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PRACTICE POINTER
UK
BS39 4BZ.UK
taraharrop@hotmail.com
Gtehisas:SA4/201;342:dl544
doi:10.1136/bmj.d1544
Box 1 1 Precautions to take before, during, and after potential exposure to tuberculosis
Before leaving
Determine the likely prevalence of tuberculosis in the work place, including the risk of
workers of any age with BCG if they have not been vaccinated
Undergo baseline chest radiography, tuberculin skin test or interferon y release assay, and
an HIV test
before, their skin test is negative, and they are HIV negative,4
as the United States) rarely use BCG.6 Repeated BCG vaccination is not recommended even if the tuberculin skin test is
While abroad
Report to occupational health before starting work explaining the nature and extent of your
exposure
A positive tuberculin skin test or interferon y'release assay may indicate active or latent
APRIL
On return
BMj
818
VOLUME
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342
PRACTICE
time spent as inpatients, staff wearing high efficiency particulate air filter masks, coughing patients wearing surgical
masks, and more rapid testing and diagnosis.10 16
How do workers know they are infected?
Fig 1 1 Estimated tuberculosis incidence rates by country, 2007. Reproduced, with permission,
from WHO. Global Tuberculosis Control2
that can later reactivate to cause disease (box 2). Thirdly, nei-
prolonged period.
Reducing exposure to tuberculosis in settings with few
most people will not know they are infected unless specific
Masks and respirators are effective at preventing infections,12 although visiting doctors may be reluctant to wear
them if they are not freely available to other staff, and some
are reported to decrease the risk of contracting tuberculosis 2.4-fold (although they provide protection only for a few
hours or until they get wet)13; high efficiency paniculate air
filter masks (FFP 2/3 or N95) by 17.5-fold; a cartridge respirator 45.5-fold; and powered air purifying respirators (which
Diabetes
Cigarette smoking
Systemic corticosteroids
Treatment with anti-tumour necrosis factor
Malnourishment
Chronic renal failure
Malignancy or chemotherapy
fold. FFP 2/3 and N95 masks are the most widely used and
Pulmonary silicosis
Gastrectomy
Common symptoms
Chest pain
minimised).14
819
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PRACTICE
hg 2 i Guidelines for
screeningfor latent
tuberculosis infection in
asymptomatic healthcare
workers' 18 19 20
Positive 1 Negative
t Positive t
computed tomography, I |
Positive 1 Negative I
treatment j ""
to active tuberculosis, but about one in 200 people on isotuberculosis,18 and the results require careful interpretation.
the symptoms and signs of tuberculosis (box 2) and are followed up with serial chest radiographs for two years.3 5 25 26
symptomatic infection.
should not start work in the NHS until they have been
workers (fig 2). All those who have worked in high incidence
radiography should be performed alongside a careful clinical examination for active disease.
Summary
820
APRIL
2011
VOLUME
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342
Response on bmj.com
"Childhood tuberculosis
clinical picture.
neglected because TB
significantly contribute
to disease transmission."
Edwin A Dias, KVG
2006;34:51-7.
14 Yassi A, Bryce E, Moore D. Protecting the faces of health care workers:
Contributors: TH, JA, and GT jointly wrote the article and all are guarantors.
O To respond to an article
the corresponding author) and declare: no support from any organisation for the
on bmj.com, click on
submitted work; no financial relationships with any organisations that might have
an interest in the submitted work in the previous three years; no other relationships
Med 2009-A:5-9.
18 Escombe AR, Moore DA, Gilman RH, Pan W, Navincopa M, Ticona E, et
al. The infectiousness of tuberculosis patients coinfected with HIV. PLoS
S/W/2008;337:alll0.
4 Andersen P, Doherty TM. The success and failure of BCG-implications
fora novel tuberculosis vaccine. NatRevMicrobiol2005;3:656-62.
5 National Institute for Health and Clinical Excellence. Clinical diagnosis
and management of tuberculosis, and measures for its prevention
6 Centers for Disease Control and Prevention. BCG vaccine factsheet. 2010.
www.cdc.gov/tb/publications/factsheets/prevention/BCG.htm.
vol8no7/01-0506.htm.
8 Escombe AR, Oeser CC, Gilman RH, Navincopa M, Ticona E, Pan W, et
al. Natural ventilation for the prevention of airborne contagion. PLoS
Med2007-A:e68.
9 Atkinson J, Chattier Y, Pessoa-Silva CL, Jensen P, Li Y, Seto W. Natural
ventilation for infection control in health-care settings. WHO, 2009. http://
/We/2008:5:el88.
/?eD2010:59(RR-5):l-25.
22 Gandhi NR, Nunn P, Dheda K, Schaaf HS, Zignol M, van Soolingen D, et al.
Multidrug-resistantand extensively drug-resistant tuberculosis: a threat
http://ecdpc.europa.eu/Health_topics/Tuberculosis/XDR/guidance.
html#prophylaxis.
26 Fraser A, PaulM, Attamna A, Leibovici L. Treatment of latent tuberculosis
10-MINUTE CONSULTATION
pulmonary disease
Christina George,1 Will Zermansky,2 John R Hurst1
management.
Consider:
j.hurst@medsch.ucl.ac.uk
explanations?
Have all available interventions to reduce
doi:10.1136/bmj.d1434
exacerbations varies between patients, and the best predictor is a patient's history of exacerbations. Patients who
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