Care of the Patient with Tuberculosis

 

Introduction

A total of 9,029 cases of tuberculosis (TB) were reported in the United States in 2018.¹ This is the lowest reported number of cases on record in the United States. The incidence of TB cases in the United States has been declining for many years.

Unfortunately, the cases for the test of the world, are not encouraging. Tuberculosis is the second leading cause of death from infectious diseases work-wide. According to the World Health Organization (WHO), TB worldwide is one of the top 10 causes of death and the leading cause of death from a single infectious disease.² The worldwide incidence of new cases has been steadily declining by approximately 2% a year.²

If TB is treated promptly and properly, it is curable in almost every case. But control and cure rates are severely affected by the lack of resources in many parts of the world. In some countries, the fatality rate of untreated TB is 50-65% within five years of infection.

Spread of Tuberculosis

The disease of TB is caused by the bacteria Mycobacterium tuberculosis. The primary organs that are infected and harmed by TB are the lungs. The TB bacteria usually spread by breathing in infected droplets. These droplets are spread by an infected person when coughing, sneezing, or talking. Some of the infected droplets can remain suspended in the air for several hours. TB bacteria can also be transmitted through the skin or other routes, but that is uncommon.

The risk of contracting TB from an infected patient increases with closer and more prolonged contact. People who are often in the household of someone who has TB is very likely to develop the disease.

An infected mother can transmit TB to the infant while in the uterus or during delivery. Tuberculosis can also be transmitted during medical procedures such as bronchoscopy, intubation, nebulizer treatments and obtaining a sputum sample. Latent tuberculosis is not contagious.

Types of Tuberculosis

Once the TB bacteria reach the lungs, one of three things occurs^{3, 4}:

1. The patient may completely clear the bacteria, and no infection develops
2. The patient may develop an active infection, primary TB
3. The body’s immune system may contain the TB bacteria, causing a chronic infection that shows no symptoms, latent TB

Latent TB is the most common of these three possibilities in the U.S.^3,4 Approximately 5-10% of the people who have latent TB will eventually develop active TB.⁴ In areas where TB is common in the community and healthcare resources are poor, primary TB is prevalent.

Primary TB happens in about 5% of all cases of infection. It typically happens to children and people with a compromised immune system. Children who are <1 year of age have approximately a 50% chance of developing primary TB, and because of the immature immune system, infants and children are quite susceptible to TB spreading to other body systems.

Tuberculosis infections, latent and primary, can be easily treated. TB can develop to be multidrug-resistant tuberculosis. This means that bacteria can no longer be killed by the common drugs used to treat TB.

The immune system does not produce long-lasting immunity against TB. Another infection and active disease can occur even if the bacteria from a previous infection were cleared.

Tuberculosis can spread through other body systems and cause non-pulmonary infections. This is more likely in children and people who are infected with HIV. Non-pulmonary TB infections occur in 10%-40% of patients. Non-pulmonary TB infections may involve the following body systems³:

1. Lymph nodes
2. Pleura
3. Genito-urinary tract
4. Bones and joints
5. Meninges
6. Peritoneum
7. Pericardium

There may be questions on forms you complete to help the RN assess the patient. One question may be, “have you been out of the country recently?” Other questions are checking for the following common signs and symptoms of TB.

• Cough for longer than two to three weeks
• Fever
• Night sweats
• Weight loss

These symptoms can be caused by many infections or medical conditions. A patient with TB may not have these symptoms or only mild symptoms.

Patient Care

Treatment of active TB is a long process. If the drug regimens are adhered to faithfully, the cure rate is very high. If the patient is not consistent with their treatment, TB can recur and may lead to types of TB that are resistant to drugs. You should encourage your patient to take all their medications for the entire time.

Patients may be required to have directly observed therapy if they are not consistent with their medication. This means a healthcare professional must witness the patient taking the medication.

You should report the following possible adverse drug reactions to the RN:

• Yellow tint to skin or eyes
• Upset stomach
• Rashes

Airborne Precautions

Patients who are initially suspected of having active TB should be placed in an airborne precautions isolation room. Airborne precautions require a private room and a negative pressure air handling system that exhausts to the outside. The door must remain closed. Patients infected with the same organism can share a room; this is called cohorting.

Airborne precautions require a gown, gloves and an N95 mask. The proper sequence for putting on personal protective equipment (PPE) is:

1. Wash hands
2. Gown
3. Mask or respirator
4. Goggles/face shield
5. Gloves

The proper sequence for removing PPE is:

1. Gloves
2. Goggles/face shield
3. Gown
4. Mask
5. Wash hands

When removing PPE, it is important only to touch areas of the PPE that are not contaminated or potentially contaminated, e.g., the front of the gown is considered to be potentially contaminated, the ties in the back of the gown would not.

A surgical N95 respirator is recommended. The N95 is a single user, disposable item that must be fit tested to be effective. Fit testing should be done when first using an N95, after the correct size and model has been chosen, and should perform a user seal check each time the N95 is used. N95 is different from a simple surgical mask that is discarded after one use as the N95 can be used more than once. There are guidelines for what has been termed extended use and reuse of the N95. This policy is defined by the facility.

Instruct patients to cover their mouth and nose with a tissue when coughing or sneezing.

The patient should not be moved out of the isolation room unless necessary. When leaving the isolation room, the patient should wear a surgical mask, which should remain on as long as they are not in the isolation room.

Airborne precautions may be stopped after treatment is started, and the healthcare provider determines the patient is not contagious.

Homecare

Healthcare workers who visit TB patients at their homes should take these precautions to protect themselves from exposure to TB:

• Instruct patients to cover their mouth and nose with a tissue when coughing or sneezing.
• Wear a personal respirator when visiting the home of an infectious patient with TB or when transporting an infectious patient with TB in a vehicle.
• When it is necessary to collect a sputum specimen in the home, collect the specimen in a well-ventilated area, away from other household members; if possible, the specimen should be collected outdoors.
• Participate in a TB testing and prevention program.

Exposure

If you have been exposed to TB, please notify your supervisor. TB screening may be indicated.

The tuberculin skin test is useful, but the results are not reliable. The current recommendations from the CDC for screening healthcare personnel for TB.⁵

• A risk assessment and an evaluation for symptoms should be done before hiring.
• A skin test can be used for screening.
• Routine serial testing for TB does not need to be done if there is no known exposure or ongoing spread of infection.
• Healthcare personnel who have untreated latent TB should have an annual screening for symptoms of TB.
• Annual TB education of all healthcare personnel is recommended.

Vaccination

The TB vaccine is Bacillus Calmette-Guérin (BCG). BCG vaccine is not routinely used in the US and not routinely recommended for healthcare personnel. BCG is used in countries with a high prevalence of TB to prevent childhood complicated tuberculosis.

Your approval agency or organization requires you to take the test.

References

1. Talwar, A., Tsang, C.A., Price, S.F., Pratt, R.H., Walker, W.L., Schmit, K.M., Langer, A.J. Tuberculosis - United States, 2018. Am J Transplant, 2019;19(5):1582-8.
2. World Health Organization. Global tuberculosis report. 2018. Retrieved June 15, 2019 Visit Source.
3. Raviglione, M.C. Tuberculosis. In: Jameson, J.L., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., Loscalzo J. Harrison's Principles of Internal Medicine, 20th ed. New York, NY: McGraw-Hill Education; 2018. Online edition. Retrieved June 15, 2019 Visit Source.
4. Riley, L.W. Tuberculosis: Natural history, microbiology, and pathogenesis. UpToDate. January 26, 2018. Retrieved June 15, 2019
5. Sosa, L.E., Gibril, J.N., Lobato, M.N., et al. Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019. MMWR Morb Mortal Wkly Rep, 2019;68(19):439-43