Tuberculosis primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mashal Awais, M.D.[2]; Alejandro Lemor, M.D. [3]

Overview

Primary prevention in tuberculosis is required to avoid the disease transmission and causing infection in healthy individuals. The BCG vaccine is given to children susceptible to TB infections, such as children living in endemic areas or who have close contact with a confirmed case of TB. Several preventive measures are used to avoid the transmission of the mycobacteria, such as respiratory isolation, use of respiratory masks among health-care professionals, and advising respiratory hygiene and cough etiquette.

Primary Prevention

BCG Vaccine

• Bacille Calmette-Guerin (BCG) is a live attenuated vaccine derived from M. bovis used for the immunization against M. tuberculosis.
• BCG vaccination is recommended for every infant that living in a highly endemic area of TB or who has a high risk of getting the infection due to exposure to TB.
• The administration of the vaccine is beneficial and is protective against severe types of tuberculosis infections, such as military or meningeal tuberculosis.
• BCG vaccine is not recommended for children with HIV infection, however, children with unknown HIV status and born to HIV positive women, should be vaccinated.
• There is no proven benefit of the vaccine for patients that already have been infected by tuberculosis.
• BCG vaccination of health care workers should be considered on an individual basis in any of the following settings:

• A high percentage of TB patients have infected with TB strains resistant to both isoniazid and rifampin
• There are ongoing transmission of drug-resistant TB strains to health care workers and subsequent infection is likely
• Comprehensive TB infection-control precautions have been implemented, but have not been successful.

• Health care workers considered for BCG vaccination should be cautioned regarding the risks and benefits associated with both BCG vaccination and also treatment of latent TB infection.

Contraindications for BCG
Immunosuppression	BCG vaccination should not be given to persons who are immunosuppressed (e.g., persons who are HIV infected) or who are likely to become immunocompromised (e.g., persons who are candidates for organ transplant).
Pregnancy	BCG vaccination should not be given during pregnancy. Even though no harmful effects of BCG vaccination on the fetus have been observed, further studies are needed to prove its safety.
Adapted from CDC

Prevention for International Travelers

• Travelers should avoid close contact or prolonged time with known TB patients in crowded, enclosed environments.
• Travelers who anticipate possible prolonged exposure to TB, such as medical staff, individuals in prison, or homeless shelter populations should have a tuberculin skin test (TST) or interferon-gamma release assay (IGRA) test before leaving the United States.

Prevention in Health-Care Settings

• Confirmed cases of TB during hospitalization should meet the following recommendations:

• Single-patient room with private bathroom.
• Healthcare workers and visitors should wear disposable respirators (at least N95).
• Doors should be closed as much time as possible.
• Adequate room ventilation or negative pressure should be monitored daily.

Determining the Infectiousness of TB Patients

Airborne Precautions
Patients who have suspected or confirmed TB disease should be considered infectious if they have the following characteristics: They are coughing, undergoing cough-inducing procedures, or have positive sputum smear results for acid-fast bacilli (AFB); and They are not receiving adequate antituberculosis therapy, have just started therapy, or have a poor clinical or bacteriologic response to therapy.
Airborne precautions can be discontinued when infectious TB disease is considered unlikely and either another diagnosis is made that explains the clinical syndrome or the patient produces three consecutive negative sputum smears collected in 8 to 24-hour intervals.
If infectious TB is still suspected after the collection of three negative sputum smear results, patients should not be released from airborne precautions until they receive standard multidrug antituberculosis treatment (minimum of 2 weeks) and demonstrate clinical improvement.
Patients who have drug-susceptible TB should remain under airborne precautions until they meet all of the following: Produce 3 consecutive negative sputum smears collected in 8 to 24-hour intervals. Receive standard multidrug antituberculosis treatment (minimum of 2 weeks). Demonstrate clinical improvement.
Adapted from CDC TB Infection Control in Health-Care Settings