Module 5 – Infectiousness and Infection Control 2 

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Self-Study Modules
 

on Tuberculosis
 

Infectiousness 

and Infection Control 

Module 5: Objectives
 

At completion of this module, learners will be able to: 

1.	 Describe the factors that determine the 

infectiousness of a TB patient 

2.	 Describe the main goals of a TB infection-control 

program 

3.	 Describe the three levels of control measures that are the basis of an effective TB infection-control 

program 

4.	 Describe the purpose and the characteristics of a TB airborne infection isolation (AII) room 

5.	 Describe the circumstances when personal 

respirators should be used 

Module 5: Overview 

•	 Infectiousness 

•	 TB Infection Control 

– TB Infection Control M easures 

– TB Risk Assessment 

– Infection Control in Nontraditiona l FacilityBased Settings 

– TB Infection Control in the Home 

•	 Case Studies 

Infectiousness
 

Infectiousness (1) 

•	 Infectiousness is directly related to number 

of tubercle bacilli TB patients expel into a ir 

•	 TB patients generally expel more tubercle 

bacilli if their cough produc es a lot of 

sputum 

•	 Only people with TB of the lungs, airway, or 

larynx are infectious 

Infectiousness (2) 

Factors generally associated with infectiousness: 

• Presence of cough • Not covering mouth 

when coughing 

• Cavity in the lung • Not receiving adequate 

treatment or prolonged 

illness 

• Acid-fast bacilli on 

sputum smear 

• Undergoing cough 

inducing procedures 

• TB of lungs, airway, or 

larynx 

• Positive sputum cultures 

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Infectiousness (3)
 

•	 Infectiousness appears to decline rapidly 

after adequate treatment is started; however: 

– How quickly infectiousness declines
 

varies from patient to patient (w eeks to
 

months)
 

– Patients with drug-resistant TB may not 

respond to initial drug regimen; meaning 

they may remain infectious for longer 

Infectiousness (4)
 

•	 Patients can be considered non-infectious 

when they meet all of the following criteria: 

– Received adequate treatment for 2 weeks or 

longer 

– Symptoms have improved 

– Three consecutive negative sputum smears 

from sputum c ollected in 8 to 24 hour 

intervals (at least one early morning 

specimen) 

Infectiousness (5) 

• Children are less likely 

than adults to be infectious 

– Children generally do 

not produce a lot of 

sputum when they 

cough 

• Young children can still 

transmit TB if the y exhibit 

signs of infectiousness 

Infectiousness 

Study Question 5.1 

List 7 factors that affect the infectiousness of a 

TB patient. 

Infectiousness 

Study Question 5.2 

Module 5 – Infectiousness and Infection Control 12 

Why does the site of disease affect the 

infectiousness of a TB patient? 

Infectiousness 

Study Question 5.3 

When can a TB patient be considered 

noninfectious? List all 3 criteria. 

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TB Infection Control


TB Infection Control (1)
 

•	 Infection control is an important strategy to 

prevent the spread of TB 

– Several outbreaks of TB in he alth care 

settings, including multidrug-resistant TB 

(MDR TB) and e xtensively drug-resistant TB 

(XDR TB), have occurred 

•	 All health care and congregate settings should 

implement TB infec tion-control measures 

13 

TB Infection Control (2) 

• TB is most likely to be transmitted when 

health care workers (HCWs) and patients 

come in contact with persons who: 

– Have unsuspected TB disease 

– Are not receiving adequate treatment 

– Have not been isolated from others 

TB Infection Control (3) 

Role of the Health Department 

• Health department TB control programs 

should: 

– Ensure each of the ir clinics develop a TB 

infection-control program 

– Provide consultation about TB infe ction 

control to other he alth care and congregate 

settings 

TB Infection Control (4)
 

Role of the Health Department
 

•	 Health departments should specifically assist 

health care settings with: 

– Understanding infection control principles 

– Reporting confirmed or suspected TB cases 

– Conducting contact investigations 

– Ensuring a plan for TB patients to receive follow-up 

care after discharge 

– Conducting risk assessments, testing, surveillance, 

and outbreak investigations 

– Planning and implementation of TB control
 

activities
 

TB Infection-Control Program (1) 

•	 Main goals of a TB infection-control program 

are to ensure early and prompt: 

– Detection of TB dis ease 

– Airborne precautions (e.g., isolation of 

people who have or are suspected of having 

TB disease) 

– Treatment of people who have or are
 

suspected of having TB disease
 

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TB Infection-Control Program (2) 

Detection of TB disease 

• HCWs should suspect TB disease 

in anyone with any of these 

symptoms: 

– Persistent cough 

– Chest pain 

– Bloody sputum 

– Weight loss or loss of appetite 

– Fever 

– Chills 

– Night sweats 

TB Infection-Control Program (3) 

Detection of TB disease 

•	 When a health care worker suspects that a patient has TB disease, the patient should be : 

– Placed in a n area away from other patients 

and evaluated 

– Given a surgical mask to wear 

– Given tissues and asked to c over nose and 

mouth when coughing or sne ezing 

TB Infection-Control Program (4) 

Airborne Precautions 

•	 Airborne precautions should be taken for any 

person who has signs or symptoms of TB 

disease 

•	 If facility has an AII room, TB s uspects and 

TB patients should be placed there 

•	 Health care settings, such as TB clinics, 

should implement a respiratory-protection 

program 

TB Infection-Control Program (5) 

Treatment 

•	 Patients diagnosed with TB should s tart 

treatment immediately 

•	 DOT should be used to ens ure adherence 

TB Infection Control


Study Question 5.4
 

Under what circumstances is TB most likely to 

be transmitted in health care facilities? 

TB Infection Control
 

Study Question 5.5
 

How can the health department assist health 

care settings in preventing the spread of TB? 

Module 5 – Infectiousness and Infection Control 24 

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TB Infection Control
 

Study Question 5.6
 

Module 5 – Infectiousness and Infection Control 25 

What are the main goals of a TB infection-control 

program? 

TB Infection Control 

Study Question 5.7 

What would make a health care worker 

suspect that a patient has TB disease? 

Module 5 – Infectiousness and Infection Control 27 

TB Infection Control
 

Study Question 5.8
 

What should be done when a health care worker 

suspects that a patient has TB disease? 

TB Infection Control
 

TB Infection Control Measures
 

Respiratory Protection 

Administrative Controls 

Environmental Controls 

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TB Infection Control Measures (1)
 

Hierarchy of Infection Control
 

TB Infection Control Measures (2) 

Three levels of control measures: 

•	 Administrative controls: managerial measures 

to reduce risk of exposure to M. tuberculosis 

•	 Environmental controls: engineering systems 

to prevent the spread of a nd reduce the 

concentration of infectious M. tuberculosis 

droplet nuclei in air 

•	 Respiratory-protection controls: personal 

protection to furthe r minimize risk for exposure 

to M. tuberculosis 

Module 5 – Infectiousness and Infection Control 29 

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TB Infection Control
 

TB Infection Control Measures 

Administrative Controls 

31 

Administrative Controls (1) 

• Administrative controls: 

– First and most importa nt level of TB
 

infection-control program
 

– Goal is to reduce risk of exposure to
 

persons who might have TB disease
 

Administrative Controls (2) 

• Administrative control activities: 

– Assigning someone responsibility for TB 

infection control 

– Developing and implementing a written TB 

infection control plan 

– Conducting a TB risk assessment 

– Ensuring availability of prompt labora tory 

processing, testing, and reporting of re sults 

Administrative Controls (3) 

• Administrative control activities (cont.): 

– Implementing effective work practices for 

managing patients who may have TB 

– Ensuring proper c leaning and sterilization or 

disinfection of equipme nt 

– Educating, training, and c ounseling HCWs 

about TB 

– Testing and e valuating workers who are at risk 

for TB or ma y be exposed to TB 

Administrative Controls (4) 

• Administrative control 

activities (continued): 

– Applying epidemiologybased prevention 

principles 

– Using posters to remind 

patients of proper cough 

etiquette 

– Coordinating efforts 

between health 

departments and high 

risk settings 

TB Infection Control


TB Infection Control Measures
 

Environmental Controls
 

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Environmental Controls
 

•	 Second level of infection-control program 

•	 Consist of tec hnologies that are designed to 

prevent the spread and re duce the 

concentration of TB in the air 

– Ventilation technologies 

– High efficiency particulate air filtration
 

(HEPA)
 

– Ultraviolet germicidal irradiation (UVGI) 

Ventilation Technologies (1)
 

•	 Ventilation is the movement of air in a 

building and the replacement of a ir inside 

with air from outside 

•	 Ventilation technologies include: 

– Natural ventilation 

– Mechanical ventilation 

Ventilation Technologies (2)
 

Natural Ventilation
 

•	 Doors and windows 

should be open 

•	 Fans can be used to 

distribute air 

•	 HCW should sit ne ar 

fresh air source 

•	 Can be useful for 

nontraditional settings 

that do not ha ve a central 

ventilation system 

Ventilation Technologies (3)
 

Mechanical Ventilation
 

•	 Refers to the use of technological equipment to 

circulate and move air 

•	 Consists of two types of technologies 

– Local exhaust ventilation 

– General ventilation 

•	 Should be used by hospitals, TB clinics, and 

other settings where TB patients are expected 

Ventilation Technologies (4)
 

Mechanical Ventilation
 

•	 Local exhaust ventilation 

– Stops airborne contaminants from spreading 

into general environment 

– Includes external hoods, booths, and tents 

– Should be used for cough-induc ing
 

procedures
 

Ventilation Technologies (5)
 

Mechanical Ventilation
 

•	 General ventilation systems: 

– Dilute contaminated air 

– Remove contaminated air 

– Control airflow patterns in patient and 

procedure rooms (e.g., negative pressure 

in AII room) 

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Image credit: Curry International TB Center 

Image credit: Curry International TB Center 

Module 5 – Infectiousness and Infection Control 43 

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Ventilation Technologies (6) 

Mechanical Ventilation 

• AII rooms are designed to 

prevent spread of droplet 

nuclei expelled by patient 

– Negative pressure 

– Clean air flows from 

corridors into AII room 

• Air cannot escape AII

room 

– Exhausted outdoors or 

passed through filter 

Image credit: Curry International TB Center 

HEPA Filters 

• HEPA filters are special 

filters used to remov e 

droplet nuclei from air 

• Must be used when 

releasing air from: 

– Local exhaust 

ventilation booths to 

surrounding area 

– AII room to gene ral 

ventilation system 

UVGI 

• UVGI is air cleaning 

technology that 

consists of lamps that 

give off UV light, which 

can kill tuberc le bacilli 

• Should be used with 

other infection control

measures 

• UV light can be harmful 

to skin and e yes 

TB Infection Control

TB Infection Control Measures
 

Respiratory-Protection Controls
 

Respiratory-Protection Controls (1)


• Third level of infection-control that includes: 

– Implementing a respiratory-protection
 

program
 

– Training health care workers on respiratoryprotection 

– Educating patients on respiratory hygiene 

Respiratory-Protection Controls (2) 

Personal Respirators 

• Respirators filter out droplet nuclei 

• Should be used in: 

– TB AII rooms 

– Rooms where cough-inducing or a erosol 

generating procedures are done 

– Ambulances transporting infectious TB
 

patients
 

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Health care worker undergoing a fit test
 

Image credit: Paul Jensen
 

Module 5 – Infectiousness and Infection Control 50 

Image credit: Greg Knobloch 

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Respiratory-Protection Controls (3)

Personal Respirators 

•	 Important that 

respirator fits 

properly: 

– Fit test used to
 

determine which
 

respirator to w ear
 

– User seal check
 

should be done
 

each time a
 

respirator is put on
 

Respiratory-Protection Controls (4)
 

Personal Respirators
 

•	 Respirators that can be used to prote ct against 

M. tuberculosis: 

– Nonpowered respirators 

with N95, N99, N100, R95, 

R99, R100, P95, P99, and 

P100 filters 

– Powered air-purifying 

respirators (PAPRs) with 

high-efficiency filters 

– Supplied-air respirators 

Respiratory-Protection Controls (5) 

Respirators and Surgical Masks 

•	 Important to unde rstand the difference between 

respirators and surgical masks 

– Respirators protect individuals from inhaling 

droplet nuclei 

– Surgical masks stop droplet nuc lei from
 

being exhaled into air by infectious TB
 

patients or suspects
 

Respiratory-Protection Controls (6) 

Respirators 

Health care worker wearing a personal respirator 

Respiratory-Protection Controls (7) 

Surgical Masks 

Patient wearing a surgical mask 

TB Infection-Control 

Study Question 5.9 

What are the three levels of control that form 

the basis of a TB infection-control program? 

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Administrative Controls

Study Question 5.10
 


 

Module 5 – Infectiousness and Infection Control 56 

List 5 administrative control measures that 

should be taken in he alth care settings to reduce the risk of exposure to persons who may have TB

disease. 

Environmental Controls 

Study Question 5.11 

Module 5 – Infectiousness and Infection Control 57 

Where should sputum induc tion, 

bronchoscopy, or other cough-inducing 

procedures be done? 

Environmental Controls
 

Study Question 5.12
 

Module 5 – Infectiousness and Infection Control 58 

What is a TB AII room? What are the 

important characteristics of an AII room? 

Ventilation Systems
 

Study Question 5.13
 

Module 5 – Infectiousness and Infection Control 59 

How do v entilation systems help prevent the 

spread of TB? 

Ventilation Systems
 

Study Question 5.14
 

Module 5 – Infectiousness and Infection Control 60 

Give 4 examples of settings where personal 

respirators should be used. 

Respiratory Protection-Controls 

Study Question 5.15 

What is the difference in use between a
 

respirator and a surgical mask?
 

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TB Infection Control
 

TB Risk Assessment 

TB Risk Assessment (1) 

•	 Administrative control measure 

•	 Helps to inform infec tion control plan 

•	 Determines types of controls needed for 

setting 

•	 Serves as an initial and ongoing monitoring 

and evaluation tool for infec tion-control 

program 

•	 Helps determine frequency of employee 

testing 

TB Risk Assessment (2)

•	 Risk assessment examines many factors, 

including: 

– Number of pa tients with TB disease in setting 

– Promptness of detection, isolation, and
 

evaluation of patients with suspected or
 

confirmed TB
 

– Evidence of transmission of M. tuberculosis 

in setting 

– Community rate of TB dise ase 

TB Risk Classification 

•	 Low risk 

– Persons with TB disease are not expected to be
 

encountered
 

•	 Medium risk 

– Possible exposure to persons with TB disease 

– Possible exposure to clinical TB specimens 

•	 Potential ongoing tra nsmission 

– Setting where there is evidence of person-to-person 

transmission of M. tuberculosis in past year 

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TB Testing Frequency


TB Risk Classification Frequency for TB Testing 

Low Risk 

• Conduct baseline test when health 

care worker is hired 

• No further testing needed unless 

exposure occurs 

Medium Risk 

• Conduct baseline test when 

health care worker is hired 

Potential Ongoing 

Transmission 

• Repeat test annually 

• Conduct baseline test when health 

care worker is hired 

• Repeat test every 8 to 10 weeks 

until there is no evidence of M. 

tuberculosis transmission in 

setting 

TB Infection Control
 

Infection Control in
 

Nontraditional
 

Facility–Based Settings
 

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Special Considerations (1)


•	 Nontraditional facility-based settings where TB 

patients receive care should establish and 

follow an infection-control program 

•	 Includes settings such as: 

– Nursing homes 

– Correctional facilities 

– Homeless shelters 

– Drug treatment centers 

– Emergency medical services 

– Home-based health care 

– Outreach settings 

Special Considerations (2)
 

Correctional Facilities
 

•	 Medical settings within correctional facilities 

should: 

– Classify as medium risk or higher 

– Test all staff annually 

– Implement a respiratory-protection program 

with at least one AII room 

Special Considerations (3)
 

Correctional Facilities
 

•	 Medical settings within correctional facilities 

should (cont.): 

– Have inmates with suspected or confirmed TB 

disease wear surgical mask when transported 

– Establish and ma intain a tracking system for 

inmate testing and treatment 

Special Considerations (4)
 

Homeless Shelters
 

•	 Should observe the same TB infectioncontrol measures as outpatient clinics 

•	 Several factors in shelter environment can 

influence likelihood of TB tra nsmission: 

– Crowdedness of shelter 

– Ventilation system of shelter 

Special Considerations (5)
 

Emergency Medical Services (EMS)
 

•	 EMS workers should be included in TB te sting 

program based on ris k for the setting 

•	 Persons with infectious TB who are transported 

in ambulance should wear surgical mask 

•	 Drivers, health care workers, and other staff 

should consider wearing a respirator 

•	 Ambulance should allow for maximum amount 

of outdoor a ir to be circulated in v ehicle 

Special Considerations (6)
 

Long-Term Care Facilities (LTCFs)


•	 LTCFs (e.g., hospices and nursing homes) 

should: 

– Symptom screen and poss ibly test new 

employees and residents 

– Have administrative and environmental 

controls IF they accept patients with 

infectious TB 

•	 Persons with TB disease who are noninfectious can stay in LTCFs and do not nee d 

AII room 

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TB Infection Control
 

TB Infection Control in the Home 

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TB Infection Control in the Home (1)


Patient Returning Home 

TB patients and TB s uspects may be sent 

home after starting treatment, even though 

they may be infectious 

TB Infection Control in the Home (2) 

Patient Returning Home 

•	 Criteria for patient to re turn home: 

– Follow-up plan has been made with the 

local TB progra m 

– Patient on TB treatme nt and DOT arranged 

– No infants or children younger than 5 years 

of age or persons with 

immunocompromising conditions in home 

TB Infection Control in the Home (3)

Patient Returning Home 

•	 Criteria for patient to re turn home (cont.): 

– All household members have already been 

exposed to TB patient 

– Patient is willing to not tra vel outside of 

home until sputum smear results are 

negative 

TB Infection Control in the Home (4)

Patient Returning Home 

•	 TB patients and members of household
 

should take steps to prevent spread of TB
 

•	 Patients with TB should be instructed to: 

– Cover mouth and nose with tissue when 

coughing or snee zing 

– Sleep alone 

– Not have visitors until noninfectious 

TB Infection Control in the Home (5)
 

Health Care Workers (HCWs)
 

•	 HCWs should: 

– Be trained in detecting TB signs and symptoms 

– Take precautions to protect themselves: 

• Instruct patient to cover mouth when coughing 

• Wear personal respirator 

• Collect sputum in well-ventilated areas 

• Participate in TB testing and prevention programs 

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TB Risk Assessment 

Study Question 5.16 

Module 5 – Infectiousness and Infection Control 80 

What are 3 different TB ris k classifications 

that can be assigned to hea lth care settings? 

TB Risk Assessment
 

Study Question 5.17
 

Module 5 – Infectiousness and Infection Control 81 

Depending on risk classification, how often 

should health care settings test workers for TB? 

TB Infection Control in the Home


Study Question 5.18
 

Module 5 – Infectiousness and Infection Control 83 

What precautions should a health care
 

worker take when visiting the home of a TB
 

patient who may be infectious?
 Case Studies
 

Module 5: Case Study 5.1 

For each of the following situations, decide 

whether the patient should be considered 

infectious or non-infectious, and explain why.

Module 5 – Infectiousness and Infection Control 84 

Module 5: Case Study 5.1 

Question 5A 

Two weeks ago, Mr. Lopez had a sputum 

smear that was positive; since then no 

sputum specimens have been tested. Mr. 

Lopez started self-administered TB tre atment 

7 days ago. He still has a cough. 

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Module 5: Case Study 5.1 

Question 5A: Answer 

Module 5 – Infectiousness and Infection Control 86 

Module 5: Case Study 5.1 

Question 5B 

Ms. Nguyen, a patient with pulmonary TB, 

has been receiving DOT treatment for 6 

weeks and no longer ha s symptoms of TB. 

She has had three sputum smears. The first 

one was positive, but the last two were 

negative. 

Module 5 – Infectiousness and Infection Control 87 

Module 5: Case Study 5.1 

Question 5B: Answer 

Module 5 – Infectiousness and Infection Control 88 

Module 5: Case Study 5.1 

Question 5C 

Mr. Martin started DOT tre atment for 

pulmonary TB in A pril. His symptoms went 

away and his sputum smears were negative 

in May. However, the outreach worker was 

unable to locate him on June 5th and has not 

been able to contact him since that time. Mr. 

Martin returned to the TB clinic on August 

2nd, and was still coughing. 

Module 5 – Infectiousness and Infection Control 89 

Module 5: Case Study 5.1 

Question 5C: Answer 

Module 5 – Infectiousness and Infection Control 90 

Module 5: Case Study 5.2 (1) 

You are checking patients into the TB clinic. 

An elderly man comes to the desk and says 

he was told to come and get c hecked 

because one of his friends has TB. You 

notice that he looks sick and is coughing 

frequently. The waiting room is full of 

patients, and you know it will probably be 

more than an hour be fore the physician can 

see him. 

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Module 5: Case Study 5.2 (2) 

• What should you do? 

Module 5 – Infectiousness and Infection Control 92 

Module 5: Case Study 5.3 (1) 

You are sent to deliv er directly observed 

therapy (DOT) to a woman who started 

treatment last week for suspected pulmonary 

TB. Her sputum smear res ults are not back 

yet. You are asked to collect another sputum 

specimen while you are at the woman’s 

home. 

Module 5 – Infectiousness and Infection Control 93 

Module 5: Case Study 5.3 (2) 

• What precautions should you take? 

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