Evaluation of Healthcare Worker with a Positive PPD or Positive QFT Result

Purpose
To establish a consistent evaluation that will be conducted on each healthcare worker who has a positive PPD skin test or a positive QuantiFERON Gold Test (QFT) defined by U-M OHS protocols.

Scope
Health care workers includes employees, volunteers, students and special purpose trainees who have broadly defined patient care duties. Testing is done at pre-placement, annually, after an exposure to a person with infectious tuberculosis, for symptoms suggestive of TB, or upon request of the employee.

Rationale
The presence of a positive tuberculin skin test or positive QFT can be the result of tuberculosis infection without disease, infection with disease, infection with non-tuberculosis bacterim, or improperly interpreted test. This protocol addresses the evaluation necessary to rule out active disease in a healthcare worker with a positive Mantoux skin test. Healthcare workers with active disease are considered infectious and cannot work in the institution until they are no longer considered contagious.

Procedure

  1. Every healthcare worker with a positive Mantoux test or positive QFT as defined by U-M OHS protocols, or an adequate history of a positive test such that repeat testing is not advisable, will be promptly evaluated for active tuberculosis with a chest radiograph and clinical evaluation. An appointment for review of radiographic results and discussion of treatment will be made at the time of the skin test reading.
  2. Chest radiographs will be interpreted by the Department of Radiology. Results should be followed up within two days. The requisition should specify the reason for radiographic exam. Unless clinically indicated, routine radiographs will be limited to PA view. If there are any abnormalities a repeat PA and Lateral will be ordered.
  3. Clinical evaluation will be conducted by an U-M OHS clinical provider, and will consist of symptom review, history of any recent or past exposure to tuberculosis, medical risk factors, and history of past infection and tuberculosis treatment. A standard form for the PPD reactors/QFT positive results will be completed.
  4. Any healthcare worker with a positive skin test or positive QFT at pre-placement or thereafter will be counseled regarding the risks of tuberculosis in persons with HIV infection. A confidential, coded HIV test will be offered.
  5. If the chest radiograph or clinical evaluation is suggestive of active disease, the healthcare worker will be seen within 48 hours by a pulmonary or infectious disease specialist with an interest in tuberculosis. This includes Drs. Simon, Paine, Christenson or Chenoweth. A referral form should accompany the patient. The employee will be taken off work by the U-M OHS clinical provider, and remain off work until considered non-infectious by the consultant. Infection Control Services will be notified of any instance of possible active disease in an employee.
  6. Workers with positive skin tests or positive QFT results without evidence for ative disease will receive annual education and counseling regarding risks of reactivation and reinfection and signs and symptoms of tuberculosis. They will be advised to immediately report to U-M OHS if any symptoms suggestive of tuberculosis develop.
  7. Routine follow up of chest radiographs are not recommended unless symptoms of TB develop.
  8. Workers with positive skin tests or positive QFT results without evidence for active disease will be evaluated for treatment of latent tuberculosis infection according to U-M OHS protocols.
  9. Healthcare workers that convert their skin test as a result of occupational exposure will be instructed to fill out a Work Connections form for reporting to Work~Connections and inclusion in the MIOSHA log.

Evaluation For Treatment of Latent Tuberculosis Infection

Purpose
The purpose of this protocol is to establish consistent guidelines for the evaluation of healthcare workers with a positive Mantoux test or positive QFT and treatment for latent tuberculosis infection.

Scope
All healthcare workers with positive Mantoux tests or a positive QFT are evaluated for recommendations regarding treatment. This protocol will be followed in the evaluation of any person who is tested by or under the auspices of the U-M Occupational Health Services. Healthcare workers include employees, volunteers, special purpose trainees, or students who have broadly defined patient care duties. Healthcare workers who have converted their skin test to positive while working at this institution will be eligible to receive treatment through U-M OHS. Healthcare workers for whom treatment is recommended on initial presentation will be referred to the Washtenaw County Health Department or their personal healthcare provider for treatment.

Rationale
Treatment of latent tuberculosis infection prevents infection with Mycobacterium tuberculosis from developing into active disease. Proper treatment can decrease the morbidity as well as the transmission of tuberculosis. Isoniazid therapy, when taken properly, is very effective, with data from many studies showing efficacy ranging from 65-90%. The most significant adverse effect of Isoniazid is the occurrence of drug-induced hepatitis, which is largely reversible on discontinuation of the drug. However, rare instances of fatal hepatitis have been reported. The risk for hepatitis increases with increasing age. Recommendations for therapy in true PPD positive individuals are based on weighing the risk of progressing to active disease with the risk of significant adverse reaction to Isoniazid. The information presented here pertains to evaluation of healthcare workers only, and some risk groups may not be represented in this protocol. This protocol is consistent with the most recent recommendations of the Centers for Disease Control and Prevention and will be revised according to future guidelines from that agency.

Procedure

  1. An assessment for treatment of latent tuberculosis infection will be conducted only after the healthcare worker has been found to have a positive PPD skin test or a positive QFT according to U-M OHS protocols, and after evaluation for active tuberculosis as outlined in U-M OHS protocols is completed.
  2. he decision to recommend treatment of latent tuberculosis infection will be based on assessment of the likelihood that the healthcare worker falls into any of the following high-risk categories. Self-reported history will be used in the assessment.
    The following groups of people are at high risk for developing disease and are candidates for treatment:

    Reaction > or = 5 mm of induration:
    • Human immunodeficiency virus (HV)-positive persons
    • Recent contacts of tuberculosis (TB) case patients
    • Fibrotic changes on chest radiograph consistent with prior TB
    • Patients with organ transplants and other immunosuppressed patients (receiving the equivalent of > or = 15mg/d of prednisone for 1 month or more)
    Reaction > or = 10 mm induration:
    • Recent immigrants (i.e., within the last 5 years) from high prevalence countries
    • Injection drug users
    • Residents and employees of the following high-risk congregate settings: prisons and jails, nursing homes and other long-term facilities for the elderly, hospitals and other healthcare facilities, residential facilities for patients with acquired immunodeficiency syndrome (AIDS), and homeless shelters
    • Mycobacteriology laboratory personnel
    • Persons with the following clinical conditions that place them at high risk: silicosis, diabetes, mellitus, chronic renal failure, some hematologic disorders (e.g., leukemias and lymphomas), other specific malignancies (e.g., carcinoma of the head, neck or lung), weight loss of > or = to 10% of ideal body weight, gastrectomy, and jejunoileal bypass
    • Children younget than 4 years of age or infants, children, and adolescents exposed to adults at high-risk
    Reaction of > or = 15 mm induration:
    • Persons with no risk factors for TB
  3. Complying with the recommendation for treatment of latent tuberculosis infection is not mandatory and will not affect employment. Employees with positive skin tests and no evidence of tuberculosis will not be restricted in their work.
  4. All healthcare workers with positive skin tests will be educated regarding the signs and symptoms of active tuberculosis and the need for immediate reporting to U-M Occupational Health Services should they develop symptoms of active disease. They will also be informed to report any change in their health status that might affect these recommendations.
  5. Healthcare workers will be advised of available resources for obtaining medication and follow up. If they choose to be treated by U-M OHS, treatment will proceed according to U-M OHS protocol for preventive therapy. They may also choose to obtain treatment from their personal healthcare provider or the Washtenaw County Health Department (WCHD). If they choose WCHD, they will be provided with contact information for the Washtenaw County Public Health Tuberculosis Control Program.

Treatment of Latent Tuberculosis Infection with Isoniazid

Purpose
The purpose of this protocol is to establish consistent guidelines for treatment of latent tuberculosis infection.

Scope
All healthcare workers with positive Mantoux tests or a positive QFT as defined by U-M Occupational Health Services (U-M OHS) protocols are evaluated for recommendations regarding treatment. Healthcare workers include employees, volunteers, students and special purpose trainees, who have broadly defined patient care duties. Healthcare workers who have converted their skin test to positive while working at this institution will be eligible to receive treatment through U-M OHS. Healthcare workers for whom treatment is recommended on initial presentation to the institution will be referred to the Washtenaw County Health Department or their personal healthcare provider for treatment.

Rationale
Treatment with Isoniazid or Rifampin will be completed according to guidelines from the Centers for Disease Control and Prevention. The decision to offer treatment is made according to U-M OHS protocol "Evaluation for treatment of latent tuberculosis infection." Nine months of Isoniazid is the preferred treatment regimen for employees who have Latent Tuberculosis Infection. The 6 - month regimen of Isoniazid or the 4 - month regimen of Rifampin are also acceptable alternatives.

Procedure

  1. If Isoniazid is used for treatment, Isoniazid will be prescribed as 300 mg daily, in one dose. Pyridoxine (Vitamin B6) 50 mg per day will be prescribed if the clinician feels there is risk of Isoniazid neuropathy. If Rifampin is used for treatment; Rifampin will be prescribed as 10 mg/kg, maximum dosage is 600 mg per day.
  2. Treatment with Isoniazid will be prescribed for nine (9) months except for healthcare workers with HIV infection and those with evidence of old, healed (untreated) tuberculosis on chest x-ray, for which 12 (twelve) months of treatment will be prescribed. Treatment with Rifampin will be prescribed for (4) months.
  3. All convertors for whom Isoniazid is prescribed will be assessed monthly in U-M OHS. Monitoring for compliance with therapy and presence of symptoms (especially relating to symptoms of hepatitis and tuberculosis) will be conducted at each visit.
  4. Liver function tests (AST, ALT) will be obtained at baseline and at intervals as determined by the U-M OHS clinical provider, based on presence of symptoms or risk factors for hepatitis. There are a number of drug interactions associated with Rifampin. Of particular concern are reductions in the serum concentrations of common drugs, such as oral contraceptives; methadone; and warfarin.
  5. Persons for whom Isoniazid is being considered will be evaluated for medical conditions such as liver disease or excessive alcohol use, which may increase the risk of Isoniazid treatment. Decision to prescribe Isoniazid for these employees will be made on an individual basis in consultation with the Medical Director of U-M OHS. Women who are pregnant, breastfeeding or wish to become pregnant while taking Isoniazid will not be given the medication without written approval from their primary care provider. Rifampin is considered safe in pregnancy.
  6. Persons for whom Isoniazid is prescribed will be educated regarding the importance of compliance with the treatment regimen and the risk of adverse reactions to Isoniazid or Rifampin. A drug information sheet on Isoniazid or Rifampin will be provided.
  7. For persons likely to be infected with multi-drug resistant tuberculosis, the Hospital Epidemiologist will be consulted for recommendations regarding a therapy regimen.

If the healthcare worker is being followed by the Washtenaw County Health Department or personal provider, an appointment will be made at three and six months (or termination of therapy) to assess compliance with the treatment regimen.