New methods of assessing risk in healthcare systems, especially before proposed changes have been implemented, have been developed and published. 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.
These recommendations usually apply to an entire health-care setting rather than areas within a setting.
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.
In addition to close contacts, the following persons are also at higher risk for exposure to and infection with M. 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. 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.
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). 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. Every health-care setting should have a TB infection-control plan that is part of an overall infection-control 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. 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.
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.
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. 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. Review the community profile of TB disease in collaboration with the local or state health department. 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. The following hypothetical situations illustrate how assessment data are used to assign a risk classification. 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. 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. The number of AII rooms should be suitable for the setting based on AIA Guidelines and the setting risk assessment. Rationale for infection-control measures and documentation evaluating the effect of these measures in reducing occupational TB risk exposure and M. 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. Importance of completing therapy for LTBI or TB disease to protect the HCW's health and to reduce the risk to others.


Required Occupational Safety and Health Administration (OSHA) record keeping on HCW test conversions for M. 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.
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. 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.
Methods: The likelihood of disease spread and the magnitude of public health impact were assessed to clarify overall risk. Discussion: There is a low to moderate public health risk related to SFTSV human infection in China. Concerns about the potential spread of this novel disease and the possibility of a high number of deaths led to the undertaking of this risk assessment. The risk assessment process involved several components including gathering information through a literature review, a comparative analysis of demographic features between reported SFTSV cases and surveillance population and consensus through group discussion of data based on the likelihood of disease spread and the impact on public health. Expertise for group discussion included a core group of four people specializing in public health surveillance, epidemiology and infectious disease.
Experts suggest that the capacity for treatment and diagnosis of SFTS is adequate in rural communities in China because of the continuous efforts by the China Ministry of Health in recent years to enhance the national public health system. Information about cost of diagnosis and treatment of SFTS was not available, although the majority of tests and drugs required for SFTS are on the reimbursement list of the New Rural Cooperative Medical Care System. No formal studies have been published that provide a quantitative or qualitative estimation of interest in health matters, health care-seeking behaviour or the psychosocial impact caused by SFTS.
In 2007, in a study linking hand, foot and mouth disease cases, media reports and a survey of hospital visitors showed that health care-seeking behaviour increased dramatically after initial cases were reported. A low level of risk for a disease would indicate that it can be managed under existing protocols for surveillance systems, response and regulation.3 As the level of risk increases, the focus and intensity of the guidance for SFTS prevention and treatment must also change so that the risk posed by the disease can be reduced to an acceptable level.
The authors thank all the experts from Chinese Center for Disease Control and World Health Organization Regional Office for the Western Pacific who gave their generous and valuable opinions and supports. 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). 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).
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). 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. 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 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.
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. 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). These tools provide a means for taking the information gathered in the parent or other primary caregiver interview and the oral health screening to classify a child’s dental caries risk at a single point in time. Estimates of likelihood and impact were then combined to decide on the overall level of risk with the assistance of a risk matrix to enhance the rigour of discussion.
Group discussions were held several times to reach consensus on the level of overall risk and the evidence that supported this level of risk. In September 2010, the China Ministry of Health held a special press conference about SFTS. This will allow the local health facilities to better handle the consequences of the changed level of risk.


Only published documents were used in this assessment as we were unable to access the primary data. Analyzing medical care conducts of rural residents and their influence factor: A survey on town X in north Jiangsu Province [in Chinese] [Social Science Edition]. 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.
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. 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. Administrators making this distinction should obtain medical and epidemiologic consultation from state and local health departments. 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.
After a determination that ongoing transmission has ceased, the setting should be reclassified as medium risk. During the preceding year, care was delivered to six patients with TB disease and approximately 50 persons with LTBI. 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. 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. In primary health care settings, they can be used to determine when a referral to a dentist is indicated.
Presentation of outcomes following core team deliberation to a broader group with expertise in public health, laboratory, epidemiology, infectious disease, logistics and risk communication provided further refinement of the outcomes.
Soon after, guidelines on SFTS control and prevention were issued by the Ministry of Health and distributed to the public. With a low to moderate level of risk for SFTS, there is an indication that current protocols are working well; however, some enhancement to current practice may be appropriate for public health management of the disease. 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). 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). Examples of assigning risk classifications have been provided (see Risk Classification Examples). 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 review should be based on the factors listed on the TB Risk Assessment Worksheet (Appendix B). Health education information was published on the Internet, printed in newspapers and broadcast on radio and TV. Good diagnostics and treatment are available; however, the most-at-risk population, elderly females in rural farming communities, may present to health care late.
Therefore there were some key gaps in information including transmission mode, seroprevalence, full spectrum of infection, health care-seeking behaviour and suspicion of disease by clinicians. 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.
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). For assistance with language interpretation, contact the local and state health department. This may increase the disease severity at presentation and thus the need for prolonged and sophisticated treatment in health care facilities.
Health-care settings include inpatient settings, outpatient settings, and nontraditional facility-based settings.
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).
Overall the combination of the level of likelihood of spread of disease and the impact on public health results in a low to moderate public health risk of SFTSV human infection in China.
Comprehensive national surveillance data and further research will be useful in understanding the risk to public health from this disease.
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. 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. This will lead to a greater need for diagnosis and health care service during the peak season.
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).



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