A. Positive reactors should have an initial chest x-ray. Sputum cultures and smears will be required if the employee is symptomatic or if chest x-ray is suspicious for active disease. The employee should not work until active contagious disease is ruled out. Follow up chest x-rays in these employees is required only if the employee develops symptoms consistent with TB, is immunosuppressed, or has had exposure to multi-drug resistant TB.

B. A chest x-ray should be done if the employee is a converter (i.e., there is a change in PPD induration of >10mm within a 2 year period if <35 years or >15mm if >35 years). If the initial chest x-ray is negative, follow-up chest x-rays are needed only if the employee develops symptoms consistent with TB, is immunosuppressed, or has had exposure to multi-drug resistant TB.

C. New converters should have further evaluation, (such as sputum smear and culture) as appropriate depending on the results of the chest x-ray or clinical symptoms. New converters should be reported to the facility Medical Director.

D. Any new converters with culture or smear evidence of active disease must be reported within 24 hours to the county and/or state health department as well as the facility Medical Director. The directions of the county and/or state health department must be followed in managing a potential outbreak.

E. The facility is required to report positive skin test results (defined as > 5mm induration) for any employee or health care worker who has had prolonged or frequent face-to-face contact with a case of active pulmonary tuberculosis. For example, if a resident is diagnosed with active disease and in the ensuing investigation of close contacts, a health care worker is found to have a skin test with > 5 mm induration, the facility must report to the county or state health department the name of the health care worker.

F. Should the employee who is a new converter choose to obtain their chest x-ray or sputum evaluation from a private physician, it is the employee's responsibility to provide the nursing facility with adequate documentation of the nature and results of the evaluation.

G. Pregnancy is not a contraindication to receiving a PPD.

H. Physicians and physician extenders are required (by OSHA) to have annual testing as described above for employees.

I. Any individual who has patient contact on a regular and repeating basis should be tested. This might include dentists, dental hygienists, psychologists, podiatrists, ombudsmen, respiratory therapists, contractual therapists, etc. CDC recommends (reference 7) and OSHA may require that others in the facility, such as volunteers, be tested.

References:

1. Creditor, MC. Screening for tuberculosis in the nursing home. Kansas Medicine 5: 136-7, 1990.
2. Wright, BA, DO Staats. Tuberculosis Surveillance Program: A nursing home experience. Geriatric Nursing 13: 257-61, 1992.
3. Prevention and Control of Tuberculosis in Facilities Providing Long Term Care to the Elderly. MMWR 39: RR-10; pp 7-20, July 13, 1990.
4. Starer, P, LS Libow. Medical care of the elderly in the nursing home, J Gen Internal Medicine 7: 350-62, 1992.
5. Finucane, TE, et al. The American Geriatrics Society statement on Two-Step PPD testing for nursing home patients on admission. Journal of the American Geriatrics Society 36: 77-8, 1989.
6. American Thoracic Society. Treatment of tuberculosis and tuberculosis infection in adults and children. Am J Resp Critical Care Medicine 149: 1359-1374 (1994).
7. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities, 1994. MMWR 43; RR-13; page 3; October 28, 1994.
8. Screening for tuberculosis and tuberculosis infection in high-risk populations. MMWR 44; RR-11; pp 19-34; September 8, 1995.
9. The use of preventive therapy for tuberculous infection in the United States. MMWR 39; RR-8 ; pp 9-12; May 18, 1990.


Approved 5/10/95; Revised 8/13/96; Revised 8/18/97

Colorado Department of Public Health and Environment
Colorado Medical Directors Association
University of Colorado Center on Aging
Colorado Medical Society

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