Countywide guidance onthe Management of Contact Screening for Tuberculosis (TB).

Transcription

1 Countywide guidance onthe Management of Contact Screening for Tuberculosis (TB). Reference No: Version: 2 Ratified by: G_IPC_23 LCHS Trust Board Date ratified: 8 th May 2018 Name of originator/author: Name of responsible committee/individual: Date issued: May 2018 Review date: May 2020 Target audience: Distributed via: Sue Silvester, TB Lead Nurse LCHS NHS TRUST Lincolnshire TB Network Control Board (LTBNCB) Local governance committees (LCHS) Effective Practice Assurance Group (LCHS) Trust Board, LCHS LCHS, ULHT, LPFT, PRIMARY, SECONDARY AND TERTIARYCARE, VOLUNTARY, CHARITABLE ORGANISATIONS. Website Chair: Elaine Baylis, QPM Chief Executive: Andrew Morgan

2 Countywide guidance on the Management of Contact Screening for Tuberculosis i. Version Control Sheet Version Section/Para/A ppendix Version/Description of Amendments Date 1 New Guidance Nov ii UPDATE: Background information July ii UPDATE: resource implication July Update Introduction Aug Update Aims Aug Update - Overview Aug Update - responsibilities Aug Updated - Definitions Aug Updated - Contact Screening Process Aug New Opportunistic case finding Aug Update Contact Screening Children NEW - Incident and outbreak response 13 Appendix C Update- Contact screening pathway 14 Appendix D Update Summary of assessment and screening Aug 2017 Sept 2017 Aug 2017 July Appendix E Update IGRA guidance Sept Appendix H Update Contact Screening Log Sept Author/Amended by S Silvester S Silvester S Silvester S Silvester S Silvester S Silvester S Silvester S Silvester S Silvester S Silvester S Silvester S Silvester S Silvester S Silvester S Silvester S Silvester Copyright 2018 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced in whole or in part without the permission of the copyright owner. 2

3 Countywide guidance on the Management of Contact Screening for Tuberculosis Contents 1. Introduction Aim of guidance Overview Responsibilities Contact screening (General) Case management of TB contacts Definitions Contact Contact Screening Contact Investigations Close contacts of Pulmonary TB: Casual/Social contacts of Pulmonary TB: Close contacts Non-pulmonary Disease: Casual/Social contacts Non-pulmonary Disease; How far back to contact screen Significant contact with index case (TB) Referrals of contacts into Community TB service Contact Screening Procedure Clinical assessment Diagnostic assessment Outcomes of screening Screening of close contacts of TB (adults) Screening of casual/social contacts (adults) Contract screening: in a Hospital/ In-patient facility Contacts in the underserved population (USP) Contact screening: cattle-to-human transmission Contact screening cases on an aircraft Opportunistic case finding New entrants from high incidence countries People using homeless or substance misuse services Active case finding in under-served populations People in prisons or immigration removal centres TB Contacts living outside Lincolnshire TB Contacts of a patient who have died before diagnosis Contact Screening: Children

4 15.1. Contact screening: Cases in schools Contact screening: community childcare Contact Screening: Healthcare staff Incident and outbreak response Contacts refusing screening Non-attendance for contact screening Documentation Risk Management Education Monitoring and Audit of Practice Evidence Base Appendices

5 Countywide guidance on the Management of Contact Screening for Tuberculosis ii. Policy Statement Background The purpose of this guidance is to advise on the standard approach to TB screening of contacts, thus minimising the risk of transmission to patients, visitors, staff and wider public. It is advised that this guidance be read in conjunction with: Hand Hygiene (Website and Infection Control Team) Standard Infection Control Precautions(Website and Infection Control Team) Decontamination of Medical Devices and Single Use Medical Devices Policies(Website and Infection Control Team) Blood and Body Fluid Spills Management Policy(Website and Infection Control Team) Safe Handling and Transport of Specimens Policy (Website and Infection Control Team). Countywide guidance on the management of patients with Latent Tuberculosis Infection (LTBI) (Website and TB Service). Countywide guidance on the management of TB in Children and young adults (Website and TB Service). NHS Lincolnshire Major Outbreak Plan (Website and Community TB Service) Statement Responsibilities Training Dissemination Resource implication This document has been developed in line with local -guidance. It will be implemented for staff within Lincolnshire Community Health Services. It may be adopted by other organisations involved in contact screening e.g. United Lincolnshire Hospitals Trust and Lincolnshire Partnership Foundation Trust, IRC, Voluntary organisations. Compliance with this guidance will be the responsibility of all staff within Lincolnshire Community Health Services and where adopted, in United Lincolnshire Hospitals Trust and Lincolnshire Partnership Foundation Trust where adopted. The Countywide Community TB Team will support any training associated with this guidance, where requested. Via LCHS Weekly Updates and Website: Lincolnshire Community Health Services. Where adopted in United Lincolnshire Hospitals Trust and Lincolnshire Partnership Foundation Trust. This guidance has been developed in line with the NHS Litigation Authority guidelines to provide a framework for staff within the organisation to ensure appropriate production, management and review of organisation wide policies. The Countywide Community TB Service would not be able to fulfil the requirements of this guidance without completion of training as advised in the annual TB Training Matrix. Additional resources will be required in large scale contact screening exercises and follow up of patients. 5

6 Countywide guidance on the Management of Contact Screening for Tuberculosis Guidance comes into December 2017 effect Guidance review date December 2019 Purpose Scope Responsibilities The purpose of this guidance is to advise on a countywide standard approach to the management of contact screening for Tuberculosis This guidance covers all aspects contact screening for Tuberculosis It is the responsibility of all staff members to familiarise themselves with this guidance and act in accordance with its requirements. 1. Introduction Contact screening, is the undertaking of investigations in people exposed to a case of active Tuberculosis (TB). Consequently, effective contact screening is an established strategy to find and treat active and latent TB cases (PHE 2015). On average each TB case will identify 2-10 close contacts and TB will be diagnosed in about 1-5% of all contacts. However, in some communities, identification of contacts may be incomplete due to high mobility, TB-related stigma and the lack of social relationships between individuals in shared occupancy accommodation or other reasons for not sharing contact details (PHE 2015). Collaborative working with other agencies, in these instances, is essential to protect public health. Ensuring a comprehensive contact screening strategy is in place locally is a key target of the National Collaborative TB Strategy Aim of guidance The aim of this guidance is to assist in: the timely identification of contacts, the prompt signposting to diagnostic testing, health care and placed on the appropriate pathway where required (PHE 2015), supporting and informing the common sources of referrals, actively seeking new cases of TB (PHE 2015), actively seeking LTBI cases, reducing the risk of transmission of TB, (PHE 2015) the early identification of potential outbreaks (PHE 2015), supporting and advising all stakeholders in collaborative working and follow up of patients. 3. Overview This guidance specifically concentrates on the management of TB contacts and has been developed in collaboration with the Lincolnshire TB Network Board members. This guidance has been based on: NHS Lincolnshire Tuberculosis Service Specification (2015), NICE (2012) PH 37 Hard to reach Groups, NICE (2016) CG 33 Tuberculosis, PHE (2015) Collaborative TB Strategy and NHSE (2017) Clinical TB Policy. 6

7 Whilst it is important for robust systems to be in place locally, the processes must remain flexible in order to meet the challenges of an unplanned service, a local changing health economy, patient presentation and the extent of the associated public health risk. N.B. This guidance refers to adults: 16 years onwards. For a child 0-16 years please refer to the children and young adults TB guidance. 4. Responsibilities The Chief Executive has overall responsibility to ensure that responsive resources and processes are in place for the effective delivery of the Countywide Community TB services. They must have an understanding of the Public Health and Legal responsibilities in identifying the risk of disease. The Countywide TB Network Board Members will review the guidance in response to the publication of any urgent communications from the Department of Health and on a bi-annual basis. The TB Lead Nurse / TB Nurse (Appendix A) will be responsible for supporting the implementation of this and other associated TB guidance. The Countywide Community TB Team will be responsible for ensuring that there are adequate resources are in place for TB contact screening, LCHS. Where mass screening exercises are required the TB Lead Nurse Specialist will work collaboratively with stakeholders to ensure resources are sourced and are appropriate for the incident. Managers/ Sisters / Charge Nurses/ Head of Health Care have responsibility to ensure that arrangements and resources are in place to support the use, implementation and monitoring of this guidance and to present evidence to assist TB prevention / audit. They must also ensure the dissemination, training and adherence of the guidance is established within their teams. Staff within Primary, Secondary and Tertiary care, alongside those in HMP, Outreach, Local, authority, Voluntary and Charitable organisation may support the TB Lead Nurse/TB Nurse in the responsive, holistic and effective contact screening e.g. identification, management, inform and educate. They should also work with the general public, under-served and high-risk groups in particular, in sharing information on TB and identifying those in need of the TB service (NICE 2016). Infection Prevention and Control Teams are responsible for liaising with the Countywide Community TB Team in achieving efficient contact screening. They are responsible for working and educating staff in appropriate risk Assessments are undertaken for those contacts identified in the in-patient facility, ensuring that screening follows. The Lead Infection Prevention Nurse will be responsible for ensuring the ratification of this guidance through their respective organisation, where adopted. Radiology Departments will be responsible for the referral of patients with imaging highly suggestive of active TB, to the Countywide Community TB Services by the next working day (Appendix B). A & E Departments, Minor Injury Departments, Walk-in Centres, Out of Hours Service, Urgent Care Centres will be responsible for following the referral pathway for patients whom have been in contact with TB and that the Countywide Community TB Service is informed, using the appropriate method (Appendix C)NICE 2016)). Department clinicians should ensure first-line diagnostic tests for TB are performed on anyone presenting as suspected TB (NICE 2016). 7

8 Occupational Health Department will ensure all staff undergo a TB pre-employment health screening and jointly manage all staff treated for TB/LTBI locally. They will be responsible for leading on contact screening of all health care staff where required, subsequent provision of information and vaccination as necessary. Any decision to vary from this guidance must be fully discussed and documented with the associated rationale stated as it may impact on the effective management of patients and wider public health. N.B. The Countywide Community TB Service does not offer routine TB screening for health care staff. Please consult with Occupational Health Departments. 5. Contact screening (General) Contact screening procedures should be carried out on an individual patient-centred basis, which is community orientated, where possible (PHE 2015). Once a person has been diagnosed with active TB, the diagnosing physician/ health care staff/manager should inform the Countywide Community TB service so that the need for contact screening can be assessed without delay. Contact screening should not be delayed until TB notification of the index case (NICE 2016). All screening will be in accordance with NICE CG33 (2016). However, variations may be dictated by clinical presentation (index case), past medical history, appropriateness, availability of local resources and extent of public health risk. The Countywide Community TB Service may be required to contact screen those individuals living in Lincolnshire, where contact with the index case has taken place outside Lincolnshire. All children (under 16years) who have been identified as a TB contact will be managed by a local Consultant Paediatrician in conjunction with the Chest Physician or Consultant Paediatrician in specialist centres, where required. Contact screening is usually conducted according to the 'stone in the pond' principle (NICE 2016, NHSE 2017). This is where close contacts are screened first, if anyone is identified with TB in that ripple, then the screening will be offered to the next ripple of contacts. 'Information and advice' should be offered to all contacts of people with TB (NICE 2016). 6. Case management of TB contacts Case management of TB contacts will be undertaken by the Countywide Community TB Service e.g. TB case worker (Appendix D). Contacts of TB cases must be supervised, where appropriate, in conjunction with a designated TB Consultant in the locality e.g. Chest Physicians, Consultant Paediatricians, Infectious Diseases Consultant. The purpose of a designated consultant is to; be a point of consultation, discuss complex outcomes of screening with the Countywide Community TB Service, provide radiology opinions/ make aware of significant radiology reports, provide advice and support to the Countywide Community TB Service Team, be aware of the patient in the event of a referral. 8

9 Clinical assessment and diagnostic investigations will usually be undertaken at the patient s place of residence/other designated area. Dependant on the outcome of the screening, additional support may be required from health care staff in the community to ensure effective case management e.g. GP, Community Nurses, Ward Staff, Health Visitors, School Nurses and external/ voluntary organisations. 7. Definitions 7.1. Contact A person who has spent time with someone with active TB. See also 'close contact' and 'social contact' (NICE 2016) Contact Screening Identifying people who may have come into contact with a person with active TB and assessing them for risk of significant exposure Contact Investigations Clinical assessment and diagnostic testing of people identified as having had significant exposure to a case of TB, including tests to diagnose latent or active TB (NICE 2016) Close contacts of Pulmonary TB: A boyfriend/girlfriend, husband/wife or partner (NICE 2016), Frequent visitors or people sharing a household (sharing a bedroom, kitchen, bathroom or sitting room), May occasionally include a staff contact at work, e.g. staff undertaking mouth to mouth resuscitation or prolonged care of a high dependency patient or repeated chest physiotherapy (Appendix E) Casual/Social contacts of Pulmonary TB: Casual/Social contacts of people with TB, will include the great majority of workplace and social contacts and should not normally be assessed (NICE 2016). Such contacts need only be assessed if the index case is direct microscopy positive and the contacts are unusually susceptible, e.g. small children, immuno-compromised contacts or a highly infectious index case (Appendix E) Close contacts Non-pulmonary Disease: People staying in a household with a non-pulmonary TB case are at a lower risk but should be examined in order to identify a possible source of secondary cases (Appendix E) Casual/Social contacts Non-pulmonary Disease; Casual/social contacts of a non-pulmonary case are at very low risk and do not warrant assessment. 8. How far back to contact screen 1 month before the patient became symptomatic OR approximately 3 months prior to the index case being identified as direct microscopy positive. 9

10 9. Significant contact with index case (TB) The degree of contact that constitutes a risk is not known with certainty but studies of transmission suggests a cumulative total exceeding 8 hours close contact (i.e. in the same room/ restricted area) with the index case, during their considered infectious period (DOH 1998). 10. Referrals of contacts into Community TB service Notification of contacts may arise from various sources within and outside Lincolnshire. The TB Case Manager will liaise with the referrer to ascertain more information on the contact and the index case where known. 11. Contact Screening Procedure The general procedure for contact screening is detailed in Appendix D. Once a person has been diagnosed with active TB, the diagnosing physician should inform the Countywide Community TB Service so that the need for contact screening can be assessed without delay. Contact screening should not be delayed until notification of TB of the index case (NICE 2016). Screening should be offered to the close contacts of any person with active TB, irrespective of the site of infection, particularly so if the index case has pulmonary or laryngeal TB (NICE 2016) Clinical assessment The name, address, NHS number and date of birth of all close contacts will be obtained, where possible within 0 30 working days of receiving notification of the index case. Contact details may be obtained with the assistance of the Index case, where known. Following a risk assessment by the TB case manager, if an incident/outbreak is suspected PHE will be notified. A wider screen of the community may be indicated. TB contacts under the age of 16 years will be referred to the Consultant Paediatricians, for screening Diagnostic assessment TB contacts aged 16 years and above will be assessed by the Countywide Community TB service and signposted to diagnostic testing as appropriate (NICE 2016). A designated consultant physician will be assigned to the patient to assist discussions around test results or complexities arising from the assessments. The patient will be informed of the test results by phone, where appropriate, followed by a letter of confirmation in their native language. Copies of letters will be sent to the designated consultant and the GP. A referral from the Countywide Community TB Service to the chest physician may be required if further management is deemed necessary. The referrer (if external to Lincolnshire) will be informed of the outcomes of screening by letter. 10

11 11.3. Outcomes of screening The outcome of the assessment screening may result in the following: Discharge from the Countywide Community TB Service, Latent TB Treatment (refer to Latent TB Treatment Guidance), Active TB case management and treatment (refer to Management of TB Guidance), Other e.g. Further tests, BCG vaccination, Mantoux testing, Referral to other Consultants. N.B. The Countywide Community TB Service does not currently offer BCG vaccination. If a BCG vaccination is deemed necessary a referral to the Paediatrician/ Chest Physician will be required Screening of close contacts of TB (adults) Standard screening for all adult close contacts should comprise (Appendix E) NICE 2016)): Symptomatic (all ages (NICE 2016)) clinical assessment, chest X-ray (where indicated/if there are no contraindications), Sputum specimens (where active TB is suspected/ productive cough present (Appendix F). interferon-gamma blood test (Appendix G) routine bloods e.g. U&E, LFT, FBC, Inflammatory markers as a minimum mantoux test (where required and assessed (Appendix H). Asymptomatic (up to 65yrs (NICE 2016)) clinical assessment, chest X-ray (if there are no contraindications/particularly those over age of 35 years), interferon-gamma blood test Asymptomatic (over 65yrs (NICE 2016)) clinical assessment, chest X-ray (if there are no contraindications/particularly those over age of 35 years), N.B. The Countywide Community TB Service does not offer Mantoux testing. If Mantoux testing is deemed necessary a referral to the Chest Physician/Paediatrician will be required Screening of casual/social contacts (adults) Do not routinely assess casual/ social contacts of people with TB; these will include most workplace contacts (NICE 2016). Screening of adult casual/social contacts of people with TB should only be assessed if: the index case is judged to be particularly infectious (for example, evidenced by transmission to close contacts), or any casual contacts are known to possess features that put them at special risk of infection (NICE 2016). 'Inform and advise' information should be offered to all contacts (NICE 2016) Contract screening: in a Hospital/ In-patient facility Transmission of TB in a hospital setting may come from 2 common sources: An in-patient (who may not have been isolated) or a health care worker/ worker. Following diagnosis of TB in a hospital patient / in-patient facility, a risk assessment should be undertaken by the Manager/ Matron/Nurse in Charge/TB Team, taking into account: the degree of infectivity of the index case the length of time before the infectious patient was isolated 11

12 whether other patients are unusually susceptible to infection the proximity of and duration of contact (NICE 2016). Contact screening and testing should be carried out only for patients for whom the risk is regarded as significant (NICE 2016). Patients should be regarded as at risk of infection if they spent more than eight hours in the same bay/ ward/ room as a patient with direct microscopy positive sputum (infectious period) who had a cough (NICE 2016). PHE/ IPC Team /TB team may assist with the risk assessment. If a patient with direct microscopy positive sputum is found to have Multi-drug resistant TB (MDRTB) or if exposed patients are HIV-positive, contact screening should be in line with The Interdepartmental Working Group on Tuberculosis Guidelines (1998 (NICE 2016)). The manager/ matron/nurse in charge should complete the form (Appendix I) for contacts of confirmed direct microscopy positive pulmonary TB where the above criterion has been met. This should be forwarded to the Countywide Community TB Services within 48 hours of identification. If the contact is still in hospital when the investigations are due, these can be undertaken during their stay. The exposure to TB, investigations and resulting actions must be recorded in the patient s record. The patient must be informed of the results of the tests verbally, if still in hospital, and by letter. A copy of the letter must be forwarded to the GP. Further advice should be sought from PHE or people experienced in the field, as required Contacts in the underserved population (USP). The Countywide Community TB Service should work in partnership with voluntary, community and statutory organisations to conduct outreach contact investigations, where deemed necessary (NICE 2016). The coordination of contact investigations should endeavour to take place where the person with TB spends significant amounts of time (NICE 2016). This is resource and number of contacts dependant. Where located, people from underserved populations must be offered a single interferon-gamma test (NICE 2016). Active case finding should be carried out among street homeless people (including those using direct access hostels for the homeless) by chest X-ray screening (and or/ sputum, IGRA) on an opportunistic and/or symptomatic basis. Simple incentives for attending, such as hot drinks and snacks, should be considered (NICE 2012, NICE 2016). The Countywide Community TB Service will assist in the investigation of all those who have been in contact with underserved children (in conjunction with Children s services where appropriate) who have pulmonary or non-pulmonary TB to identify the primary source of infection, where deemed necessary (NICE 2016). Healthcare professionals working with people with TB should reinforce and raise awareness about TB and referral pathways, to primary care colleagues, social workers and voluntary workers who work with homeless people (NICE 2012, Nice 2016) 12

13 11.8. Contact screening: cattle-to-human transmission Bovine tuberculosis is almost entirely caused by M. bovis, which can be differentiated from M. tuberculosis (NICE 2016). Diagnostic tests for latent TB should be considered only for children younger than 16 who have not had BCG vaccination and have regularly drunk unpasteurised milk from animals with TB udder lesions (NICE 2016). 'Inform and advise' information should be given to people in contact with TB-diseased animals (NICE 2016) Contact screening cases on an aircraft. Following diagnosis of TB in an aircraft traveller, contact screening of fellow passengers should not routinely be undertaken (NICE 2016). The notifying clinician should inform the relevant consultant in communicable disease control (CCDC) or PHE if: less than 3 months has elapsed since the flight and the flight was longer than 8 hours and: the index case is direct microscopy positive and either the index case has multidrug-resistant TB or the index case coughed frequently during the flight (NICE 2016). The CCDC or PHE should provide the airline with 'inform and advise' information to send to passengers seated in the same part of the aircraft as the index case (NICE 2016). If the TB index case is an aircraft crew member, contact screening of passengers should not routinely take place (NICE 2016). If the TB index case is an aircraft crew member, contact screening of other members of staff is appropriate, in accordance with the usual principles for screening workplace colleagues. (NICE 2016) Opportunistic case finding New entrants from high incidence countries Primary care services should support local, community-based and voluntary organisations that work with vulnerable migrants to ensure they: register with a primary care provider know how to use NHS services (emergency or primary care)(nice 2016) Healthcare professionals, including primary care staff, responsible for testing new entrants should test all vulnerable migrants who have not previously been checked. This is regardless of when they arrived in England. People born in countries with an incidence of more than 150 per 100,000 per year should be made a priority for latent TB testing when they arrive in the UK (NICE 2016). The Countywide Community TB Service and primary care services will assess and manage TB in new entrants from high incidence countries who present to healthcare services as follows: assess risk of HIV, including HIV prevalence rates in the country of origin, and take this into account when deciding whether to give a BCG vaccination /offer testing for latent TB assess for active TB if the test for latent TB is positive offer treatment to people aged 65 years or younger in whom active TB has been excluded but who have a positive interferon-gamma release assay for latent TB infection 13

14 consider offering BCG for unvaccinated people who are interferon-gamma release assay-negative, give 'inform and advise' information to people who do not have active TB and are not being offered BCG or treatment for latent TB infection (NICE 2016) People using homeless or substance misuse services In areas of identified need commissioners should: ensure there is a programme of active case-finding using mobile X-ray in places where homeless people and people who misuse substances congregate (this includes: homeless day centres, rolling shelters, hostels and temporary shelters established as part of cold weather initiatives and venues housing needle and syringe programmes) base the frequency of screening at any 1 location on population turnover where local demand does not warrant a mobile X-ray team, consider commissioning mobile X-ray capacity from another area (NICE 2016). Multidisciplinary TB teams should consider using simple incentives, such as providing hot drinks and snacks, to encourage people to attend for testing (NICE 2016) Commissioners of TB prevention and control programmes should consider offering people who are homeless and people who misuse substances other health interventions when they are screened for TB at a mobile X-ray unit. (Examples may include blood-borne virus screening, dentistry and podiatry services.) (NICE 2016) Multidisciplinary TB teams should work closely with mobile X-ray teams and frontline staff in hostels and day centres to promote TB screening and to ensure appropriate onward referrals and follow-up. (NICE 2016) Multidisciplinary TB teams should consider using peer educators to promote the uptake of TB screening in hostels and day centres(nice 2016) Multidisciplinary TB teams should provide routine data to TB control boards on: screening uptake, referrals and the number of active TB cases identified (NICE 2016) Active case finding in under-served populations Multidisciplinary TB teams should, if available and appropriate, encourage peer educators or TB programme support workers to help with contact investigations involving under-served people who have complex social networks(nice 2016) Multidisciplinary TB teams dealing with someone from an under-served group should work alongside health and social care professionals known to them to help trace relevant contacts. They should also work in partnership with voluntary, community and statutory organisations to conduct outreach contact investigations(nice 2016) Multidisciplinary TB teams should follow NICE recommendations on contact screening. They should coordinate contact investigations at places where the person with TB spends significant amounts of time. Examples could include pubs, crack houses, parks and community centres. The aim is to help identify people who have been living with them and people they frequently socialise with(nice 2016) Multidisciplinary TB teams in discussion with local Public Health England health protection teams should consider using digital mobile X-ray for active case-finding in settings identified by looking at social networks as places where under-served people at risk congregate. They should also provide the necessary support so that multidisciplinary TB teams can use strain-typing and social network analysis to ascertain where transmission is occurring in the community. (Examples of transmission sites may include pubs, crack houses, hostels and day centres.) They should focus on active case-finding in the settings identified (NICE 2016). 14

15 12.4. People in prisons or immigration removal centres Healthcare professionals in prisons and immigration removal centres should ensure prisoners and detainees are screened for TB within 48 hours of arrival (NICE 2016). Prison and immigration removal centre health staff should report all suspected and confirmed TB cases to the local multidisciplinary TB team within 1 working day (NICE 2016). Multidisciplinary TB staff should visit every confirmed TB case in a prison or immigration removal centre in their locality within 5 working days (NICE 2016). If a case of active TB is identified, the local Public Health England unit, in conjunction with the multidisciplinary TB team, should plan a contact investigations exercise. They should also consider using mobile X-ray to check for further cases (NICE 2016). Prisons with Department of Health-funded static digital X-ray facilities for TB screening should X-ray all new prisoners and detainees (including those being transferred from other establishments) if they have not had a chest X-ray in the past 6 months. This should take place within 48 hours of arrival. (NICE 2016) TB Contacts living outside Lincolnshire Any TB contacts identified in Lincolnshire but are resident outside of Lincolnshire will be referred to the relevant TB service/phe TB Contacts of a patient who have died before diagnosis Liaison with the consultant in charge of the case, GP, Coroner and the PHE must take place before approaching close contacts of the deceased Contact Screening: Children All children identified as a contact of a TB case will be referred to a Consultant Paediatrician. Common tests performed with children are: Mantoux Skin Test, Chest x-ray and IGRA blood test. In complex cases advice may be sought form specialist Paediatric Consultants e.g. Nottingham, Sheffield or Leicester. Any adults associated with a child with TB should be referred to the Countywide Community TB Service, screened as part of the contact screening regime, to rule out an adult source Contact screening: Cases in schools Following diagnosis of TB in a school pupil or member of staff, the CCDC should be prepared to explain the prevention and control procedures to staff, parents and the press (NICE 2016) If a school pupil is diagnosed with direct microscopy positive sputum, the rest of his or her class (if there is a single class group), or the rest of the year group who share classes, should be assessed as part of contact screening (NICE 2016). If a teacher has direct microscopy positive sputum, the pupils in his or her classes during the preceding three months should be assessed as part of contact screening. 15

16 The TB Service conducting contact screening in a school should consider extending it to include children and teachers involved in extracurricular activities, and non-teaching staff, on the basis of: the degree of infectivity of the index case the length of time the index case was in contact with others whether contacts are unusually susceptible to infection the proximity of contact (NICE 2016) Secondary cases of direct microscopy positive sputum should be treated as index cases for contact screening If the index case of a school pupil's TB infection is not found, and the child is not in a high-risk group for TB, contact screening and screening (by either symptom enquiry or chest X-ray) should be considered for all relevant members of staff at the school. The incident/ outbreak guidance must be adhered to Contact screening: community childcare Children, particularly of pre-school age, are more likely to acquire TB infection, and progress to TB disease, than older children and adults if they are exposed (NICE 2016). When an adult who works in childcare (including people who provide childcare informally/ foster care) is diagnosed with direct microscopy positive sputum follow recommendation as in section 11.0.(NICE 2016). PHE must be advised of such situations Contact Screening: Healthcare staff Occupational health should send reminders of the symptoms of TB, and the need for prompt reporting of such symptoms, to staff after a TB incident on an in-patient area (NICE 2016). Local Occupational Health Guidance applies Incident and outbreak response Multidisciplinary TB teams should coordinate incident or outbreak contact investigations at places where the person with active TB spends significant amounts of time. Examples include workplaces, schools, colleges, universities, childcare settings. Identify people that the person with TB frequently spends substantial time with (NICE 2016). Multidisciplinary TB teams should refer any incident in a congregate setting to the local Public Health England health protection team for risk assessment within 5 working days of suspicion of a potential incident (NICE 2016). TB networks/ control boards working with local health protection teams should, through local arrangements, mobilise existing staff or have access to an incident team that will: undertake an incident risk assessment and provide advice support or undertake contact investigations provide information and communication support to the multidisciplinary TB team, the local director of public health, the setting in which the incident has occurred and the people affected including: o written advice, printed or by o question and answer sessions o telephone advice o media engagement 16

17 o o gather and collate data, and report on outcomes to measure the effectiveness of the investigation (for example, offering testing to all people identified at risk and monitoring uptake) report back to TB control boards at appropriate times. This includes when outcomes of initial investigation of people classified as close contacts are available. It also includes when a decision is made to broaden the investigation to the next stage using the concentric circle method for risk assessment (NICE 2016). When incidents have been identified, multidisciplinary TB teams in discussion with local Public Health England health protection teams should consider providing support for strain-typing/whole genome sequencing (WGS) and other analysis to ascertain where transmission is occurring. (Examples of transmission sites may include workplaces, schools, colleges, universities, childcare settings.) (NICE 2016). In all types of contact investigation scenarios (active case finding, incident or outbreak investigations) multidisciplinary TB teams should investigate all people who have been in contact with children who have pulmonary or non-pulmonary TB to identify the primary source of infection. If necessary, they should look beyond immediate close contacts to find the source. (NICE 2016) Contacts refusing screening Refusal to be assessed and or screened should be documented in the patient record and the person s GP informed in writing. The patient is to be advised / informed of the consequences of not being screened and who to contact in event symptoms of TB are experienced. e.g. TB leaflets Non-attendance for contact screening If contacts do not attend for screening, it is important to ascertain the reason for non-attendance and reinforce the importance of attending. The contact will be re-invited for assessment /screening a second time. Contacts who do not attend (DNA), require TB services active follow-up especially when contacts were identified from cases of pulmonary TB and contacts who are children, (NHSE 2017) The contact s GP should be informed in writing of all non-attendance, and discharge from the service. Non-attendance must be documented in the patient record. Patients not attending for the second time will be discharged. A letter will be sent to the patient advising of TB symptoms and how to contact the TB service Documentation All activity with and advice provided to the contacts will be documented in the patients records e.g. Systmone. Where it is deemed unsafe to take I.T. equipment with you to record patient data, local Information Governance guidance should be adhered to where paper copies of assessment forms / monitoring plans are used. 17

18 20.0. Risk Management A local incident reporting form must be completed if the following is experienced: Non-compliance with this guidance is evidenced Any incident involving suspected / confirmed patients with Pulmonary Tuberculosis and the potential for cross infection e.g. Positive patient nursed in an open bay. Any suspicions / indications of an outbreak of Pulmonary Tuberculosis. Please seek the advice of the Countywide Community TB Service or PHE Education The Trust recognises that there is a need to ensure awareness amongst employees on the relevance and application of this policy. The Countywide Community TB Service will support training where requested Monitoring and Audit of Practice It is the responsibility of the manager/ matron/ Nurse in charge to ensure that audit is conducted noting facilities, practice and documentation on a pre-planned basis. An audit programme for the Countywide Community TB service will be in place Evidence Base Department of Health (1998) The Interdepartmental Working Group on Tuberculosis guidelines 1998 at: ions/publicationspolicyandguidance/dh_ Department of Health (2007) Tuberculosis preventing and treatment: a toolkit for planning, commissioning and delivering high quality services in England. Accessed on 10 Oct LCHS (2015) TB Service Specification LCHS (2017) Guidance on rapid access and referrals into the Countywide Community TB Service. NHSE (2017) TB Clinical Policy NICE Clinical Guidelines 33 (2016) Tuberculosis NICE Clinical Guidelines CG 37 (2012) Identification and Management of TB in vulnerable and hard to reach Public Health England (2015) Collaborative Tuberculosis Strategy for England 2015 to Appendices Appendix A. Appendix B. Appendix C. Appendix D. Appendix E. Appendix F. Appendix G. Appendix H. Appendix I. Countywide Community TB Service Contact details TB Notifications - Radiology Pathway TB Rapid Access and referrals Walk-in/ OOH/ MIU / Urgent care Contact Screening Pathway Summary of assessment and screening based in Index case status Sputum Specimen Collection IGRA (Quantiferon) Test Mantoux Skin Test Contact Screening Log 18

19 Appendix J. Appendix K Equality Impact Assessment Monitoring Template 19

20 Appendix A Countywide Community TB Service Details Countywide Community TB Service, Lincolnshire. Office Base: Unit 7, The Point, Lions Way, Sleaford, Lincolnshire, NG34 8GG Tel: Fax: Hours of Operation: Monday to Friday, (9am 5pm) Geographical Area: Lincolnshire Natalie Radley TB Administrator Unit 7, The Point, Lions Way, Sleaford, Lincolnshire, NG34 8GG. Tel: Fax: Natalie.Radley@lincs-chs.nhs.uk Secure Natalie.Radley@nhs.net Hours of Operation: Monday to Friday, (9am 1pm) Geographical Area: Lincolnshire Sue Silvester TB Nurse Specialist/TB Lead Unit 7, The Point, Lions Way, Sleaford, Lincolnshire, NG34 8GG Tel: Fax: Mob: Sue.Silvester@lincs-chs.nhs.uk Secure Sue.Silvester@nhs.net Hours of Operation: Monday to Friday, (9am 5pm) Geographical Area: Lincolnshire Rachel Rodgers TB Nurse Unit 7, The Point, Lions Way, Sleaford, Lincolnshire, NG34 8GG Tel: Fax: Mob: Rachel.Rodgers@lincs-chs.nhs.uk Secure Rachel.Rodgers@nhs.net Hours of Operation: Monday to Friday, (9am 5pm) Geographical Area: South Lincolnshire Di Swift TB Nurse 20

21 Awaiting photo Beech House, Witham Park, Waterside South, Lincoln, LN5 7JH Tel: Fax: Mob: Secure Hours of Operation: Monday to Friday, (9am 5pm) Geographical Area: North Lincolnshire Countywide Community TB Service Details Geographical area. Countywide TB Lead Sue Silvester Tel: Mob: TB Service Case Manages - Lincolnshire TB Service Case Manages -South Lincolnshire TB Service Case Manages -North Lincolnshire TB Administration Lincolnshire Sue Silvester, TBNS Tel: Mob: Rachel Rodgers, TBN Tel: Mob: Di Swift, TBN Tel: Mob: Natalie Radley Unit 7, The Point, Lions Way, Sleaford, Lincolnshire, NG34 8GG. Tel: Fax: PHE (Lincolnshire) Senior Nurse CCDC Gail Beckett Jharna Kumbang Seaton House, City Link, London Road, Nottingham, NG2 4LA Phone no Option 1 Fax:

22 Appendix B - TB Notifications - Radiology Pathway Countywide Community Tuberculosis Services Pathway 1d. Rapid Accecss Radiology Jan 2017 Lincolnshire Community Health Services RAPID ACCESS REFERRAL - Radiology Department RADIOGRAPHER X-RAY DEPT. Suspected TB/ *Significant/ Unexpected Radiological findings RADIOLOGIST/ REPORTING RADIOGRAPHER Reporting on Suspected TB/ *Significant/ Unexpected Radiological findings ORANGE ALERT (5.6 ULHT) TARGET TIMESCALE E 5 working days TARGET TIMESCALE E 1 working days TARGET TIMESCALE E 60 mins Refer to CW TB Service AND Refer to local Chest Physician TB Admin / TB Team Take details of referrer Take details of patient Registration on Systems: SystmOne / Local data base Explore Medway, Web V, Radiology, Exeter TB Admin/ TB team to Allocate to Designated TB Key worker by Phone / Task TB Lead / TBN Discuss Consultant Chest Physician Not appropriate. Refer on. Discharge. Allocate Pathway Pathway 1 Pathway 2 Pathway 3 Pathway 4 Pathway 5 1. RAPID ACCESS Pathway 2. Confirmed TB/ On TB pathway 3. TB Screening: Contacts 4.Latent TB Screening Confirmed Latent TB/ on Latent TB pathway 5. Other - e.g. query, incident / outbreak Best evidence: As per Countywide guidance on rapid access and routine referrals into the CW Community TB Service. 22

23 Appendix C TB Rapid Access and referrals Walk-in/ OOH/ MIU / Urgent care Countywide Community Tuberculosis Services Lincolnshire Community Health Services Pathway 1c. Rapid Access Walk IN /OOH / MIU 2017 RAPID ACCESS REFERRAL - Walk -in / OOH / MIU Suspected TB/ Displaying signs & symptoms of TB/ Microbiological/Radiological confirmation AND Transfers to Ward/ Dept. Discharge / Self Discharge If you refer to the TB Service advise the patient to expect a call ( working Hours) Pass on the TB Service details to patient TARGET TIMESCALE E 5 working days TARGET TIMESCALE E 1 working days TARGET TIMESCALE E 60 mins Refer to CW TB Service AND Refer to local Chest Physician TB Admin / TB Team Take details of referrer Take details of patient Registration on Systems: SystmOne / Local data base Explore Medway, Web V, Radiology, Exeter TB Admin/ TB team to Allocate to Designated TB Key worker by Phone / Task TB Lead / TBN Arrange A&E contact (Advise on TB tests) ward contact/ Locate patient/ Home visit/ Outreach Visit Triage/ Clinical History/ Physical Assessment/ TB investigations by TB Lead/ TBN: Immediate advice. Discussion with 'virtual' consultant as required. Follow up as required. Allocate pathway Refer onwards / Discharge Not appropriate. Refer on. Discharge. Allocate Pathway Pathway 2 Pathway 3 Pathway 4 Pathway 5 2. Confirmed TB/ On TB pathway 3. TB Screening: Contacts 4.Latent TB Screening Confirmed Latent TB/ on Latent TB pathway 5. Other - e.g. query, incident / outbreak Best evidence: As per Countywide guidance on rapid access and routine referrals into the CW Community TB Service. 23

24 Appendix D - Contact Screening Pathway Countywide Community Tuberculosis Services Pathway 3. Contact Screening - TOTAL PROCESS Lincolnshire Community Health Services Contact Screen (all groups) TARG ET TIMESCALE E 5-30 working days TARG -ET TIMESCALE E 1-5 working days TARGET TIMESCALE E 60 mins Symptomatic Contacts will automatically be placed on Rapid Acccess Referral Pathway Phone Call to CW TB Service Service 9am - 5pm with answerphone facility (please leave message) TB Admin / TB Team Take details of referrer Take details of patient Registration on Systems: SystmOne / Local data base Explore Medway, Web V, Radiology, Exeter TB Admin/ TB team to Allocate to Designated TB Key worker (Nth/Sth) Triage by TB Key Worker: Confirm routine / urgency within 1 working day Assess / Explore details on case, e.g. results, outreach, social care etc. Discuss details with relevant parties:e.g. Consultant, GP, PHE, TB teams, Outreach where required. Not appropriate. Refer on. Discharge. Contact screen - Urgent (Index Smear pos Pulmonary TB) Allocate Pathway Smear day contact 2 appointments Clinical History Physical Assessment TB Investigations Results. F/u Pathway 2, 4, 5, 6, Refer onwards / Discharge Contact screen - Routine (Index Smear neg / Non Pul) Contact screen - Other groups (Immigrants, OH ) Procedure In Pathway (summary) Non Pul wk contact All other groups 2 appointments Clinical History Physical Assessment TB Investigations Results. Pathway 2, 4, 5, 6, Refer onwards / Discharge 0-6 wk contact 2 appointments Clinical History Physical Assessment TB Investigations Results. Pathway 2, 4, 5, 6, Refer onwards / Discharge Best evidence: As per Countyw ide guidance on rapid access and routine referrals into the CW Communit TB Service. PHE (2015) National TB Strategy for England National Institute Clinical Excellence (2015) Clinical Guideline 33: Tuberculosis: 33 National Institute Clinical Excellence (2012) Public health Guideline 37: Management of tuberculosis in hard to reach community. National TB Strategy British Thoracic Society (2005) Recommendations for assessing risk and for managing Mycobacterium tuberculosis infection and disease in patients due to start anti-tnf-a treatment.thorax 2005;60: British HIV Association (2011) Guidelines for the treatment of TB/HIV co-infection. HIV Medicine (2011), 12,

25 Appendix E Summary of assessment and screening based in Index case status Pathway Contact screen Urgent Contact Screen Routine Contact Screen Routine Index Case Close Contacts Close Contacts Casual Contacts Pulmonary MTB (Direct Microscopy Positive) Symptomatic contacts must be processed via the Rapid Access referral route. Initial assessment. Not routinely required. Offer screening >65yrs IGRA CXR (as indicated) Assess workplace contacts only if contact is judged equivalent to household contacts Pulmonary MTB (Direct Microscopy Negative) Non Pulmonary disease (e.g.closed TB) > 65yrs CXR and further investigations as required. Initial assessment. Offer screening >65yrs IGRA CXR (as indicated) > 65yrs CXR and further investigations as required. Close contacts only Initial assessment. Offer screening >65yrs IGRA CXR (as indicated) Not routinely required. Consider only if the index case is particularly infectious or if casual contacts are at special risk of infection Not routinely required. Consider only if the index case is particularly infectious or if casual contacts are at special risk of infection Pulmonary M. bovis cases > 65yrs CXR and further investigations as required. Inform and advise < 16yrs refer to Paediatrician Offer screening only for children younger than 16 years, without BCG who have regularly drunk unpasteurised milk from animals with TB udder lesions. Inform and advise adults OTHER CONTACTS Other Immigrants, New Entrants (1&2), USP, HCW*, Vets, Travel. Priority 1.>150 /100,000popn /100,000popn Immunocompromised contacts (e.g. HIV) Transmission amongst close contacts identified Potential outbreak Contacts (external to Lincolnshire) Initial assessment. Offer screening >65yrs IGRA CXR (as indicated) > 65yrs CXR and further investigations as required. Offer screening to any immunocompromised individual with significant contact with an index case. Extended screening may be required e.g. larger groups of friends, work colleagues, carers, sexual partners, regular social contacts. Discuss PHE Extended screening may be required. Discuss with PHE Follow Incident/outbreak procedure. Refer to the Local TB teams Refer to section 13.0 Contacts in Hospital Refer to section 11.0 Contacts in Hospital (Staff) Refer to section 16.0 Risk assessment Discuss with IPCT, Occupational Health and PHE 25

26 Appendix F. Sputum Specimen Collection Community TB Service: Obtaining Sputum Specimens for TB Definition: Sputum specimen collection is a procedure designed to collect expectorated secretions from a patient's respiratory tract. Purpose: Sputum collected is to be used as a laboratory specimen for the isolation of organisms that might be causing abnormalities of the respiratory tract e.g. TB. Collecting a good sputum specimen requires that the patient be given clear instructions. Precautions: Standard Infection Control Precautions apply. Refer to local guidance. Amount to Collect: Approximately 5 ml (about 1 teaspoon) is necessary. Multiple tests may be required to test for certain organisms e.g. collection of specimens, 3 days in a row. When to Collect: Collecting sputum specimens first thing in the morning enhances the quality of specimen. Collection Container: Refer to Pathlinks Guidance. Ensure Container and Form has a Biohazard sticker present (where TB is suspected) How to collect: Equipment Apron and gloves; Mask where applicable Appropriate container; Appropriate documentation. How to collect: Procedure 1. Explain to patient and obtain consent 2. Wash hands and don protective clothing. 3. Where possible, the patient should be sat upright supporting as necessary with pillows. 4. Encourage the patient to gargle and rinse your mouth with water before you collect the specimen. (This helps to eliminate accumulated cells arid normal bacteria that may interfere with your test results.) 5. Where possible encourage the patient to Inhale to the full capacity of your lungs and exhale the air with a cough. This should produce mucus from the lungs that is to be expectorated into the container. "Spit" from the mouth is inadequate and will give incorrect results to the physician. 6. Collect specimen in pot and seal. 7. Label pot with the patient's details, date, time and specimen type ( AFB and Culture must be requested (select TB from drop down menu) / written in the microbiological section on the lab form and on the specimen pot) 8. Send to relevant laboratory 9. Ensure the patient is safe and comfortable 10. Remove protective clothing and wash hands NB Aerosols containing tuberculosis bacteria may be formed when the patient coughs to produce a sputum specimen. Patients should therefore produce specimens either outside or away from other people. Alternative methods of collection are available if the patient cannot expectorate. These situations must be discussed with the Physician. After collection: Transport specimen to the lab as soon as practicably possible (preferable within 2 hours). 26

27 Specimen pots can be obtained from: the local Pathlinks laboratory. Life of bottles: Please ensure specimen pots are stored in a dry and clean area. Interpretation of results: All direct microscopy positive and/or culture positive results must be notified to the Countywide Community TB Team, as soon as identified. The results of the test must be interpreted in conjunction with clinical presentation and other test results, by experienced individuals e.g. Chest Physicians, TB Service. Further advice is available from the consultant microbiologists. Outbreak situation / Mass screening: In the event there is an outbreak situation or mass screening is required. Please contact the lab to advise sputum specimens contact the laboratory to advise and confirm details around patients and transportation sputum specimens - contact the laboratory to advise. Alternative arrangements may have to be made by Pathlinks. Contact: Pathlinks: Mark Cioni, Nick Duckworth, Richard Gorden1, Brian Davies via NHS net . Tel

28 Appendix G. IGRA (Quantiferon) Test CW Community TB Service: Obtaining Specimens of blood for Interferon Gamma (e.g. Quantiferon TB test). Definition: The QuantiFERON-TB Gold test (QFT-G) is a whole-blood test for use as an aid to the diagnosis of Mycobacterium tuberculosis complex infection, including latent tuberculosis infection (LTBI) and tuberculosis (TB) disease. It is advised this test should be used in conjunction with clinical assessment, and additional tests such as chest x-ray, sputum microscopy, and culture. The test uses the response of the immune system from the patient (IFN-gamma produced by sensitized lymphocytes) to specific TB antigens in the blood bottles. The results are based on the amount of IFNgamma that is released in response to the antigens. Bottles for these tests can be obtained via the TB Service, Chest Physicians or the PathLinks Laboratories. Purpose: The whole-blood test is used as an aid in diagnosing Mycobacterium tuberculosis infection. Precautions: Standard Infection Control Precautions apply. Refer to local guidance. When to Collect: This service is currently only available on Monday, Tuesday and Wednesdays. Storage of bottles prior to collection: Bottles are to be stored at room temperature in clean dry conditions. Do not refrigerate. How to collect: Equipment Apron and gloves, Wipable/Disposable Tourniquet and Venepuncture equipment, Appropriate containers, Appropriate documentation and hazard labels where appropriate. How to collect: Procedure Collection information 1. Ensure all equipment is obtained prior to commencing procedure. 2. Confirm patient personal details. 3. Don disposable apron, wash hands and place on gloves prior to starting blood collection. 4. Each person will require 3 bottles (in sets) which need exactly 1ml (up to black mark) of blood each (vacutainer style bottles). Grey capped bottle (Nil control) Green capped bottle (TB1 antigen test) Yellow capped bottle ( TB2 antigen test) Purple capped bottle (Mitogen control) Bottles must be used in this order only, or results may be invalid. 5. As 1ml of blood draws relatively slowly in each bottle keep the tube on the needle for 2 3 seconds once the tube appears to have completed filling; to ensure that the correct volume is drawn). 28

29 CW Community TB Service: Obtaining Specimens of blood for Interferon Gamma (e.g. Quantiferon TB test). 6. If a butterfly needle is used to collect blood, a purge tube should be used prior to using the Quantiferon bottles. 7. When taken, the bottles need to be inverted, to ensure the inner surface of the tube has been coated with blood. 8. Ensure all bottles and lab forms are correctly labelled with personal and clinical details. 9. Ensure all 4 bottles per person to be placed in specimen bag with laboratory form. 10. All specimens must be transferred to lab as soon as possible after collection and before 4pm, thus enabling all specimens to be transferred to an incubator (TB Service only), at the laboratory and within 16 hours of collection. Where a portable incubator is used locally, the specimens can be placed straight into the incubator and transported to the laboratory (incubation should not be for more than 24hours total the laboratory must be informed about the amount of time that the sample has already spent being incubated at the time of receipt e.g. state when incubated on specimen form). 11. Do not refrigerate specimens. Transport the filled bottles to: the local Pathlinks laboratory, from where they will be referred for testing after the initial processing stages. N.B. Please advise pathology staff, when depositing the samples, that they are Quanitiferon specimens. Life of bottles: the bottles have on average a shelf life of a year. Always check the expiry date prior to use and ensure stock rotation is practised locally. Interpretation of results: The results of the test must be interpreted in conjunction with clinical presentation and other test results, by experienced individuals e.g. Chest Physicians, TB Service. Further advice is available from the consultant microbiologists. Outbreak situation / Mass screening: In the event there is an outbreak situation or mass screening is required. Please contact the lab to advise Quantiferon specimens contact the laboratory to advise and confirm details around specimen bottles, patients and transportation to designated laboratory. 48+ Quantiferon specimens - contact the laboratory to advise. The outbreak services of the manufacturers may have to be purchased. Contact: Pathlinks: Mark Cioni, Nick Duckworth, Richard Gordon1, Brian Davies via NHS net . Tel AND Dr B Stoddart, Grantham and District Hospital

30 Appendix H. Mantoux Skin Test The Mantoux Skin Test. ENGLISH What is the Mantoux Skin Test? The Mantoux skin test is used to detect: old Tuberculosis (TB) infection and/ or recent infection with TB. Why is the Mantoux Skin Test needed? The test is used to look for evidence of previous infection by TB, before deciding to give a BCG Vaccination (TB vaccination). How is the Mantoux Skin Test given? The Mantoux skin test involves a small injection of fluid, just under the skin on the forearm. It will only take a few seconds. Following your Mantoux skin test you will see a small raised area on the inner part of your forearm (induration). This will go away over the next few hours. Observing the reaction The Doctor / Nurse will look at and feel the reaction at the site of the Mantoux skin test at your second appointment; hours after the skin test. The skin may or may not show any reaction to the test. A reaction is a firm swelling at the site of the injection Where the small raised area is identified, this will be measured. 30