National Tuberculosis Coalition of America (NTCA) Guidelines for Respiratory Isolation and Restrictions to Reduce Transmission of Pulmonary Tuberculosis in Community Settings

Abstract

Advisory Council for the Elimination of Tuberculosis acid-fast bacilli airborne infection isolation American Thoracic Society anti-tuberculosis therapy cough aerosol sampling US Centers for Disease Control and Prevention colony-forming units certainty of evidence coronavirus disease 2019 cycle threshold value directly observed therapy drug-susceptibility testing Division of Tuberculosis Elimination early bactericidal activity Evidence Synthesis Group evidence to recommendation face-mask sampling Guideline Development Group high-efficiency particulate air Infectious Diseases Society of America interferon-gamma release assay nucleic acid amplification test National Center for HIV, Viral Hepatitis, STD and TB Prevention non-pharmaceutical public health intervention National Tuberculosis Coalition of America para-amino salicylic acid Population, Intervention, Comparison, Outcome person or persons with TB randomized controlled trial respiratory isolation and restriction rRNA synthesis severe acute respiratory syndrome coronavirus 2 tuberculosis tuberculin skin test United Nations video directly observed therapy World Health Organization extremely drug-resistant The guidelines outlined in the following document are recommendations from the National Tuberculosis (TB) Coalition of America (NTCA; formerly the National TB Controllers Association) on public health practices related to respiratory isolation and restrictions (RIRs) for persons with pulmonary TB (PWTB) in community settings (ie, non-healthcare and non-congregate settings). Healthcare settings, by contrast, include hospitals, nursing homes, and other healthcare facilities and are not covered in this set of guidelines. This guidance also may not reflect considerations for other types of congregate and institutional settings, including homeless shelters and correctional facilities, which have historically been locations at increased risk of transmission of TB. The intent of these guidelines is to fill the gap that stems from a lack of existing US national-level guidance for community settings. The guidelines in this document incorporated ethical and legal principles outlined in the prior “TB Control Laws and Policies’ document endorsed by the NTCA, Advisory Council for the Elimination of Tuberculosis (ACET), and Centers for Disease Control and Prevention (CDC) [1]. The guidelines were informed by a balanced representation of TB survivors and advocates, TB clinicians, TB public health practitioners, TB nurses, TB epidemiologists, researchers, and bioethicists. These guidelines are intended to be used by individuals within TB public health programs to make decisions related to community-based RIRs for public health purposes and may include, but are not limited to, clinicians, health officers, or other designated practitioners at state or local health departments. Guidance for the prevention of TB in healthcare settings and high-risk congregate living facilities has been provided elsewhere [2, 3]. TB programs are encouraged to update or develop local guidelines and practices and involve physician and public health consultants with TB expertise, to ensure that local practices reflect current scientific evidence and concepts and recommendations outlined in this work. This document is organized into an Executive Summary (abridged guidelines), as well as the Full Recommendations. The Executive Summary outlines the background, methodology, and key findings and provides a summary of recommendations (Table 1), explanation of community-based RIRs (Table 2), as well as a schematic representation of the guidelines (Table 3), and a quick reference for implementation purposes (Tables 4 and 5). More detailed information about each of these sections is found in the complete Full Recommendations section. Recommendations for Community-Based Respiratory Isolation and Restriction for Persons With Tuberculosis Abbreviations: ATT, anti-tuberculosis therapy; NAAT, nucleic acid amplification test; PWTB, person or persons with tuberculosis; RIR, respiratory isolation and restriction; TB, tuberculosis. aEffective ATT is defined as a recommended multidrug regimen to which the organism is susceptible or anticipated to be susceptible. bNo single test or ATT duration universally predicts noninfectiousness. While there is individual variability in infectiousness, available evidence indicates most PWTB are unlikely to transmit to others after the first few days (24–72 h) of ATT initiation. Recognizing pragmatic considerations for time needed to assess ATT adherence and tolerance, and conduct clinical and public health evaluation, community-based be in most after days of ATT, with that may be include the of ATT and adherence and clinical to ATT is not to information that with may be in settings and with risk or of including to and or other The duration of in is and community and While PWTB on of ATT are to be on of are anticipated to in increased or be has of Respiratory Isolation and Restriction for Persons With Tuberculosis in a Community-Based to an as a or other to be and with the local health an individual the of as for a healthcare to TB transmission risk may be including but not limited to, for (ie, for the PWTB, and for in or not living in the be by the local health and of time at an as a or may the for most and as with public health may in most in or to including a (ie, be for there is with or with individuals not or in settings of or be settings at risk of transmission healthcare or risk of transmission to to transmission risk may be including but not limited to, for (ie, for the PWTB, and for or be by the local health and have restrictions and may in as of or not be but a for individual The duration of restrictions the as well as the and of transmission to others and are in Abbreviations: high-efficiency particulate PWTB, person or persons with tuberculosis; RIR, respiratory isolation and restriction; TB, tuberculosis. that transmission risk is in settings and locations with with and that the of transmission from a PWTB to an include and of is or of that of While or to tuberculosis are not after to of the of transmission is to with (ie, for in settings at and to Community-Based Respiratory Isolation and Restriction Recommendations for With Tuberculosis Abbreviations: ATT, anti-tuberculosis therapy; NAAT, nucleic acid amplification test; PWTB, person or persons with tuberculosis; RIR, respiratory isolation and restriction; TB, tuberculosis. to of respiratory may include testing and cycle may ATT of may be with is individual variability in the of of following ATT but available evidence in after initiation. individuals be to have a of after days of ATT, defined as a multidrug regimen to which the organism is susceptible or anticipated to be susceptible that may be with a duration of may include respiratory on bactericidal and activity of the and adherence and of decisions on also include an of transmission risk to others in the community to TB the and for the community and the PWTB restrictions or duration may be in of or drug-resistant TB, community settings and increased of in settings with to or clinical to ATT, or adherence to recommendations community and or is is for of Community-Based Respiratory Isolation and Restriction for Persons With Tuberculosis and transmission risk or of prior or of TB in the respiratory have that a and NAAT, and with or or may have a and may be individuals with with limited or pulmonary and are not as or respiratory and regimen risk of transmission to the community to or of community there with individuals have not been assess transmission be (ie, a or time in with or and other settings PWTB there to be or in with there to be with as in healthcare there of the PWTB is anticipated to community-based is the PWTB have evidence of pulmonary the individual and at risk of transmission in the of for PWTB is not for individuals with TB in TB of the respiratory has been is for most PWTB with pulmonary or respiratory have not at days of outlines decisions for the duration of community-based The to the and for the community and the PWTB of to community-based be with the to that be The to of community TB transmission be used on the of the and of the PWTB or community-based is most that are risk for TB transmission be More restrictions may be prior to with restrictions on The and duration of be on individual considerations and clinical and community Abbreviations: ATT, anti-tuberculosis therapy; Centers for Disease Control and drug-susceptibility tuberculosis; NAAT, nucleic acid amplification PWTB, person or persons with tuberculosis; RIR, respiratory isolation and TB, tuberculosis. transmission risk is in settings and locations with with and that the of transmission from a PWTB to an include and of is or of that of While or to tuberculosis are not after to of the of transmission is to with (ie, for in settings at for considerations to ensure of are to of for Persons With Tuberculosis for Community-Based Respiratory Isolation and Restriction PWTB has been community-based PWTB been community-based for be at as well as with in of infectiousness, and related to and community and or duration has for PWTB PWTB duration of (ie, or ATT is to with duration of is to in for PWTB ATT is defined as a multidrug regimen to which the organism is susceptible or anticipated to be susceptible. is decisions may be on available information and clinical of of individuals at days of ATT have and may be While ATT a there may be individual not of are to a may in on (ie, and clinical to ATT, and duration of not and testing to assess may to ATT to and test on ATT may not with a community risk of TB transmission there risk of community TB related to be there an of and risk of community there to or other community be for most PWTB are to have after at days of may be on of the community and of TB and individual considerations that may a to including and individuals healthcare to congregate living facilities homeless or with or TB the of transmission be with the of to individual of with anticipated community duration has days and Abbreviations: acid-fast ATT, anti-tuberculosis therapy; directly observed therapy; drug-susceptibility NAAT, nucleic acid amplification test; PWTB, person or persons with tuberculosis; RIR, respiratory isolation and restriction; TB, tuberculosis; video directly observed that transmission risk is in settings and locations with with and that the of transmission from a PWTB to an include and of is or of that of While or to tuberculosis are not after to of the of transmission is to with (ie, for in settings at tuberculosis is a infection that airborne transmission and and prevention The for Tuberculosis in the United set by the American Thoracic Society and the Infectious Diseases Society of America in 4 principles to and TB, as of testing and and transmission prevention in high-risk settings that document is that institutional in the were in transmission in healthcare settings The not recommendations for isolation in community settings as a but guidelines to which and anti-tuberculosis therapy More the the from the National Center for HIV, Viral Hepatitis, STD and TB Prevention This a to and from TB with related to TB related to respiratory isolation or other public health restrictions The Division of Tuberculosis Elimination also a that with the of the from the but also not community-based practices for respiratory isolation of PWTB in the community has been used with a of the transmission of TB in the United with the of state and local to public health the to restrictions for in a for Health and by the and for the which principles public health that may on individual health the of public health risk the of individuals and ensure for and [1]. The of and to transmission of severe acute respiratory syndrome coronavirus 2 the coronavirus disease 2019 increased of the these practices have on individuals is increased of the on individuals respiratory isolation for from and and from or other by in the of to and decisions isolation US public health The there a for an on current scientific evidence to community-based practices for TB. in the the of guidelines for community-based RIRs for persons with TB of the and respiratory to as the of this Guideline Development Group by the to include representation and from TB programs in the United and and and the National Society of TB National TB Coalition Society for of TB Control TB and for Evidence Synthesis Group also to scientific to the Intervention, Comparison, as well as related to of PWTB were to the evidence related to the of isolation for PWTB on public health and and on and The in and and in the and legal for community-based isolation The ethical principles of public health with the scientific evidence provided by the to an of (ie, the and by the from nurses, epidemiologists, clinicians, and public health on an of the in and by the and scientific The guidelines were endorsed by the Infectious Diseases Society of America in The of the scientific found few that the of respiratory isolation in community settings on in TB or of the of on this a clinical trial in the in with pulmonary TB to ATT isolation in a or at in TB infection or disease in were most to develop TB disease within the first in transmission prior to ATT and of isolation that in TB transmission may be isolation other and to the the were to limited evidence the of isolation on TB that isolation practices have and on health and with a on is to that the of respiratory isolation as a health intervention to TB transmission is with limited existing and current scientific the of evidence is not to evidence to assess current evidence related to the of disease on and ATT with transmission risk from a PWTB to individual on in to an include duration and of and of each to tuberculosis infection individual and risk of transmission to others and the (ie, of of an individual with pulmonary TB. The to the of infectiousness, to in which a person is or has of to anti-tuberculosis cough aerosol and of (ie, may to an to anti-tuberculosis has been there is in infectiousness, of The duration of anti-tuberculosis that a person is to individual This is an schematic the in with anti-tuberculosis on from available transmission and available risk of transmission on an to the of and other which include the in which TB duration of and of a to TB, tuberculosis. is single that to or aerosol that of the of a person with TB. in for prior to anti-tuberculosis include of on and nucleic acid amplification to ATT of tuberculosis as or nucleic acid amplification test cycle threshold value and clinical (ie, and (ie, with the of pulmonary disease are with TB transmission risk that for acid-fast bacilli may have with other of cough aerosol and face-mask sampling these to be of TB transmission to but are in and not available for clinical the early bactericidal activity of including and in tuberculosis bacilli within a few days of ATT aerosol sampling also that from a of cough within days of ATT of and to after 2 of ATT (ie, to of tuberculosis in may not to the of the organism to be and infection in an the transmission in settings have that multidrug ATT to which the organism susceptible in as as of The of ATT on tuberculosis in current ATT to that may including with ATT that are ATT, a infection risk for after 2 of ATT, the PWTB is Evidence that as and are not of after of ATT in available to the duration of ATT at which individuals are to be have the of ATT on at and others at as 2 but at time has not been or the available evidence that infectiousness, and and after of of recommendations were for community-based TB practices on the available evidence and a of the of public health with individual an summary of these recommendations is provided in the recommendations are found in of community-based The to TB respiratory isolation and restriction the and for the community and the person or persons with TB decisions be and isolation restrictions in community settings be as a of restrictions that are for restrictions to of is community-based restrictions for a PWTB include on to a designated as a there is risk of airborne transmission to or restrictions or in as well as to most the of to is be or restrictions most or in community settings. Recommendations and transmission risk for for in which be with an of a and community transmission risk and individual and are most to be prior to ATT initiation. ATT has PWTB with or and of of and the respiratory of TB or pulmonary and (ie, are to be with a cough and (ie, of are in most and not community-based lack the to or have of organism in respiratory with TB with respiratory and pulmonary or be as and to are or that the of PWTB after of on current ATT is to be the of for the ATT is defined as a multidrug regimen to which the organism is susceptible or anticipated to be susceptible drug-susceptibility testing be to of the of or drug-susceptibility testing is clinical is which risk for or of or other may testing or clinical to of a drug-resistant TB regimen a of or on ATT, (ie, of of with individual variability The of to ATT is and is to prior to or not on ATT or on (ie, are to be with on ATT for days or of is ATT duration that universally predicts that a PWTB is The available evidence from transmission and that (ie, within with ATT in the of PWTB, including with by or pulmonary on for individual variability and time to conduct clinical and public health and to drug-susceptibility as well as for of ATT adherence and days of ATT is recommended as a pragmatic to of most individuals on at days of ATT be as or of or that are on ATT of of are to in in that may of on ATT include the of and and adherence and clinical to While testing to ATT decisions and clinical for a PWTB evidence that of NAAT, on ATT not to public health decisions related to community-based is and not an of a to a within settings with or of a PWTB and to may a risk of transmission to with settings and or of provides a schematic and risk of transmission to others which be in of community-based an of and community transmission public health programs community-based is Recommendations is for in which there is individual community risk of transmission may community-based (Table provides an and 4 and implementation is not recommended for individuals with of TB (ie, TB in which and not the of pulmonary restrictions are not recommended be in for most individuals with (ie, PWTB on ATT for with individual for community settings and (Table of community-based is recommended for most individuals with of (ie, prior to of or prior to at days of of The duration of be and and to the community and the community-based be after days of or there is a that a person has the duration of is days may include, but are not limited to, of or drug-resistant TB in which there is or clinical to ATT of may be include with settings that are at risk for transmission in or with with including but not to, or persons have a risk of TB infection and to TB a to community-based has been the of restrictions be to ensure in community TB transmission risk to PWTB 5). of are anticipated to in to PWTB, is to with (ie, to of or is Recommendations the of most community-based is a or set of restrictions is with on individual or and duration for PWTB be and may be on individual considerations or anticipated or are public health programs ensure that the restrictions are to community and ensure that for are used to to TB in the United may include community-based as a of a that early and of PWTB, as well as testing and of to The these guidelines on the of in community settings to fill in existing national-level a for health or TB programs to community-based with a to TB transmission individual that each may of community-based and that of each of the recommendations 5). schematic and is provided in The to a PWTB with an of individual and community in to the of community-based (Table be with of to on ATT of of community-based on PWTB, and community (Table 5). of key principles is in 2 to implementation and of these guidelines. Summary of key principles community-based respiratory isolation and restriction for persons with pulmonary tuberculosis. Abbreviations: ATT, anti-tuberculosis therapy; drug-susceptibility NAAT, nucleic acid amplification test; PWTB, person or persons with tuberculosis; RIR, respiratory isolation and restriction; TB, tuberculosis. Tuberculosis is a disease with a on public health and individual and the United TB with an of persons of TB in the United for the PWTB to TB transmission are needed to the of the that to an in TB and The of TB in the United is the is for and TB from with a were to transmission person with TB is to the of early While TB and are the duration of ATT to PWTB is Isolation of PWTB is as a public health to the of local transmission and While the of TB in the United is public health and prevention are to TB Respiratory isolation is an used to transmission of airborne including TB. a person is to have an airborne disease is from other to disease This an individual is to be or has a of tuberculosis to others US TB the most used duration of respiratory isolation is days after of TB with also in decisions This recommendation from a that with pulmonary TB are after 2 on on evidence to this duration in the the US recommendations for isolation practices in healthcare settings that not include TB isolation Respiratory isolation a used TB a limited evidence community settings is that and of TB, including the of respiratory have a on PWTB, including and health of isolation and other restrictions at TB transmission may also individual of PWTB The of PWTB from others to the the first for TB in and others were in the United the early there were TB in the United these were to a for the and of PWTB at a time TB to be a of as were to for by the the provided an a and to health PWTB and and the public the the as the of and of disease transmission The that the on TB and is there are US guidelines for implementation of isolation as an intervention to the transmission of TB in community settings. the 2 and on recommendations for TB and Tuberculosis in the United and for the of tuberculosis in [2, The document provides information on for individual infectiousness, within healthcare settings. The document outlines for the prevention of transmission in healthcare settings. community settings, to or isolation have been these decisions have been on clinical TB or health This lack of guidance for community-based isolation practices in the United and has been and the of national-level individual and local have community-based isolation for local community-based TB isolation recommended for healthcare facilities This lack of and healthcare and TB to in the of isolation restrictions and this may not the public health and the of of and the and in TB transmission to isolation practices in the community are a for Health and by the and for the that public health be balanced restrictions of individual The by the United Nations and Council in a for recommendations that individual in the of public health These principles state that restrictions on the on and legal be as and the to the of the restrictions there is which public health or other is for community-based isolation and for or legal are are limited existing for the of public health guidelines. While clinical guidelines are to health for public health guidance individual and and and public health be decisions related to community-based isolation practices [1]. to TB isolation for transmission the public in settings but have not been in scientific isolation may to the principles of healthcare the the to a person from others in the community and the on that there are that public The and for these guidelines were by used for the of isolation US found the a which survivors of TB related to individual of public health The of this by the which has and of non-pharmaceutical public health as and recommendations related to by and health the public and may have limited the and of these a there is increased public and a healthcare the for and decisions for community-based for this the to develop guidelines for the of community-based to transmission of tuberculosis. tuberculosis is airborne with disease (ie, pulmonary are not set by and by the World Health TB are to TB by by TB by by and to to of PWTB by these to and of existing TB and infection and that the most intervention to TB include a of to and and TB of TB disease to of TB in transmission and and the of respiratory isolation of PWTB after is most in healthcare and institutional settings [2, in the were in TB transmission in healthcare settings While most and local have health or local respiratory isolation a PWTB is there are guidelines from the other health or local and of respiratory isolation for PWTB are in of and for an The guidance Tuberculosis in the United by the and in 4 and persons with TB, and for TB TB testing and of TB and high-risk settings for TB transmission and the guidance not recommendations for the of TB in community settings, to a which ATT that the of have for as few as 2 days with the regimen (ie, and be to have an that of that at the time of days of of the for the release of a PWTB from respiratory isolation in settings were in for with pulmonary TB in airborne infection isolation are multidrug therapy; have clinical and have acid-fast bacilli of with at an early The document not the of to time of at which individuals in isolation in community settings. The a guidance in for the of tuberculosis in which that PWTB be in has current local and state programs and the for the duration of respiratory isolation in community settings. a for Health and by the and for the which principles public health that may on individual [1]. This that public health the of public health risk the of individuals or and ensure for and that legal may from to persons with TB, the on individual have the as there is for [1]. that public health to that individual of or may be may to a state that is and there are other available to the health and the and be a on individual guidelines also with to community-based respiratory isolation The Center for Disease Prevention and update to the for Tuberculosis respiratory isolation within a is but not community-based isolation practices The for a document and on TB transmission in and 2019 as which a of the related to TB This document that the that isolation on for to a PWTB of the evidence that but not a duration of for isolation or decisions The 2019 on Tuberculosis Prevention and Control isolation for PWTB, with a on healthcare duration of isolation is provided and be by of of Health TB guidance that the of that to of the to in that a is for PWTB to in isolation for 2 are which time of have to This is on duration of of with pulmonary TB may be from isolation after have a of of include for of which include of on and with to of isolation the Tuberculosis a of scientific evidence on TB and provided recommendations for that of that PWTB within a few days of for and also that and are of are on TB isolation practices in other settings, the on airborne may isolation and with public health this guidance a of 2 of therapy has been and there are but for airborne to be there is after a of 4 of the are the Diseases of set guidance that isolation in the and at settings, guidance that PWTB in

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