Section S - Tuberculosis Policy

Section S - Tuberculosis Policy Version 6 Important: This document can only be considered valid when viewed on the Trust s Intranet. If this document has been printed or saved to another location, you must check that the version number on your copy matches that of the document online. Page 1 of 30

Document Summary Table Reference Number C-67-2013 Status Ratified Version 6 Implementation Date January 2003 Current/Last Review November 2008, May 2013, June 2015 Dates Next Formal Review June 2017 Sponsor Director of Infection Prevention & Control Author Senior Infection Prevention & Control Nurse Where available Trust Intranet Target audience All Staff Ratifying Committees Executive Board 1 October 2015 Consultation Committees Committee Name Committee Chair Date Infection Prevention & Control Committee June 2015 Consultant Microbiologist / Infection Prevention & Control Doctor Other Stakeholders Consulted All members of Infection Prevention and Control Committee Respiratory Consultants and TB Team Does this document map to other Regulator requirements? Regulator details Regulator standards/numbers etc Document Version Control Version No. Brief details of revisions or rationale of new Trust wide policy 6 Amendment Jan 2017, links updated. 5 Guidance on notifying TB cases has been included in Appendix 1. Links have been added to various documents in the References and Further Reading section. A link to the gov.uk website has been included in Section 17, providing information regarding notifiable diseases and the form to be used. The PHE Guide for risk assessment of TB exposure incidents in hospitals has been included in Appendix 4. The Standard Operating Procedure (Appendix 6) regarding Contact Tracing has been revised and amended. 4 The MDR-TB section has been revised and moved from an appendix to the main body of the policy. NICE guidelines have been verified and the policy has been cross referenced in accordance with this. The Trust Equality Statement has been updated. 3 The document has been redesigned to ensure that all new and revised procedural documents are set out to a Trust wide format and the content of which includes a minimum set of criteria which include: the training requirements for implementation Page 2 of 30

monitoring arrangements for the document Equality Impact of the document In addition, the monitoring arrangements for this document have been included. Page 3 of 30

Contents Section Page Document Summary Table 2 Contents 4 1. 2. Introduction Purpose 5 5 3. 4. Definitions Duties 5 6 5. Management 7 6. 7. Alert Signs and Symptoms for Pulmonary TB Hospital Admission 7 7 8. Isolation of patients 7 9. Use of Masks 9 10. Care and Management of patients with known or suspected MDR-TB 10 11. 12. Transfer of known or suspected Pulmonary TB Sputum 13 13 13 Operating Theatres & Respiratory / Invasive Interventions 13 14. 15. Cough Inducing Procedures Death 14 14 16. Staff screening / immunity 14 17. Notification 15 18. Notification after Death 16 19. Hospital Laundry 16 20. Termination of Isolation 16 21. Cleaning of the Isolation Room post patient discharge / death 16 22. 23. 24. 25. 26. 27. 28. 29. 30. Appendices Discharge from Hospital Close Contacts (Pulmonary TB) and Contact tracing Casual contacts Management of Outbreaks & Incidents Tuberculosis Management Contacts Training and Implementation Trust Equalities Statement Process for Monitoring Compliance / Effectiveness References and Further Reading 16 17 17 17 18 18 18 19 20 1. 2. 3. 4. 5. 6. Guidance on notifying Tuberculosis cases Location of Negative Pressure Rooms at CRH Assessment of Isolation Requirements PHE Guidance for risk assessment TB exposure incidents in hospital Contact Tracing Patients who have come into contact with Index Case Standard Operating Procedure for Contact Tracing for the IPCT 22 23 24 25 30 31 Page 4 of 30

1. Introduction Tuberculosis (TB) is an infectious disease caused by a bacterium belonging to the Mycobacterium tuberculosis complex, which includes: Mycobacterium tuberculosis, Mycobecterium africanum, Mycobacterium bovis, some rare bacteria such as Mycobacterium microti and Mycobacterium pinnipedii. NB: Mycobacterial species other than M. tuberculosis are commonly seen in the United Kingdom but are much less pathogenic. These are not considered to pose an infection hazard to other patients or staff and are usually referred to as non-tuberculous (NTM) or atypical mycobacteria. TB usually affects the lungs, but can affect other parts of the body including lymph nodes, pleural cavity, bones and brain. Infection is usually acquired by inhalation of TB bacilli expelled from the mouth and nose of an infectious individual after close and prolonged exposure by coughing, sneezing and talking. TB has major health and social impacts for those affected and each infectious case represents a risk of onward transmission (Ref: Collaborative TB Strategy for England, 2015). It should be noted that the majority of TB cases are curable. TB is a notifiable disease in the UK; suspected and confirmed cases must be notified to Public Health England within 3 working days (see App 1: Guidance on notifying TB cases). 2. Purpose The purpose of this policy is to ensure that suspected or confirmed TB cases are managed in line with best practice and the risks of cross infection to patients, staff and others are minimised. 3. Definitions Contact tracing - Contact tracing is undertaken after notification of an active case of TB to find associated cases, to detect people infected but without evidence of disease (latent infection) and to identify those not infected and for whom BCG vaccination may be appropriate. Drug resistant TB M tuberculosis resistant to isoniazid, rifampicin, pyrazinamide or ethambutol. Extensively drug resistant TB (XDR TB) MDR TB and resistant to any fluoroquinolone and at least one of three injectable second- line drugs (i.e amikacin, kanamycin or capreomycin). Frequent - areas that routinely care for patients with suspected or confirmed TB. Page 5 of 30

Infrequent - areas that do not routinely care for patients with suspected or confirmed TB. Latent TB infection (LTBI) - is when a person has the bacteria that cause TB in their body but they are not causing any disease or symptoms, ie the bacteria are asleep or dormant. There is a chance that the bacteria may cause disease in the future. Multi- drug resistant TB (MDR- TB) M tuberculosis resistant to isoniazid and rifampicin; with or without resistance to other anti-tb drugs. Mycobacteria including M. tuberculosis are acid and alcohol fast. Acid and Alcohol Fast Bacilli (AAFB) are rod-shaped bacteria from which certain microscopy stains are not leached by treatment with acid and alcohol. Pulmonary tuberculosis A pulmonary case is defined as a case with TB involving the lungs and/or tracheo-bronchial tree, with or without extra-pulmonary TB diagnosis. Negative pressure isolation rooms are used for patients with an airborne transmitted disease. Airflow goes from the corridor into the patient's room and is vented to the outside. Respiratory Isolation is the physical separation of one patient from another in order to prevent the spread of infection and is used for diseases that are spread through particles that are exhaled. Tuberculosis (TB) is a contagious disease that can affect most parts of the body but is mainly an infection of the lungs. It is caused by a bacterial microorganism, the tubercle bacillus or Mycobacterium tuberculosis. 4. Duties The Chief Executive is responsible for ensuring that there are effective infection control arrangements in the Trust. Duties within the Organisation As a healthcare establishment, CHFT has a duty of care that is covered by the Health & Safety Act (1974), (HSE 2003), COSHH (HSE 2005) and the Health and Social Care Act (DH 2008). The management of Tuberculosis is covered in the compliance criteria 1-9 of this latter Act. Consultation and Communication with Stakeholders The Infection Prevention & Control Committee (IPCC), TB Clinical Leads and the Infection Prevention & Control Team (IPCT) have commented on and Page 6 of 30

contributed to this policy. The policy will be ratified at the IPCC and approved by the Executive Board (EB). 5. Management of TB The management of TB is a specialist area and should always be supervised by a respiratory physician (adult/paediatric). 6. Alert Signs and Symptoms for Pulmonary TB TB usually affects the lungs but can also affect almost any other area of the body. The condition usually develops slowly and it may take several months for symptoms to appear. The most common symptoms include: Shortness of breath Cough Unexplained loss of weight Loss of appetite Fever and night sweats Fatigue (Ref: gov.uk: Tuberculosis and other mycobacterial diseases ) Any CHFT staff member who develop symptoms suggestive of TB need to seek advice from their GP and report to Occupational Health Services as soon as possible. 7. Hospital Admission Patients with suspected or confirmed pulmonary TB should not be admitted to an open ward or bay. Please see Appendix 3 for assessment of isolation requirements. Please see Appendix 2 for location of negative pressure rooms, if required. If an infective TB patient has been nursed with other patients on a ward / bay, resulting in significant TB exposure (>8 hours), a risk assessment must be carried out. Public Health England (PHE) must be involved in the risk assessment process: See Appendix 4 Guide for the Risk Assessment of TB exposure incidents in hospitals. 8. Isolation of Patients The advice of the IPC Team should be sought. All patients with confirmed or suspected TB should be risk assessed for drug resistance. Please see section 11 for risk assessment for MDR-TB. Page 7 of 30

Patients without any identified risk factors for drug resistance will fall into the following categories: A. Clinically and/or radiologically suspected respiratory TB but sputum smear results awaited (on the basis of three samples see below). Respiratory TB is active TB affecting the lungs, pleural cavity, mediastinal lymph nodes, and/or larynx. B. Sputum or bronchoscopy smear (AAFB) positive tuberculosis on the basis of one or more samples. These patients should be considered significantly infectious. Any sputum smear positive (AAFB) should be assumed to be M. tuberculosis until confirmed otherwise. C. Smear negative sputum status is on the basis of three sputum samples collected at least 8 hours apart, with at least one being an early morning sample. Each sputum sample should be at least 5 mls, and obtained from a deep productive cough. Saliva and naso-pharyngeal secretions are not sputum. Patients who are sputum smear negative normally present a reduced risk of infection to others in hospital. Such patients may be managed on a standard ward according to standard IP&C precautions, but only if there are no immune-compromised patients present and there is no risk of MDR TB. This should be discussed and agreed with the IP&C Team. In hospital, any patient in categories A or B, including those initially sputum smear negative but sputum smear positive after bronchoscopy, should be isolated in a single room on a designated respiratory ward. Patients with suspected or confirmed multi-drug resistant TB must be isolated in a negative pressure room (see Appendix 1&2). In hospital, patients in category C normally present minimal or no risk of transmission; however any secretions or tissue from a tuberculosis disease site should be treated in the same way as sputum from a case of respiratory TB (see section 13). The door should be closed at all times except for necessary access. Patients in isolation should not visit communal or public areas of the ward or hospital, nor should they visit or pass through areas that may contain immune-suppressed patients. All staff are required to follow CHFT Isolation policy (Section K) when caring for patients within isolation. Respiratory hygiene/cough etiquette: Patients should use tissues to cover their mouth and nose when coughing/sneezing to contain respiratory secretions. Patients should dispose of tissues into an appropriate waste receptacle prior to discarding into an orange clinical waste bag. Patients should perform hand hygiene after contact with respiratory secretions and contaminated items. Page 8 of 30

All children with tuberculosis (of any site) and their visitors should be isolated from other patients until they have been screened and pronounced non-infectious. One of the visitors may be the source of the child s TB and pose a significant infection risk to other patients on the ward. Visitors should be limited to those who have already been in close contact with the patient before diagnosis (such as persons living in the same house). Children under two years of age should not visit unless the children have had significant contact with the patient and are being followed up as a close contact. Staff contact should be kept to a reasonable minimum without compromising patient care. Hands must be washed before and after contact with the patient and/or his/her environment. Standard Infection Prevention and Control Precautions (Infection Control Policies & Guidelines, Section C) must be maintained for all patients e.g. single use gloves and aprons where appropriate. All clinical waste should be disposed of via the hazardous waste stream i.e. the orange waste bags and placed in an appropriate storage area for collection and subsequent incineration. 9. Use of Masks Fit tested FFP 3 Masks are recommended for staff when: Exposure to large numbers of M. tuberculosis bacilli is possible, e.g. bronchoscopy and aerosol generating procedures, including chest physiotherapy, sputum induction and nebulisation. Prolonged (>8hrs/shift) high dependency care of a coughing patient. Entering the negative pressure room of an MDR TB patient (see section 11). All staff that frequently care for pulmonary TB patients should ensure they are fit tested for the FFP 3 masks prior to use. Areas that infrequently care for pulmonary TB patients are not required to fit test all staff but should have an identified fit test trainer to fit test staff if a suspected or confirmed pulmonary TB patient is admitted. Further information about fit testing can be found on the intranet under Influenza. If FFP 3 masks are urgently required, a very small stock is available in the Infection Prevention and Control Emergency Cupboard. At the earliest Page 9 of 30

opportunity the ward must ensure they have ordered and have an adequate supply of FFP3 masks. 10. Care and Management of Patients with Known or Suspected Multi-Drug Resistant Tuberculosis (MDR-TB), including Extensively Drug Resistant Tuberculosis (XDR-TB) Drug-resistant TB is an increasing problem in England (8) with numbers of cases of MDR TB increasing from 46 (1.2% of cases) in 2004 to 68 (1.6% of cases) in 2013 (4).(Ref: Collaborative TB Strategy for England 2015-2020: PHE, 2015). MDR-TB is not necessarily more infectious than a drug sensitive organism; however due to the reduced efficacy of the anti-tb regimes available an infectious patient can remain infectious for a much longer period of time with the consequences of transmission of MDR-TB greater. For infection prevention purposes XDR TB should be managed as for MDR-TB. Risk assessment for multi-drug resistance: NICE Guidance outlines the risk factors that should be considered for TB drug resistance and states that a risk assessment for drug resistance should be made for each patient with TB. 1. History of prior TB drug treatment; prior TB treatment failure 2. Contact with a known case of drug-resistant TB 3. Birth in a foreign country, particularly high-incidence countries as defined by Public Health England on its website: https://www.gov.uk/government/uploads/system/uploads/attachment_data/ file/581013/who_estimates_of_tuberculosis_incidence_by_country 201 5.pdf 4. HIV infection 5. Residence in London If any of the above circumstances are known to apply at, or discovered after, the time of patient admission, then MDR-TB precautions should be instituted. If any of the other circumstances are known on, or discovered after admission, a risk assessment must be carried out by a Respiratory Physician and MDR-TB precautions applied if considered necessary. If this risk assessment cannot be done expeditiously, then MDR-TB precautions should be applied until confirmed otherwise. Page 10 of 30

MDR-TB precautions Admission If in-patient care is necessary the patient must be admitted or transferred to one of the designated negative-pressure isolation rooms at Calderdale Royal Hospital without delay (See Appendix 2). Patients with MDR-TB take absolute priority in the allocation of these rooms. In order for the negative pressure to work correctly the isolation room door, en-suite door and window must remain closed. Cofely have the equipment to enable planned maintenance to be carried out on a six monthly basis in each negative pressure room to meet the recommendations in the HTM 03-01 Heating and Ventilation and HBN 4 supplement 1: Isolation Facilities in Acute Settings. Before the patient is admitted to the negative pressure room the ventilation and pressure record reading should be documented in the patient s notes and advice given as to whether the room is suitable for use. This information can be obtained from Cofely. Throughout the patient s stay, the negative pressure reading should be documented on a daily basis within the patient s notes. The IPCT, Consultant Chest Physician and if appropriate the TB physician who specialises in MDR-TB at St. James University Hospital, Leeds, must be informed of the admission as soon as possible. It is also advised the leading clinician inform the MDR-TB Service at the Liverpool Heart and Chest Hospital. Infection control management while the patient remains isolated: The patient must remain in his/her room at all times. The door must remain closed at all times, except for necessary access. Staff should only enter the room when necessary, without compromising the quality of patient care. Staff and visitors entering the room must wear a properly fitting FFP3 mask. Staff should follow the CHFT Standard Isolation Policy. Note: We cannot knowingly allow exposure to MDR-TB. Visitors who refuse to wear masks on the grounds that they have been, or may continue to be, exposed outside the hospital should not be prevented from visiting but such refusal should be documented. Disposable FFP3 masks once removed should be discarded and under no circumstances re-used. Page 11 of 30

Visitors should be restricted to those persons defined as "contacts" of the patient by the contact tracing procedure while the patient remains isolated. Wherever possible family members must be assessed by the TB team for possible active tuberculosis and declared non-infectious before being allowed to visit. Visitors who have yet to be assessed as above, and who have a persistent cough should be asked not to visit until declared clear as above. Respiratory hygiene/cough etiquette: Patients should receive active instruction and supplies to ensure they cover their mouth and nose when coughing/sneezing and use tissues to contain respiratory secretions. Provision should be made for patients to dispose of tissues into an appropriate waste receptacle prior to discarding into the orange (hazardous) waste stream. Provision should be made for patients to perform hand hygiene after contact with respiratory secretions and contaminated items. Standard precautions should be continued as with all isolated patients. Other precautions are not required e.g. disposable crockery. Visits to other areas for investigation or treatment If possible any investigations should be performed in the patient s room. If this is not feasible the patient should wear an FFP3 mask while outside their own room. Cough-inducing procedures should be avoided if at all possible, and if absolutely necessary must be performed in the patient s room which is at negative pressure. If it is necessary for the patient to go to Theatre e.g. for a line insertion, the Theatre pressure should be set to neutral. The IPCT should be contacted for advice on every occasion, where this does not unnecessarily delay or compromise patient treatment. Termination of isolation precautions Isolation as described above must be continued until the patient is declared noninfectious by the IPCT, Consultant Chest Physician and the CCDC or is discharged from the hospital. Discharge planning Full consideration must be given to any infection risk the patient may pose on discharge. The discharge plan should be made in consultation with the CCDC and Community Infection Prevention and Control Team/TB liaison staff of the Page 12 of 30

patient s area of residence as well as those involved in his or her management in hospital. Special arrangements may be needed for outpatient appointments or investigations and these should be decided by discussion between the relevant department, Consultant Chest Physician and the IP&CT. Re-admission Until declared otherwise, the patient should be considered infectious at each readmission and should be managed according to these guidelines The following sections apply to uncomplicated (sensitive) TB, drug resistant TB, MDR-TB and XDR-TB: 11. Transfer of Known or Suspected Pulmonary TB HCWs assisting with a patient transfer from standard isolation should use single apron and gloves. The Inter healthcare Infection Control Transfer Form should be completed for all patients being permanently transferred to another area (Infection Prevention and Control Policy for Bed Management and Movement of Patients section W/X). It is recommended that patients with suspected or confirmed but untreated pulmonary tuberculosis (sputum smear positive) should wear a mask when being transported through public or patient areas. All masks must be discarded after each use and hand hygiene performed. Patients with suspected or confirmed MDR-TB should wear an FFP3 mask when being transported through public areas. 12. Sputum Sputum and bronchoalveolar lavage (BAL) specimens from known or suspected TB patients should be labelled danger of infection and SHOULD NOT UNDER ANY CIRCUMSTANCES BE TRANSPORTED BY ANY AIR TUBE SYSTEM. Spillage of sputum should be dealt with as potentially infectious and disinfected according to the IPC Standard Precautions Policy (Section C). 13. Operating Theatres & Respiratory / Invasive Intervention If infectious TB is confirmed or suspected the patient should be placed last on the operating list. Consideration should be given as to whether the Page 13 of 30

procedure can be deferred (notably if involving a general anaesthetic) until the patient is deemed non-infectious. The operating theatre should be cleaned as normal following the list. If patients with confirmed or suspected respiratory TB require assisted ventilation in either ICU or theatre the ventilator should be fitted with a bacterial filter and as far as is practicable to isolate the patient. If patients require suction via an endotracheal tube or tracheostomy a closed suction system should be used. All respiratory equipment (endotracheal tubes, ventilator circuits etc.) must be single use. Bronchoscopes should be decontaminated according to agreed local policy for TB. These patients should be scoped at the end of the list. 14. Cough Inducing Procedures When TB is confirmed or suspected, cough inducing procedures and production of sputum should NEVER be performed on the open ward or bay. They should be performed in the isolation room with the door closed. 15. Death If a patient with confirmed or suspected TB of any type and from any body site dies the mortuary must be informed as soon as possible. The body should be placed in a cadaver bag with Danger of Infection stickers attached to the mortuary labels (Care of the Deceased Body, Section P). For notification after death, please see Section B Notifiable Diseases Policy. 16. Staff Screening/Immunity Staff should comply with Occupational Health Service procedure for screening and protection. In particular: Attending Occupational Health if they have been requested to do so. Staff who have been working clinically in countries with a high TB incidence (WHO definition >40 cases per hundred thousand): https://www.gov.uk/government/uploads/system/uploads/attachment_data/ file/581013/who_estimates_of_tuberculosis_incidence_by_country 201 5.pdf If staff are advised they require screening following exposure to an infectious TB case at work. Page 14 of 30

All healthcare workers must attend Occupational Health screening/immunisation for TB on commencement of employment or at any time when they may have reason to believe they have been exposed to TB. Staff who do not have evidence of protection/immunity should avoid contact with known or suspected cases of TB. Staff who have suppressed immunity MUST avoid contact with known or suspected cases of TB. Managers should ensure that staff comply with the above requirements. For further information please follow the link: http://www.nice.org.uk/guidance/ng33 If unsure of their status, staff should refer themselves to CHFT Occupational Health Service. 17. Notification Please see Appendix 1 for Guidance on notifying TB cases. For sputum smear positive patients especially if they have been in contact with children or others at a high risk of acquiring TB, the TB nurses should also be informed. This does NOT remove the need for statutory notification, but may enable quicker contact tracing. Patients with inadequately controlled TB may pose a significant infection risk to others, especially if they are sputum smear positive, and noncompliant with prescribed oral therapy, or have MDR-TB. The isolation of such patients is paramount to protect other individuals. In very occasional circumstances a Court Order restricting a patient s location/movements may be required in the interests of the wider public health. Any individual CHFT patient case where such legal restrictions might be required should be discussed with a CCDC (see Section 27). The IPCT should also be informed. If a staff member is suspected to have acquired TB during the course of their work at CHFT, this should be reported to the Health and Safety Executive as a disease identified under the Reporting of Injuries, Disease and Dangerous Occurrences Regulations (RIDDOR). A link to the list of notifiable diseases and the appropriate form is included below. Link: https://www.gov.uk/government/publications/notifiable-diseasesform-for-registered-medical-practitioners Page 15 of 30

18. Notification after Death Notification must include those patients diagnosed after death so their contacts can be screened. Notification should be made by the person making the diagnosis to the CCDC, who will then inform the TB Nurse of the index case s details. 19. Hospital Laundry Linen should be treated as normal unless visible body fluid contamination is present, then treat as infected i.e. red water soluble bag which should then be placed within a clear outer bag. 20. Termination of Isolation The decision to terminate isolation is made by the supervising physician in collaboration with the Infection Prevention and Control Team and the CCDC only. Uncomplicated (sensitive) pulmonary TB will become non-infectious after two weeks of compliant anti-tb therapy. The results of sputum cultures and the response to treatment will be taken into account. In the circumstances outlined below, three negative sputum smear examinations on successive days must be confirmed before removing a patient from isolation: If the patient was particularly infectious (infection transmitted to more than 10% of close household and/or casual contacts). If drug resistant disease is possible or confirmed (section 11). If the patient is to be transferred to an open ward containing immunecompromised or HIV positive patients. 21. Cleaning of the Isolation Room Post Patient Discharge/Death A terminal clean of the room (amber clean) should be carried out with a chlorine based disinfectant (e.g. Tristel). 22. Discharge from Hospital A management plan should be agreed between community and hospital staff before discharge. The amount of community and voluntary care input required will be decided on a case by case basis. Page 16 of 30

23. Close Contacts (Pulmonary TB) and Contact Tracing Close contact is an individual spending at least eight hours in close continuous contact with a proven infectious case. Contact tracing may be extended if a number of immediate contacts prove positive. Occasionally, a contact at work or in a hospital ward is close enough to be equivalent to a close continual contact. If the ward is informed of a suspected or confirmed TB case, please follow the guidance in Appendix 4 i.e. Guide for risk assessment of TB exposure incidents in hospitals. There is a table that can be used (Appendix 5) to record details of people who have come into contact with the index case. In general, procedures for close contacts should be completed within 2 to 6 weeks after notification of the index case except where repeat Mantoux testing is required. If the patient is MDR, then the contact should have an IGRA (interferon gamma release assay) this should be Quanteferon in the first instance. 24. Casual Contacts Most occupational contacts, including health care workers are considered to be casual contacts. Examination is only necessary if: The index case is smear positive and contacts are unusually susceptible, e.g. young children or immunocompromised adults. The index case is considered highly infectious as shown by transmission to more than 10% of close contacts. In an outbreak. 25. Management of Outbreaks & Incidents The Infection Prevention & Control Doctor (IPCD) has overall responsibility for co-ordinating the management of an outbreak of TB or an incident involving TB. Please see Appendix 4 for Standard Operating Procedure for the IPCD and the IPCN. The IPCD will co-ordinate immediate action to: Prevent or reduce the risk of further cases. Arrange collection and recording of microbiological and epidemiological information as required. Convene an urgent Outbreak Control Team (OCT) meeting. Page 17 of 30

26. Tuberculosis Management Contacts: Huddersfield Royal Infirmary TB Team Tel: 01484 344322 TB Nurse Specialist (in office hours) Mob: 07970 754219 TB Nurse Specialist (in office hours) Mob: 07534 265793 Calderdale Royal Hospital Lead TB Consultant s Secretary Tel: 01422 223122 Paediatric cases: Consultant Tel: 01422 224687 Consultant s secretary: Tel: 01422 224450 TB Team Tel: 01422 307307 Public Health England Consultant in Communicable Disease Control West Yorkshire HPU, Leeds Tel: 0113 3860300 Occupational Health Department Calderdale Royal Hospital Tel: 01422 222037 27. Training and Implementation Basic information regarding IPC precautions required when caring for patients with TB is included in the Right from the Start mandatory training sessions which should be attended by all staff commencing employment with CHFT who will work in a clinical area. The IPCT also delivers targeted training sessions to key personnel / areas including Link Infection Prevention and Control Practitioners in departments and wards across the Trust who will then cascade the information to appropriate colleagues within their area / departments. 28. Trust Equalities Statement Calderdale and Huddersfield NHS Foundation Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. We therefore aim to ensure that in both employment and services no individual is discriminated against by reason of their gender, gender reassignment, race, disability, age, sexual orientation, religion or religious/philosophical belief, marital status or civil partnership. Page 18 of 30

29. Process for Monitoring Compliance/Effectiveness If a patient cannot be isolated appropriately, an incident form must be completed by clinical staff and communicated to the IPCT. Records of non-availability of single rooms and hand hygiene audit compliance should be monitored by the Divisions. 30. References and Further Reading Annual TB Update 2015: Public Health England. London. March 2015. CDC. Notice to readers: revised definition of extensively drug-resistant tuberculosis. MMWR 2006; 55:1176. Collaborative Tuberculosis Strategy for England 2015-2020. Public Health England, NHS England. London. 2015. The Collaborative Tuberculosis Strategy for England 2015-2020 can be accessed via the link: https://www.gov.uk/government/publications/collaborativetuberculosis-strategy-for-england Communicable Disease Control Handbook. Dr J Hawker, Dr N Begg, Dr I Blair, Dr R Reintjes and Professor J Weinbert. Blackwell Science Ltd 2001. Health and Safety Executive. A guide to the Reporting of Injuries, Disease and Dangerous Occurrences Regulations 1995. HSE Reprinted with amendments 2009. The Interdepartmental Working Group on Tuberculosis. The Prevention and Control of Tuberculosis in the United Kingdom: Recommendations for the Prevention and Control of Tuberculosis at Local Level. Department of Health and the Welsh Office, 1996. The Interdepartmental Working Group on Tuberculosis. The Prevention and Control of Tuberculosis in the United Kingdom: UK Guidance on the Prevention and Control of Transmission of: 1. HIV-related Tuberculosis 2. Drug-resistant, Including Multiple Drug-resistant, Tuberculosis. Department of Health, the Scottish Office and the Welsh Office, 1998. Joint Tuberculosis Committee of the British Thoracic Society. Chemotherapy and management of tuberculosis in the United Kingdom: recommendations. Thorax 1998; 53: 536-548. Joint Tuberculosis Committee of the British Thoracic Society. Control and prevention of tuberculosis in the United Kingdom: Code of practice 2000. Thorax 2000; 55:887-901. Page 19 of 30

National Collaborating Centre for Chronic Conditions. Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control. London: Royal College of Physicians, 2006. Patientleaflet:https://www.gov.uk/government/uploads/system/uploads/attachme nt_data/file/363765/8584_tb_the_disease_leaflet_2014_01_.pdf PHE (2014) Tuberculosis in the UK: 2014 report. Public Health London. England. London. Public Health England TB Strategy Monitoring Indicators Tool: http://fingertips.phe.org.uk/profile/tb-monitoring Pratt RJ, Grange JM, Williams VG (2005) Tuberculosis: A Foundation for Nursing and Healthcare practice for Nursing and healthcare practice. Hodder Arnold: London: Chapter 17. Tuberculosis: Clinical Diagnosis and Management of Tuberculosis and Measures for its Prevention and Control; (2011); National Institute for Health and Clinical Excellence; London. (www.nice.org.uk/guidance/cg117/chapter/1-guidance). Tuberculosis (TB) and other Mycobacterial diseases: diagnosis, screening, management and data. https://www.gov.uk/government/collections/tuberculosis-and-othermycobacterial-diseases-diagnosis-screening-management-anddata#screening Ventilation in Healthcare Premises: Please follow the link below for more information about ventilation in healthcare premises HTM 03-01 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/ 144029/HTM_03-01_Part_A.pdf World Health Organisation. Anti-tuberculosis drug resistance in the world - Fourth Global Report. Geneva. 2008. [Last accessed on 02/10/09] Available via the world wide web :> http://www. WHO/HTM/TB/2008.394. World Health Organisation: Post-2015 Global TB Strategy: www.who.int/tb/post2015_strategy/en/ Page 20 of 30

Guidance on notifying Tuberculosis cases Appendix 1 Page 21 of 30

Appendix 2 Location of Negative Pressure Rooms at Calderdale Royal Hospital Total number of negative pressure rooms = 26 Ward 1-1D Room 074 Ward 2-2C Room 073 2D Room 072 Ward 3C - Room 005 Ward 4-4C Room 071, 075 4D Room 094 Ward 5-5C Rooms 068, 054, 072, 058 5D Rooms 073, 069 Ward 6-6C Room 074 6D Room 075 Ward 7-7C Room 072 7D Room 073 Ward 8-8C Room 074 8D Room 073 SCBU - Rooms 015, 016 ICU/HDU - Rooms 006, 013, 015, 025 CCU - Room 013 NB: There are NO negative pressure rooms at HRI. If patients require negative pressure facilities, arrangements must be made to transfer the patient to CRH as soon as possible. Page 22 of 30

Assessment of Isolation Requirements (applies to pulmonary TB only). (as per NICE Guidelines March 2011) Appendix 3 Pulmonary TB: culture positive but sputum smear negative for AAFB, asymptomatic patient, fully compliant with TB treatment Suspected or confirmed smear positive respiratory TB from one or more of 3 respiratory samples, no risk for MDR TB Sputum TB smear positive with risk factors for MDR-TB, or confirmed MDR- TB Patient is unlikely to need isolation in a single room. Transfer immunosuppressed people e.g. those who are HIV positive to another area. Isolate in a single room with the door closed; transfer those who are immunosuppressed to another ward or isolate the infectious patient in a negative pressure room. Refer to specialist centre with facilities for isolation in a negative pressure room (CRH or Leeds if the patient is also HIV +ve) Transfer immunosuppressed patients to another area in the interim period. Risk assessment for multi-drug resistance: 1. History of prior TB drug treatment; prior TB treatment failure 2. Contact with a known case of drug-resistant TB 3. Birth in a foreign country, particularly high-incidence countries as defined by Public Health England on its website: https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil e/393840/worldwide_tb_surveillance_2013_data_high_and_low_incidenc e_tables 2_.pdf *High incidence rate is estimated incidence rate of 40 per 100,000 or greater. 4. HIV infection 5. Residence in London Page 23 of 30

Appendix 4 Page 24 of 30

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Contact Tracing In collaboration with the IPCT, the Ward Manager is required to collate a list of patient contacts. Initial risk assessment would take place between an IPCN, the patient s clinical team and the CHFT Microbiologist. This list is then passed onto the TB team to contact patients. Risk assessment should be as per Appendix 4. The IPCT or TB Specialist Nurses will advise ward or work area manager to collate a list of staff potentially exposed to the patient with undiagnosed pulmonary tuberculosis. It is important the list does not exclude health care workers such as physiotherapists. The list does not need to consider the degree of risk to each individual health care worker. Information about the signs and symptoms of TB and the action to be taken if these occur, will be cascaded to staff via the Ward Manager, Matron and the TB Team. Any required follow-up of patient (or visitor) contacts (including provision of Inform and Advise information) will be done via the CHFT Chest Clinic. Page 28 of 30

UNIQUE IDENTIFER NO: C-67-2013 Review Date: June 2015 Review Lead: Lead Infection Prevention & Control Nurse Patients Who Have Come into Contact with Index Case Appendix 5 Index case- Initials and Unit Number. Ward/Department. Admission Date.. Discharge Date. Patients Name Date of Admission Patients Address Unit Number DOB Consultant Date of Discharge Discharged To 30

UNIQUE IDENTIFER NO: C-67-2013 Review Date: June 2015 Review Lead: Lead Infection Prevention & Control Nurse Appendix 6 Standard Operating Procedure for Contact Tracing of hospital inpatients IPCN alerted via ICNet, the Lab or the Microbiologist of an AAFB positive sputum smear/culture IPCN to contact the ward to ensure respiratory precautions are in place or to organise respiratory isolation if required. IPCN to take Care Plan to the ward; document actions in patient notes and on ICNet. If patient has been isolated since admission then no contact tracing is required. Complete, or ask ward staff to complete the contact trace list (App 5) for: Patients who have been in contact with the index case >8hrs; staff in close contact with the index case; staff who have performed aerosol generating procedures without appropriate PPE (see guidance p 27). Inform the TB Specialist Nurses of the index patient and the results. If a contact list has been generated, pass on to the TB nurses. If the list includes staff members, pass on to the Occupational Health Department. The IPCD will be informed of smear/culture results and the reference laboratory results and will convene an incident/outbreak meeting dependent upon these. 31