TB Infection Control

TB is an infection of the alveolar macrophage and with rare exception, a puncture wound in the laboratory. I have never seen a report of primary lesion of the eye, so my answer is an unequivicol "no", eye protection is not needed. Once TB are on HEPA filters they are extremely difficult to aerosolize, and die quickly on the filter, so that even respiratory protection, while a good precaution in case, is probably not absolutely necessary since it is aerosolized TB we must be concerned about.

Ed Nardell

I think the reason the CDC suggested eye protection is because it is part of transmission based precautions rather than TB specifically. I agree with Ed, there is no documented case of TB transmission via splashing in the eye- it is an added precaution.
Regards
Shaheen

Prof Shaheen Mehtar
MBBS, FRC Path (UK), FCPath (Micro) (SA), MD (Eng)
Head of Academic Unit for Infection Prevention and Control
Tygerberg Hospital & Stellenbosch Uni
PO Box 19063,
Tygerberg 7505, Cape Town

Visit our UIPC Website
http://www.sun.ac.za/uipc

Dear colleagues,
Many thanks for your comments. I agree with you, that transmission of M. tuberculosis by changing HEPA filters is very doutable indeed. But actually my main question was, whether health workers should wear eye protection when taking care of a ventilated intubated patient with contagious tuberculosis to avoid getting in contact with infectious
material (e.g. with sputum by provoking coughing by suction), same could be asked in case of intubation or bronchoscopy.

Hans Rieder kindly send me some historical articles (1930-1950ies) of case reports of tuberculous eye lesions, which were supposed to be primary ones. In times, when children´s eye lids were cleaned with the (potentielly tuberculous) spittle of their parents and when in iron and steal works even professional "lickers" were ready for emergencies to remove particles of steal and iron, some experts believed that there was a risk of transmission (especially when the eye was somehow injured). M. bovis eye infections (predominantely of the left eye) were seen in milking women, whose eyes got in contact with contaminated milk. One case of a Swiss med student was described, who developed eye tuberculosis after opening an abscess and pus spurted into his eye. Rabbit´s ...

Dear colleagues,
Many thanks for your comments. I agree with you, that transmission of M. tuberculosis by changing HEPA filters is very doutable indeed. But actually my main question was, whether health workers should wear eye protection when taking care of a ventilated intubated patient with contagious tuberculosis to avoid getting in contact with infectious
material (e.g. with sputum by provoking coughing by suction), same could be asked in case of intubation or bronchoscopy.

Hans Rieder kindly send me some historical articles (1930-1950ies) of case reports of tuberculous eye lesions, which were supposed to be primary ones. In times, when children´s eye lids were cleaned with the (potentielly tuberculous) spittle of their parents and when in iron and steal works even professional "lickers" were ready for emergencies to remove particles of steal and iron, some experts believed that there was a risk of transmission (especially when the eye was somehow injured). M. bovis eye infections (predominantely of the left eye) were seen in milking women, whose eyes got in contact with contaminated milk. One case of a Swiss med student was described, who developed eye tuberculosis after opening an abscess and pus spurted into his eye. Rabbit´s eyes inoculated with the material from tuberculous nodules became tuberculous.

But even at the times described, eye TB was a very rare event, and I couldn´t find any recent report in the literature. Therefore I conclude, that there is a very small risk of transmission, but the question is, whethter it is neglectable (I tend to that) or if this should result in a (practicable?) recommendation to wear eye protection in the above mentioned situations.
What is your opinion?
Many thanks in advance!

Kind regards,

Dr. Barbara Hauer, MPH

Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose
Prof. Dr. Robert Loddenkemper
Generalsekretär (Secretary General)
(German Central Committee against Tuberculosis)

Lungenklinik Heckeshorn
HELIOS Klinikum Emil von Behring
Walterhöferstr. 11
14165 Berlin

www.dzk-tuberkulose.de

Suctioned sputm may be blood tinged and hence may pose a risk of transmitting bloodborne pathogens such as hepatitis or HIV. Therefore, irrespective of whether the patient has TB, CDC recommends the use of eye protection during procedures, such as suctioning where there may splashes or sprays of potentially infectious material that can contact mucous membranes of the conjunctiva.
Mlp
--------------------------
Sent using BlackBerry

Dear Barbara,

Greetings from Tbilisi where Paul and I are conducting a TB-IC training course for the countries of the region. Just to share my humble view, while it is important to think TB, one shall not forget about other infectious agents, particularly when providing care for a patient at ICU. Therefore whether it would be relevant in preventing a very rare condition such as eye TB or not, in the conditions you mentioned, wearing eye protection or a face shield would be certainly beneficial in decreasing the risk of occupational exposure to a range of other pathogens and can be recommended in line with the Standard Precautions.

You may refer to Principles of Critical Care by Jesse B Hall et al 2005, page 47 for further information.

Best regards,
Masoud


Dr Masoud Dara
Senior Consultant
International Unit
KNCV Tuberculosis Foundation
* Parkstraat 17, The Hague 2514 JD, The Netherlands
More than 1.5 million people lose their lives to tuberculosis every year. With early detection and proper treatment, most people with tuberculosis will fully recover. Our efforts and investment in tuberculosis control help to save millions of lives worldwide. For more information, please visit www.kncvtbc.nl.

Dear All
I think the point I made, but perhaps not clearly enough was that wearing eye protection was part of transmission based precautions. Suction, bronchoscopy etc are all considered high risk procedures, irrespective of whether the person has a blood borne virus,TB or not and therefore eye protection IS recommended in such situations. It is basic IPC practice- not TB-IPC but basic IPC practice which is applicable to all healthcare workers in the clinical environment and there is a subtle difference between the two.
However, if one is standing in a room with a TB patient (at a safe distance, say 1 m) and he coughs, that is not considered a high risk procedure- it is medium risk exposure but not a procedure. In this case, eye protection is not indicated.
I do hope this helps. There is some confusion about the difference between clinical procedures and Occupational Health situations and is a subject of much debate in my hospital.
So, Ed is right from an OH point of view ( my second example) and the others are also correct when relating to a high risk procedure (first example).
I would like the opinion of others on this matter ...

Dear All
I think the point I made, but perhaps not clearly enough was that wearing eye protection was part of transmission based precautions. Suction, bronchoscopy etc are all considered high risk procedures, irrespective of whether the person has a blood borne virus,TB or not and therefore eye protection IS recommended in such situations. It is basic IPC practice- not TB-IPC but basic IPC practice which is applicable to all healthcare workers in the clinical environment and there is a subtle difference between the two.
However, if one is standing in a room with a TB patient (at a safe distance, say 1 m) and he coughs, that is not considered a high risk procedure- it is medium risk exposure but not a procedure. In this case, eye protection is not indicated.
I do hope this helps. There is some confusion about the difference between clinical procedures and Occupational Health situations and is a subject of much debate in my hospital.
So, Ed is right from an OH point of view ( my second example) and the others are also correct when relating to a high risk procedure (first example).
I would like the opinion of others on this matter as well please.
Regards
Shaheen


Prof Shaheen Mehtar
MBBS, FRC Path (UK), FCPath (Micro) (SA), MD (Eng)
Head of Academic Unit for Infection Prevention and Control
Tygerberg Hospital & Stellenbosch Uni
PO Box 19063,
Tygerberg 7505, Cape Town

Visit our UIPC Website
http://www.sun.ac.za/uipc

I agree with Dr. Mehtar on wearing eye protection as a general
precaution for aerosol generating procedures. I do bronchoscopy and
always wear eye protection - not for TB - but as a general precaution
against infections that may transmit through mucous membranes.

Edward A. Nardell, MD
Associate Professor
Harvard Medical School (Medicine; Global Health and Social Medicine)
Harvard School of Public Health (Environmental Health; Immunology and
Infectious Diseases)

Brigham and Women's Hospital
Division of Global Health Equity
FXB Building, 709c
651 Huntington Ave.
Boston, MA 02115