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Persons using assistive technology might not be able to fully access information in this file. Please note: This report has been corrected and replaces the electronic PDF version that was published on December 30, 2005. The material in this report originated in the National Center for HIV, STD, and TB Prevention, Kevin Fenton, MD, PhD, Director; and the Division of Tuberculosis Elimination, Kenneth G. In 1994, CDC published the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, 1994. The TB infection-control measures recommended by CDC in 1994 were implemented widely in health-care facilities in the United States. Given the changes in epidemiology and a request by the Advisory Council for the Elimination of Tuberculosis (ACET) for review and update of the 1994 TB infection-control document, CDC has reassessed the TB infection-control guidelines for health-care settings. In 1994, CDC published the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health Care Facilities, 1994 (1). The 1994 guidelines, which followed CDC statements issued in 1982 and 1990 (1,6,7), presented recommendations for TB infection control based on a risk assessment process. The TB infection-control measures recommended by CDC in 1994 were implemented widely in health-care facilities nationwide (8–15). Despite the general decline in TB rates in recent years, a marked geographic variation in TB case rates persists, which means that HCWs in different areas face different risks (10).
Given the changes in epidemiology and a request by the Advisory Council for the Elimination of Tuberculosis (ACET) for review and updating of the 1994 TB infection-control document, CDC has reassessed the TB infection-control guidelines for health-care settings. CDC prepared the guidelines in this report in consultation with experts in TB, infection control, environmental control, respiratory protection, and occupational health.
The risk assessment process includes the assessment of additional aspects of infection control.
The term "tuberculin skin tests" (TSTs) is used instead of purified protein derivative (PPD). The frequency of TB screening for HCWs has been decreased in various settings, and the criteria for determination of screening frequency have been changed. The scope of settings in which the guidelines apply has been broadened to include laboratories and additional outpatient and nontraditional facility-based settings. These recommendations usually apply to an entire health-care setting rather than areas within a setting. New terms, airborne infection precautions (airborne precautions) and airborne infection isolation room (AII room), are introduced. Recommendations for annual respirator training, initial respirator fit testing, and periodic respirator fit testing have been added. Information on ultraviolet germicidal irradiation (UVGI) and room-air recirculation units has been expanded.
In accordance with relevant local, state, and federal laws, implementation of all recommendations must safeguard the confidentiality and civil rights of all HCWs and patients who have been infected with M. The 1994 CDC guidelines were aimed primarily at hospital-based facilities, which frequently refer to a physical building or set of buildings. Inpatient settings include patient rooms, emergency departments (EDs), intensive care units (ICUs), surgical suites, laboratories, laboratory procedure areas, bronchoscopy suites, sputum induction or inhalation therapy rooms, autopsy suites, and embalming rooms. Outpatient settings include TB treatment facilities, medical offices, ambulatory-care settings, dialysis units, and dental-care settings. In addition, HCWs who perform any of the following activities should also be included in the TB screening program. In the United States, LTBI has been diagnosed traditionally based on a PPD-based TST result after TB disease has been excluded. Additional cytokine-based immunoassays are under development and might be useful in the diagnosis of M.
Close contacts are persons who share the same air space in a household or other enclosed environment for a prolonged period (days or weeks, not minutes or hours) with a person with pulmonary TB disease (39).
In addition to close contacts, the following persons are also at higher risk for exposure to and infection with M. HCWs with unprotected exposure to a patient with TB disease before the identification and correct airborne precautions of the patient. Certain populations who are medically underserved and who have low income, as defined locally.
Populations at high risk who are defined locally as having an increased incidence of TB disease. Persons who use tobacco or alcohol (40,41), illegal drugs, including injection drugs and crack cocaine (42–47), might also be at increased risk for infection and disease. HIV infection is the greatest risk factor for progression from LTBI to TB disease (22,39,48,49). All HCWs should be informed regarding the risk for developing TB disease after being infected with M.
The percentage of patients with TB disease who are HIV-infected is decreasing in the United States because of improved infection-control practices and better diagnosis and treatment of both HIV infection and TB. Vaccination with BCG probably does not affect the risk for infection after exposure, but it might decrease the risk for progression from infection with M. Inadequate local or general ventilation that results in insufficient dilution or removal of infectious droplet nuclei. Of the reported TB outbreaks in health-care settings, multiple outbreaks involved transmission of MDR TB strains to both patients and HCWs (56,57,70,87,91–94).
After the release of the 1994 CDC infection-control guidelines, increased implementation of recommended infection-control measures occurred and was documented in multiple national surveys (13,15,98,99). Less information is available regarding the implementation of CDC-recommended TB infection-control measures in settings other than hospitals. All health-care settings need a TB infection-control program designed to ensure prompt detection, airborne precautions, and treatment of persons who have suspected or confirmed TB disease (or prompt referral of persons who have suspected TB disease for settings in which persons with TB disease are not expected to be encountered). The first and most important level of TB controls is the use of administrative measures to reduce the risk for exposure to persons who might have TB disease. The second level of the hierarchy is the use of environmental controls to prevent the spread and reduce the concentration of infectious droplet nuclei in ambient air.
Secondary environmental controls consist of controlling the airflow to prevent contamination of air in areas adjacent to the source (AII rooms) and cleaning the air by using high efficiency particulate air (HEPA) filtration or UVGI. Every health-care setting should have a TB infection-control plan that is part of an overall infection-control program. The TB infection-control program should consist of administrative controls, environmental controls, and a respiratory-protection program. Assign supervisory responsibility for the TB infection-control program to a designated person or group with expertise in LTBI and TB disease, infection control, occupational health, environmental controls, and respiratory protection. Develop a written TB infection-control plan that outlines a protocol for the prompt recognition and initiation of airborne precautions of persons with suspected or confirmed TB disease, and update it annually. Conduct a problem evaluation (see Problem Evaluation) if a case of suspected or confirmed TB disease is not promptly recognized and appropriate airborne precautions not initiated, or if administrative, environmental, or respiratory-protection controls fail.
Perform a contact investigation in collaboration with the local or state health department if health-care–associated transmission of M. Collaborate with the local or state health department to develop administrative controls consisting of the risk assessment, the written TB infection-control plan, management of patients with suspected or confirmed TB disease, training and education of HCWs, screening and evaluation of HCWs, problem evaluation, and coordination.
Implement and maintain environmental controls, including AII room(s) (see Environmental Controls). Perform ongoing training and education of HCWs (see Suggested Components of an Initial TB Training and Education Program for HCWs).
Create a plan for accepting patients who have suspected or confirmed TB disease if they are transferred from another setting. Settings in which TB patients might stay before transfer should still have a TB infection-control program in place consisting of administrative, environmental, and respiratory-protection controls. Develop a written TB infection-control plan that outlines a protocol for the prompt recognition and transfer of persons who have suspected or confirmed TB disease to another health-care setting. Conduct a problem evaluation (see Problem Evaluation) if a case of suspected or confirmed TB disease is not promptly recognized, separated from others, and transferred.
Perform an investigation in collaboration with the local or state health department if health-care–associated transmission of M.
Collaborate with the local or state health department to develop administrative controls consisting of the risk assessment and the written TB infection-control plan. Every health-care setting should conduct initial and ongoing evaluations of the risk for transmission of M.
Review the community profile of TB disease in collaboration with the state or local health department. Consult the local or state TB-control program to obtain epidemiologic surveillance data necessary to conduct a TB risk assessment for the health-care setting. Review the number of patients with suspected or confirmed TB disease who have been encountered in the setting during at least the previous 5 years. Determine if persons with unrecognized TB disease have been admitted to or were encountered in the setting during the previous 5 years. Determine which HCWs need to be included in a TB screening program and the frequency of screening (based on risk classification) (Appendix C). Ensure the prompt recognition and evaluation of suspected episodes of health-care–associated transmission of M. Identify areas in the setting with an increased risk for health-care–associated transmission of M. Determine the types of environmental controls needed other than AII rooms (see TB Airborne Precautions). Review the community profile of TB disease in collaboration with the local or state health department. Determine if persons with unrecognized TB disease were encountered in the setting during the previous 5 years.
Determine the types of environmental controls that are currently in place, and determine if any are needed in the setting (Appendices A and D). Document procedures that ensure the prompt recognition and evaluation of suspected episodes of health-care–associated transmission of M. Risk classification should be used as part of the risk assessment to determine the need for a TB screening program for HCWs and the frequency of screening (Appendix C).
The three TB screening risk classifications are low risk, medium risk, and potential ongoing transmission. The classification of medium risk should be applied to settings in which the risk assessment has determined that HCWs will or will possibly be exposed to persons with TB disease or to clinical specimens that might contain M.
If uncertainty exists regarding whether to classify a setting as low risk or medium risk, the setting typically should be classified as medium risk.
All HCWs should receive baseline TB screening upon hire, using two-step TST or a single BAMT to test for infection with M. The classification of potential ongoing transmission should be used as a temporary classification only.
The following hypothetical situations illustrate how assessment data are used to assign a risk classification. HCWs transferring from low- or medium-risk settings to settings with a temporary classification of potential ongoing transmission. Calculate a conversion rate by dividing the number of conversions among HCWs in the setting in a specified period (numerator) by the number of HCWs who received tests in the setting over the same period (denominator) multiplied by 100 (see Use of Conversion Test Data for M.
Conversion rates above the baseline level (which will be different in each setting) should instigate an investigation to evaluate the likelihood of health-care–associated transmission. Evaluation of HCWs for LTBI should include information from a serial testing program, but this information must be interpreted as only one part of a full assessment. Annual evaluations of the TB infection-control plan are needed to ensure the proper implementation of the plan and to recognize and correct lapses in infection control.
Number of visits to outpatient setting from the start of symptoms until TB disease was suspected (for outpatient settings). Work practices related to airborne precautions should be observed to determine if employers are enforcing all practices, if HCWs are adhering to infection-control policies, and if patient adherence to airborne precautions is being enforced. Data from the most recent environmental evaluation should be reviewed to determine if recommended environmental controls are in place (see Suggested Components of an Initial TB Training and Education Program for HCWs). Environmental control maintenance procedures and logs should be reviewed to determine if maintenance is conducted properly and regularly. Environmental control design specifications should be compared with guidelines from the American Institute of Architects (AIA) and other ventilation guidelines (117,118) (see Risk Classification Examples) and the installed system performance. Environmental data should be used to assist building managers and engineers in evaluating the performance of the installed system. The number of AII rooms should be suitable for the setting based on AIA Guidelines and the setting risk assessment. Symptoms and signs of TB disease and the importance of a high index of suspicion for patients or HCWs with these symptoms.
Indications for initiation of airborne precautions of inpatients with suspected or confirmed TB disease. Principles of treatment for LTBI and for TB disease (indications, use, effectiveness, and potential adverse effects).
Rationale for infection-control measures and documentation evaluating the effect of these measures in reducing occupational TB risk exposure and M. Responsibility of HCWs to promptly report a diagnosis of TB disease to the setting's administration and infection-control program.
Responsibility of clinicians and the infection-control program to report to the state or local health department a suspected case of TB disease in a patient (including autopsy findings) or HCW.
Responsibilities and policies of the setting, the local health department, and the state health department to ensure confidentiality for HCWs with TB disease or LTBI.
Responsibility of the setting to inform EMS staff who transported a patient with suspected or confirmed TB disease.
Responsibilities and policies of the setting to ensure that an HCW with TB disease is noninfectious before returning to duty. Importance of completing therapy for LTBI or TB disease to protect the HCW's health and to reduce the risk to others. Proper implementation and monitoring of environmental controls (see Environmental Controls). Required Occupational Safety and Health Administration (OSHA) record keeping on HCW test conversions for M. Proper use of (see Respiratory Protection) and the need to inform the infection-control program of factors that might affect the efficacy of respiratory protection as required by OSHA.


Success of adherence to infection-control practices in decreasing the risk for transmission of M. Available tests and counseling and referrals for persons with HIV infection, diabetes, and other immunocompromising conditions associated with an increased risk for progression to TB disease. Procedures for informing employee health or infection-control personnel of medical conditions associated with immunosuppression. Role of the local and state health department's TB-control program in screening for LTBI and TB disease, providing treatment, conducting contact investigations and outbreak investigations, and providing education, counseling, and responses to public inquiries. Availability of information, advice, and counseling from community sources, including universities, local experts, and hotlines. Responsibility of the setting's clinicians and infection-control program to promptly report to the state or local health department a case of suspected TB disease or a cluster of TST or BAMT conversions. Responsibility of the setting's clinicians and infection-control program to promptly report to the state or local health department a person with suspected or confirmed TB disease who leaves the setting against medical advice.
The primary TB risk to HCWs is the undiagnosed or unsuspected patient with infectious TB disease.
Within health-care settings, protocols should be implemented and enforced to promptly identify, separate from others, and either transfer or manage persons who have suspected or confirmed infectious TB disease. A diagnosis of respiratory TB disease should be considered for any patient with symptoms or signs of infection in the lung, pleura, or airways (including larynx), including coughing for ?3 weeks, loss of appetite, unexplained weight loss, night sweats, bloody sputum or hemoptysis, hoarseness, fever, fatigue, or chest pain.
Immunocompromised persons, including those who are HIV-infected, with infectious TB disease should be physically separated from other persons to protect both themselves and others. Within health-care settings, TB airborne precautions should be initiated for any patient who has symptoms or signs of TB disease, or who has documented infectious TB disease and has not completed antituberculosis treatment. The classification of the risk assessment of the health-care setting is used to determine how many AII rooms each setting needs, depending on the number of TB patients examined.
Settings that plan to evaluate and manage patients with TB disease should have at least one AII room or enclosure that meets AII requirements (see Environmental Controls; and Supplement, Environmental Controls). Settings in which patients with suspected or confirmed TB disease are not expected to be encountered do not need an AII room or a respiratory-protection program for the prevention of transmission of M. I’ve talked before about some alternative growing systems, but I want to use an article I just read as an excuse to cover them again. Nowadays when you talk about hydroponics, mist people think about illegitimate uses for the method, generally oriented around growing pot. Generally speaking, most hydroponics systems consist of growing beds, a growing medium, nutrient solution, and water. Aquaponics is quite similar to hydroponics, but it addresses a major drawback of hydroponics. Aquaponics doesn’t eliminate the need for external input into the growing system, but it definitely reduces it to something that most people can handle on their own, which is important for sustainability. So this post was triggered by reading an article from Fast Company about a guy who is using shipping containers to house portable hydroponics solutions. I have also thought of an off-grid setup, either as a proof of concept, or just to save some in electricity costs. I stumbled upon this link a while ago written by an electrical engineer who decided to live off grid. It would be a fun experiment to get a few car batteries, solar panels, this battery desulfator and see how self sufficient the system could be. You could even grow duckweed to feed the fish with, the only input after setup would be light from the sun!
The size of the tie is a factor that sometimes becomes an important criterion in selection. SettingSetting a tie involves tightening all parts of the tie so that all of the rope parts touch, grab, and cause friction upon other parts of the tie so as to render it secure. Figure Eight Follow ThroughThe Figure Eight Follow Through can be used as a primary end-line rigging around an anchor, such as a tree. In-Line Figure EightThe In-Line Figure Eight is a directional knot and when it is running or sliding, trips trough pulleys easier and over tree limbs more easily. Double Overhand BendTheDouble Overhand bendis a good bend to use to form endless loops of rope. Prusik HitchThe Prusik hitch is primarily a gripping friction tie and the one most often referred to when speaking of a friction tie.
Clove HitchA clove hitch can be useful for tying around objects for hoisting, or as anchor. Standing at only 30 cm (12 in.) tall, meerkats, also known as suricats, depend on group cooperation to survive in the Kalahari Desert.
These family groups, called gangs or mobs, are led by an alpha pair, with the female being the most dominant. The meerkat is not currently endangered and is considered at lower risk of becoming endangered by the IUCN. You can help meerkats by spreading awareness of their vital role in the Kalahari’s ecological balance.
With this adorable baby onesie by Grizzly Bear Greetings, your baby's legs become the sloth's legs!
Jensen, PhD, Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, 1600 Clifton Rd., NE, MS E-10, Atlanta, GA 30333. The guidelines were issued in response to 1) a resurgence of tuberculosis (TB) disease that occurred in the United States in the mid-1980s and early 1990s, 2) the documentation of several high-profile health-care–associated (previously termed "nosocomial") outbreaks related to an increase in the prevalence of TB disease and human immunodeficiency virus (HIV) coinfection, 3) lapses in infection-control practices, 4) delays in the diagnosis and treatment of persons with infectious TB disease, and 5) the appearance and transmission of multidrug-resistant (MDR) TB strains.
The result has been a decrease in the number of TB outbreaks in health-care settings reported to CDC and a reduction in health-care–associated transmission of Mycobacterium tuberculosis to patients and health-care workers (HCWs).
This report updates TB control recommendations reflecting shifts in the epidemiology of TB, advances in scientific understanding, and changes in health-care practice that have occurred in the United States during the preceding decade. The guidelines were issued in response to 1) a resurgence of tuberculosis (TB) disease that occurred in the United States in the mid-1980s and early 1990s, 2) the documentation of multiple high-profile health-care–associated (previously "nosocomial") outbreaks related to an increase in the prevalence of TB disease and human immunodeficiency virus (HIV) coinfection, 3) lapses in infection-control practices, 4) delays in the diagnosis and treatment of persons with infectious TB disease (2,3), and 5) the appearance and transmission of multidrug-resistant (MDR) TB strains (4,5).
In this process, health-care facilities were classified according to categories of TB risk,with a corresponding series of environmental and respiratory-protection control measures. As a result, a decrease has occurred in 1) the number of TB outbreaks in health-care settings reported to CDC and 2) health-care–associated transmission of M. This report updates TB-control recommendations, reflecting shifts in the epidemiology of TB (27), advances in scientific understanding, and changes in health-care practice that have occurred in the United States in the previous decade (28). This report replaces all previous CDC guidelines for TB infection control in health-care settings (1,6,7). Other settings in which suspected and confirmed TB patients might be encountered might include cafeterias, general stores, kitchens, laundry areas, maintenance shops, pharmacies, and law enforcement settings. Part time, temporary, contract, and full-time HCWs should be included in TB screening programs. A suspect TB patient is a person in whom a diagnosis of TB disease is being considered, whether or not antituberculosis treatment has been started.
However, because of multiple other potential risk factors that commonly occur among such persons, use of these substances has been difficult to identify as separate risk factors.
Therefore, voluntary HIV counseling, testing, and referral should be routinely offered to all persons at risk for LTBI (1,50,51). With increased voluntary HIV counseling and testing and the increasing use of treatment for LTBI, TB disease will probably continue to decrease among HIV-infected persons in the United States (58).
The majority of the patients and certain HCWs were HIV-infected, and progression to TB and MDR TB disease was rapid. In a survey of approximately 1,000 hospitals, a TST program was present in nearly all sites, and 70% reported having an AII room (13). One study identified major barriers to implementation that contribute to the costs of a TST program in health departments and hospitals, including personnel costs, HCWs' time off from work for TST administration and reading, and training and education of HCWs (100).
Such a program is based on a three-level hierarchy of controls, including administrative, environmental, and respiratory protection (86,107,108). In addition, HCWs with TB disease should be allowed to return to work when a physician knowledgeable and experienced in managing TB disease determines that HCWs are noninfectious (see Treatment Procedures for LTBI and TB Disease).
The specific details of the TB infection-control program will differ, depending on whether patients with suspected or confirmed TB disease might be encountered in the setting or whether patients with suspected or confirmed TB disease will be transferred to another health-care setting.
Every setting in which services are provided to persons who have suspected or confirmed infectious TB disease, including laboratories and nontraditional facility-based settings, should have a TB infection-control plan. Give the supervisor or supervisory body the support and authority to conduct a TB risk assessment, implement and enforce TB infection-control policies, and ensure recommended training and education of HCWs. The plan should indicate procedures to follow to separate persons with suspected or confirmed infectious TB disease from other persons in the setting until the time of transfer. The risk classification for the setting should help to make this determination, depending on the number of TB patients examined. The classification of low risk should be applied to settings in which persons with TB disease are not expected to be encountered, and, therefore, exposure to M. If greater than or equal to six TB patients for the preceding year, classify as medium risk. If greater than or equal to three TB patients for the preceding year, classify as medium risk. The risk classifications are for settings in which patients with suspected or confirmed infectious TB disease are expected to be encountered.
A hospital located in a large city admits 35 patients with TB disease per year, uses QFT-G to measure M. The setting is an ambulatory-care center associated with a large health maintenance organization (HMO). A home health-care agency employs 125 workers, many of whom perform duties, including nursing, physical therapy, and basic home care.
Infection-control plans should address HCWs who transfer from one health-care setting to another and consider that the transferring HCWs might be at an equivalent or higher risk for exposure in different settings.
TST or BAMT conversion criteria for administrative (surveillance) purposes are not applicable for medical evaluation of HCWs for the diagnosis of LTBI (see Supplement, Surveillance and Detection of M. Previous hospital admissions and outpatient visits of patients with TB disease should be noted before the onset of TB symptoms. Data from the case reviews and observations in the annual risk assessment should be used to determine the need to modify 1) protocols for identifying and initiating prompt airborne precautions for patients with suspected or confirmed infectious TB disease, 2) protocols for patient management, 3) laboratory procedures, or 4) TB training and education programs for HCWs. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has adapted the AIA guidelines when accrediting facilities (118). A high index of suspicion for TB disease and rapid implementation of precautions are essential to prevent and interrupt transmission.
The index of suspicion for TB disease will vary by geographic area and will depend on the population served by the setting.
Patients with symptoms suggestive of undiagnosed or inadequately treated TB disease should be promptly referred so that they can receive a medical evaluation.
For patients placed in AII rooms because of suspected infectious TB disease of the lungs, airway, or larynx, airborne precautions may be discontinued when infectious TB disease is considered unlikely and either 1) another diagnosis is made that explains the clinical syndrome or 2) the patient has three consecutive, negative AFB sputum smear results (109–112,123). At least one AII room is needed for settings in which TB patients stay while they are being treated, and additional AII rooms might be needed depending on the magnitude of patient-days of persons with suspected or confirmed TB disease (118).
These settings should develop written policies that specify 1) indications for airborne precautions, 2) persons authorized to initiate and discontinue airborne precautions, 3) specific airborne precautions, 4) AII room-monitoring procedures, 5) procedures for managing patients who do not adhere to airborne precautions, and 6) criteria for discontinuing airborne precautions. If a patient has suspected or confirmed TB disease, airborne precautions should be promptly initiated. Hydroponics uses a mineral nutrient solution in water to grow plants without any sort of soil.
The growing medium helps the roots have something to grab onto, and can hang onto some of the nutrients after the nutrient system has receded somewhat. The growing medium sits in a growing bed, which is periodically flooded with the water containing the nutrient solution. Here’s some resources of various types that you can check out for more information or even instructions on how to do it yourself. In hydroponic systems, you’re dependant upon nutrient solutions that come from outside the growing system. Tilapia in particular can be fed duckweed, which can be grown in the hydroponics system, which helps reduce the overal systems input required.
It’s a lot easier to find duckweed for tilapia or worms and bugs for trout than it is to find a chemical nutrient solution for a hydroponics system.
The system provides the exact amount of water, lights, and nutrients that a crop requires–so there is no wasted energy (though the pods are still hooked up to the power grid).
The rigger ties off the ropes and pads, and weighs the advantages and disadvantages of one tie-off point over others. It is the basic necessary knot that forms the Figure Eight on a Bight, Figure Eight Bend, Double Figure Eight, and the In-line Figure Eight.By itself it is often used as a stopper so a rappeller or piece of gear won't slide past the knotted point. If back-up rigging is employed, an In-line Figure Eight makes an easily adjustable first knot.
One meerkat will stand on its hind legs, propped up by its tail, and act as a lookout while the rest of the mob is outside looking for food and frolicking in the sun. Dark patches around their eyes help them be effective lookouts by reducing the glare of the sun, much like a baseball player who paints dark lines beneath his eyes.
Their dark-skinned bellies are covered with only a thin layer of fur, allowing the meerkats warm themselves by lying face up in the sun. Their diet mostly consists of insects, which they sniff out using their enhanced sense of smell.
That said, by no means should they be disregarded; they play an important part in maintaining ecological harmony in the desert.
You can also support the Meerkat Magic Conservation Project, which uses funds raised through eco-tourism to subsidize landowners and farmers. The 1994 guidelines, which followed statements issued in 1982 and 1990, presented recommendations for TB-infection control based on a risk assessment process that classified health-care facilities according to categories of TB risk, with a corresponding series of administrative, environmental, and respiratory-protection control measures. Concurrent with this success, mobilization of the nation's TB-control programs succeeded in reversing the upsurge in reported cases of TB disease, and case rates have declined in the subsequent 10 years. Primary references citing evidence-based science are used in this report to support explanatory material and recommendations. In certain settings, this change will decrease the number of HCWs who need serial TB screening. Setting has been chosen instead of "facility" to expand the scope of potential places for which these guidelines apply (Appendix A).
All HCWs who have duties that involve face-to-face contact with patients with suspected or confirmed TB disease (including transport staff) should be included in a TB screening program. Future FDA-licensed products in combination with CDC-issued recommendations might provide additional diagnostic alternatives.


The risk for progression of LTBI to TB disease is highest during the first several years after infection (36–38).
Health-care settings should be particularly aware of the need for preventing transmission of M. Although HIV infection increases the likelihood of progression from LTBI to TB disease (39,49), whether HIV infection increases the risk for becoming infected if exposed to M. The magnitude of the risk varies by setting, occupational group, prevalence of TB in the community, patient population, and effectiveness of TB infection-control measures.
Factors contributing to these outbreaks included delayed diagnosis of TB disease, delayed initiation and inadequate airborne precautions, lapses in AII practices and precautions for cough-inducing and aerosol-generating procedures, and lack of adequate respiratory protection.
Other surveys have documented improvement in the proportion of AII rooms meeting CDC criteria and proportion of HCWs using CDC-recommended respiratory protection and receiving serial TST (15,98). In the United States, the problem of MDR TB, which was amplified by health-care–associated transmission, has been substantially reduced by the use of standardized antituberculosis treatment regimens in the initial phase of therapy, rapid drug-susceptibility testing, directly observed therapy (DOT), and improved infection-control practices (1).
These control levels also reduce, but do not eliminate, the risk for exposure in the limited areas in which exposure can still occur.
Implementation of the TB infection-control guidelines described in this document is essential for preventing and controlling transmission of M.
Administrators making this distinction should obtain medical and epidemiologic consultation from state and local health departments. Evaluate the plan annually, if possible, to ensure that the setting remains one in which persons who have suspected or confirmed TB disease are not encountered and that they are promptly transferred.
The TB risk assessment determines the types of administrative, environmental, and respiratory-protection controls needed for a setting and serves as an ongoing evaluation tool of the quality of TB infection control and for the identification of needed improvements in infection-control measures.
At least one AII room is needed for settings in which TB patients stay while they are being treated, and additional AII rooms might be needed, depending on the magnitude of patient-days of cases of suspected or confirmed TB disease.
Repeat radiographs are not needed unless symptoms or signs of TB disease develop or unless recommended by a clinician (39,116).
After a determination that ongoing transmission has ceased, the setting should be reclassified as medium risk.
During the preceding year, the hospital admitted two patients with a diagnosis of TB disease. During the preceding year, care was delivered to six patients with TB disease and approximately 50 persons with LTBI. The hospital admits an average of 150 patients with TB disease each year, comprising 35% of the city burden. The patient volume is high, and the HMO is located in the inner city where TB rates are the highest in the state. The agency did not care for any patients with suspected or confirmed TB disease during the preceding year. Infection-control plans might need to be customized to balance the assessed risks and the efficacy of the plan based on consideration of various logistical factors.
On a case-by-case basis, expert medical opinion might be needed to interpret results and refer patients with discordant BAMT and TST baseline results. The setting should have ongoing communication with the local or state health department regarding incidence and epidemiology of TB in the population served and should ensure that timely contact investigations are performed for HCWs or patients with unprotected exposure to a person with TB disease.
Medical records of a sample of patients with suspected and confirmed TB disease who were treated or examined at the setting should be reviewed to identify possible problems in TB infection control. The medical evaluation should include an interview conducted in the patient's primary language, with the assistance of a qualified medical interpreter, if necessary. The index of suspicion should be substantially high for geographic areas and groups of patients characterized by high TB incidence (26).
These patients should not be kept in the setting any longer than required to arrange a referral or transfer to an AII room.
Each of the three sputum specimens should be collected in 8–24-hour intervals (124), and at least one specimen should be an early morning specimen because respiratory secretions pool overnight. Additional rooms might be considered if options are limited for transferring patients with suspected or confirmed TB disease to other settings with AII rooms.
Persons with suspected or confirmed TB disease who are inpatients should remain in AII rooms until they are determined to be noninfectious and have demonstrated a clinical response to a standard multidrug antituberculosis treatment regimen or until an alternative diagnosis is made. People have been experimenting with hydroponics since the 1600s, though it didn’t actually work without any soil until 1859. The waste byproducts from the fish accumulate in the water, which is converted to nitrates by bacteria in the system. Figure Eight on a BightBy forming a bight near the end of the rope, an easy, reliable non-slipping loop can be formed for hauling, life support or gear lifting. Because survival of the pups is vital to sustaining their social unit, meerkats have been known to risk their lives trying to protect the young.
They provide food for predators like jackals and eagles, and they curb pest infestation by eating insects.
In this way, development and farming are decreased, allowing for increased preservation of meerkat habitat.
Concurrent with this success, mobilization of the nation's TB-control programs succeeded in reversing the upsurge in reported cases of TB disease, and case rates have declined in the subsequent 10 years (4,5). Review articles, which include primary references, are used for editorial style and brevity. Persons infected with HIV who are already severely immunocompromised and who become newly infected with M.
A survey of New York City hospitals with high caseloads of TB disease indicated 1) a decrease in the time that patients with TB disease spent in EDs before being transferred to a hospital room, 2) an increase in the proportion of patients initially placed in AII rooms, 3) an increase in the proportion of patients started on recommended antituberculosis treatment and reported to the local or state health department, and 4) an increase in the use of recommended respiratory protection and environmental controls (99).
CDC-recommended TB infection-control measures are implemented in correctional facilities, and certain variations might relate to resources, expertise, and oversight (104–106). DOT is an adherence-enhancing strategy in which an HCW or other specially trained health professional watches a patient swallow each dose of medication and records the dates that the administration was observed.
Part of the risk assessment is similar to a program review that is conducted by the local TB-control program (42). Additional AII rooms might be considered if options are limited for transferring patients with suspected or confirmed TB disease to other settings with AII rooms. Examples of assigning risk classifications have been provided (see Risk Classification Examples). This classification should also be applied to HCWs who will never be exposed to persons with TB disease or to clinical specimens that might contain M. This screen should be accomplished by educating the HCW about symptoms of TB disease and instructing the HCW to report any such symptoms immediately to the occupational health unit.
The details should include date of blood draw, result in specific units, and the laboratory interpretation (positive, negative, or indeterminate—and the concentration of cytokine measured, for example, interferon-gamma [IFN-?]). One was admitted directly to an AII room, and one stayed on a medical ward for 2 days before being placed in an AII room. During the preceding year, one patient who was known to have TB disease was evaluated at the center. Approximately 30% of the agency's workers are foreign-born, many of whom have immigrated within the previous 5 years. Therefore, infection-control programs should keep all records when documenting previous test results.
If transmission seems to be ongoing, consider including the HCW in the screenings every 8–10 weeks until a determination has been made that ongoing transmission has ceased.
The review should be based on the factors listed on the TB Risk Assessment Worksheet (Appendix B).
HCWs who are the first point of contact should be trained to ask questions that will facilitate detection of persons who have suspected or confirmed infectious TB disease. While in the setting, symptomatic patients should wear a surgical or procedure mask, if possible, and should be instructed to observe strict respiratory hygiene and cough etiquette procedures (see Glossary) (120–122). Generally, this method will allow patients with negative sputum smear results to be released from airborne precautions in 2 days. For example, for a hospital with 120 beds, a minimum of one AII room is needed, possibly more, depending on how many TB patients are examined in 1 year.
If the alternative diagnosis cannot be clearly established, even with three negative sputum smear results, empiric treatment of TB disease should strongly be considered (see Supplement, Estimating the Infectiousness of a TB Patient). CDC prepared the current guidelines in consultation with experts in TB, infection control, environmental control, respiratory protection, and occupational health. The closer the proximity and the longer the duration of exposure, the higher the risk is for being infected.
Because various interventions were implemented simultaneously, the effectiveness of each intervention could not be determined. Reports of increased implementation of recommended TB infection controls combined with decreased reports of outbreaks of TB disease in health-care settings suggest that the recommended controls are effective in reducing and preventing health-care–associated transmission of M. DOT is the standard of care for all patients with TB disease and should be used for all doses during the course of therapy for TB disease and for LTBI whenever feasible. The TB Risk Assessment Worksheet (Appendix B) can be used as a guide for conducting a risk assessment.
A contact investigation of exposed HCWs by hospital infection-control personnel in consultation with the state or local health department did not identify any health-care–associated transmission.
Risk classification: medium risk (Correctional facilities should be classified as at least medium risk). However, on annual testing, three of the 20 respiratory therapists tested had QFT-G conversions, for a rate of 15%. The person was recognized as a TB patient on his first visit and was promptly triaged to an ED with an AII room capacity. All patients are screened for TB disease upon enrollment, and airborne precautions are promptly initiated for anyone with respiratory complaints while the patient is being evaluated. At baseline two-step testing, four had a positive initial TST result, and two had a positive second-step TST result. For example, an infection-control program using a BAMT strategy should request and keep historic TST results of a HCW transferring from a previous setting. When the setting is reclassified back to medium-risk, annual TB screening should be resumed.
For assistance with language interpretation, contact the local and state health department. Outpatients with suspected or confirmed infectious TB disease should remain in AII rooms until they are transferred or until their visit is complete. The loop formed should be only large enough to contain what is intended to be placed or clipped into it.
Health-care settings include inpatient settings, outpatient settings, and nontraditional facility-based settings. After the droplet nuclei are in the alveoli, local infection might be established, followed by dissemination to draining lymphatics and hematogenous spread throughout the body (33). Persons with LTBI are asymptomatic (they have no symptoms of TB disease) and are not infectious.
Use of respiratory protection can further reduce risk for exposure of HCWs to infectious droplet nuclei that have been expelled into the air from a patient with infectious TB disease (see Respiratory Protection).
This worksheet frequently does not specify values for acceptable performance indicators because of the lack of scientific data.
All of the respiratory therapists who tested positive received medical evaluations, had TB disease excluded, were diagnosed with LTBI, and were offered and completed a course of treatment for LTBI. While in the ambulatory-care center, the patient was held in an area separate from HCWs and other patients and instructed to wear a surgical or procedure mask, if possible.
During the preceding year, seven patients who were encountered in the clinic were subsequently determined to have TB disease. Even if the HCW is transferring from a setting that used BAMT to a setting that uses BAMT, historic TST results might be needed when in the future the HCW transfers to a setting that uses TST. In fact, some say that knowing a Bowline and a Figure Eight , and all their variations, can accomplish all the needs in rope work. Research has shown that ropes really don't break in the tight bends of a tie, rather, ropes and webbing break at a point going into a tie. The term "health-care setting" includes many types, such as inpatient settings, outpatient settings, TB clinics, settings in correctional facilities in which health care is delivered, settings in which home-based health-care and emergency medical services are provided, and laboratories handling clinical specimens that might contain M.
QFT-G was used for infection-control surveillance purposes, and a contact investigation was conducted among exposed staff, and no QFT-G conversions were noted. All patients were promptly put into an AII room, and no contact investigations were performed.
Similarly, historic BAMT results might be needed when the HCW transfers from a setting that used TST to a setting that uses BAMT.
If five of the 10 HCWs whose test results converted were among the 100 HCWs employed in the ICU of Hospital X (in Medical Center A), then the ICU setting-specific conversion rate for 2004 is 5%.
Knowing a few ties and knowing them well is far better than being familiar with dozens of ties about which one feels only vaguely comfortable.Ties are essential to a successful rigging. Risk classification: medium risk (with close ongoing surveillance for episodes of transmission from unrecognized cases of TB disease, test conversions for M. The home health-care agency is based in a major metropolitan area and delivers care to a community where the majority of persons are poor and medically underserved and TB case rates are higher than the community as a whole. They should be as simple to untie as they are to tie, should not be able to work themselves loose, and should be simple, allowing for easy inspection.
The term "setting" has been chosen over the term "facility," used in the previous guidelines, to broaden the potential places for which these guidelines apply. Persons with TB pleural effusions might also have concurrent unsuspected pulmonary or laryngeal TB disease. The problem evaluation revealed that 1) the respiratory therapists who converted had spent part of their time in the pulmonary function laboratory where induced sputum specimens were collected, and 2) the ventilation in the laboratory was inadequate. Risk classification: low risk (because HCWs might be from populations at higher risk for LTBI and subsequent progression to TB disease because of foreign birth and recent immigration or HIV-infected clients might be overrepresented, medium risk could be considered). CDC recommendations for the United States regarding QFT and QFT-G have been published (34,35). Because this field is rapidly evolving, in this report, BAMT will be used generically to refer to the test currently available in the United States.



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