Which mask should the nurse don when caring for a client with tuberculosis?

Mycobacterium tuberculosis is transmitted in airborne particles called droplet nuclei that are expelled when persons with pulmonary or laryngeal TB cough, sneeze, shout, or sing. The tiny bacteria can be carried by air currents throughout a room or building. Tuberculosis is not transmitted by direct contact or via contaminated surfaces or items.

Health care personnel are potentially exposed to TB during health care activities, case management activities, or when persons with unrecognized pulmonary TB are present in the facility. Facilities should establish TB infection control programs that include administrative, environmental, and respiratory protection measures to help prevent TB transmission among staff and visitors.

General TB precautions

• Maintain airborne precautions for necessary visits by patients with suspect or infectious TB until infectiousness is ruled out or resolves.
• Reduce exposure by eliminating or delaying nonurgent appointments for patients with suspect or infectious TB until infectiousness is ruled out or resolves.
• Establish cough etiquette practices among staff and clients. Provide tissue, surgical masks, hand-hygiene products, and waste containers in common areas, such as waiting rooms, so people with respiratory symptoms can contain coughing and sneezing.
• Implement a TB screening protocol for clients presenting with cough lasting more than three weeks and any of the following symptoms:
  • Blood in sputum
  • Night sweats
  • Unexplained weight loss
  • History of TB disease or TB exposure
• If screening is positive, ask the client to wear a surgical mask, place in a private exam room, and implement airborne precautions.
• Do not perform aerosol-inducing procedures or sputum collections if negative pressure room or or local exhaust ventilation enclosure (sputum collection booth) is not available.

In all settings, prompt recognition of individuals needing airborne precautions is the cornerstone to infection prevention.

Airborne precautions

Airborne precautions are used in addition to standard precautions to prevent disease transmission from individuals known or suspected to have diseases spread by fine particles, including TB.

• All health care personnel should don a National Institute for Occupational Safety and Health (NIOSH)-certified, fit-tested, N95 respirator or a powered air-purifying respirator (PAPR) just before entry to an area of shared air space and wear at all times while in the area of shared air space.
• Remove the respirator just after exiting the area. The N95 respirator may be discarded into the regular trash; a PAPR may be cleaned for reuse according to manufacturer guidelines.
• Other airborne precaution components may vary depending on setting and the environmental capabilities of the facility (see below)

In airborne precautions, patients may be asked to wear surgical masks outside of a negative pressure room. Health care personnel should only wear N95 or PAPR respirators and never wear surgical masks.

Setting-specific TB precautions

Hospital-based precautions

• Patients with confirmed infectious TB or those being evaluated for active TB disease should be kept in airborne isolation precautions until active TB disease is ruled out or the patient is deemed to be noninfectious.
• Work with your infection control practitioner to identify airborne isolation rooms and their instructions for use.
• Limit patient time outside of the isolation room to medically necessary purposes. If transportation outside a negative pressure room is necessary, instruct patient to wear a surgical mask and follow respiratory etiquette.
• For patients with active TB disease, familiarize yourself with criteria for removing respiratory isolation and who is authorized to discontinue it. See Heartland National TB Center guidance for more information.

Clinic-based precautions

• Schedule essential appointments at the end of the day to limit exposure to other patients and visitors and follow appropriate precautions.
• Delay nonurgent appointments for patients with suspect or infectious TB until active TB disease is ruled out or patient is deemed to be noninfectious.
• Work with your infection control practitioner to identify airborne isolation rooms.
• Upon patient arrival, have patient don a surgical mask and immediately escort them to a private room, preferably one with negative pressure capabilities, and close the door. If no negative pressure room is available, instruct the patient to wear a surgical mask for the entire length of the visit and change it if it gets damp or soiled.
• If a negative pressure room is unavailable, consider portable HEPA filtration units, if available, in the area where the infected individual is located to filter out infectious particles. (Use of such a unit does NOT eliminate the need for employees to wear respiratory protection).
• Once the room is empty, it should remain unoccupied with the door closed with clear signage for a period of time to allow the air to clear of infectious particles. The (see Table 1) specifies the amount of clearance time required based on the number of air exchanges that occur in the room per hour. Contact your building maintenance staff if you do not know the air exchange rate of the room.

Health department-based precautions

• Delay nonurgent appointments for patients with suspect or infectious TB until active TB disease is ruled out or the patient is deemed to be noninfectious.
• Schedule essential appointments at the end of the day to limit exposure to other patients and visitors.
• The client should don a surgical mask and immediately be escorted to a private room, preferably one with negative pressure capabilities, and close the door. If no negative pressure room is available, instruct the patient to wear a surgical mask for the entire length of the visit and change it if it gets damp or soiled.
• If a negative pressure room is unavailable, consider portable HEPA filtration units, if available, in the area where the infected individual is located to filter out infectious particles. (Use of such a unit does NOT eliminate the need for employees to wear respiratory protection).
• Once the room is empty, it should remain unoccupied with the door closed with clear signage for a period of time to allow the air to clear of infectious particles. The (see Table 1) specifies the amount of clearance time required based on the number of air exchanges that occur in the room per hour. Contact your building maintenance staff if you do not already know the air exchange rate of the room.
• See the next section for implementing airborne precautions in the client's home.

At the client's home

• Wear proper personal protective equipment (PPE), including a NIOSH-certified fit-tested N95 respirator or a powered air-purifying respirator (PAPR), for the duration of home visit.
• Educate household members on risks of TB transmission and on contact investigation.
• Remove children younger than 5 from the home, if possible. If unable to remove children, consider removing the client until no longer infectious.
• Minimize close contact as much as possible for the remaining household members. Family should be instructed to avoid social gatherings in the home. The patient should sleep in a separate area. Household members do not need to wear masks in the house. If guests are unavoidable, provide education on appropriate N95 respirator use, such as donning and doffing and changing the respirator if soiled or damp. Guests do not need to be fit tested to wear respirator, but should be taught how to fit check instead. Guests who decline a mask should be educated on risks of TB transmission, of progression to disease, and signs and symptoms of disease.
• Educate the patient and family to follow respiratory etiquette.
• For patients with active TB disease, familiarize yourself with criteria for removing respiratory isolation and who is authorized to discontinue it.

Patients with infectious TB can be released from home isolation when all of the following criteria are met:

• Patient has three consecutive negative AFB sputum smears, at least eight hours apart.
• Patient has received appropriate anti-tuberculosis medication for two weeks and is compliant.
• Patient is clinically improving.
• Patient has plan for follow-up care.

Long-term care facility, corrections, and other congregate settings-based precautions

• Have a written plan to transfer residents with suspect or infectious TB if no negative pressure room is available.
• If transfer is not immediately available, place patient in a temporary holding area in which the heating, ventilation, and air-conditioning (HVAC) reduces outward flow of aerosols, with exhaust flowing directly outdoors. Also consider use of portable HEPA filtration units.
• Familiarize yourself with criteria for removing airborne isolation and who is authorized to discontinue it. See Heartland National TB Center guidance for more information.
• Sputum specimens should be collected in a negative pressure room or outdoors.

What are the environmental protection measures in TB precautions?

Environmental controls are the second line of defense in TB infection control programs. Environmental controls include technologies for removal or inactivation of TB in the air. These technologies include:

• General ventilation (whole air movement, usually measured in air exchanges per hour)
• HEPA filters
• UV light
• Negative pressure rooms

You should be aware of the environment of your facility, including air flow, UV lighting, and availability of HEPA filters, negative pressure rooms, or alternative methods for achieving negative pressure. The (see Table 1) specifies the amount of clearance time required based on the number of air exchanges that occur in the room per hour. Contact your building maintenance staff if you do not know the air exchange rate of the room.

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