is publication is produced by a coop

U.S. Department of Health and Hu

U.S. Centers for Disease Control an

U.S. President’s Emergency Plan for 

e World Health Organizati

e International Union Against Tuberculo
 



TUBERCULOSIS INFECTION CONTROL

IN THE ERA OF EXPANDING HIV CARE AND TREATMENT

Addendum to WHO Guidelines for the Prevention of 

Tuberculosis in Health Care Facilities in

Resource-Limited Settings

Writing committee:

Centers for Disease Control and Prevention (CDC): Naomi Bock, 

Paul Jensen, Wanda Walton, Michael Iademarco, Bess Miller

World Health Organization (WHO): Alasdair Reid, Pierre-Yves 

Norval, Paul Nunn 

International Union Against Tuberculosis and Lung Disease (The 

Union): Riitta Dlodlo

Acknowledgements

Mary Catlin, William Coggin, Elizabeth L. Corbett, Reuben 

Granich, Chris W. Green, Eric Ikoona, Pecharin Kaewrakmook, 

Saiyud Moolphate, Mary Nandili, Supalert Nedsuwan, Lisa 

Nelson, Jintana Ngamvithayapong-Yanai, Joseph Odhiambo, 

Naraworn Puraksa, Caroline Ryan, Supaporn Trongsakul, Jeroen 

van Gorkom and Charles Wells reviewed these guidelines and 

provided useful comments.

Materials developed by the Francis J Curry National Tuberculosis 

Center Institutional Consultation Services provided helpful 

templates.

 

 

This publication is produced by a cooperative effort of:

U.S. Department of Health and Human Services,U.S. Centers for Disease Control and Prevention,

U.S. President’s Emergency Plan for AIDS Relief, The World Health Organization, and

The International Union Against Tuberculosis and Lung Disease
 



Cover photos

Top: Tom Furtwangler with I-Tech/Tambaram

Bottom: Pierre Virot with the Lung Health Image Library
 



CONTENTS

Preface

 Why this addendum was developed 5

 Who should use this addendum 6

 Note on the use of “TB” 

 and “Mycobacterium tuberculosis“ 6

Introduction

 Why TB is a problem in HIV 

 care settings 7

 How Mycobacterium tuberculosis

 is spread 8

 The difference between TB infection

 and TB disease 9

 When TB is infectious 11

 How HIV care settings can reduce

 the risk of spreading TB 12

Work practice and administrative control measures

 Overview 12

 Infection control plan 13

 Administrative support 19

 Training of staff 19

 Education of patients and 

 community awareness 20

 Coordination and communication

 with the national and local 

 TB program 20

 Personal respiratory protection 21

Environmental control measures 22
 



Protection of health care workers 

 Increasing awareness of TB in 

 health care workers and staff 23

 Increasing access to HIV 

 voluntary counseling and testing 25

Multi-drug resistant TB 26

Drug rehabilitation centers/ 

correctional institutions 27

Operational research priorities 28

References 29

Other Resources 

Glossary 33

Annexes

 A.1. Sample infection control plan 36

 A.2. Sample monitoring tools 44

 A.3. Training material for staff 46

 A.4. Education materials for patients 72

 B. Information on Ventilation and Fans 75

 C. Inpatient settings 81

 D. Multi-drug resistance - 

 Frequently Asked Questions 83

 

 
 



PREFACE

WHY THIS ADDENDUM WAS DEVELOPED

The goal of this addendum is to help management and staff 

minimize the risk of TB transmission at facilities in resourcelimited settings in which:

•	 HIV-infected persons receive diagnosis, care, treatment, 

and/or support, such as voluntary counseling and testing 

centers, clinics for HIV care including primary health care 

clinics, antiretroviral therapy (ART) clinics, and support 

clubs for people living with HIV/AIDS; and

•	 There is a high prevalence of HIV infection, both known 

and undiagnosed, in settings such as prisons, jails, other 

detention centers, and drug rehabilitation centers.

In this era of increasing access to HIV counseling and testing, 

care, and treatment for people living with HIV, more people 

living with HIV-associated immunosuppression are attending 

health care and community facilities than ever before. 

Persons, including health care workers, with HIV-associated 

immunosuppression are particularly vulnerable to developing 

TB disease if they become infected with Mycobacterium 

tuberculosis (M. tuberculosis, the germ that can cause TB) as a 

result of exposure in these settings. 

The Guidelines for the Prevention of Tuberculosis in Health 

Care Facilities in Resource-Limited Settings1 published by the 

World Health Organization in 1999 addresses issues related 

to inpatient facilities. This document supplements rather than 

replicates that guidance and addresses inpatient facilities only in 

Annex C. It aims to give the reader a greater understanding of 

the following issues in the context of HIV care settings:

•	 TB transmission in facilities providing services to people 

living with HIV infection and disease;

•	 Infection control procedures to reduce the risk of M. 
 



tuberculosis transmission in HIV/AIDS care facilities;

•	 Protection of health care workers and staff through 

HIV voluntary counseling and testing (VCT), increasing 

awareness of TB in staff and preventive action;

•	 Importance of TB infection control in drug rehabilitation 

centers; correctional institutions including prisons, jails, 

other detention centers; and other facilities where large 

numbers of HIV infected individuals gather;

•	 Issues of multi-drug resistant TB (MDRTB).

WHO SHOULD USE THIS ADDENDUM

This document is for policy makers, health care workers, 

administrators, and stake holders in the public, private, and 

nongovernmental health sector involved in providing care and 

treatment to persons with HIV/AIDS. It can also be helpful for 

persons or institutions responsible for the health and well-being 

of large numbers of persons living with HIV/AIDS (PLWHA). 

Settings include VCT centers, community-based outreach 

centers, ARV and other HIV care clinics, hospices, general 

health care facilities, drug rehabilitation centers, and correctional 

institutions including prisons and jails. 

Note on the use of “TB”, M. tuberculosis and “TB 

suspect” 

The words “tuberculosis (TB)” and “M. tuberculosis,” the 

bacterium that causes TB, are used in different ways. This 

document uses “TB” to describe clinical events, such as TB 

infection, TB transmission, and TB disease; M. tuberculosis is 

used when describing potentially infectious germs that a person 

with TB disease of the lungs or larynx expels when coughing. 

“TB suspect” refers to a person who presents with symptoms 

or signs suggestive of TB disease, in particular a cough of long 

duration. 
 



INTRODUCTION

WHY IS TB A PROBLEM IN HIV CARE SETTINGS?

Persons with undiagnosed, untreated and potentially contagious 

TB are often seen in HIV care settings. TB is the most common 

opportunistic infection and a leading cause of death in persons 

living with HIV/AIDS (PLWHA).

In high TB burden settings, surveys have shown that up to 10% 

of persons with HIV infection may have previously undiagnosed 

TB at the time of HIV voluntary counseling and testing (VCT), 

including at centers providing prevention-of-mother- to-child HIV 

transmission (PMTCT) services. 2,3,4 Up to half of these may be 

infectious TB cases. 

Between 30% and 40% of PLWHA living in high burden TB 

settings will develop TB in their lifetime, in the absence of 

isoniazid preventive therapy or antiretroviral therapy.5 The risk of 

developing TB disease doubles in the first year after becoming 

HIV-infected and gets progressively higher over time. 6 Persons 

without TB disease at the time of HIV diagnosis may still 

develop TB in later years, and will then be at risk of spreading 

M. tuberculosis in the community as well as to fellow patients, 

healthcare workers, and staff at their HIV care clinics and in 

community programs. 

Persons with HIV-associated immunosuppression may become 

infected or re-infected with TB if they are exposed to someone 

with infectious TB disease. They can progress rapidly from 

TB infection to disease – over a period of months rather than a 

period of years as is common for persons with a normal immune 

system. 

Health care workers and other staff are also at particularly 

high risk of infection with TB because of frequent exposure 

to patients with infectious TB disease. Health care workers 

and staff may themselves be immunosuppressed due to HIV 
 



infection and be at higher risk of developing TB disease once 

infected. 

Multiple TB outbreaks affecting HIV-infected patients and 

health care workers due to health care facility exposures 

were documented in industrialized countries in the 1990s.

7

 These coincided with the early period of the HIV epidemic, 

before TB infection control procedures in health care facilities 

were strengthened. This document provides information on 

measures that can be taken, even in resource-limited settings, 

to prevent unnecessary morbidity and mortality due to TB 

transmission in health care settings.

Work practice, administrative control measures and 

environmental control measures are the focus of this addendum. 

Other issues addressed are HIV and TB in health care workers 

and staff, and protecting their health; MDRTB; and specialized 

facilities such as drug rehabilitation centers.

HOW IS TB SPREAD?

TB is caused by M tuberculosis. People who have TB 

disease in their lungs can release tiny particles containing M. 

tuberculosis into the air by coughing. These particles are called 

droplet nuclei. They are invisible to the naked eye. Droplet 

nuclei can remain airborne in room air for many hours, until they 

are removed by natural or mechanical ventilation.

To spread, there must be a source, a person with TB disease 

who produces M. tuberculosis, and an exposed person to 

inhale droplet nuclei containing the bacteria. Although TB is not 

usually spread by brief contact, anyone who shares air with a 

person with TB disease of the lungs in an infectious stage is at 

risk. A person who inhales one or more of the droplet nuclei can 

become infected with M. tuberculosis.
 



HOW IS TB DISEASE IN THE LUNGS DIAGNOSED

The most common part of the body to have TB disease is the 

lungs. In resource-limited settings TB disease in the lungs is 

diagnosed by examining samples of sputum with a microscope. 

The sputum is smeared onto a small glass plate, stained with 

chemicals, and viewed under the microscope. If M. tuberculosis

bacilli are present, they can often (but not always) be seen. 

These diagnostic tests are referred to as “sputum smears”. 

Sometimes chest radiography is done to assist with making the 

diagnosis.

VACCINATION WITH BCG

The Bacille Calmette-Guérin (BCG) vaccine is a live vaccine 

derived from a strain of Mycobacterium bovis (similar to M. 

tuberculosis) first administered to humans in 1921. Since 

that time, many different strains have been derived and are 

used today throughout the world to prevent TB disease. BCG 

vaccination reduces the risk for progression from latent TB 

infection to TB disease, especially disseminated or central 

nervous system disease in children. BCG vaccination may 

cause a positive reaction to a tuberculin skin test. 

THE DIFFERENCE BETWEEN TB INFECTION AND TB 

DISEASE

TB Infection

•	 TB infection is the state of having a small number of M. 

tuberculosis bacteria in the body which are unable to 

grow due to control by the immune system. The bacteria 

are inactive, but remain alive in the body and can 

become active later. This condition is also referred to as 

latent TB infection (LTBI). 

•	 TB infection does not cause a person to feel sick, and 
 

10

there are no symptoms, nor are there signs detected 

upon medical evaluation.

•	 A tuberculin skin test is the main method used to 

diagnose TB infection. A positive result usually means 

that TB infection is present, but persons with HIVassociated immunosuppression can have a false 

negative TB skin test even with TB infection. Also, 

persons who have received BCG vaccination may have a 

false positive skin test.

•	 Only one out of 10 people with TB infection and a normal 

immune system will develop TB disease in their lifetime. 

For persons with HIV infection and TB infection, one out 

of 10 each year will develop TB disease.

•	 Treatment for TB infection with the anti-TB drug isoniazid 

can reduce the risk that TB disease will develop, though 

the protective benefit only lasts about two years in 

persons with HIV infection.

TB Disease

•	 Most TB disease occurs in the lungs. In persons with 

HIV infection, up to half of TB cases have disease in 

other parts of the body.

•	 A person with TB disease of the lungs usually has a 

cough and sometimes coughs up blood.

•	 General symptoms of TB disease include fever, sweating 

at night, loss of appetite, weight loss, and fatigue.

•	 With standard treatment TB disease can be cured, even 

in persons with HIV infection. 

•	 Untreated TB is often fatal, especially in persons infected 

with HIV.
 

11

TB Infection versus TB Disease

TB Infection TB Disease (in the 

lungs)

M. tuberculosis in the body

Tuberculin skin test reaction usually positive

No symptoms Symptoms such as 

cough, fever, weight 

loss

Chest x-ray usually 

normal

Chest x-ray usually 

abnormal

Sputum smears and 

cultures negative

Sputum smears 

and cultures usually 

positive*

Not infectious Often infectious

before treatment

Not a case of TB A case of TB

* Sputum smears more often negative in HIV-infected TB cases

WHEN TB IS INFECTIOUS

TB can be infectious when it occurs in the lungs or larynx. In 

general, a person with TB disease of the lungs or larynx should 

be considered infectious until the person:

•	 Has completed at least two weeks of standard antiTB therapy, preferably with direct observation by a TB 

program-appointed treatment supervisor; and

•	 Has had three consecutive negative sputum smears on 

three different days, with at least one morning specimen;* 

and

•	 Has improvement in symptoms.

A TB suspect should be considered infectious until a diagnostic 

investigation is completed.

* Note: Frequent evaluation of AFB sputum smear status may not be done routinely 

in resource-limited settings.
 

12

HOW TO REDUCE THE RISK OF SPREADING M. 

TUBERCULOSIS IN HIV CARE SETTINGS

It is very likely that persons with infectious TB will be found in 

HIV care settings. There is also a strong likelihood that these 

persons will spread M. tuberculosis to other persons, including 

immunocompromised patients or staff. However, there are 

interventions which can significantly reduce this risk. 8 There are 

two main ways in which even settings with limited resources can 

reduce the chances that TB will spread:

1. work practice and administrative control measures

2. environmental control measures 

In general, work practice and administrative control measures 

have the greatest impact on preventing TB transmission within 

settings, and they are the first priority in any setting regardless 

of available resources. These measures prevent droplet nuclei 

containing M. tuberculosis from being generated in the facility, 

and thus reduce exposure of patients and staff to TB. Ideally, 

if generation of droplet nuclei is eliminated then exposure is 

eliminated; no further controls are needed. However, since it 

is not possible to eliminate all exposure, environmental control 

measures must be added to reduce the concentration of 

droplet nuclei in the air. Although many environmental control 

measures require resources not available in resource-limited 

settings, some can be implemented, and staff can be trained in 

their purpose, capabilities, proper operation, and maintenance.

WORK PRACTICE AND ADMINISTRATIVE CONTROLS

Work practice and administrative control measures have the 

greatest impact on preventing TB transmission within facilities 

caring for PLWHA. They serve as the first line of defense 

for preventing the spread of TB in HIV care settings. Their 

goals are [1] to prevent TB exposure to staff and patients, 
 

13

and [2] to reduce the spread of infection by ensuring rapid 

and recommended diagnostic investigation and treatment for 

patients and staff suspected or known to have TB. This can best 

be accomplished through the prompt recognition, separation, 

provision of services, and referral of persons with potentially 

infectious TB disease. 

There are five components to good work practice and 

administrative controls:

•	 Infection control plan;

•	 Administrative support for procedures in the plan, 

including quality assurance;

•	 Training of staff;

•	 Education of patients and increasing community 

awareness; and

•	 Coordination and communication with the TB program.

INFECTION CONTROL PLAN

Each facility should have a written TB infection control plan 

that outlines a protocol for the prompt recognition, separation, 

provision of services, investigation for TB and referral of patients 

with suspected or confirmed TB disease.

Early recognition of patients with suspected or confirmed TB 

disease is the first step in the protocol. A staff member should 

be assigned to screen patients for prolonged duration of cough 

immediately after they arrive at the facility. Patients with cough 

should be allowed to enter, register, and get a card without 

standing in line with other patients. 

Patients who are identified as TB suspects on the screening 

must be given advice on respiratory hygiene/cough etiquette, 

and provided with a face mask (e.g., surgical mask) or tissues to 

cover their mouths and noses. They should then be separated

from other patients and requested to wait in a separate well-
 

14

ventilated waiting area. 

Placing symptomatic patients at the front of the line, to quickly 

provide care and reduce the amount of time that others are 

exposed to them, is recommended. 

Some patients who are found to have symptoms suggestive 

of TB may have attended the clinic for another reason. If 

possible, these patients should receive the services they were 

originally accessing (e.g. VCT, medication refills) before being 

investigated for TB or referred to the TB diagnostic center. In an 

integrated service delivery setting, if possible, the patient should 

receive the services they are accessing before TB investigation.

TB suspects should promptly be investigated for TB following 

national protocols. If TB diagnostic services are not available 

onsite, the facility should have an established link with a 

TB diagnostic center to which symptomatic patients can be 

referred. Also, each facility should have a linkage with a TB 

treatment center to which those who are diagnosed with TB can 

be referred (see Coordination and Communication between 

TB and HIV/AIDS Care Programs). Ideally, sputum samples 

should be collected and sent to the nearest laboratory. Sputum 

collection always should be done in a designated area with a 

lot of air circulation and away from other people, not in small 

rooms such as toilet rooms or other enclosed areas. If this is 

not possible the patient should be referred to the nearest TB 

diagnostic center. Every attempt should be made to facilitate this 

referral (e.g., through subsidizing transport costs or incentives) 

as further delays in diagnosis will increase the risk of exposing 

others to TB infection.

The plan should designate a staff member to be the infection 

control officer who is responsible for ensuring the infection 

control procedures are implemented. The plan will include, but 

not be limited to, the following policy areas:
 

15

1. Screening all patients as soon as possible after arrival at 

the facility to identify persons with symptoms of TB disease 

or persons who are being investigated or treated for TB 

disease.

2. Instructing the above designated persons identified 

through screening in respiratory hygiene/cough etiquette. 

This includes instructing them to cover their nose and mouth 

when coughing for sneezing, and when possible providing 

face masks or tissues to assist them in covering their 

mouths. 

 

Face masks help prevent the spread of M. tuberculosis from 

the patient to others. The face mask can capture large wet 

particles near the mouth and nose of the patient, preventing 

the bacteria from being released into the environment. Face 

masks could be provided to persons who have a positive 

symptom screen to wear until they leave the facility. Cloth 

masks can be sterilized and reused. Paper tissues provided 

to these persons, with instructions to cover their mouths and 

noses when coughing or sneezing, are less costly and also 

less likely to identify people as TB suspects with attendant 

risk of stigma. However, they are less likely to be used 

effectively. (See A Note on Personal Respiratory Protection)

Tissues and face masks should be disposed in waste 

receptacles. Clients and especially staff should be 

encouraged to wash their hands after contact with 

respiratory secretions. M. tuberculosis cannot be spread 

from the hands, but other serious lung infections can.

3. Placing TB suspects and cases in a separate wellventilated waiting area such as a sheltered open-air space is 

ideal in warm climates.

4. Speeding up management of these persons so that they 

spend as little time as possible at the facility.
 

16

5. Ensuring rapid diagnostic investigation of TB suspects, 

including referring TB suspects to TB diagnostic services if 

not available on site; and ensuring that persons reporting TB 

treatment are adhering with their treatment.

6. Using and maintaining environmental control measures 

(see Environmental Control Measures).

7. Training and educating all staff on TB and the TB infection 

control plan (training should include special risks for TB for 

HIV-infected persons, and need for diagnostic investigation 

for those with signs or symptoms of TB). 

8. Providing voluntary, confidential HIV counseling and 

testing for staff with adequate access to treatment. 

9. Monitoring the TB infection control plan’s implementation 

and correcting any inappropriate practices or failure to 

adhere to institutional policies. 

(See Annex A.1. Sample infection control plan) 
 

17

Five Steps for Patient Management

to Prevent Transmission of TB in 

HIV Care Settings

Step Action Description

1. Screen

Early recognition of patients with suspected or confirmed 

TB disease is the first step in the protocol. It can be 

achieved by assigning a staff member to screen patients 

for prolonged duration of cough immediately after they 

arrive at the facility. Patients with cough of more than two 

weeks duration, or who report being under investigation or 

treatment for TB*, should not be allowed to wait in the line 

with other patients to enter, register, or get a card. Instead, 

they should be managed as outlined below. 

2. Educate

Instructing the above mentioned persons identified through screening 

in cough hygiene. This includes instructing them to cover their noses 

and mouths when coughing or sneezing, and when possible providing 

face masks or tissues to assist them in covering their mouths. 

3. Separate

Patients who are identified as TB suspects or cases by the 

screening questions must be separated from other patients 

and requested to wait in a separate well-ventilated waiting 

area, and provided with a surgical mask or tissues to cover 

their mouths and noses while waiting. 

4. Provide HIV 

services

Triaging symptomatic patients to the front of the line for the 

services they are seeking (e.g. voluntary HIV counseling 

and testing, medication refills), to quickly provide care and 

reduce the amount of time that others are exposed to them 

is recommended. In an integrated service delivery setting, 

if possible, the patient should receive the HIV services they 

are accessing before the TB investigation.

5. Investigate for 

TB or

Refer

TB diagnostic tests should be done onsite or, if not available 

onsite, the facility should have an established link with a 

TB diagnostic center to which symptomatic patients can be 

referred. Also, each facility should have a linkage with a TB 

treatment center to which those who are diagnosed with TB 

can be referred.

*Although TB patients on adequate treatment are no 

longer infectious, it may be difficult for the facility to 
 

18

determine if anyone reporting being on treatment for 

TB has indeed received adequate treatment. The most 

cautious procedure is to manage those who are on 

treatment in the manner described.
 

19

ADMINISTRATIVE SUPPORT

Each facility should appoint one person to serve as the infection 

control officer. Larger facilities may also have a committee. 

The officer is responsible for overseeing the infection control 

committee and developing a written infection control plan, 

monitoring its implementation, and providing effective training 

for health care workers and other staff. (See Annex A.2. 

Sample monitoring tools)

TRAINING OF STAFF 

Infection control is effective only if all staff working in a facility 

understands the importance of the infection control policies and 

their role in implementing them. As part of training, each health 

care worker and staff member, including any lay workers, should 

receive job category-specific instruction. Training should be 

conducted before initial assignment and continuing education 

should be provided to all employees and volunteers annually. 

Training should include the seven issues below:

•	 Basic concepts of M. tuberculosis transmission and 

pathogenesis (i.e., the difference between infection and 

disease);

•	 Risk of TB transmission to health care workers and staff

•	 symptoms and signs of TB;

•	 Impact of HIV infection on increasing risk of developing 

TB disease and the importance of TB as a major cause of 

disease and death in PLWHA;

•	 Importance of the infection control plan and the 

responsibility that each staff member has to implement 

and maintain infection control practices;

•	 Specific infection control measures and work practices 

that reduce the likelihood of transmitting TB; and

•	 Measures staff can take to protect themselves from TB. 

(See Annex A.3. Training materials for staff)
 

20

EDUCATION OF PATIENTS AND COMMUNITY AWARENESS

As noted in the introduction, up to one-third or more of HIVinfected persons living in areas with widespread TB will develop 

TB disease during their lifetime. Educating communities and 

patients to recognize symptoms of TB and to seek health 

care and further investigations should be routine in settings 

providing care for HIV-infected persons. In addition, patients 

should understand how to protect themselves, and others, 

from exposure to TB by simple cough hygiene measures. (See 

Annex A.4. Patient education materials)

COORDINATION AND COMMUNICATION BETWEEN TB AND 

HIV/AIDS CARE PROGRAMS

Coordination and communication between HIV/AIDS and 

TB programs is one aspect of a major initiative of STOP TB 

Department of the World Health Organization to prevent 

TB in persons with HIV. In most countries, national TB/HIV 

coordinating bodies are being established with a goal of having 

similar committees at every level of health care service. Each 

facility caring for persons with HIV should determine what 

coordinating mechanisms already exist at their local level. Each 

facility without an integrated system providing care for both 

TB and HIV should develop an agreement with the local TB 

program which establishes: 

•	 A referral mechanism for patients suspected of having 

TB disease to be investigated in the TB diagnostic center 

and started on treatment, if indicated; and 

•	 A monitoring mechanism which provides feedback to 

the referring facility to evaluate both the linkage with TB 

diagnostic services and the appropriateness of referrals 

as indicated by the proportion of suspects actually 

confirmed as having TB disease. (See Annex A.2 

Sample monitoring tools)
 

21

PERSONAL RESPIRATORY PROTECTION

Personal respiratory protection (i.e., the selection, training, 

and use of respirators) is not a priority intervention in the HIV 

care settings addressed in this addendum. Respirators can 

protect health care workers from inhaling M. tuberculosis only 

if standard work practice and environmental controls are in 

place. In addition, they are expensive to purchase and require 

specialized equipment to determine proper fit. Frequently, they 

are unavailable in resource-limited settings. Their use should 

be restricted to specific high risk areas in hospitals and referral 

centers, such as rooms where spirometry or bronchoscopy are 

performed or specialized treatment centers for persons with 

MDRTB. 

If a respirator is needed, a U.S.-certified N95 (or greater) 

or EU-certified FFP2 (or greater) respirator should be used. 

Respirators are different from face masks, such as surgical 

masks made of cloth or paper. Use of a face mask does not 

protect health care workers, other staff, patients, or visitors 

against TB. Therefore, it is NOT recommended that health care 

workers and other staff or visitors in HIV care settings wear 

them.

For more detailed information, please refer to pages 45-48 of 

the Guidelines for the prevention of tuberculosis in health care 

facilities in resource-limited settings. 1

 
 

22

ENVIRONMENTAL CONTROL MEASURES

Environmental controls are the second line of defense for 

preventing the spread of TB in HIV care settings. It is important 

to recognize that if work practice or administrative controls are 

inadequate, environmental controls will not eliminate the risk. 

Environmental controls include: 

•	 Ventilation (natural and mechanical), 

•	 Filtration, and 

•	 Ultraviolet germicidal irradiation. 

Many environmental control measures are technologically 

complex and expensive, and therefore only practical for referral 

hospitals. However, controlled natural ventilation can reduce 

the risk of spreading M. tuberculosis. 

Face mask – has large pores and 

lacks air tight seal around edges 

Respirator – has only tiny pores 

which block droplet nuclei and 

relies on an air tight seal around 

the entire edge 
 

23

Ventilation is the movement of air in a building and replacement 

of air in a building with air from outside. Natural ventilation 

relies on open doors and windows to bring in air from the 

outside; ”controlled” implies that checks are in place to make 

sure that doors and windows are maintained in an open position 

that enhances ventilation. Fans may also assist to distribute the 

air. When fresh air enters a room it dilutes the concentration 

of particles in room air, such as droplet nuclei containing M. 

tuberculosis. Designing waiting areas and examination rooms 

so that they maximize natural ventilation can help reduce the 

spread of TB. In warm climates, this means open-air shelters 

with a roof to protect patients from sun and rain (See Annex B. 

Information on Ventilation and Fans).

If patients are asked to provide sputum specimens for TB 

diagnosis onsite, they should always do so in an adequately 

ventilated booth or outside in the open air and away from other 

people, not in small rooms such as toilets or other enclosed 

areas. (See Additional Resources for more information on 

sputum collection booths.)

Studies show that M. tuberculosis is killed if the organisms 

are exposed to sufficient ultraviolet germicidal irradiation 

(UVGI). The major concerns about UVGI have been adverse 

reactions, such as acute and chronic skin and eye changes 

from overexposure if the UVGI is not installed and maintained 

properly. Information on installation, cleaning, maintenance, 

and ongoing monitoring is available from Additional Resources.

PROTECTION OF HEALTH CARE WORKERS AND STAFF

INCREASING AWARENESS OF TB IN HEALTH CARE 

WORKERS AND STAFF

Investigations in countries in Africa, Asia, and South America 

have documented increased risk of TB disease or infection in 
 

24

health care workers compared with the general population1. 

Those at risk include not just health care providers, but any 

staff, including volunteers, who have contact with persons with 

TB who have not yet been diagnosed and started on treatment. 

This could include porters and cleaners, as well as peer 

educators, adherence supporters, and volunteers working as 

counselors or in support groups. PLWHA in these roles are at 

particular risk of rapid progression to TB disease if they become 

infected or re-infected due to exposure to M. tuberculosis in the 

facility. They should be included in all training programs. A third 

group, staff in correctional institutions and drug rehabilitation 

centers, also has been documented to have higher rates of TB 

infection and disease than the general population. 

The infection control measures recommended in this addendum 

should reduce the time persons with undiagnosed TB spend 

in HIV care settings and should improve ventilation and thus 

dilution of any M. tuberculosis particles in the environment. 

Nevertheless, the risk to staff will never be zero, and an 

additional aspect of protecting staff is promoting early 

recognition of TB disease and standard treatment.

Annual screening programs for TB disease, such as annual 

chest radiography, have not been shown to effectively reduce 

the amount of time between developing symptoms and 

diagnosis, as only a fraction of those who develop TB do so 

around the time of screening. Instead, reminders that health 

care workers and other staff can develop TB, regardless of 

previous infection status or BCG vaccination, should occur with 

annual re-training on infection control. It is recommended that 

staff be investigated for TB free of charge if they have a cough 

for two weeks or more. The infection control plan should list 

designated staff members who should be contacted to initiate 

TB investigations, and reinforce that all services are confidential. 

Tuberculin skin testing can diagnose persons with TB infection 

who are most likely to develop TB disease, and who could 

potentially benefit from preventive treatment for TB infection. 
 

25

However, TB preventive therapy programs are not yet widely 

implemented in resource-limited settings.9 In the new era 

of expanding access to care for persons living with HIV, TB 

preventive therapy for HIV-infected health care workers should 

be considered.

INCREASING ACCESS TO VOLUNTARY HIV COUNSELING 

AND TESTING

Encouraging and enabling health care workers and all staff 

to know their HIV status should be a priority of all health care 

services, and HIV care programs, in particular. The rate of HIV 

infection among health care workers and staff may be similar 

to that of the broader community. In the past, stigma, lack of 

confidentiality, and lack of treatment options have contributed 

to failure of health care workers to know their HIV status. The 

expansion of the types of facilities addressed in this addendum 

is a sign that conditions are changing. 

Encouraging and enabling health care workers and all staff to 

know their HIV status can be facilitated by providing accessible, 

acceptable, confidential VCT, including periodic retesting, to 

staff. Policies which prioritize ART for health care workers who 

need it can motivate them to know their HIV status. Health 

care workers are a valuable resource, and they must receive 

adequate care and treatment to remain healthy and in the 

workforce. Furthermore, HIV-infected health care workers and 

other staff are at increased risk of developing TB disease if 

exposed in the workplace, and additional precautions should 

be taken to protect them. Immunocompromised health care 

workers should be given opportunities to work in areas with a 

lower risk of exposure to TB.

Leadership and advocacy at the national level, from health 

care worker unions, and from medical and nursing associations 

will encourage health care workers to know their HIV status. 

Locally, programs can consider confidential testing options 
 

26

such as use of rapid test kits at home; travel to another setting 

where one could be tested truly confidentially; bringing in a 

mobile counseling team (not from the community), who will not 

personally know any of the staff they test. 

There is no role for mandatory HIV testing of health care 

workers.

Health care workers have the same rights as all individuals to 

confidential HIV testing with counseling and conducted only with 

an informed consent.

Education directed to health care workers concerning HIV 

testing can also be linked to their role in educating patients and 

communities about the benefits of testing and knowing one’s 

HIV status and may further reduce stigma. 

MULTI-DRUG RESISTANT TB (MDRTB)

TB disease that is caused by organisms susceptible to the firstline anti-TB drugs can generally be treated effectively without 

side effects from treatment, even in persons with HIV infection. 

TB disease caused by organisms resistant to at least the two 

most potent first-line drugs (isoniazid and rifampicin) is called 

multi-drug resistant TB (MDRTB). Treating MDRTB takes 

longer and requires drugs that are more toxic, more expensive, 

often of limited availability in resource-limited settings, and 

generally less effective particularly in persons with HIV infection. 

Because of the risk of severe morbidity and mortality to 

HIV-infected persons from MDRTB, persons with known 

MDRTB should receive routine care outside of normal HIV 

care settings. 

HIV care facilities can obtain estimates of the prevalence of 

MDRTB in their community from the local TB program. Through 

joint coordination and communication, the TB and HIV programs 
 

27

can plan for how to care for these patients. In areas where 

MDRTB is rare, special arrangements can be made to provide 

HIV care for an MDRTB patient. In areas where MDRTB is 

more prevalent, specialized clinics can be established (See 

Annex D. FAQ on MDRTB).

DRUG REHABILITATION CENTERS AND CORRECTIONAL 

INSTITUTIONS

In many areas the proportion of persons with HIV infection in 

drug rehabilitation centers and correctional institutions (e.g., 

jails and prisons) is much higher than in the general population. 

This is in part due to the high prevalence of HIV infection among 

injection drug users and sex workers, who in turn represent 

a large proportion of those incarcerated or in rehabilitation 

in some parts of the world. Additionally, TB is spread even 

more readily in these settings than in outpatient settings 

because of the longer duration of potential exposure, crowded 

environment, poor ventilation, and limited access to health 

care services. WHO has published guidelines for TB control in 

correctional institutions.10 These guidelines emphasize effective 

administrative and environmental controls, including screening 

detainees upon entry into the facility, and on a regular basis 

during times of prolonged detention.

Because the same TB infection control policies will protect HIVinfected and uninfected detained persons as well as staff, it is 

not necessary to know who in the population at the institution is 

HIV-infected to conduct effective TB infection control. However, 

voluntary, confidential HIV counseling and testing with consent 

can identify persons in need of HIV treatment with antiretroviral 

drugs, and prevention services such as preventive therapy for 

latent TB infection, which may contribute to TB control. 
 

28

OPERATIONAL RESEARCH PRIORITIES

The recommendations in this addendum are based on current 

state of the art knowledge about TB infection control in 

resource-limited settings. However, operational research can 

further inform practice. Areas in which carefully collected and 

analyzed data would be useful include:

•	 Screening tools and algorithms to quickly identify 

potentially infectious TB patients presenting for HIV 

services;

•	 Mechanisms for referrals and links between HIV and TB 

services;

•	 Strategies for increasing the proportion of health care 

workers who know their HIV status and are able to 

access adequate care, including antiretroviral therapy 

and isoniazid preventive therapy;

•	 Designs for enhancing total air flow and air flow direction 

through controlled natural ventilation;

•	 Utility of ultraviolet germicidal irradiation in resourcelimited settings;

•	 Feasibility of prolonged treatment with isoniazid for 

prevention of TB in immunocompromised health care 

workers; and

•	 Interventions with health care workers that reduce stigma 

towards HIV and TB/HIV patients. 
 

29

References 

1. World Health Organization. Guidelines for the Prevention 

of Tuberculosis in Health Care Facilities in ResourceLimited Settings. Geneva, World Health Organization, 

1999.

2. World Health Organization. Report of a “Lessons 

Learnt” Workshop on the Six ProTest Pilot Projects I 

Malawi, South Africa and Zambia. Geneva, World Health 

Organization, 2004.

3. Nachega J et al. Tuberculosis active case finding in a 

mother-to-child HIV transmission prevention programme 

in Soweto, South Africa. AIDS, 2003, 17:1398-1400.

4. Burgess A et al. Integration of tuberculosis screening at 

an HIV voluntary counseling and testing center in Haiti. 

AIDS, 2001, 15:1875-1879.

5. Corbett E et al. The growing burden of tuberculosis: 

global trends and interactions with the HIV epidemic. 

Archives of Internal Medicine, 2003, 163:1009-1021.

6. Sonnenberg P et al. How soon after infection with 

HIV does the risk of tuberculosis start to increase? A 

retrospective cohort study in South African gold miners.

Journal of Infectious Diseases, 2005, 191(2):150-8. 

7. Centers for Disease Control and Prevention. Multi-drug 

resistant Tuberculosis outbreak on an HIV ward – Madrid, 

Spain, 1991-1993. Morbidity and Mortality Report, 1996, 

44:330.

8. Harries AD et al. Practical and affordable measures 

for protection of health care workers from tuberculosis 

in low-income countries. Bulletin of the World Health 

Organization, 1997, 75:477-489.

9. World Health Organization. Preventive therapy 

against tuberculosis in people living with HIV. Weekly 

Epidemiological Record, 1999, 46:385-397.

10.Tuberculosis Control in Prisons: A Manual for Program 

Managers, Geneva, World Health Organization, 2000

 http://www.who.int/docstore/gtb/publications/prisonsNTP/ 

 PDF/tbprisonsntp.pdf
 

30

Additional Resources

TB Infection Control and TB/HIV Collaborative Activities

Guidelines for the prevention of tuberculosis in health care 

facilities in resource-limited settings, Geneva, World Health 

Organization, 1999 http://www.who.int/docstore/gtb/publications/

healthcare/PDF/WHO99-269.pdf

Guidelines for Preventing the Transmission of Mycobacterium 

tuberculosis in Health-Care Settings, Morbidity and Mortality 

Weekly, 2005

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm

Guidelines for Preventing the Transmission of Mycobacterium 

tuberculosis in Health-Care Facilities, Morbidity and Mortality 

Weekly, Centers for Disease Control and Prevention, 1994

http://www.cdc.gov/mmwr/preview/mmwrhtml/00035909.htm

Interim policy on collaborative TB/HIV activities, WHO 2004 

http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.336.pdf

Strategic framework to decrease the burden of TB/HIV, Geneva, 

World Health Organization, 2002 

http://www.who.int/docstore/gtb/publications/tb_hiv/2002_296/

pdf/tb_hiv_2002_296_en.pdf

A Guide to Monitoring and Evaluation for Collaborative TB/HIV 

activities, Geneva, World Health Organization, 2004

http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.342.pdf

TB/HIV: A Clinical Manual, Geneva, World Health Organization, 

2nd edition, 2004

http://whqlibdoc.who.int/publications/2004/9241546344.pdf

The following guidelines were developed for the US domestic 

situation but contain useful material:
 

31

Francis J. Curry National Tuberculosis Center, Institutional 

Consultation Services. A guideline for establishing effective 

practices: Identifying persons with infectious TB in the 

emergency department. 1998

http://www.nationaltbcenter.edu/catalogue/downloads/

emergencyRoomGuidelines.pdf

Francis J. Curry National Tuberculosis Center, Institutional 

Consultation Services, and California Department of Health 

Services. TB in Homeless Shelters: Reducing the Risk through 

Ventilation, Filters, and UV. 2000.

http://www.nationaltbcenter.edu/catalogue/downloads/

tbhomelessshelters.pdf

Isoniazid Preventive Therapy

Policy Statement on Preventive Therapy Against Tuberculosis in 

People Living with HIV: Report of a meeting held in Geneva 18-

20 February 1998, Geneva, World Health Organization, 1998 

http://www.who.int/docstore/gtb/publications/TB_HIV_polstmnt/

PDF/tbhivpolicy.pdf

MDRTB

DOTS-Plus for Standardized Management of Multi-drug 

resistant Tuberculosis in South Africa – Policy Guidelines, South 

African Medical Research Council/National Department of 

Health, 2004

The Management of Multi-drug resistant Tuberculosis in South 

Africa, South African Medical Research Council/National 

Department of Health, 2nd Edition, 1999

Anti-tuberculosis Drug Resistance in the World. Report No. 

3. The WHO/IUATLD Global Project on Anti-tuberculosis Drug 

Resistance Surveillance, Geneva, World Health Organization, 

2004 

http://www.who.int/tb/publications/who_htm_tb_2004_343 

en/index.html
 

32

Correctional Institutions

Tuberculosis Control in Prisons: A Manual for Program 

Managers, Geneva, World Health Organization, 2000

http://www.who.int/docstore/gtb/publications/prisonsNTP/PDF/

tbprisonsntp.pdf

The following guidelines were developed for US domestic 

situation but contain useful material:

Francis J. Curry National Tuberculosis Center and California 

Department of Health Services, 2002: Tuberculosis Infection 

Control Plan Template for Jails

http://www.nationaltbcenter.edu/jailtemplate/docs/tb_section1.

pdf

Laboratory Issues

World Health Organization. Communicable Diseases 

Prevention and Control. Laboratory Services in Tuberculosis 

Control. Edition 1. Geneva, World Health Organization, 1998.
 

33

Glossary and Abbreviations

Bacille Calmette-Guérin (BCG) vaccine: A live vaccine 

against TB derived from an attenuated strain of Mycobacterium 

bovis.

Droplet nuclei: microscopic particles which are estimated 

at 1-5 microns in diameter and are produced when a person 

coughs, sneezes, shouts or sings. Such particles may remain 

suspended in the air for hours.

Environmental control measures: measures that can be used 

in high-risk areas to reduce the concentration of droplet nuclei 

in the air (e.g., maximizing natural ventilation or controlling the 

direction of airflow).

Exhaust ventilation: an efficient environmental control 

technique (e.g. laboratory hoods, tents, booths, ventilation 

device) to contain airborne particles near the source before they 

can disperse widely into the air.

Face mask: cloth or paper mask (e.g. surgical mask) that 

prevents the spread of micro-organisms from the wearer to 

others by capturing the large wet particles near the source 

(mouth); it does not provide sufficient protection from inhaling 

airborne infectious through.

Health care workers: group of people that includes nurses, 

physicians, nursing and medical students, laboratory workers, 

counselors, and others who work in health care facilities and 

may be exposed to patients with communicable diseases.

HIV: human immunodeficiency virus, the causative agent of 

AIDS.

Infection with M. tuberculosis: the subclinical, latent infection 

with the organisms that cause TB, manifested by a positive 

tuberculin skin test, but without clinical evidence of disease.
 

34

Infection control: specific measures and work practices that 

reduce the likelihood of transmitting M. tuberculosis.

Isolation room: single patient room with negative pressure 

ventilation where an infectious TB patient can be isolated from 

other patients.

Mechanical ventilation: methods used to direct airflow to 

dilute and remove air, and to produce negative pressure in 

isolation rooms (e.g. window fan, exhaust ventilation systems).

Multidrug-resistant tuberculosis (MDRTB): TB caused by 

strains of M. tuberculosis which are resistant to both isoniazid 

and rifampicin with or without resistance to other drugs.

Mycobacterium tuberculosis: the bacterium that causes TB.

Natural ventilation: defined as natural air movement to 

achieve dilution and air exchange in an area with free-flow of 

ambient air (e.g. through the open windows).

PMTCT: prevention of mother-to-child transmission of HIV 

infection

Respirators: special type of closely-fitted mask with the 

capacity to filter particles 1 micron in size to protect from 

inhaling infectious droplet nuclei.

Smoke tubes: devices used to monitor proper airflow direction 

and to determine the correct function of ventilation systems.

Tuberculin skin testing (TST): intracutaneous injection of 

purified protein derivative (PPD) to identify persons who have 

been sensitized to mycobacterial antigens by infection with M. 

tuberculosis, environmental mycobacteria or administration of 

BCG.
 

35

Tuberculosis (TB): a clinically active, symptomatic disease 

caused by bacteria belonging to the M. tuberculosis complex (M. 

tuberculosis, M. bovis, M. africanum).

Ultraviolet germicidal irradiation (UVGI): an environmental 

control measure to kill or inactivate micro-organisms like M. 

tuberculosis through exposure to UVGI.

VCT: voluntary counseling and testing for HIV infection

Work practice and administrative controls: defined as 

managerial or administrative measures which guide work 

practices to reduce significantly the risk of TB transmission 

by preventing the generation of droplet nuclei. These include 

early diagnosis, prompt isolation or separation of infectious 

TB patients, prompt initiation of appropriate anti-tuberculosis 

treatment.
 

36

ANNEX A.1. SAMPLE INFECTION CONTROL PLAN

A. The plan will include, but not be limited to, the following 

policy areas:

1. Screening patients to identify persons with symptoms 

of TB disease or who report being under investigation 

or treatment for TB disease.

2. Providing face masks or tissues to persons with 

symptoms of TB disease (“TB suspects”) or who 

report being under investigation or treatment for TB 

disease (“TB suspects or cases”), and providing 

waste containers for disposal of tissues and masks.

3. Placing TB suspects and cases in a separate waiting 

area.

4. Triaging TB suspects and cases to the front of the line 

to expedite their receipt of services in the facility. 

5. Referring TB suspects to TB diagnostic services and 

confirming that TB cases are adhering with treatment.

6. Using and maintaining environmental control 

measures.

7. Educating staff periodically on signs and symptoms 

of TB disease, specific risks for TB for HIV-infected 

persons, and need for diagnostic investigation for 

those with signs or symptoms of TB.

8. Training and educating staff on TB, TB control, and 

the TB infection control plan.

9. Monitoring the TB infection control plan’s 

implementation. 
 

37

B. The facility will implement each policy by following the 

procedure(s) that accompany it.

Policy and Procedures 

Purpose: Early identification, separation, receipt of services, 

and referral of patients with TB disease is essential in 

preventing spread of TB 

Lead: _____________________ has the responsibility 

for overseeing the implementation of these policies and its 

procedures, and reports to (District health executive committee, 

etc).

Policy 1: Screening patients to identify persons with symptoms 

or recent history of TB disease. 

Procedures:

1. Before patients enter an enclosed part of the facility, 

a designated staff person should ask each adult and 

any child capable of coughing forcefully (usually age 

14 or older) about symptoms or recent history of TB. 

The questioning should occur before patients wait in 

line for long periods to register or obtain services.

2. Many combinations of symptoms have been 

recommended as sensitive and specific for TB. A 

simple screen is

“Do you have a cough?” If patient answers” yes,” 

ask

“For how long have you been coughing?”

An adult who has coughed for two weeks or more may 

be considered a “TB suspect” for pulmonary TB.
 

38

To determine whether a patient may be under 

investigation or a diagnosed case of TB, who may still 

be infectious, ask

“Are you being investigated or treated for TB?”

If the answer to either is “yes,” the screen classifies 

the patient as a TB suspect or case, and he should 

be managed as described in the procedures under 

policies 2 – 5 below.

3. As patients who are not identified as a TB suspect 

or case on the initial symptoms screen enter an 

examination room with the clinical officer, nurse, or 

counselor, they should again be asked the simple 

screening questions. Those patients who report 

a cough of two or more weeks or who are being 

investigated or treated for TB should be managed 

as follows in the procedures under policies 2 – 5 

below. Staff seeing patients in examination rooms 

should report patients they find to be a suspect or 

case to the infection control officer in a timely manner 

so that factors contributing to the potential exposure 

(e.g., an emergency or short staffing interfering with 

the designated person screening all patients) can be 

documented and corrected.

Policy 2: Instructions on cough hygiene

 Procedures:

1. Patients who are found to be TB suspects or cases 

should immediately be informed about the importance 

of cough hygiene and be handed tissues (or pieces of 

cloth) and instructed to cover their mouths and noses 

when they cough. Alternatively, patients should be 

given a face mask, and asked to wear it while in the 

facility. Patients should also be instructed to dispose 
 

39

of used tissues or masks in identified no-touch 

receptacles and not on the ground.

When tissues, cloths or face masks are not available, 

clients should be instructed to lift their arm up and 

cover their nose and mouth with the inner surface of 

the arm or forearm when they cough or sneeze. M. 

tuberculosis cannot be spread from the hands, but 

other serious lung infections can.

2. No-touch receptacles for disposal of used tissues and 

masks should be available in the waiting areas.

Policy 3: Placing TB suspects and cases in a separate waiting 

area

 Procedures

1. A staff person should direct or escort the patient to 

a separate waiting area. This special waiting area 

should have the highest natural ventilation possible. 

Patients should be assured of their place in the line 

for registration and/or services. 

Policy 4. Triaging TB suspects and cases to the head of the 

line to receive services in the facility

 Procedures

1. TB suspects and cases should be moved to the head 

of the line for whatever services they want or need, 

e.g., VCT, medication refills, or medical investigation. 

This reduces the duration of potential exposure while 

they wait in the facility and may be an incentive to 

disclose information during screening.

Policy 5. Referring TB suspects to TB diagnostic services 
 

40

 Procedures

1. ____________________ is the designated staff 

person to counsel patients about obtaining TB 

diagnostic services. 

2. Patients will be referred to ____________________

________ (TB diagnostic center the HIV care facility 

has a previously negotiated agreement, see section 

__).

3. Patients should be given a card with the name, 

location, and operating hours of the TB diagnostic 

center. The card should also have the name of the 

referring facility on it, with date of referral marked. 

These cards can be collected at the TB center and 

used as an anonymous check on number of referrals 

who successfully obtain TB services. (See also the 

TB suspect and case form listed in Annex A2 below, 

which can be used to cross-reference referrals that 

are made/successful).

Policy 6. Using and maintaining environmental control 

measures

 Procedures

1. ____________________ is the designated staff 

person to check on environmental control measures 

and maintain a log of monitoring and maintenance. 

2. Windows and doors should be checked on a daily 

basis to assure they are in proper position (open 

or closed as called for in the plan). Generally, all 

windows and doors should be open when natural 

ventilation is the primary environmental control to 

allow for the free, unencumbered movement of air 

(e.g., across room, from window to door or vice 
 

41

versa). Generally, all windows and doors should be 

closed when using mechanical ventilation to ensure 

air movement in a controlled manner (air from supply 

vent and from slots either under or in door toward the 

exhaust vent).

3. Fans should be checked on a monthly basis to assure 

they are clean, are pulling (or pushing) the correct 

amount of air, and are pulling (or pushing) air in the 

correct direction.

Policy 7. Providing confidential TB and HIV services to health 

care workers and staff

 Procedures

1. Health care workers and all other staff working 

at the facility should be educated about the signs 

and symptoms of TB and encouraged to seek 

investigations promptly if they develop symptoms and 

signs suggestive of TB.

2. Health care workers and other staff should be 

informed about the special specific risks for TB for 

HIV-infected persons (see section on Training of 

staff).

3. Health care workers and staff should be encouraged 

to undergo HIV testing, and given information on 

relevant HIV care resources. 

4. Staff training should include reduction of stigma of TB 

and HIV.

5. _____________________ is responsible for 

determining when staff who develop TB disease may 

return to work.

6. Staff who develop TB disease may return to work 
 

42

when determined to be no longer infectious after:

a. Having completed at least two weeks of standard 

anti-TB therapy; and

b. Exhibiting clinical improvement; and

c. Having continued medical supervision and 

monitoring of treatment until cured; and

d. Where possible, having had three consecutive 

negative sputum smears obtained on three 

different days with at least one morning specimen. 

(Note: Frequent evaluation of sputum smear 

status may not be done routinely in resourcelimited settings.)

Policy 8. Training of staff on all aspects of TB and the TB 

infection control plan

 Procedures

1. ____________________ is the designated staff 

person to provide training to new staff as it is hired 

and to maintain a log indicating who has had initial 

training.

2. ____________________ is the designated staff 

person to provide annual training to all staff and to 

maintain a log indicating who has attended training. 

This may be incorporated into a broader training topic 

or be stand alone TB infection control training. 

(See Annex A.3 for Sample Training Materials)

Policy 9. Monitoring the TB infection control plan’s 

implementation

 Procedures

1. Determine the frequency of the infection control plan
 

43

a. During initiation of procedures, monitoring and 

evaluation should be done frequently, perhaps 

monthly or bi-monthly.

b. When procedures are running well, less 

frequent evaluation will be necessary – at a 

minimum, annually.

2. Evaluate the screening process

a. Were patients with significant cough missed 

when entering the facility and only detected at 

a later time or in the examination room?

b. What correctable factors were associated with 

these potential exposures?

3. Evaluate the success of referrals to the TB diagnostic 

center

a. Did referred patients access care?

b. Did referred patients have TB disease?

c. What changes in screening or referral process 

should be made, if any?

4. Evaluate the training process

a. Did all new staff receive training on TB infection 

control during their induction?

b. Did all staff receive annual re-training on TB 

infection control?

5. Revise the infection control plan to reflect changes in 

staff responsibilities, policies, and procedures

6. Develop a plan for correcting inappropriate practices 

or failure to adhere to institutional policies

a. identify incentives to participate fully and 

adhere to policies

b. identify corrective actions if policies are not 

followed
 

44

Annex A.2. Sample monitoring tools

_____________________ has the responsibility for overseeing 

the evaluation of the TB infection control policies and its 

procedures, and reports to (Program director, District health 

executive committee, etc).

___________________ has the responsibility for filling out The 

“TB case and suspect log” on a daily basis, entering the date, 

names of patients who were found to be a case or suspect 

that day, whether they were missed at intake screening, and to 

which facility they were referred. 

___________________ has the responsibility for conducting 

follow up on patients referred to a TB diagnostic facility and 

recording the outcomes of their investigation in the log.

 ___________________ has the responsibility to summarize 

and present the results of the screening process to relevant 

management and staff periodically. 

TB Case and Suspect Log

Date Patient 

Name 

Case 

or 

Suspect 

(c/s)

Missed at 

intake?*

(y/n) 

 

 

Referred 

to (name 

of facility)

Outcome** 

(TB,

not TB,

NS)

*Missed at intake = symptoms or history detected only after 

patient enters private room with clinician or counselor instead 
 

45

of upon entry to the facility; or after numerous visits while 

symptomatic yet undetected: y=yes, n=no

**Outcomes: TB diagnosed or confirmed=TB; TB ruled out 

after diagnostic investigation=not TB; Did not present to referral 

facility for investigation=NS (not seen).

Staff TB Infection Control Training Log

Staff Name Start 

Date

Date 

first IC 

training

Date 

annual 

training

Date 

annual 

training

Date 

annual 

training
 

46

Annex A.3. Training materials for staff

The following is a set of overheads with a script that can be 

used by a training facilitator or lecturer. Alternatively the staff 

person can read through the materials. Users may modify as 

needed to meet local needs.

 

Annex A.3

Review of Tuberculosis 

Infection Control

Review of Tuberculosis 

Infection Control
 

47

Why is there concern about TB 

infection control in HIV care 

facilities?

TB is the most common 

opportunistic infection and a 

leading cause of death in 

persons with HIV-infection
 

48

Persons with undiagnosed, 

untreated, and potentially 

infectious (contagious) TB are 

often seen in HIV care settings

Health care workers and other 

staff at HIV care facilities are at 

particularly high risk of infection 

with TB because of frequent 

exposure to persons with 

infectious TB disease in the 

workplace
 

49

Persons who work in HIV care 

settings need to know about TB, 

how it is transmitted, and how 

infection control procedures in 

the workplace can protect them

TB is caused by an organism 

called Mycobacterium 

tuberculosis
 

50

TB is spread from person to 

person through the air

Transmission is the spread of an 

organism, such as M. 

tuberculosis, from one person to 

another
 

51

Not everyone who is exposed to 

an infectious TB patient becomes 

infected

Infection begins when TB 

organisms in the droplet nuclei 

reach the small air sacs of the 

lung called alveoli
 

52

TB infection means that tubercle 

bacilli are in the body but the 

immune system is keeping them 

under control

The lungs and the alveoli.
 

53

People who have TB infection but 

not TB disease are NOT 

infectious

Infectiousness of People Known to Have 

or Suspected of Having TB Disease* 

Receiving adequate treatment 

for 2-3 weeks

Not receiving adequate 

treatment

No acid-fast bacilli on sputum 

smear

Acid-fast bacilli on sputum 

smear

Patient covering mouth when 

coughing

Patient not covering mouth 

when coughing

No cough or cough-inducing 

procedures

Cough or cough-inducing 

procedures

Cavity in the lung No cavity in the lung

TB of the lungs or larynx Most extrapulmonary TB

Factors Associated with

Noninfectiousness

Factors Associated with

Infectiousness

Receiving adequate treatment 

for 2-3 weeks

Not receiving adequate 

treatment

No acid-fast bacilli on sputum 

smear

Acid-fast bacilli on sputum 

smear

Patient covering mouth when 

coughing

Patient not covering mouth 

when coughing

No cough or cough-inducing 

procedures

Cough or cough-inducing 

procedures

Cavity in the lung No cavity in the lung

TB of the lungs or larynx Most extrapulmonary TB

Factors Associated with

Noninfectiousness

Factors Associated with

Infectiousness
 

54

TB disease develops when the 

immune system cannot keep the 

tubercle bacilli under control and 

the bacilli begin to multiply rapidly

TB disease can develop very 

soon after infection or many 

years after infection 
 

55

Some conditions appear to 

increase the risk that TB infection 

will progress to disease

People who are infected with 

both M. tuberculosis and HIV are 

much more likely to develop TB 

disease than people who are 

infected only with M. tuberculosis
 

56

Pulmonary TB occurs 

in the lungs 

Extrapulmonary TB occurs in 

places other than the lungs 
 

57

Miliary TB occurs when tubercle 

bacilli enter the bloodstream and 

are carried to all parts of the 

body, where they grow and 

cause disease in multiple sites

Common symptoms of TB 

disease are persistent cough, 

bloody sputum, weight loss or 

loss of appetite, fever, or night 

sweats
 

58

What factors affect the 

infectiousness 

of a TB patient? 

The infectiousness of a TB 

patient is directly related to the 

number of tubercle bacilli that he 

or she expels into the air
 

59

Usually, only people with 

pulmonary or laryngeal TB are 

infectious

Patients who have a cavity in the 

lung may be expelling tubercle 

bacilli if they are coughing 
 

60

Patients expel more tubercle 

bacilli if they have a cough that 

produces a lot of sputum

Patients who do not cover 

their mouths when they 

cough are more likely 

to expel tubercle bacilli 
 

61

The presence of tubercle bacilli 

on a sputum smear indicates that 

the patient may be expelling 

tubercle bacilli

Patients who have not been 

receiving adequate treatment are 

much more likely to be infectious 

than patients who have been 

receiving adequate treatment
 

62

Young children with TB disease 

are usually not infectious

Infectiousness appears to decline 

very rapidly after adequate 

treatment is started, but how 

quickly it declines varies from 

patient to patient
 

63

TB Infection Control

About 30% of people who spend 

a lot of time with someone who 

has infectious TB disease 

become infected with M. 

tuberculosis
 

64

TB is most likely to be 

transmitted when health care 

workers and patients come in 

contact with clients or patients 

who have unsuspected TB 

disease, who are not receiving 

adequate treatment, and who 

have not been isolated from 

others 

The main goal of an infection 

control program is to detect TB 

disease early and to promptly 

isolate and treat people who 

have TB disease and prevent 

others from getting TB
 

65

There are two main ways to 

reduce the risk of TB 

transmission in the outpatient 

facility. These are:

- work practice and administrative 

control measures and

- environmental control measures

Work practice and administrative 

controls mean establishing and 

following guidelines for 

•Promptly detecting patients who may 

have infectious TB disease

•Placing these patients in an area 

away from other patients

•Instructing them in cough hygiene

•Making sure they get a diagnostic 

evaluation, and then treatment if they 

have TB disease
 

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Patients who have signs or 

symptoms of TB disease should 

be placed in an area away from 

other patients, promptly seen for 

whatever purpose they came to 

the facility and then referred for a 

diagnostic evaluation

In hospitals and other inpatient settings, 

patients known to have TB disease or 

suspected of having TB disease ideally should 

be placed in a special TB isolation room right 

away

This is frequently not possible, so rapid 

collection and evaluation of sputum specimens 

with microscopy, and prompt initiation of 

treatment for those diagnosed with TB, are 

priorities
 

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In the outpatient facility, each 

client should be asked about 

symptoms and history of TB 

when he or she enters the facility. 

Adults and any children with the ability 

to cough forcefully should be asked:

“Do you have a cough?” If client 

answers yes, ask

“For how long have you been 

coughing?”

An adult who has coughed for 2 weeks 

or more is a “TB suspect” for 

pulmonary TB.
 

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To determine whether a client may be under 

evaluation or a diagnosed case of TB, who 

may still be infectious, ask

“Are you being evaluated or treated 

for TB?”

If the answer to either is yes, the client is 

classified as a TB suspect or case.

TB suspects and cases 

should be

•Given face masks or tissues

•Instructed in cough hygiene

•Directed to a separate waiting area

•Receive whatever services they are 

accessing quickly (ahead of the queue)

•Referred to a TB diagnostic and 

treatment facility
 

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Cough hygiene refers to the 

following measures:

• Covering the nose and mouth when 

coughing or sneezing

– Clients should be given tissues, face masks 

or scraps of cloth to assist in covering the 

mouth and nose

• The tissues, cloths or masks should be 

used to contain respiratory secretions; 

they should be disposed of in nearby notouch waste receptacles after use

When tissues, cloths or masks 

are not available, clients should 

be instructed to lift their arm up 

and cover their mouth and nose 

with the inner surface of the arm 

and forearm. This is to keep 

germs away from the hands. TB 

cannot be spread by the hands, 

but other respiratory germs such 

as influenza can.
 

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Environmental controls are the 

second line of defense for 

preventing the spread of TB in 

out-patient HIV care facilities. 

The main environmental control 

is natural and mechanical 

ventilation. 

Health care workers who may be 

exposed to TB should be 

included in a TB screening 

program
 

71

Describe the infection control 

procedures at this facility
 

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Annex A.4 Education materials about TB for patients

Health care workers can use this guide to remind them of what 

to ask and say about TB during an initial information session 

with any patient. Questions they can ask to find out how 

much the patient knows about TB are in bold on the left; and 

messages related to the questions are on the right. They can 

emphasize different messages with different patients depending 

on the patient’s current knowledge about TB.

What is TB? TB is an illness (i.e., disease) caused 

by a germ that is breathed into the 

lungs. TB germs can settle anywhere 

in the body, but we most often hear 

about TB of the lungs. When the lungs 

are damaged by TB, a person coughs 

up sputum (mucus from the lungs) and 

cannot breathe easily. Without correct 

treatment, a person can die from TB. 

What kind of 

symptoms do you 

think people with 

TB have?

People with TB of the lungs have a 

chronic cough, generally lasting for 

more than two weeks. They can also 

cough up blood. People with TB in 

any part of the body have fevers, night 

sweats, and weight loss. People with 

these symptoms should tell a health 

care provider so they can be evaluated 

for TB.
 

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Have you ever 

known anyone 

with TB? What 

happened to that 

person?

(just listen to their response)

Do you know 

that TB can be 

completely cured?

TB can be cured with the correct drug 

treatment. The patient must take all of 

the recommended drugs for the entire 

treatment time (six or eight months) to 

be cured. Drugs for treatment of TB are 

provided free of charge, and treatment 

can be done without interrupting normal 

life and work.

How do you think 

that TB spreads?

TB spreads when an infected person 

coughs or sneezes, spraying TB germs 

into the air. Others may breathe in 

these germs and become infected.

It is easy for germs to pass to family 

members when many people live 

closely together. Anyone can get TB. 

However, not everyone who is infected 

with TB will become sick.
 

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How can someone 

with TB avoid 

spreading it?

There are several ways that a person 

with TB can prevent infecting others. 

An important step it to take regular 

treatment to become cured. Another 

measure to prevent infecting others is 

for infected persons to cover to their 

noses and moths when coughing or 

sneezing. Finally, infected persons 

should open windows and doors to 

allow fresh air into their homes.

Is TB a problem 

for people with HIV 

infection?

People living with HIV/AIDS are at 

extra risk of getting sick from TB 

because their body cannot fight off 

germs very well. If someone develops 

symptoms of coughing for more than 

two weeks, coughing up blood, weight 

loss, fevers or night sweats, it is 

important to get checked for TB. TB 

can be cured even in persons with HIV/

AIDS.

Source: Stop TB Department, WHO: Management of 

Tuberculosis Training for Health Facility Staff, Geneva, 2003
 

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Annex B. Information on Ventilation and Fans

Controlled natural ventilation

Natural ventilation refers to fresh dilution air that enters and 

leaves a room or other area though openings such as windows 

or doors. Natural ventilation is controlled when openings are 

deliberately secured open to maintain air flow. Unrestricted 

openings (that cannot be closed) on opposite sides of a room 

provide the most effective natural ventilation.

Propeller fans

Propeller fans may be an inexpensive way to increase the 

effectiveness of natural ventilation, by increasing the mixing of 

airborne TB as well as assisting in the direction of air movement 

by pushing or pulling of the air.

Types of propeller fans

Propeller fans include:

•	 Ceiling fans,

•	 Small fans that sit on a desk or other surface,

•	 Fans that stand on the floor, and

•	 Fans mounted in a window opening.
 

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Air mixing and removal

A propeller fan helps mix air in a room. Mixing of air will reduce 

pockets of high concentrations, such as in the corners of a room 

or in the vicinity of patients where natural ventilation alone is not 

enough. The total number of infectious particles in the room will 

not change with mixing; however, the concentration of particles 

near the source will be reduced, and the concentration in other 

parts of the room may increase.

If this dilution effect is combined with a way to replace room air 

with fresh air, such as by opening windows and doors, the result 

will be fewer infectious particles in the room.

A room with an open window, open door, and a fan will have 

less risk than an enclosed room with no fan, an enclosed 

room with a fan, or a room with an open window but no fan. 
 

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In addition, mixing may increase the effectiveness of other 

environmental controls. 

Directional airflow 

If placed in or near a wall opening, propeller fans can also be 

used to enhance air movement into and out of a room.

Consider fans installed in the windows or through wall openings 

on the back wall of a building. The fans exhaust air outside, 

away from people or areas where air may come back into 

the building. If doors and windows in the front of the building 

are kept open, the overall effect should be to draw in fresh air 

through the front of the building and exhaust air through the 

rear. Health care staff should be mindful of the direction of 

airflow to ensure the patient is closest to the exhaust fans and 

the staff are closest to the clean air source. 

 
 

78

With this arrangement, the risk that TB will be spread is greater 

near the back of the building; however, once the contaminated 

air is exhausted, dilution into the environment will be fast. 

Exhaust fans

There are a wide variety of exhaust fan systems. A system can 

be as simple as a propeller fan installed in the wall, or it could 

include a ceiling grille, a fan, and a duct leading to discharge on 

an outside wall or on the roof. 

Over time, dust and lint accumulate on exhaust fan blades. The 

fans, motors, blades, and ducts become dirty and less air is 

exhausted. For this reason, these systems should be cleaned 

regularly.

Checking natural ventilation

People can usually feel the existence or lack of air movement in 

a space. A ventilated space has a slight draft. In the absence 

of ventilation, air will feel stuffy and stale and odors will linger. 

Use the following checklist to assess natural ventilation in your 

waiting areas and examination rooms:

•	 Check air mixing and determine directional air movement 

in all parts of rooms or areas. One way to visualize air 

movement is to use incense sticks as described in these 

six steps.

1. Hold two incense sticks together and light them.

2. As soon as the incense starts to burn, blow out the 

flame. Now the incense should produce a continuous 

stream of smoke.

3. Observe the direction of the smoke.

4. Observe how quickly the smoke dissipates. This is a 

subjective test that may require some practice (see 

box below). It does not give a definite result but is 

useful for comparing one room or area to another.

5. Check natural ventilation once a year after the 

prevailing wind patterns have been determined. 
 

79

Recheck if any changes in the physical environment 

are made and confirm procedures for ensuring free 

movement of air are followed.

6. Keep records of all routine activities and dates.

Checking fans

•	 Check that all room fans are working and cleaned once a 

month. Use cloth or vacuum cleaner to remove dust and 

lint from fans, grilles, and ducts.

•	 Check that exhaust fans are working and cleaned once 

a month. Use cloth or vacuum cleaner to remove dust 

and lint from fans, grilles, and ducts. Clean ducts behind 

grilles as far back as can be reached. 

•	 To check fans that have a grille, hold a tissue or piece of 

paper against the grille. If the exhaust fan is working, the 

tissue or paper should be pulled against the grille. 

•	 Flow rates through exhaust fans and grilles can be 

measured using a simple velocity meter and a means to 

measure that velocity over a known cross-sectional area. 

The air flow rates can be calculated from simple velocity 

measurements (see Boxes 1 and 2).

•	 Air exchange rates (also called air-changes per hour) can 

be calculated as shown in boxes below. If mechanically 

ventilating a room, the fan should provide a minimum of 

six air exchanges per hour.

•	 Keep records of all routine activities and dates.

Box 1. Estimating air velocity.

Measure 0.5 meter distance and mark it on a tabletop. Move your hand from one end to the other (0.5 

meters) in one second. This is equivalent to 0.5 m/s! In order to have directional control of

contaminants in air, one should have air moving at least 0.5 m/s. 

Example air flow calculation: 

Fan, duct, or box opening: 0 ..5 m high, 0.5 m wide

Area = 0 .5 m x 0.5 m = 0.25 m2

Average air velocity through fan, duct, or box opening: 2.5 m/s 

Average flow rate = Area times average air velocity 

 0 .25 m2 x 2.5 m/s x 3600 s/hour = 2 250 m3/hour 
 

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Box 2. Example air exchange rate calculation 

Window opening: 0..5 m high, 0.5 m wide 

Window area = 0.5 m x 0.5 m = 0.25 m2

Average air velocity through window: 0.5 m/s 

Room dimensions: 3 m wide, 5 m deep, and 3 m high 

Room volume = 3 m x 5 m x 3 m = 45 m3

Average flow rate = Area of window times average air velocity

 0 .25 m2 x 0.5 m/s x 3600 s/hour = 450 m3/hour

Air exchange rate = Average flow rate divided by room volume 

 450 m3/hour ÷ 45 m3 = 10 air exchanges per hour
 

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Annex C. Inpatient settings

Although the information in this addendum is directed primarily 

toward outpatient facilities, many of the recommendations also 

apply to inpatient facilities. Specifically, measures regarding 

the infection control plan, health care worker and staff training, 

patient education, sputum collection, and triage and evaluation 

of suspect TB patients are similar. Prevention of TB in hospitals 

requires a combined effort of infection control practices; more 

information on prevention of transmission of M. tuberculosis in 

hospital settings is available in Additional Resources.

One of the most effective means to reduce the risk of 

transmission of M. tuberculosis in hospital settings is to manage 

TB patients in the outpatient setting whenever possible. Many 

patients can be managed entirely as outpatients, thereby 

avoiding hospitalization and the risk of exposing other patients 

and staff. If hospitalized, patients should be re-evaluated 

frequently for possible discharge with continuation of therapy as 

outpatients. 

Ideally, infectious TB patients should be isolated from other 

patients so that others are not exposed to the infectious droplet 

nuclei that they generate. If sputum smear is performed 

at the time of admission, those who have positive sputum 

smear results, and thus most infectious, should be isolated or 

separated from other patients. 

The hospital administration should attempt to:

•	 Limit the number of areas in the facility where exposure to 

potentially infectious TB patients may occur.

•	 Establish separate wards, areas or rooms for confirmed 

infectious TB patients. These wards/areas should be located 

away from wards with non-TB patients, especially wards with 

pediatric or immunocompromised patients.

As in the outpatient setting, early identification, diagnosis, and 

treatment of TB cases is the highest priority. Assigning the 
 

82

role of “ward cough officer” to a staff member, who assures 

sputum specimen collection, rapid transport of specimens to the 

laboratory, and the delivery of results to the ward medical team, 

can be effective [8]. The ward cough officer may help to identify 

patients in need of investigation and to enforce TB infection 

control policies.

Radiology departments in hospitals often provide services to 

a variety of patient who may be at particularly high risk for TB, 

such as young children or immunocompromised patients. 

Radiology departments should attempt to:

•	 Schedule inpatient chest radiographs on infectious and 

suspect TB patients for non-busy times, such as the end of 

the afternoon.

•	 Provide coughing patients with a surgical mask to wear, or 

tissues or cloth to cover their mouths.

•	 Provide priority service to potentially infectious TB patients to 

minimize the length of time spent in the department.

•	 Restrict access to the radiology suite to patients and 

essential personnel only.

•	 Use the room with the best ventilation for taking images of 

potentially infectious TB patients.
 

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Annex D. FAQ – Multi-drug-resistant TB (MDRTB)

What is MRDTB?

Multi-drug resistant TB, usually called MDRTB, is TB that is 

resistant to at least the two most important anti-TB drugs, 

isoniazid and rifampicin. This means those two drugs do not 

effectively treat the TB disease.

Why is MDRTB a problem?

Because the two most important anti-TB drugs are not effective 

in treating MDR-TB, treatment requires drugs which are more 

toxic, more expensive, take longer to work and do not work as 

well (called “second line” drugs). Also, these second line drugs 

are not widely available in resource-limited settings.

What causes MDRTB?

MDRTB may result from poor anti-TB treatment adherence or by 

incorrect treatment. Adherence means taking the correct drugs 

with the correct doses at the correct time. If the wrong drugs or 

the wrong combinations of drugs are prescribed, or providers fail 

to ensure that they are taken correctly on schedule, the bacteria 

causing TB may develop resistance to the drugs. When this 

happens, the patient who initially had nonresistant TB develops 

drug-resistant TB. If the patient who has MDRTB spreads TB to 

others, they will have MDRTB as well. 

How is MDRTB prevented?

MDRTB is a condition that can be prevented by following the 

international TB control strategy called DOTS, which stands 

for Directly Observed Treatment, Short-course. Health care 

providers should always adhere to the National Tuberculosis 

Program Guidelines and use only the recommended anti-TB 

treatment regimens, drug combinations and drug dosages. 
 

84

Anti-TB drugs, preferably Fixed Dose Combinations (one tablet 

contains all the drugs), of high quality should be available in 

regular and sufficient quantities. Adherence to anti-TB 

treatment must be ensured with support, encouragement and 

monitoring of adherence by a relative, community volunteer, or a 

clinic nurse.

 

How do we know if a patient has MDRTB?

The diagnosis of MDRTB can only be made in a laboratory that 

can test sputum specimens for the presence of M. tuberculosis 

(the TB germ isolated by culture) and then test those TB isolates 

for drug resistance. Patients who report interrupted treatment 

for TB, or failure to have symptoms improve after one to two 

months of TB treatment, may have drug-resistant TB, and 

should be separated from persons with HIV infection until their 

condition is evaluated.

Is there MDRTB is my community?

The District Medical Officer and national TB program can 

provide information on rates of MDRTB in specific communities.
 

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is publication is produced by a coop

U.S. Department of Health and Hu

U.S. Centers for Disease Control an

U.S. President’s Emergency Plan for 

e World Health Organizati

e International Union Against Tuberculo