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TB Death during Treatment Investigation Form  

1) Borang Siasatan Kematian Kes Tibi Dalam Rawatan (TBIS 10J) 

  

Page1/1

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14.   IN‐HOSPITAL  ACTION  PLAN  FOR  DELAYED  DETECTION  OF SMEAR‐POSITIVE TB IN GENERAL WARDS   

14.1.1All patients suspectedof infectiousTB should be isolated. In the event ofmissedordelayeddiagnosisofsmear‐positiveTB,whereinisolationandotherairborneinfectioncontrolmeasureshadnotbeeninplace,transmissionriskinthegeneralwardsishigh.

14.1.2 Upondiagnosis,UKAshouldbenotifiedverballyimmediately.14.1.3 ImmediateinvestigationshouldbecarriedoutbyTBICTaskForcewiththe

assistanceoftheaffectedWardSisterandHeadofUnit,todetermineexposurerisk,andscopeofcontactscreen.

14.1.4Closecontacts,egattendingnurses,especiallyifhavingperformedmultiple

aerosolizingprocedures,egendotracheal/ tracheostomysuctioning, shouldbescreenedwithin2weeksofidentification.Screeningshouldbeinclusiveofsymptom,MantouxaswellasCXRscreening,andfollowedup8weeksafterlastexposure,andthen8monthlyfor2years.

14.1.5ExpandedcontactscreenbyMantouxtestforotherasymptomaticHCWin

theunitwillbeperformedafteran8weekswindowperiod.(SeeSection12,page22,SGHHCWContactScreeningWorkFlowfordetails)

14.1.6 The scope of contact screen for other in‐patients and carers will be

determinedbyTBICTaskForcewiththehelpofTBCPKuching,dependingonthepatientcharacteristics,proximityanddurationofexposure.

14.1.7TheTBIS10C‐3/pin.1“KadPemeriksaanKontak”willbefilledupbyPPKP,

and handed over to TBCP for contact screening follow‐up of significantlyexposedpatients,andhandedovertoStaffClinic/OHUforcontactscreeningfollow‐upofHCWs.

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15. HEALTH CARE WORKERS AND TB  

 

15.1 Introduction  

Healthcare workers  (HCWs)  are  exposed  to  patients  with  TB  and  are  at  risk  of  nosocomial 

infection. Failure to use personal protection was associated with an almost 3 fold increased risk 

of TB among HCWs. 

 

A cost‐effectiveness study among HCWs at different risk of TB exposure showed that regular 

tuberculin screening among them is cost‐effective and results in a net cost‐savings. The National 

Institute for Health and Care Excellence (NICE), UK recommends reminders of TB symptoms, 

and  prompt  reporting  of  such  symptoms  should  be  included  with  annual  reminders  about 

occupational health for staff who are at high risk of TB contact. 

15.2 Investigation of TB in Health Care Workers 15.2.1 AllHCWsconfirmedtohaveactivepulmonaryTBinfectionshouldbegiven

medicalleaveforatleasttwoweeksoruntilthesputumAFBisnegative.

15.2.2 HCWTBistobenotifiedusingWEHUL1&L2(JKKP7)inadditiontotheusualTBIS10A1.

15.2.3 The PPKP of SGHUKA should be notified regarding tuberculosis inHCW,

eitherby theattendingdoctor, ifdiagnosedwithin thishospital, orby theHCW’sHeadofUnit,ifthediagnosishadbeenmadeelsewhere,e.g.inotherhealthcareinstitutions.

15.2.4Uponnotification,theHealthInspectorwillinterviewtheinfectedHCWusing

FormatPenyiasatanKesTuberkulosisDiKalanganKakitanganKementerianKesihatanMalaysia.

15.2.5 EffortsshouldbemadebytheattendingdoctorandPPKPininterviewingthe

HCWtoidentifypossiblesourcesofexposuretoTB15.2.6TheOHUDirectorwouldconcludewhetheritisacaseofoccupational‐related

TBornotSource:https://www.nice.org.uk

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15.1.8Simultaneously,theTBICTaskForceshouldbenotifiedregardinginfectedHCWbyStaffClinicorHealthInspector.

15.1.9 TheTBICTaskForcewillreviewthecaseandmay interviewtheHCWfor

furtherinvestigationofanylapseininfectioncontrol.15.1.10TheTBICTaskForcewillconveneameetingtodecideoncontactscreening,

andactionplantocounteranyidentifiedlapseininfectioncontrol.15.1.11 Investigation and contact screening should be completed, and report

submittedtotheHospitalDirectorbyTBICTF,within1monthofnotification.

15.3 Medical Leave AllHCWswithconfirmedactivepulmonaryTBinfectionshouldbegivenmedicalleaveatleast2weeksoruntilsputumAFBisnegative.

15.4 Return to Work Policy 

15.4.1 HCWwith TB should be allowed to return toworkwhen a physician hasconfirmedtheHCWisnoninfectious.

15.4.2Thereturntoworkcriteria: i.WorkersreceivesadequateantiTB ii.Coughhasresolved iii.Resultsofthree(3)consecutivesputumAFBsmearsnegative. (sputum

shouldbe8‐24hoursapart).15.4.3Monthly/ regular followupwhen theHCWresumeduty toensureeffective

treatment and DOT should be practised. The HCW should be underRespiratoryUnitfollowupincomplicatedcase.

15.5 Record Keeping 15.5.1AccordingtoNotificationofAccident,DangerousOccurence,OccupationalPoisoningandOccupationalDisease(NADOPOD)Regulations2004,therecordshouldbekeptatleast5yearsfromthedateonwhichitismade.15.5.2 A detailed records on TB of HCW should be kept by facilities inwhich they areworking.OnecopyshouldbesenttoOccupationalHealthUnitMOHthroughStateHealthDepartment.

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15.6 Contact Screening of TB in Health Care Workers 15.6.1TheHCWshouldbeadvisedthatcontactscreeningwillbecarriedout.TheinfectedHCW’spreferencesonconfidentialityshouldbeexplored,andrespectedasfaraspossible.However,HCWshouldbewarnedthatinadvertantdisclosureisprobablefromthemedicalleaveandcontactinvestigations.15.6.2Closecontactsarepersonswhosharethesameairspaceinahouseholdorotherenclosedenvironmentforaprolongedperiod–daysorweeks,notminutesorhours–withapersonwithpulmonaryTBdisease.(CDC,2005)15.6.3 Following the guidance of “Garispanduan Pelaksanaan & Penyeliaan ProgramKawalanPenyakitTB,JKNS2017”,thefollowingwouldbescreenedascontacts: 1)Household 2)Allresidentsofthesamelonghouse 3)Exposure>8hoursadayegworkplace 4)Closesocialcontacts

5)Airlinepassengerswithin2rowstothefrontandtothebackofflights>8hours

15.6.3 Identificationand investigationofclosecontacts,outsideofSGH,eghousehold/housematecontacts,willbeperformedbytheHCW’sassignedTBCPcentre,asperroutine,withinoneweek.Onaverage,10contactsarelistedforeachpersonwithacaseofinfectiousTBbyTBCP,andfollowedup8monthlyfor2years.15.6.4 TracingofotherHCWsofcontactwithinSGH,isunderthepurviewofSGHOHU.TBICTask Force will investigate and determine prioritization of contacts within 1week ofnotification.15.6.5Anyidentifiedclosecontactswillbescreenedpromptly,followedup8weeksafterlastexposure,and8monthlyfor2years.15.6.6TheexpandedcontactscreeningofotherHCWsinSGHofcasuallowprioritycontactwillproceedafterthe8weekswindowperiod.15.6.7 HCWs have a responsibility to comply with screening directed by OHU withendorsementoftheHospitalDirector,pursuanttotheOccupationalSafetyAndHealthAct1994.[AktaKeselamatanDanKesihatanPekerjaanDanPeraturan‐Peraturan,Edisi2010.BahagianVI.KewajipanAmPekerja.Seksyen24(1)(d)]

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15.6.8 For recording of Mantoux testing, HCWwho have been determined to be closecontacts,orHCWinhighriskgroup,i.e.diabetics,immunosuppressed,smokers,etc,willbeconsideredpositiveat>10mm,asperMOHManagementofTuberculosis(3rdEdition)ClinicalPracticeGuidelines,2002.15.6.9WhereasforHCWparticipatinginexpandedscreening,whoareatotherwiselowrisk,Mantouxtestof>15mmprovideshigherspecificity,andistakenasthecut‐offaspertheGuidelinesonPreventionandManagementofTuberculosisforHealthCareWorkersinMinistryofHealthMalaysia2012.15.6.10 AlthoughMantouxtestof10‐14mmareconsiderednegativeby the15mmcutpoint,HCWwhohadpreviousMantoux>10mm,andrequirecontactscreening,shouldbeevaluated by symptoms and CXR. Repeat Mantoux testing should not be performed asresultswouldnotprovideadditionalinformation.(CDC,2005)

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15.7 Guideline for Prioritization of Contacts Reference:CentersforDiseaseControlandPrevention.GuidelinesfortheInvestigationofContacts of Persons with Infectious Tuberculosis. Recommendations from the NationalTuberculosisControllersAssociationandCDC.2005.MMWR2005;54(No.RR‐15)

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60

SGH HCW TB Contact Screening

  

61

Format Borang Penyiasatan Kes TB HCW

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64

65

66

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15.8 Baseline and Periodic Screening of TB in Health Care Workers 15.8.1 All hospital staff need to comply with TB screening outlined in “Guidelines on

PreventionandManagementofTuberculosisforHealthCareWorkersinMinistryofHealthMalaysia2012”.Thisincludes:

1.Pre‐employmentscreeningfornewstaff2.Periodicannualscreeningforexistingstaff3.Pre‐retirement/Pre‐transferscreening

15.8.2AllcategoriesofSGHemployeesneedtoundergoTBscreening.Thisincludesclinical,

aswellasnon‐clinicalstaff.15.8.3AllHCWTBscreeningshouldbeperformedbyStaffClinic,assistedbyRespiratoryDay

CarestaffandOccupationalHealthUnit(OHU).15.8.4HCWshouldNOTperformTBscreeningontheirown.15.8.5AllChest‐Xraysonceperformed,shouldbereportedbySGHRadiologyDepartment.15.8.6SGHHumanResourceUnitshouldinformOHUregardinganystaffnewlyemployed/

transferred/plannedforretirement,withname,unit,post,andcontactnumberforpurposesofTBscreening.

15.8.7 Briefing for new personnel upon reporting for duty, should include instructions to

attendPre‐PlacementMedicalExaminationatStaffClinic.15.8.8The“FormatPemeriksaanKesihatanPraPenempatanAnggotaKementerianKesihatan

Malaysia” OHU TB‐1 form shall be used for the pre‐placement medical screening.(Appendix6ofGuidelinesonPreventionandManagementofTuberculosisforHealthCareWorkersinMinistryofHealthMalaysia,2012)

15.8.9 The OHU TB‐1 forms shall be placed in the Staff Clinic, forwarded to Respiratory

DayCareUnit(RCU)ifdecisionmadeforMantouxtesting,andreviewedbyStaffClinicafterreadingofMantouxtest.

15.8.10Theseproceduresshouldbecompletedwithin2weeksofreportingforduty.15.8.11RCUstaffwillstampandfillindetailsofMantouxadministrationintheOHUTB‐1form.

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5.0 Ujian

MANTOUX X-RAY DADA UJIAN KAHAK Berat

Badan

(Kg)

Tarikh Keputusan

(mm)

Tarikh Keputusan Tarikh Keputusan

Mikroskopi

Keputusan

Kultur

Keputusan

Ujian

Sensitiviti

(Tandatangan & Cop Rasmi)

Tarikh:

Nama Doktor :

No. Pendaftaran MMC:

Alamat Tempat Kerja:

No. Telefon:

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 CARTA ALIR PROSES SARINGAN TiBi PRA‐PENEMPATAN BAGI ANGGOTA BARU DILANTIK 

 

Anggota baru dilantik dan pertama kali melapor diri serta tidak pernah melakukan ujian saringan TiBi perlu menjalani ujian saringan 2 minggu selepas 

melapor diri 

Ujian

Mantoux  

>15 mm<15 mm 

X‐RayDada

tidak normal normal 

Rujuk kepada Pakar Perubatan /pakarperubatan respiratori/ pakar perubatan keluarga/ Pakar Kesihatan Pekerjaan 

SARINGAN TAMAT

SARINGAN TAMAT 

ANGGOTA MELAPOR DIRI DI TEMPAT YANG 

DITETAPKAN 

CARTA ALIR PROSES PROSES SARINGAN TiBi BERKALA (PERIODIC) 

 

Kenalpasti anggota kumpulan berisiko tinggi danbertugas di tempat berisiko tinggi 

Ujian

Mantoux  

>15 mm<15 mm 

X‐RayDada

tidak normal normal 

Rujuk kepada Pakar Perubatan / pakar perubatan respiratori/ pakar perubatan keluarga

Digalakkan untuk jalani X‐ray Dada setiap2 tahun dan nasihat berjumpa pakar perubatan/ pakar perubatan respiratori jika ada simptom pada bila‐bila masa

SARINGAN TAMAT  

Digalakkan untuk jalani X‐ray Dada setiap 2 tahun 

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Source:TatacaraPerlaksanaanPekelilingKetuaPengarahKesihatanBil.9/2012:ProcesssaringanTiBibagianggotakementeriankesihatan.

CARTA ALIR PROSES SARINGAN TiBi BAGI ANGGOTA PRA PERSARAAN / PRA PERPINDAHAN 

 

Anggota kesihatan yang mendapat arahan untukditukarkan keluar daripada TBT  atau akan bersara 

X‐RayDada

tidak normalnormal

Rujuk kepada Pakar Perubatan /Pakar perubatan respiratori/ Pakar Perubatan Keluarga 

SARINGAN TAMAT 

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15.9  Screening Location 15.9.1Historytaking/symptomscreeningandmedicalexaminationshallbedoneinStaffClinic15.9.2 Tuberculin Skin Test (TST) administration and reading is performed at RespiratoryDaycareUnit(RCU)15.9.3ChestX‐rayshallbeperformedandreportedinRadiologyDepartment.15.9.4InterferonGamaReleaseAssay(IGRA)test,ifdeemednecessarybyphysician,wouldbeoutsourced.

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15.10  Type of Screening 

Symptomscreening

Mantoux/TuberculinSkinTest(TST)SeeSection14.6

ChestX‐ray

IfasymptomaticHCWhadbeenradiographedlessthan6monthsearlier,arepeatCXRisnotnecessary.However,theCXRshouldbereportedbyRadiologyDepartment,andreviewedbyStaffClinic.

InterferonGamaReleaseAssay(IGRA)

WhenrecommendedbyChest/InfectiousDiseasePhysician

15.11 Mantoux Test / Tuberculin Skin Test (TST) 

AdaptedfromCanadianTuberculosisStandards.7thedition.Chapter4:DiagnosisofLatentTuberculosisInfection.2014

15.11.1ContraindicationsforTST Previouspositive,severeblisteringTSTreactions ExtensiveburnsoreczemapresentoverTSTtestingsites ActiveTB/TreatedTB(TSTwouldbeofnoclinicalutility) Currentmajorviralinfections(e.g.measles,mumps,varicella) Livevirusimmunization,particularlymeasles,withinthepast4weeks

(possiblefalse‐negativeTST)

15.11.2ThosewiththefollowingconditionscanreceiveTST: BCGvaccination Commoncold Pregnantorbreastfeeding Immunizedwithanyvaccineonthesameday Immunizedwithintheprevious4weekswithvaccinesotherthantheoneslistedearlier HistoryofapositiveTSTreactionthatwasnotdocumented Takinglowdosesofsystemiccorticosteroids,<15mgprednisone(orequivalent)daily.

Itgenerallytakesasteroiddoseequivalentto≥15mgprednisonedailyfor2‐4weekstosuppresstuberculinreactivity

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15.11.3BallpointmethodforreadingtransversediameterofTSTinduration

• The TST should be read by a trained health professional. Individuals withoutexperience in reading a TSTmay not feel slight induration, and the TSTwould bemistakenlyrecordedas0mm.

• Self‐readingisveryinaccurateandisstronglydiscouraged.• Reading should be performed 48 to 72 hours after administration, as maximuminduration can take up to 48 hours to develop, but after 72 hours it is difficult tointerpretareaction.Reactionsmaypersistforupto1week,butforasmanyas21%ofindividualswithapositivereactionat48to72hoursthereactionwillbenegativeafter 1 week. If the TST cannot be read within 72 hours because of unforeseencircumstances,itshouldberepeatedataninjectionsitefarenoughfromthatoftheprevioustestthatthereactionsdonotoverlap.Nominimumwaitisrequiredbeforetherepeattest.

• Theforearmshouldbesupportedonafirmsurfaceandslightlyflexedattheelbow.Indurationisnotalwaysvisible.Palpatewithfingertipstocheckwhetherindurationispresent.Ifthereisinduration,marktheborderofindurationbymovingthetipofapenata45°anglelaterallytowardthesiteoftheinjection.Thetipwillstopattheedgeoftheinduration,ifpresent.Repeattheprocessontheoppositesideoftheinduration.Thispenmethodhastheadvantagesofbeingasreliableasthetraditionalpalpationmethod(whichreliesentirelyonfingertips)amongexperiencedreadersandofbeingeasierfornewreaderstolearnanduse.

• Usingaflexibleruler,measurethedistancebetweenthepenmarks,whichreflectsthediameteroftheindurationatitswidesttransversediameter(atarightangletothelongaxisoftheforearm).

• Disregardanddonot recorderythema (redness).Approximately2%‐3%ofpeopletestedwillhavelocalizedrednessorrash(withoutinduration)thatoccurswithinthefirst12hours.Theseareminorallergicreactions,arenotseriousanddonotindicateTBinfection.TheyarenotacontraindicationtofutureTSTs.

• Blistering,which can occur in 3% to 4%of subjectswith positive tests, should berecorded.

• Recordtheresultinmillimetres(mm).Recordnoindurationas"0mm."Recordingsofpositive,negative,doubtful,significantandnon‐significantarenotrecommended.

• Do not round off the diameter of the induration to the nearest 5mm as this caninterferewithdeterminingwhetherTST conversionhasoccurred in the eventof afutureTST.Ifthemeasurementfallsbetweendemarcationsontherules,thesmallerofthetwonumbersshouldberecorded.

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15.12  Management 15.12.1 After completion of screening, the attending Staff ClinicMedical Officer shall certify

whetherthenewpersonnelhaveactive,latentornoevidenceofTB.15.12.2HCWfoundtohaveactiveTB,willbemanagedaspertheprecedingSection12.1ofthis

policy,andaccordingtoClinicalPracticeGuidelinesfortheControlandManagementofTuberculosis.

15.13 Screening Reports 15.13.1AreportshallbesubmittedbyStaffClinic toPPKPUKAat theconclusionofcontact

screen,usingTBIS10A‐3(a).15.13.2AdetailedreportshallbesubmittedbyTBICTaskForcetotheHospitalDirectoratthe

conclusionofcontactscreening.15.13.3Areportonpre‐placementandperiodicscreeningshallbesubmittedbySGHPPKPto

KetuaPenolongPengarahKesihatanPekerjaandanAlamSekitar(KPAS),StateHealthDepartmenteverymonthusingOHUTB3aandOHUTB3b.(MOHAppendix7and12)

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15.13.4HCWswillbegivenacopyoftheTBscreeningformfortheirpersonalrecord:

Furtherreading:LobueandMenzies.TreatmentofLatentTuberculosisInfection:AnUpdate.Respirology(2010)15,p604

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RespiratorProgramAdministrators.May2015.

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