This document discusses the prevention of Mycobacterium tuberculosis (MTB) in healthcare settings. It begins with an introduction to mycobacteria and the diseases they cause like tuberculosis, leprosy, and atypical mycobacterial infections. It then provides facts about MTB globally and its symptoms. The remainder of the document outlines administrative, environmental, and respiratory precautions that can be taken to prevent MTB transmission in healthcare settings, including proper patient management, cleaning/disinfection, staff training/surveillance, and use of airborne isolation rooms and respiratory protection equipment.

1. PREVENTION OF
MYCOBACTERIUM
TUBERCULOSIS IN HEALTHCARE
SETTINGS
Dr. Moustapha A.Ramadan

2. Introduction
 The mycobacteria are acid-fast rod-shaped
bacteria. They are usually slow-growing.
 There are many different kinds, the most
common one causes tuberculosis and leprosy.
 Still others cause infections that are called
atypical mycobacterial infections, because they
don't cause tuberculosis and can still harm
people with low immunity status.

3. Introduction
The mycobacteria includes:
 Mycobacterium tuberculosis -- which causes
tuberculosis
 Mycobacterium leprae -- which causes leprosy
 Mycobacterium ulcerans -- which causes Buruli
ulcer

4. Introduction
The mycobacteria includes:
 Mycobacterium avium -- which causes
tuberculosis -like illness in birds and
immunodeficient people;
 Mycobacterium marinum – which causes
swimming pool granuloma;
 Mycobacterium abscessus – which causes cystic
fibrosis and skin lesions

5. Facts
 In 2013, 9 million people fell ill with TB and 1.5
million died from the disease
 Globally in 2013, an estimated 480 000 people
developed multidrug resistant TB (MDR-TB).
 In 2013, an estimated 550 000 children became
ill with TB and 80 000 HIV-negative children
died of TB.

6. Facts
 About one-third of the world's population has
latent TB.
 TB is a leading killer of HIV-positive people
causing one fourth of all HIV-related deaths.
 The TB death rate dropped 45% between
1990 and 2013

7. Facts
 TB is spread from person to person through
the air. When people with lung TB cough,
sneeze or spit, they propel the TB germs into
the air.
 The symptoms may be mild for many months.
 People ill with TB can infect up to 10-15 other
people through close contact over the course
of a year

8. Symptoms
 a bad cough that lasts 3 weeks or longer
 coughing up blood or sputum
 pain in the chest
 weakness or fatigue
 weight loss, loss of appetite
 chills, fever
 sweating at night

9.  Multidrug-resistant tuberculosis (MDR-TB) is a
form of TB caused by bacteria that do not
respond to, at least, isoniazid and rifampicin,
the two most powerful anti-TB drugs.
 The primary cause of MDR-TB is inappropriate
treatment, inappropriate or incorrect use of
anti-TB drugs, or use of poor quality
medicines.

10. PREVENTION & CONTROL

11. Preventing transmission of
M.tuberculosis
I. Administrative Measures
II. Environmental Control
III. Respiratory Protection

12. Administrative Measures
The first and most important level of TB controls is
the use of administrative measures to reduce the
risk for exposure to persons who might have TB
disease.

13. Setting Assessment
Conduct periodic reassessments (annually, if
possible) to ensure:
 proper implementation of the TB infection control
plan
 prompt detection and evaluation of suspected TB
cases
 prompt initiation of airborne precautions of
suspected infectious TB cases

14. Setting Assessment
Conduct periodic reassessments (annually, if possible)
to ensure:
 recommended medical management of patients with
suspected or confirmed TB disease
 functional environmental controls
 implementations of the respiratory protection program
 ongoing HCW training and education regarding TB.

15. Processing and Reporting of lab
results
It is essential that sputum collection and delivery to
the laboratory be done in a timely manner, and
results should be available within 24 hours of
specimen collection.

16. Processing and Reporting of lab
results
The laboratory performing acid fast bacilli (AFB) smears
should be proficient at:
 Methods of sputum specimen processing
 The administrative aspects of specimen processing
(e.g., record keeping, notification)
 Maintaining quality control of diagnostic procedures
(e.g., AFB sputum smears)
 Ensuring adequate supplies for processing sputum

17. Managing patients with suspected
or confirmed TB disease
A high index of suspicion for TB disease and rapid
implementation of precautions are essential to
prevent and interrupt transmission.

18. Managing patients with suspected
or confirmed TB disease
I. Prompt triage/ Proper history taking:
1) a history of TB exposure, infection, or disease;
2) symptoms or signs of TB disease;
3) medical conditions that increase their risk for
TB disease.

19. Managing patients with suspected
or confirmed TB disease
II. TB airborne precautions
1. should be initiated for any patient who has
symptoms or signs of TB disease.
2. has documented infectious TB disease and has
not completed anti-tuberculosis treatment.
3. patients who have confirmed TB disease or who
are considered highly probable to have TB
disease, promptly start anti-tuberculosis treatment

20. Managing patients with suspected
or confirmed TB disease
II. TB airborne precautions discontinuation
(suspected)
 another diagnosis is made that explains the
clinical syndrome
 the patient has three consecutive, negative AFB
sputum smear results

21. Managing patients with suspected
or confirmed TB disease
II. TB airborne precautions discontinuation
(confirmed)
 have received appropriate anti-tuberculosis
chemotherapy directly observed for a minimum
of two weeks
and
 have shown clinical improvement

22. Managing patients with suspected
or confirmed TB disease
II. TB airborne precautions discontinuation
(confirmed)
In setting known to have high prevalence of MDR-
TB sputum smear negative should be added to
the previous criteria

23. Cleaning, disinfection, sterilization
of patient care equipment and
rooms
The same cleaning procedures used in other
rooms in the health-care setting should be used to
clean AII rooms.
Personnel should follow airborne precautions while
cleaning these rooms when they are still in use.

24. Cleaning, disinfection, sterilization
of patient care equipment and
rooms
Critical Medical Instruments should be sterile at
the time of use.
Semi-critical Medical Instruments is preferred to
be sterile however, high-level disinfection that
destroy vegetative microorganisms is accepted
Non-critical Medical Instruments or devices
cleaning and disinfection

25. Training and Education of
HCWs
HCW training and education can increase
adherence to TB infection-control measures.
Training and education should emphasize the
increased risks posed by an undiagnosed person
with TB disease in health-care setting and the
specific measures to reduce this risk.

26. Training and Education of
HCWs
Follow-up TB Training and Education is based
 on the number of untrained and new HCWs,
 changes in the organization and services of the
setting,
 availability of new TB infection control
information.

27. HCW surveillance
Baseline testing for M. tuberculosis infection is
recommended for all newly hired HCWs,
regardless of the risk classification of the setting
Any HCW with a newly recognized positive test
result for M. tuberculosis infection, test conversion,
or symptoms or signs of TB disease should be
promptly evaluated.

28. HCW surveillance
Such HCWs should be excluded from the
workplace and should be allowed to return to work
when the following criteria have been met:
 Three consecutive sputum samples collected in
8–24-hour intervals that are negative, with at
least one sample from an early morning
specimen;
 The person has responded to antituberculosis
treatment that will probably be effective

29. HCW surveillance
Such HCWs should be excluded from the
workplace and should be allowed to return to work
when the following criteria have been met:
 The person is determined to be noninfectious by
a physician experienced in managing TB disease.
HCWs with extra pulmonary TB disease usually do
not need to be excluded from the workplace as long
as no involvement of the respiratory tract has
occurred.

30. Patient Education
Patients should be educated about M.tuberculosis
transmission and the importance of cough
etiquette.
Posters emphasizing cough etiquette should be
placed in the waiting areas.

31. Environmental Controls
The second level of the hierarchy is the use of
environmental controls to prevent the spread and
reduce the concentration of infectious droplet nuclei
in ambient air.
By law, the local health department must be notified
when TB disease is suspected or confirmed in a
patient or HCW so that follow up can be arranged
and a community contact investigation can be
conducted.

32. Environmental Controls
Primary environmental controls consist of controlling
the source of infection by using local exhaust
ventilation (e.g., hoods, tents, or booths) and diluting
and removing contaminated air by using general
ventilation.
Secondary environmental controls consist of
controlling the airflow to prevent contamination of air
in areas adjacent to the source (AII rooms) and
cleaning the air by using high efficiency particulate air
(HEPA) filtration

33. AII Room Practices
AII rooms should be single bed and has a private
bathroom.
Keep doors to AII rooms closed except when
patients, HCWs, or others must enter or exit the
room.
Monitor and record direction of airflow (i.e.,
negative pressure) in the room on a daily basis,
while the room is being used for TB airborne
precautions.

34. AII Room Practices
Perform diagnostic and treatment procedures
(e.g., sputum collection and inhalation therapy) in
an AII room.
Ensure that patients with suspected or confirmed
infectious TB disease who must be transported to
another area bypass the waiting area and wear a
surgical mask

35. AII Room Practices
Schedule procedures on patients with TB disease
when a minimum number of HCWs and other
patients are present and as the last procedure of
the day to maximize the time available for removal
of airborne contamination.

36. Maintenance of environmental
control measures
Ensure the optimal selection, installation,
operation, and maintenance of environmental
controls.
Personnel should schedule routine preventive
maintenance for all components of the ventilation
systems (e.g., fans, filters, ducts, supply diffusers,
and exhaust grills) and air-cleaning devices.

37. Respiratory Protection
The third level of the hierarchy is the use of
respiratory protective equipment in situations that
pose a high risk for exposure .
training HCWs on respiratory protection, and
training patients on respiratory hygiene and cough
etiquette procedures

38. Respiratory Protection
All persons, including HCWs and visitors,
entering rooms in which patients with suspected
or confirmed infectious TB disease are being
isolated;
Persons present during cough-inducing or
aerosol generating procedures performed on
patients with suspected or confirmed infectious
TB disease;
Laboratorians conducting aerosol-producing
procedures might require respiratory protection.

39. Respiratory Protection
Persons who transport patients with suspected or
confirmed infectious TB disease in vehicles (e.g.,
EMS vehicles or, ideally, ambulances) and persons
who provide urgent surgical or dental care to
patients with suspected or confirmed infectious TB
disease.

40. Respiratory Protection
Disposable respirators (e.g., N-95s) are commonly
used in TB isolation rooms, in transport of TB
cases, or in other areas of the health care facility.
Full face piece negative-pressure respirators,
powered air-purifying respirators (PAPRs) is
required when high-risk procedures such as
bronchoscopy or autopsy are conducted.