The Tuberculosis (TB) skin testing guidelines can be found in a document called Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings 2005. It says, in part, that EMS personnel should be included in a comprehensive TB screening program and should receive a baseline test and follow-up testing as indicated by the risk assessment. They should also be included in the follow-up of contacts with patients with infectious TB. Since Wisconsin is considered to be low risk for TB, no routine testing is recommended after the initial test upon hire or beginning of EMS work, unless the person is symptomatic (cough lasting more than two months; cough productive of sputum; night sweats; fevers; weight loss; bloody sputum) OR has had a known exposure to a person with TB. When considering the need for additional TB testing, it is necessary to consider exposures outside of EMS work, such as medical missions to areas with high rates of TB.
A positive TST or blood test does NOT mean the person has TB disease; unless the person is symptomatic with cough and/or sputum production. That person (who is asymptomatic) may continue to work as an EMS staff until the medical evaluation and chest radiograph are complete, and a determination of TB infection vs. TB disease has been made. A diagnosis of TB infection means that the person will be offered preventive medication that decreases the chance that the infection will progress to disease. A person with TB infection cannot spread TB to others; ONLY persons with active TB disease can spread it.
Prevention of Exposure of EMS Personnel to Persons with Known or Suspected TB
Protection of EMS personnel from persons who may have infectious TB is important. TB is spread through respiratory droplets which are inhaled by those physically close to the person with TB, so using standard respiratory care protocols will help to protect EMS personnel. Persons with an active cough should cover their cough if at all possible with a surgical mask during care and transport. EMS personnel may wear fit-tested N95 respirators to protect themselves from inhaling TB-laden droplets. If a patient is strongly suspected to have TB, it is important for EMS personnel to identify themselves to medical personnel as having been exposed to that person, in case follow-up testing is required. Local public health departments oversee the investigations into suspect TB, and provide treatment for those with TB. If EMS personnel need information about whether they have been exposed, they may call the state or local public health department for information about exposures.
Transportation of persons with active TB requires that the patient wear a surgical mask during transport, and that EMS personnel wear fit-tested N95 respirators. The guideline for Emergency Medical Services reads as follows:
“The ambulance ventilation system should be operated in the non-recirculating mode, and the maximum amount of outdoor air should be provided to facilitate dilution. If the vehicle has a rear exhaust fan, use this fan during transport. If the vehicle is equipped with a supplemental recirculating ventilation unit that passes air through HEPA filters before returning it to the vehicle, use this unit to increase the number of ACH. Air should flow from the cab (front of vehicle), over the patient, and out the rear exhaust fan. If possible, physically isolate the cab from the rest of the vehicle.”
“EMS personnel should be included in the follow-up contact investigations of patients with infectious TB disease. The Ryan White Comprehensive AIDS Resource Emergency Act of 1990 (Public law 101--381) mandates notification of EMS personnel after they have been exposed to a patient with suspected or confirmed infectious TB disease (Title 42 U.S. Code 1994).The entire guideline can be found at http://www.cdc.gov/tb/publications/guidelines/infectioncontrol.htm. (exit DHS)
Wisconsin is a low TB incidence state, and numbers of persons with TB have been decreasing yearly. County-specific numbers and rates can be found at the website of the State of Wisconsin TB Program. If you have any questions about test protocols, results, exposure, or specific patient issues, please call the TB Program and speak with one of the TB nurse consultants.