D(GPP) - TB services should assess local language and other communication needs and, if there is a demonstrated need, provide patient information accordingly. (Note: Patient information should be drawn from national high-quality resources if available; for examples, see www.hpa.org.ukor www.nks.nhs.uk)

Risk Assessment and Infection Control in Drug-Resistant TB

Risk Factors

C - A risk assessment for drug resistance should be made for each patient with TB, based on the risk factors listed below:

1. History of prior TB drug treatment; prior TB treatment failure
2. Contact with a known case of drug-resistant TB
3. Birth in a foreign country, particularly high-incidence countries as defined by the Health Protection Agency (HPA) on its website. (Go to www.hpa.org.uk and search for 'WHO country data TB".)
4. HIV infection
5. Residence in London
6. Age profile, with highest rates between ages 25 and 44
7. Male gender

D(GPP) - The TB service should consider the risk assessment for drug resistance and, if the risk is regarded as significant, urgent molecular tests for rifampicin resistance should be performed on smear-positive material or on positive cultures when they become available (see "Diagnosing Active Tuberculosis" above).

D(GPP) - Response to treatment should be closely monitored in patients at increased risk of drug resistance. If there is no clinical improvement, or if cultures remain positive after the fourth month of treatment ("treatment failure"), drug resistance should be suspected and treatment reviewed with a clinician experienced in the treatment of MDR TB.  (See "Drug Treatment" under "Management of Respiratory Tuberculosis" above for details of the standard recommended regimen.)

Referral

D(GPP) - The options for organising care for people with MDR TB should be discussed with clinicians who specialise in this. The views of the patient should be sought and taken into account, and shared care should be considered.

Infection Control

D(GPP) - Patients with suspected or known infectious MDR TB who are admitted to hospital should be admitted to a negative pressure room. If none are available locally, the patient should be transferred to a hospital that has these facilities and a clinician experienced in managing complex drug-resistant cases. Care should be carried out in the negative pressure room until the patient is found to be non-infectious or non-resistant, and ideally until cultures are negative.

D(GPP) - Staff and visitors should wear FFP3 masks* (during contact with a patient with suspected or known MDR TB while the patient is considered infectious.

*Note: European standard EN149:2001; masks should meet the standards in the Health and Safety Executive's Respiratory protective equipment at work: a practical guide HSG53)

D(GPP) - Before the decision is made to discharge a patient with suspected or known MDR TB from hospital, secure arrangements for the supervision and administration of all anti-TB therapy should have been agreed with the patient and carers.

D(GPP) - The decision to discharge a patient with suspected or known MDR TB should be discussed with the infection control team, the local microbiologist, the local TB service, and the consultant in communicable disease control.

D(GPP) - Negative pressure rooms used for infection control in MDR TB should meet the standards of the Interdepartmental Working Group on Tuberculosis (Interdepartmental Working Group on Tuberculosis, 1998) and should be clearly identified for staff, for example by a standard sign. Such labelling should be kept up to date.

Treatment of Non-MDR TB Resistance

Patients with drug-resistant TB, other than MDR, should be under the care of a specialist physician with appropriate experience in managing such cases. First-choice drug treatment is set out in the table below.

Management of Latent Tuberculosis

Treatment Regimens for Latent Tuberculosis Infection

D(GPP) - Treatment of latent TB infection should be considered for people in the following groups, once active TB has been excluded by chest x-ray and examination:

• People identified through screening who are:
  • Younger than 36 years (because of increasing risk of hepatotoxicity with age)
  • Any age with HIV
  • Any age and a healthcare worker

  and are either:

  • Mantoux positive (6 mm or greater), and without prior Bacille Calmette-Guerin (BCG) vaccination, or
  • Strongly Mantoux positive (15 mm or greater), interferon-gamma positive, and with prior BCG vaccination
• Children aged 1 to 5 years identified through opportunistic screening, to be:
  • Strongly Mantoux positive (15 mm or greater), and
  • Interferon-gamma positive (if this test has been performed), and
  • Without prior BCG vaccination
• People with evidence of TB scars on chest x-ray, and without a history of adequate treatment.

D(GPP) - People with HIV who are in close contact with people with sputum smear-positive respiratory TB should have active disease excluded and then be given treatment for latent TB infection. Mantoux testing may be unreliable in people with HIV. (Note: Close contacts may include a boyfriend or girlfriend and frequent visitors to the home of the index case, in addition to household contacts.)

D(GPP) - Treatment for latent TB infection should not be started in close contacts of people with sputum smear-positive MDR TB who are strongly Mantoux positive (15 mm or greater), as no regimen is of proven benefit, and only a small proportion of people infected will develop the disease. Long-term monitoring should be undertaken for active disease.

C - People who have agreed to receive treatment for latent TB infection should be started on one of the following regimens:

• A - Either six months of isoniazid (6H) or three months of rifampicin and isoniazid (3RH) for people aged 16–35 not known to have HIV
• (GPP) - Either six months of isoniazid (6H) or three months of rifampicin and isoniazid (3RH) for people older than 35 in whom treatment for latent TB infection is recommended (see above) and who are not known to have HIV D
• A - Six months of isoniazid (6H) for people of any age who have HIV
• D(GPP) - Six months of rifampicin (6R) for contacts, aged 35 or younger, of people with isoniazid-resistant TB

D(GPP) - People eligible for treatment of latent TB infection, but who decline to take this treatment, should be given "inform and advise" information about TB and have chest x-rays three and 12 months later.

D(GPP) - Neonates who have been in close contact with people with sputum smear-positive TB who have not received at least two weeks' anti-tuberculosis drug treatment should be treated as follows.

• The baby should be started on isoniazid 5 mg/kg for three months and then a Mantoux test performed after three months' treatment.
• If the Mantoux test is positive (6 mm or greater) the baby should be assessed for active TB (see section "Diagnosing Active Tuberculosis" above). If this assessment is negative, then isoniazid should be continued for a total of six months.
• If the test is negative (less than 6 mm), then isoniazid should be stopped and a BCG vaccination performed (see "BCG Vaccination" below).

D(GPP) - Children older than four weeks but younger than two years who have not had BCG vaccination and are in close contact with people with sputum smear-positive TB should be treated as follows.

• The child should be started on isoniazid 5 mg/kg and a Mantoux test performed.
• If the Mantoux test is positive (6 mm or greater), the child should be assessed for active TB (see section "Diagnosing Active Tuberculosis" above). If active TB is ruled out, full treatment for latent TB infection should be given (see recommendation below in this section)
• If the test is negative (less than 6 mm), then isoniazid should be continued and the Mantoux test repeated after six weeks.
• If the repeat test is negative, isoniazid may be stopped and BCG vaccination performed (see "BCG Vaccination" below).
• If the repeat test is positive (6 mm or greater), an interferon-gamma test should be conducted, if available. If this is positive, full treatment for latent TB infection should be given. If the test is not available, the child should be started on treatment for latent TB infection after a positive repeat Mantoux test result.

Contact tracing for children younger than two years when the index case is sputum smear positive is summarised in an algorithm (see section 12.2 in the original guideline document).

D(GPP) - BCG-vaccinated children aged older than four weeks but younger than two years, in close contact with people with sputum smear-positive respiratory TB, should be treated as follows.

• The child should have a Mantoux test. If this is positive (15 mm or greater), the child should be assessed for active TB (see "Diagnosing Active Tuberculosis" above). If active TB is excluded, then treatment for latent TB infection should be given (see next recommendation).
• If the result of the test is as expected for prior BCG (less than 15 mm), it should be repeated after six weeks.
• If the repeat test is also less than 15 mm, no further action is needed.
• If the repeat test becomes more strongly positive (15 mm or greater and an increase of 5 mm or more over the previous test), an interferon-gamma test should be conducted, if available. If this is positive, the child should be assessed for active TB (see section "Diagnosis of Active Tuberculosis" above). If the interferon-gamma test is not available, the child should be assessed for active TB after a positive repeat Mantoux test result. If active TB is excluded, treatment for latent TB infection should be given.

D(GPP) - For children requiring treatment for latent TB infection, a regimen of either three months of rifampicin and isoniazid (3RH) or six months of isoniazid (6H) should be planned and started, unless the child is known to be HIV positive, when 6H should be given.

D(GPP) - Healthcare workers should be aware that certain groups of people with latent TB are at increased risk of going on to develop active TB, including people who:

• Are HIV positive
• Are injecting drug users
• Have had solid organ transplantation
• Have a haematological malignancy
• Have had a jejunoileal bypass
• Have chronic renal failure or receive haemodialysis
• Have had a gastrectomy
• Are receiving anti-tumour necrosis factor (TNF)-alpha treatment
• Have silicosis

Patients in these groups should be advised of the risks and symptoms of TB, on the basis of an individual risk assessment basis, usually in a standard letter of the type referred to as "inform and advise" information.

Prevention and Control

BCG Vaccination

Overview (Overall Recommendations)

D(GPP) - When BCG is being recommended, the benefits and risks of vaccination and remaining unvaccinated should be discussed with the person (or, if a child, with the parents), so that they can make an informed decision. This discussion should be tailored to the person, be in an appropriate language, and take into account cultural sensitivities and stigma.

D(GPP) - People identified for BCG vaccination through occupational health, contact tracing, or new entrant screening who are also considered to be at increased risk of being HIV positive, should be offered HIV testing before BCG vaccination. (See previous section for details of further action in HIV-positive patients.)

For Neonates

D(GPP) - Neonatal BCG vaccination for any baby at increased risk of TB should be discussed with the parents or legal guardian.

D(GPP) - Primary care organisations with a high incidence of TB (as defined by the HPA; go to www.hpa.org.uk and search for "tuberculosis rate bands") should consider vaccinating all neonates soon after birth.

D(GPP) - In areas with a low incidence of TB (as defined by the HPA; go to www.hpa.org.uk and search for 'tuberculosis rate bands'), primary care organisations should offer BCG vaccination to selected neonates who:

• Were born in an area with a high incidence of TB (as defined by the HPA; go to www.hpa.org.uk and search for "tuberculosis rate bands"), or
• Have one or more parents or grandparents who were born in a high-incidence country (go to www.hpa.org.uk and search for "WHO country data TB"), or
• Have a family history of TB in the past five years

D(GPP) - Mantoux testing should not be done routinely before BCG vaccination in children younger than six years.

For Infants and Older Children

Routine BCG vaccination is not recommended for children aged 10 to 14.

• C - Healthcare professionals should opportunistically identify unvaccinated children older than four weeks and younger than two years at increased risk of TB (see section 10.2 in the full version of the original guideline document) who would have qualified for neonatal BCG and provide Mantoux testing and BCG (if Mantoux negative).
• D(GPP) - This opportunistic vaccination should be in line with the Chief Medical Officer's advice (www.dh.gov.uk/assetRoot/04/11/81/35/04118135.pdf) on vaccinating this age group following the end of the school-based programme

D(GPP) - Mantoux testing should not be done routinely before BCG vaccination in children younger than six years unless they have a history of residence or prolonged stay (more than one month) in a country with a high incidence of TB.

For New Entrants from High-Incidence Countries

Readers should also be aware of the recommendations under new entrant screening (see below). This process should include Mantoux tests on appropriate new entrants and risk assessment for HIV prior to vaccination.

BCG vaccination should be offered to Mantoux-negative new entrants who:

• B - Are from high-incidence countries, (go to www.hpa.org.uk and search for "WHO country data TB") and
• B - Are previously unvaccinated (that is, without adequate documentation or a characteristic scar), and
• D(GPP) - Are aged 35 or younger. (Note: The draft 2006 Green Book recommends BCG for new entrants only up to the age of 16. However in this guideline BCG is recommended for those up to 35 years who come from the countries with the very highest rates of TB because there is some evidence of cost-effectiveness.)

For Healthcare Workers

D(GPP) - BCG vaccination should be offered to healthcare workers, irrespective of age, who:

• Are previously unvaccinated (that is, without adequate documentation or a characteristic scar), and
• Will have contact with patients or clinical materials, and
• Are Mantoux (or interferon-gamma) negative

BCG Vaccination for Contacts of People with Active Tuberculosis

D(GPP) - BCG vaccination should be offered to Mantoux-negative contacts of people with respiratory TB (see section "Contract Tracing: Human to Human Transmission" below for details of contact tracing) if they are previously unvaccinated (that is, without adequate documentation or a characteristic scar) and are:

• Aged 35 or younger
• Aged 36 and older and a healthcare or laboratory worker who has contact with patients or clinical materials (see previous section)

Other Groups

D(GPP) - BCG vaccination should be offered to previously unvaccinated, Mantoux-negative people under 35 in the following groups at increased risk of exposure to TB, in accordance with the "Green Book": (Department of Health, 2006)

• Veterinary and other staff such as abattoir workers who handle animal species known to be susceptible to TB, such as simians
• Prison staff working directly with prisoners
• Staff of care homes for elderly people
• Staff of hostels for homeless people and facilities accommodating refugees and asylum seekers
• People going to live or work with local people for more than 1 month in a high-incidence country. (go to www.hpa.org.uk and search for "WHO country data TB")

See "For Healthcare Workers" above for advice on healthcare workers.

Active Case Finding

Contact Tracing: Human-to-Human Transmission

D(GPP) - Once a person has been diagnosed with active TB, the diagnosing physician should inform relevant colleagues so that the need for contact tracing can be assessed without delay. Contact tracing should not be delayed until notification.

D(GPP) - Screening should be offered to the household contacts of any person with active TB, irrespective of the site of infection. Household contacts are defined as those who share a bedroom, kitchen, bathroom, or sitting room with the index case. Screening should comprise:

• Standard testing for latent TB for those aged 35 or younger, and consideration of BCG or treatment for latent TB infection once active TB has been ruled out
• Interferon-gamma test six weeks after the Mantoux test, and consideration of BCG or treatment for latent TB infection once active TB has been ruled out, for those who:
  • Are previously unvaccinated and
  • Are household contacts of a person with sputum smear-positive TB and
  • Are Mantoux negative (<6 mm)
• Chest x-ray (if there are no contraindications) for those older than 35, possibly leading to further investigation for active TB

D(GPP) - For people with sputum smear-positive TB, other close contacts should be assessed. These may include boyfriends or girlfriends and frequent visitors to the home of the index case. Occasionally, a workplace associate may be judged to have had contact equivalent to that of household contacts, and should be assessed in the same way.

C - Casual contacts of people with TB, who will include the great majority of workplace contacts, should not normally be assessed.

D(GPP) - The need for tracing casual contacts of people with TB should be assessed if:

• The index case is judged to be particularly infectious (for example, evidenced by transmission to close contacts), or
• Any casual contacts are known to possess features that put them at special risk of infection (See "Management of Latent Tuberculosis" above)

D(GPP) - "Inform and advise" information should be offered to all contacts of people with smear-positive TB.

Contact Tracing: Cattle-to-Human Transmission

D(GPP) - "Inform and advise" information should be given to people in contact with TB-diseased animals. Diagnostic tests for latent TB should be considered only for children younger than 16 who have not had BCG vaccination and have regularly drunk unpasteurised milk from animals with TB udder lesions.

Contact Tracing: Cases on Aircraft

D(GPP) - Following diagnosis of TB in an aircraft traveller, contact tracing of fellow passengers should not routinely be undertaken.

D(GPP) - The notifying clinician should inform the relevant consultant in communicable disease control (CCDC) if:

• D(GPP) - Less than three months has elapsed since the flight and the flight was longer than eight hours, and
• D(GPP) - The index case is sputum smear positive, and
• C - The index case has MDR TB, or
• D(GPP) - The index case coughed frequently during the flight.

D(GPP) - The CCDC should provide the airline with "inform and advise" information to send to passengers seated in the same part of the aircraft as the index case. (Note: Published evidence does not allow for a precise definition, but such contact tracing on aircraft has often only included people within three rows on either side of the index case.)

D(GPP) - If the TB index case is an aircraft crew member, contact tracing of passengers should not routinely take place.

B - If the TB index case is an aircraft crew member, contact tracing of other members of staff is appropriate, in accordance with the usual principles for screening workplace colleagues. (See "Contact Tracing: Human to Human Transmission" above)

Contact Tracing: Cases in Schools

D(GPP) - Following diagnosis of TB in a school pupil or member of staff, the CCDC should be prepared to explain the prevention and control procedures to staff, parents and the press. Advice on managing these incidents and their public relations is available from the Health Protection Unit (HPU).

B - If a school pupil is diagnosed with sputum smear-positive TB, the rest of his or her class (if there is a single class group), or the rest of the year group who share classes, should be assessed as part of contact tracing.

C - If a teacher has sputum smear-positive TB, the pupils in his or her classes during the preceding three months should be assessed as part of contact tracing.

D(GPP) - Clinicians conducting contact tracing in a school should consider extending it to include children and teachers involved in extracurricular activities, and non-teaching staff, on the basis of:

• The degree of infectivity of the index case
• The length of time the index case was in contact with others
• Whether contacts are unusually susceptible to infection
• The proximity of contact

Secondary cases of sputum smear-positive TB should be treated as index cases for contact tracing (see recommendations above for class of recommendation).

D(GPP) - If the index case of a school pupil's TB infection is not found, and the child is not in a high-risk group for TB, contact tracing and screening (by either symptom enquiry or chest x-ray) should be considered for all relevant members of staff at the school.

Contact Tracing: Community Childcare

D(GPP) - When an adult who works in childcare is diagnosed with sputum smear-positive TB, management is as for contact tracing (see "Contact Tracing: Human-to-Human Transmission" above).

Contact Tracing: Cases in Hospital Inpatients

D(GPP) - Following diagnosis of TB in a hospital inpatient, a risk assessment should be undertaken. This should take in to account:

• The degree of infectivity of the index case
• The length of time before the infectious patient was isolated
• Whether other patients are unusually susceptible to infection
• The proximity of contact

Contact tracing and testing should be carried out only for patients for whom the risk is regarded as significant.

D(GPP) - Patients should be regarded as at risk of infection if they spent more than eight hours in the same bay as an inpatient with sputum smear-positive TB who had a cough. The risk should be documented in the contact's clinical notes, for the attention of the contact's consultant. The contact should be given "inform and advise" information, and their general practitioner should be informed.

D(GPP) - If patients were exposed to a patient with sputum smear-positive TB for long enough to be equivalent to household contacts (as determined by the risk assessment), or an exposed patient is known to be particularly susceptible to infection, they should be managed as equivalent to household contacts (see "Contact Tracing: Human-to-Human Transmission" above).

D(GPP) - If an inpatient with sputum smear-positive TB is found to have MDR TB, or if exposed patients are HIV positive, contact tracing should be in line with the Interdepartmental Working Group on Tuberculosis guidelines (Interdepartmental Working Group on Tuberculosis, 1998)

D(GPP) - In cases of doubt when planning contact tracing after diagnosing sputum smear-positive TB in an inpatient, further advice should be sought from the regional or national Health Protection Agency and/or people experienced in the field.

New Entrants (People Recently Arriving in or Returning to the UK)

Healthcare professionals, including primary care staff, responsible for screening new entrants* should maintain a coordinated programme to:

• B - Detect active TB and start treatment.
• B - Detect latent TB and start treatment.
• D(GPP) - Provide BCG vaccination to those in high-risk groups who are not infected and who are previously unvaccinated.
• D(GPP) - Provide relevant information to all new entrants

*Note: In this guideline, new entrants are defined as people who have recently arrived in or returned to the UK from high-incidence countries, as defined by the HPA; go to www.hpa.org.uk and search for "WHO country data TB".

D(GPP) - New entrant screening for tuberculosis should be incorporated within larger health screening programmes for new entrants, linked to local services.

D(GPP) - Assessment for, and management of, TB in new entrants should consist of the following.

• A chest x-ray for those who have not had one recently taken, unless they are younger than 11 or are possibly pregnant
• Clinical assessment for those with an abnormal chest x-ray
• Risk assessment for HIV, including HIV prevalence rates in the country of origin, which is then taken into account for Mantoux testing and BCG vaccination
• A Mantoux test for people with normal recent chest x-ray who are:
  • Younger than 16, or
  • Aged 16 to 35, from sub-Saharan Africa or a country with a TB incidence greater than 500 per 100,000
• A Mantoux test for:
  • Children younger than 11 years
  • Pregnant women
• Interferon-gamma test (if available) if Mantoux test positive (6 mm or greater) in someone who has not had BCG vaccination, or strongly positive (15 mm or greater) in someone who has been vaccinated.
• Assessment for active TB if interferon-gamma test is positive; interpret chest x-ray first if it is not contraindicated.
• Treatment for latent TB infection for people aged 35 or younger in whom active TB has been excluded, with a positive Mantoux test inconsistent with their BCG history, and a positive interferon-gamma test (if this test was available), and who are:
  • Younger than 16, or
  • Aged 16 to 35, from sub-Saharan Africa or a country with a TB incidence greater than 500/100,000
• Consideration of BCG for unvaccinated people who are Mantoux negative (see section on "BCG Vaccination for New Entrants from High-Incidence Countries" above).
• "Inform and advise" information for people who do not have active TB and are not being offered BCG or treatment for latent TB infection.

See the algorithm in Figure 10 in the full version of the original guideline document for further detail.

New entrants should be identified for TB screening from the following information:

• D(GPP) - Port of arrival reports
• B - New registrations with primary care
• D(GPP) - Entry to education (including universities)
• D(GPP) - Links with statutory and voluntary groups working with new entrants

D(GPP) - Any healthcare professional working with new entrants should encourage them to register with a GP.

Street Homeless People

D(GPP) - Active case finding should be carried out among street homeless people (including those using direct access hostels for the homeless) by chest x-ray screening on an opportunistic and/or symptomatic basis. Simple incentives for attending, such as hot drinks and snacks, should be considered.

D(GPP) - Healthcare professionals working with people with TB should reinforce and update education about TB, and referral pathways, to primary care colleagues, social workers, and voluntary workers who work with homeless people.

Preventing Infection in Specific Settings

Healthcare Environments: New Employees

D(GPP) - Employees new to the NHS who will be working with patients or clinical specimens should not start work until they have completed a TB screen or health check, or documentary evidence is provided of such screening having taken place within the preceding 12 months.

D(GPP) - Employees new to the NHS who will not have contact with patients or clinical specimens should not start work if they have signs or symptoms of TB.

D(GPP) - Health checks for employees new to the NHS who will have contact with patients or clinical materials should include:

• Assessment of personal or family history of TB
• Symptom and signs enquiry, possibly by questionnaire
• Documentary evidence of TB skin testing (or interferon-gamma testing) and/or BCG scar check by an occupational health professional, not relying on the applicant's personal assessment
• Mantoux result within the last five years, if available

D(GPP) - If an employee new to the NHS has no (or inconclusive) evidence of prior BCG vaccination, a Mantoux or interferon-gamma test (see "Diagnosing Latent Tuberculosis" above) should be performed.

D(GPP) - Employees who will be working with patients or clinical specimens and who are Mantoux negative (less than 6 mm) should have an individual risk assessment for HIV infection before BCG vaccination is given.

D(GPP) - Employees new to the NHS should be offered BCG vaccination, whatever their age, if they will have contact with patients and/or clinical specimens, are Mantoux negative (less than 6 mm), and have not been previously vaccinated. (See "For Healthcare Workers" above for more detail.)

D(GPP) - Employees of any age who are new to the NHS and are from countries of high TB incidence, or who have had contact with patients in settings with a high TB prevalence should have a Mantoux test. If negative (less than 6 mm), the two preceding recommendations should be followed. If positive (6 mm or greater), the person should be referred for clinical assessment for diagnosis and possible treatment of latent infection or active disease.

D(GPP) - If a new employee from the UK or other low-incidence setting, without prior BCG vaccination, has a positive Mantoux or interferon-gamma test, they should have a medical assessment and a chest x-ray. They should be referred to a TB clinic for consideration of TB treatment if the chest x-ray is abnormal, or for consideration of treatment of latent TB infection if the chest x-ray is normal.

D(GPP) - If a prospective or current healthcare worker who is Mantoux negative (less than 6 mm), declines BCG vaccination, the risks should be explained and the oral explanation supplemented by written advice. If the person still declines BCG vaccination, he or she should not work where there is a risk of exposure to TB. The employer will need to consider each case individually, taking account of employment and health and safety obligations.

D(GPP) - Clinical students, agency and locum staff, and contract ancillary workers who have contact with patients or clinical materials should be screened for TB to the same standard as new employees in healthcare environments, according to the recommendations set out above. Documentary evidence of screening to this standard should be sought from locum agencies and contractors who carry out their own screening.

D(GPP) - NHS trusts arranging care for NHS patients in non-NHS settings should ensure that healthcare workers who have contact with patients or clinical materials in these settings have been screened for TB to the same standard as new employees in healthcare environments (See the first two recommendations in this section).

Healthcare Environments: Occupational Health

These recommendations set the standard for NHS organisations and therefore should apply in any setting in England and Wales where NHS patients are treated.

D(GPP) - Reminders of the symptoms of TB, and the need for prompt reporting of such symptoms, should be included with annual reminders about occupational health for staff who:

• Are in regular contact with TB patients or clinical materials, or
• Have worked in a high-risk clinical setting for four weeks or longer

One-off reminders should be given after a TB incident on a ward.

D(GPP) - If no documentary evidence of prior screening is available, staff in contact with patients or clinical material who are transferring jobs within the NHS should be screened as for new employees (see "Healthcare Environments: New Employees" above).

D(GPP) - The risk of TB for a new healthcare worker who knows he or she is HIV positive at the time of recruitment should be assessed as part of the occupational health checks.

D(GPP) - The employer, through the occupational health department, should be aware of the settings with increased risk of exposure to TB, and that these pose increased risks to HIV-positive healthcare workers.

D(GPP) - Healthcare workers who are found to be HIV positive during employment should have medical and occupational assessments of TB risk, and may need to modify their work to reduce exposure.

Prisons and Remand Centres

D(GPP) - Healthcare workers providing care for prisoners and remand centre detainees should be aware of the signs and symptoms of active TB (see "Diagnosing Active Tuberculosis" above). TB services should ensure that awareness of these signs and symptoms is also promoted among prisoners and prison staff.

Prisoners should be screened for TB by:

• D(GPP) - A health questionnaire on each entry to the prison system, then
• C - For those with signs and symptoms of active TB, a chest x-ray
• D(GPP) - and three sputum samples taken in 24 hours for TB microscopy, including a morning sputum sample (see "Diagnosing Active Tuberculosis" above)

D(GPP) - All prisoners receiving treatment for active or latent TB should receive DOT.

D(GPP) - Prison medical services should have liaison and handover arrangements to ensure continuity of care before any prisoner on TB treatment is transferred between prisons.

D(GPP) - If a prisoner is being treated for active or latent TB, the prison medical services should draw up as early as possible a contingency plan for early discharge, which could happen directly from a court appearance. This plan should include firm arrangements for clinical follow-up and treatment monitoring in the intended district of residence, and should take into account that there may not be a fixed residence arranged for the prisoner after release. The prisoner should be given contact details for a named key worker, who will visit and monitor the prisoner after release and liaise between services involved.

D(GPP) - Prison service staff and others who have regular contact with prisoners (for example, probation officers and education and social workers) should have pre- and on-employment screening at the same level as for healthcare workers with patient contact (see "Healthcare Environments: New Employees" and "Healthcare Environments: Occupational Health" above).

Definitions:

Levels of Evidence for Intervention Studies

1⁺⁺ High-quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias

1⁺ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1^– Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2⁺⁺ High-quality systematic reviews of case–control or cohort studies. High-quality case-control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal

2⁺ Well-conducted case-control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal

2^– Case-control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal

3 Non-analytical studies (for example, case reports, case series)

4 Expert opinion, formal consensus

Levels of Evidence for Studies of the Accuracy of Diagnostic Tests

Ia Systematic review (with no or minor variations in the directions and degrees of results between studies) of level-1 studies, which are studies that use:

• A blind comparison of the test with a validated reference standard (gold standard)
• A sample of patients that reflects the population to whom the test would apply

Ib Level-1 studies

II Level-2 studies, which are studies that have only one of the following:

• The population is narrow (the sample does not reflect the population to whom the test would apply).
• A poor reference standard is used (defined as that where the 'test' is included in the 'reference', or where the 'testing' affects the 'reference').
• The comparison between the test and reference standard is not blind.
• The study is a case-control study.

Systematic reviews of level-2 studies

III Level-3 studies, which are studies that have at least two of the features listed for level-2 studies or

Systematic reviews of level-3 studies

IV Expert committee reports, opinions and/or clinical experience without explicit critical appraisal; or based on physiology, bench research, or 'first principles'

Classification of Recommendations on Interventions

A At least one meta-analysis, systematic review, or randomised controlled trial (RCT) that is rated as 1⁺⁺, and is directly applicable to the target population, or
A systematic review of RCTs or a body of evidence that consists principally of studies rated as 1⁺, is directly applicable to the target population, and demonstrates overall consistency of results, or
Evidence drawn from a NICE technology appraisal

B A body of evidence that includes studies rated as 2⁺⁺, is directly applicable to the target population, and demonstrates overall consistency of results, or
Extrapolated evidence from studies rated as 1⁺⁺ or 1⁺

C A body of evidence that includes studies rated as 2⁺, is directly applicable to the target population, and demonstrates overall consistency of results, or
Extrapolated evidence from studies rated as 2⁺⁺

D Evidence level 3 or 4, or
Extrapolated evidence from studies rated as 2⁺, or
Formal consensus

D(GPP) A good practice point (GPP) is a recommendation for best practice based on the experience of the Guideline Development Group or extrapolated from level 2 clinical evidence, supplemented with health-economic modelling

Classification of Recommendations on Diagnostic Tests

A(DS) Studies with level of evidence Ia or Ib

B(DS) Studies with level of evidence II

C(DS) Studies with level of evidence III

D(DS) Studies with level of evidence IV

References open in a new window

Members of the Guideline Development Group declared any interests in accordance with the National Institute for Health and Clinical Excellence (NICE) technical manual. A register is available from the National Collaborating Centre for Chronic Conditions (NCC-CC) for inspection upon request (ncc-cc@rcplondon.ac.uk).

Electronic copies: Available in Portable Document Format (PDF) format from the National Institute for Health and Clinical Excellence (NICE) Web site.

• National Collaborating Centre for Chronic Conditions. Tuberculosis. Clinical diagnosis and management of tuberculosis, and measures for its prevention and control. London (UK): National Institute for Health and Clinical Excellence (NICE); 2006 Mar. 66 p. (Clinical guideline; no. 33). Electronic copies: Available in Portable Document Format (PDF) format from the National Institute for Health and Clinical Excellence (NICE) Web site.
• Tuberculosis. Clinical diagnosis and management of tuberculosis, and measures for its prevention and control. Quick reference guide. National Collaborating Centre for Chronic Conditions, 2006 Mar. 23 p. Electronic copies: Available from the NICE Web site.
• National Institute for Health and Clinical Excellence. Implementation advice. Suggested actions for implementing the NICE clinical guideline on tuberculosis. London (UK): National Institute for Health and Clinical Excellence (NICE); 2006 Mar. 23 p. Electronic copies: Available from the NICE Web site.
• Tuberculosis (TB): clinical diagnosis and management of tuberculosis and measures for its prevention and control. London (UK): National Institute for Health and Clinical Excellence (NICE); 2006 Mar. 22 p. Electronic copies: Available from the NICE Web site.
• Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control. Costing report. London (UK): National Institute for Health and Clinical Excellence (NICE); 2006 Mar. 37 p. Electronic copies: Available from the NICE Web site.
• Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control. Costing template. London (UK): National Institute for Health and Clinical Excellence (NICE); 2006 Mar. Various p. Electronic copies: Available from the NICE Web site.

Print copies: Available from the National Health Service (NHS) Response Line 0870 1555 455. ref: N1008. 11 Strand, London, WC2N 5HR.

Additionally, Audit Criteria can be found in Appendix D of the NICE version of the original guideline document.

Electronic copies: Available from the National Institute for Health and Clinical Excellence (NICE) Web site.

Print copies: Available from the National Health Service (NHS), 11 Strand, London, WC2N 5HR. Response Line 0870 1555 455, ref N1009.

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