The control of tuberculosis in healthcare settings requires a combination of different measures. Administrative controls for tuberculosis include the following activities:

1. developing and instituting a written TB infection control plan to ensure prompt detection, initiation of Airborne Precautions, and treatment of persons who have suspected or confirmed TB disease;
2. ensuring the timely availability of recommended laboratory testing;
3. ensuring proper cleaning and sterilization or disinfection of potentially contaminated high risk equipment (usually endoscopes);
4. training and educating healthcare workers regarding TB, with specific focus on prevention, transmission, and symptoms;
5. screening and evaluating healthcare workers who are at risk for TB disease or who might be exposed to M. tuberculosis (i.e., TB screening program);
6. using appropriate signage advising respiratory hygiene and cough etiquette;
7. prudent scheduling of OR cases to prevent exposure in a positive pressure environment
8. coordinating efforts with local or state health departments

Environmental controls consist primarily of negative pressure or Airborne Infection Isolation rooms that control airflow direction to minimize spread of airborne pathogens such as M. tuberculosis.

The third level of the hierarchy for preventing the transmission of TB is the use of respiratory protective equipment in situations that pose a high risk for exposure. All healthcare workers entering the room of a patient with suspected or proven pulmonary tuberculosis should wear a properly fitted N 95 respirator. For healthcare workers who cannot be fit tested (due to facial hair, anatomic abnormalities, or claustrophobia), Emory healthcare offers powered air purifying respirators (PAPRs) that are available should they be needed.

All patients suspected of having active pulmonary tuberculosis should be placed in Airborne Infection Isolation until pulmonary tuberculosis has been excluded. The primary test for excluding active pulmonary tuberculosis is the sputum stainAFB. stain and culture Unfortunately, approximately half of the patients who have active pulmonary tuberculosis will have negative sputum stains but positive sputum cultures. While patients who are AFB stain negative but culture positive are less contagious than stain positive patients, they are still capable of transmitting tuberculosis. In one study, patients with stain-negative but culture-positive sputum samples for tuberculosis were responsible for 17% of tuberculosis transmission in the community.

Criteria for excluding pulmonary tuberculosis in patients suspected of having active pulmonary tuberculosis vary somewhat between facilities.

At Grady Hospital, patients who have 2 negative sputum stains may be removed from Airborne Precautions unless a strong suspicion remains that the patient still could have pulmonary tuberculosis.

Emory Healthcare Hospitals have previously required 3 sputum specimens for TB rule out. With the use of molecular diagnostics (PCR), Emory Hospitals have changed to requiring only 2 specimens (one sent for AFB stain/culture and the second sent for AFB stain/culture and TB PCR). In addition to negative sputum specimens, patients should have an alternative diagnosis for their pulmonary disease or be improving on a regimen that does not treat tuberculosis before isolation is discontinued. Infection Prevention should be contacted prior to discontinuation of airborne infection isolation precautions.

Patients found to have active pulmonary tuberculosis at any of the Emory hospitals should not be removed from airborne infection isolation until at minimum:

• they are on adequate anti-TB chemotherapy for 2 weeks
• they demonstrate clinical improvement, and they have had three negative sputum stains collected at 8 to 24 hour intervals (at least one should be an early morning specimen)

In general, patients with active pulmonary tuberculosis will remain in Airborne Infection Isolation until discharged, as they will rarely be hospitalized long enough to meet the criteria for removal. Patients with multidrug resistant tuberculosis almost always remain in isolation until discharge due to the danger of relapse and development of further resistance.

The discharge of patients being treated for active tuberculosis requires careful coordination between clinicians, infection prevention, and the county health department. The Infection Prevention Department should be contacted at least one day prior to patient discharge to make sure that appropriate follow up will occur. Because the infection control policies covering patients with suspected or proven tuberculosis can be complex, providers are encouraged to consult with the Infection Prevention team to ensure proper patient management early in the evaluation process.