TB Manual

The following recommendations for discontinuation of isolation and airborne precautions (de-isolation^a) are intended for patients in the community and in healthcare settings. The decision to de-isolate remains subject to expert clinical and public health judgment. TB treatment providers or infection control professionals may prolong isolation beyond the recommended minimal times; this is described further in the caveat section.

Recommendations:

Smear-negative^b, rifampin-susceptible pulmonary TB^c:

We conditionally recommend that airborne precautions can be discontinued (and person de-isolated) once there is clinical evidence of improvement and a minimum of 2 weeks of effective therapy^d,e has been completed (poor evidence).

Smear-positive, rifampin-susceptible pulmonary TB:

We conditionally recommend that airborne precautions can be discontinued once there is clinical evidence of improvement^f, a minimum of 2 weeks of effective therapy has been completed and there are 3 consecutive negative acid-fast bacilli sputum smears.^g Airborne precautions may be discontinued if there is clinical evidence of improvement after completing a minimum of 4 weeks^h of effective therapy, even if the sputum smears are persistently positive (poor evidence).

Confirmed or suspected rifampin-resistant pulmonary TB:

We conditionally recommend that airborne precautions may be discontinued once there is clinical improvement, second-line drug susceptibility results are available, and a minimum of 4 weeks of effective therapy has been completed. In addition, for those initially smear positive, 3 consecutive sputum smears must be negative (poor evidence).

Definitions/Footnotes:

1. De-isolation: Airborne precautions can be discontinued and/or lifting of home-isolation restrictions. People de-isolated would be allowed to return to school and work and enter indoor public spaces without restriction unless otherwise stipulated by public health professionals.

2. Smear-negativity can be re-confirmed at the time of treatment start, to exclude progression to smear-positive disease during the time from initial specimen collection to culture positivity. However, repeat sampling at the end of 2 weeks of therapy is not required.

3. Rifampin susceptibility for the purposes of this protocol can be determined by genotypic or phenotypic methods.

4. Two weeks refers to 14 doses of daily administered treatment or 2 calendar weeks of 5 days per week of direct-observed therapy.

5. Effective treatment: For the purposes of de-isolation, effective therapy for rifampin-susceptible cases (based on genotypic and/or phenotypic testing) consists of at least 3 drugs, one of which is rifampin. For rifampin resistant TB, effective therapy consists of at least 3 drugs to which the isolate is confirmed susceptible or highly likely to be susceptible to.

6. Treatment Response: Clinical evidence of improvement refers to a broad range of symptoms, including but not limited to improvement in cough, resolution of fevers, or decreased night-sweats.

7. Sputum smear conversion: This is confirmed when at least 2 consecutive sputum samples (collected at least 1 hour apart) are smear-negative on fluorescent microscopy.

8. Four weeks refers to 28 doses of daily administered therapy or 4 calendar weeks of 5 days per week direct-observed therapy.

Important Additional Caveats

Before allowing de-isolation, ensure that the person is tolerating the treatment regimen and that an acceptable treatment plan with supported adherence is established.

The decision to de-isolate remains subject to expert clinical and public health judgment. TB treatment providers or infection control professionals may prolong isolation or apply restriction beyond the aforementioned guidelines under certain circumstances. For example, longer de-isolation might be warranted for people with pulmonary TB who reside or work in congregate settings together with immunologically vulnerable individuals (such as day care facilities, neonatal or pediatric intensive care units, hospital wards and clinics for transplant recipients or those under treatment for hematologic malignancies).

Sputum samples used to guide de-isolation should be of adequate volume and sputum induction may be required. Bronchoscopy should not be employed simply to obtain respiratory tract samples that are used to guide duration of isolation. In the event follow-up sputum samples cannot be obtained, de-isolation should be performed in consultation with TB expert and/or public officer of health.

Home Isolation:

For people with TB that are medically well enough, ambulatory treatment and home isolation is preferred over hospital isolation.

Home isolation is acceptable when the following conditions are met:

• First, the person is tolerating the treatment regimen and an acceptable treatment plan with supported adherence is established.

• Second, the person does not share a common airspace with non-household members (eg, rooming house) and the household air is not being recirculated to other housing units (eg, as seen in some apartment complexes).

• Third, all household members have been previously exposed to the person. If any household members are TST negative, they should be informed and understand the potential risks of ongoing exposure.

• Fourth, any children under the age of 5 or persons with immunocompromising conditions present in the home are receiving treatment for active TB disease or latent TB infection.

When on home-isolation, no visitors should be allowed in the home except for health care workers wearing appropriate personal protective equipment (see Chapter 14: Prevention and Control of Tuberculosis Transmission in Healthcare Settings). The person on home isolation should not go to work, school or any other public indoor environment and should not use any form of public transportation (if absolutely necessary, a taxi can be used to attend essential healthcare appointments provided the person is wearing a mask). While on home isolation, the person can ambulate outdoors.

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