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Context: Patients with tuberculosis (TB) who are nonadherent to therapy or have complicated medical or social problems pose a threat to public health. In some cases, hospitalization may be a necessary component of a comprehensive TB control program.Objective: To describe experience with a new inpatient program for TB control.Design: Retrospective review.Setting: Eighteen-bed, secure, TB treatment unit in a state public health hospital providing a spectrum of acute and chronic care services.Patients: Patients with known or suspected TB who were unable to be treated as outpatients and were hospitalized from 1990 through 1995.Interventions: Voluntary or involuntary hospitalization, with medical, psychosocial, and legal services.Main Outcome Measures: Admissions, treatment completion, and disposition.Results: A total of 166 patients with a confirmed diagnosis of TB accounted for 214 hospitalizations for TB. The mean age was 42 years, 132 (79.5%) were men, 84 (50.6%) were nonwhite, and 45 (27.1%) were foreign born. At the time of admission, 58 patients (34.5%) were homeless, 116 (69.9%) had a history of abuse of alcohol or other drugs, and 46 (31.7%) were positive for human immunodeficiency virus. The mean length of stay was 119.7 days (median, 70 days; range, 7-656 days), and was higher among homeless patients than nonhomeless patients (168.8 vs 93.4 days). Of 48 patients (28.9%) who were admitted involuntarily, 21 required long-term confinement under court order. Admission indications (not mutually exclusive) changed over 5 years: nonadherence decreased (95% to 34%), medical complexity increased (14% to 77%), short-term isolation increased (19% to 39%), and involuntary admission decreased (54% to 13%). Of 157 patients with positive cultures for Mycobacterium tuberculosis, 36 (23.1%) were resistant to at least 1 drug, including 16 who were multidrug resistant. A total of 123 patients (74.7%) were discharged to an outpatient setting to complete therapy, 40 (24.1%) required inpatient care to complete therapy, and 3 died (1 from TB) before discharge.Conclusions: A high proportion of patients with TB who failed outpatient therapy completed treatment in a combined medical and psychosocial inpatient unit. During the 5-year study period, involuntary admissions decreased and most patients completed therapy as outpatients. In Massachusetts, this program plays an important role in protecting public health and in providing specialized medical management for patients to complete therapy in a safe and supportive environment. [ABSTRACT FROM AUTHOR]

Bioterrorism is an area of increasing public health concern. The intent of this article is to review the air cleansing technologies available to protect building occupants from the intentional release of bioterror agents into congregate spaces (such as offices, schools, auditoriums, and transportation centers), as well as through outside air intakes and by way of recirculation air ducts. Current available technologies include increased ventilation, filtration, and ultraviolet germicidal irradiation (UVGI) UVGI is a common tool in laboratories and health care facilities, but is not familiar to the public, or to some heating, ventilation, and air conditioning engineers. Interest in UVGI is increasing as concern about a possible malicious release of bioterror agents mounts. Recent applications of UVGI have focused on control of tuberculosis transmission, but a wide range of airborne respiratory pathogens are susceptible to deactivation by UVGI. In this article, the authors provide an overview of air disinfection technologies, and an in-depth analysis of UVGI-its history, applications, and effectiveness. [ABSTRACT FROM AUTHOR]

We used automated pharmacy dispensing data to characterize tuberculosis (TB) management for 45 health maintenance organization (HMO) members. Pharmacy records distinguished patients treated in HMOs from those treated elsewhere. For cases treated in HMOs, they provided useful information about appropriateness of prescribed regimens and adherence to therapy. [ABSTRACT FROM AUTHOR]

Data collected by health maintenance organizations (HMOs), which provide care for an increasing number of persons with tuberculosis (TB), may be used to complement traditional TB surveillance. We evaluated the ability of HMO-based surveillance to contribute to overall TB reporting through the use of routinely collected automated data for approximately 350,000 HMO members. During approximately 1.5 million person-years, 45 incident cases were identified in either HMO or public health department records. Eight (18%) confirmed cases had not been identified by the public health department. The most useful screening criterion (sensitivity of 89% and predictive value positive of 30%) was dispensing of two or more TB drugs. Pharmacy dispensing information routinely collected by many HMOs appears to be a useful adjunct to traditional TB surveillance, particularly for identifying cases without positive microbiologic results that may be missed by traditional public health surveillance methods. [ABSTRACT FROM AUTHOR]

Hospital personnel are subject to various occupational hazards. Awareness of these risks, compliance with basic preventive measures, and adequate resources for interventions are essential components of an occupational health program. Physical, chemical, and radiation hazards; important infectious risks; and psychosocial problems prevalent in hospital workers are reviewed. A rational approach to managing and preventing these problems is offered. [ABSTRACT FROM AUTHOR]

Background: Respiratory isolation of people with pulmonary tuberculosis (TB), including after treatment initiation, is used to prevent community-based transmission; yet guidelines on duration are limited and implementation is heterogeneous. This systematic review synthesized evidence on respiratory isolation for TB to inform National TB Coalition of America guidelines., Methods: After searching 6 databases, 8 reviewers screened and extracted data in duplicate on effects of respiratory isolation compared to no isolation or masking. Studies were stratified by outcomes: TB infection or disease in contacts, mortality, hospitalization duration, patient and health system costs, and impact on mental health or stigma. We used a convergent integrated approach to synthesize quantitative and qualitative findings and assess limitations., Results: Seventeen studies were included. There were limited data directly comparing isolation to non-isolation interventions, including effects after treatment initiation. One randomized controlled trial suggested treatment in a sanatorium versus at home did not affect TB incidence in contacts. Modeling studies suggest isolation may reduce transmission but relied on various assumptions, and isolation was implemented alongside other interventions. Descriptive, mixed-methods, and qualitative studies described adverse impacts of isolation on employment, education, food/housing security, and mental health due to transmission fears, stigma, and social isolation. Impacts were compounded in marginalized groups including Indigenous and incarcerated persons., Conclusions: Data to support current isolation practices, particularly after effective treatment initiation, to reduce TB transmission in communities are limited. Public health guidance should weigh the negative impacts on people with TB against decreased community transmission to make evidence-based decisions about respiratory isolation., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Determining the extent and duration of infectiousness of people with pulmonary tuberculosis (PWPTB) is critical for various aspects of tuberculosis care, including decisions regarding isolation. Studies suggest considerable heterogeneity in infectiousness of PWPTB. Pretreatment, measures of bacillary burden, including sputum smear microscopy, culture time to positivity, and Xpert MTB/RIF cycle threshold (Ct) value, predict the risk of transmission to contacts. Index patients with smear-negative disease pose lower infectious risk than those who have smear-positive disease, and household contact infection is more likely with index patients who have lower Xpert Ct values. Newer tools that enable detection of Mycobacterium tuberculosis complex from cough aerosol sampling and face mask sampling may be better predictors of contact infection risk. Clinical factors such as cough strength and frequency, and presence of cavitation on chest imaging, may also assist with risk prediction. Posttreatment, smear and culture status are poor predictors of infectiousness. While the exact duration of infectiousness post-treatment initiation remains uncertain, data from human-to-guinea pig transmission studies and clinical studies suggest that effective treatment results in a rapid decline in infectiousness, irrespective of smear or culture conversion. This is largely supported by early bactericidal activity and transcriptomic studies, as well as cough aerosol sampling studies, although a subset of patients may have persistent cough aerosol positivity. These findings can enable a more nuanced approach to isolation decision making while further research studies are awaited., Competing Interests: Potential conflicts of interest. The authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Far-UVC radiation between 200 and 230 nm is a promising technology for reducing airborne disease transmission. Previous work with far-UVC lamps has demonstrated the efficacy of far-UVC radiation to inactivate bacteria and viruses while presenting minimal human health hazards. While far-UVC intentionally exposes the occupied space, effectively disinfecting air between occupants, installations must still ensure that occupant eye and skin exposure is within the recommended daily limits. This study examines far-UVC-sensitive films for measuring the dose received by occupants within two real-world far-UVC installations. The film is characterized for accuracy, angular response, wavelength response, and sources of uncertainty in film response, and used to obtain individual exposure doses that account for both the non-uniform irradiance and the unique motion of individuals within the space. Dosimetry results using the films, which account for the time-weighted average exposure of an occupant, ranged from 10% to 49% of the maximum calculated stationary dose based on peak irradiance measurements. Results from this study spotlight the need to incorporate time-weighted average considerations into the design and safety assessment of far-UVC installations to ultimately operate far-UVC technology with its full potential to prevent the spread of potentially fatal infectious diseases., (© 2024 The Authors. Photochemistry and Photobiology published by Wiley Periodicals LLC on behalf of American Society for Photobiology.)

Closing the TB diagnostic gap is an urgent priority, for which non-sputum-based tests are needed. We evaluated the diagnostic accuracy of Aeonose, an exhaled breath test (EBT), as a TB triage test.Patients with cough or TB risk factors admitted to a tertiary hospital in Lima, Peru, were prospectively enrolled and underwent EBT. We evaluated EBT sensitivity and specificity for diagnosing pulmonary TB using culture and Xpert as primary and secondary reference standards and conducted stratified analyses based on risk factors.EBT sensitivity was 85% (95% CI 72.9-93.4), and specificity was 51% (95% CI 46.0-56.6) in the training cohort ( n = 417). EBT sensitivity was 70% (95% CI 47.1-86.8), and specificity was 54% (95% CI 44.8-63.6) in the validation cohort (n = 139) using the culture reference standard, with higher sensitivity (78%) when using the Xpert reference standard ( n = 156). Sensitivity (60%) and specificity (48%) were lower when patients with prior TB were included. In a subset of participants randomly selected for interviews, 94% (15/16) preferred EBT to sputum-based testing.EBT had moderate sensitivity and low specificity as a TB triage test in this hospitalised cohort with cough or risk factors. Diagnostic accuracy was lower in people with prior TB..

Tuberculosis (TB) transmission in healthcare facilities is common in high-incidence countries. Yet, the optimal approach for identifying inpatients who may have TB is unclear. We evaluated the diagnostic accuracy of qXR (Qure.ai, India) computer-aided detection (CAD) software versions 3.0 and 4.0 (v3 and v4) as a triage and screening tool within the FAST (Find cases Actively, Separate safely, and Treat effectively) transmission control strategy. We prospectively enrolled two cohorts of patients admitted to a tertiary hospital in Lima, Peru: one group had cough or TB risk factors (triage) and the other did not report cough or TB risk factors (screening). We evaluated the sensitivity and specificity of qXR for the diagnosis of pulmonary TB using culture and Xpert as primary and secondary reference standards, including stratified analyses based on risk factors. In the triage cohort (n = 387), qXR v4 sensitivity was 0.91 (59/65, 95% CI 0.81-0.97) and specificity was 0.32 (103/322, 95% CI 0.27-0.37) using culture as reference standard. There was no difference in the area under the receiver-operating-characteristic curve (AUC) between qXR v3 and qXR v4 with either a culture or Xpert reference standard. In the screening cohort (n = 191), only one patient had a positive Xpert result, but specificity in this cohort was high (>90%). A high prevalence of radiographic lung abnormalities, most notably opacities (81%), consolidation (62%), or nodules (58%), was detected by qXR on digital CXR images from the triage cohort. qXR had high sensitivity but low specificity as a triage in hospitalized patients with cough or TB risk factors. Screening patients without cough or risk factors in this setting had a low diagnostic yield. These findings further support the need for population and setting-specific thresholds for CAD programs., Competing Interests: The authors declare that no competing interests exist., (Copyright: © 2024 Biewer et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Tuberculosis (TB) transmission in healthcare facilities is common in high-incidence countries. Yet, the optimal approach for identifying inpatients who may have TB is unclear. We evaluated the diagnostic accuracy of qXR (Qure.ai, India) computer-aided detection (CAD) software versions 3.0 and 4.0 (v3 and v4) as a triage and screening tool within the FAST (Find cases Actively, Separate safely, and Treat effectively) transmission control strategy., Methods: We prospectively enrolled two cohorts of patients admitted to a tertiary hospital in Lima, Peru: one group had cough or TB risk factors (triage) and the other did not report cough or TB risk factors (screening). We evaluated the sensitivity and specificity of qXR for the diagnosis of pulmonary TB using culture and Xpert as primary and secondary reference standards, including stratified analyses based on risk factors., Results: In the triage cohort (n=387), qXR v4 sensitivity was 0.91 (59/65, 95% CI 0.81-0.97) and specificity was 0.32 (103/322, 95% CI 0.27-0.37) using culture as reference standard. There was no difference in the area under the receiver-operating-characteristic curve (AUC) between qXR v3 and qXR v4 with either a culture or Xpert reference standard. In the screening cohort (n=191), only one patient had a positive Xpert result, but specificity in this cohort was high (>90%). A high prevalence of radiographic lung abnormalities, most notably opacities (81%), consolidation (62%), or nodules (58%), was detected by qXR on digital CXR images from the triage cohort., Conclusions: qXR had high sensitivity but low specificity as a triage in hospitalized patients with cough or TB risk factors. Screening patients without cough or risk factors in this setting had a low diagnostic yield. These findings further support the need for population and setting-specific thresholds for CAD programs.

The COVID-19 pandemic has created an urgent need to utilize existing and develop new intervention technologies for SARS-CoV-2 inactivation on surfaces and in the air. Ultraviolet (UV) technology has been shown to be an effective antimicrobial intervention. Here a study was conducted to determine the efficacy of commercially available UV and blue light-based devices for inactivating HCoV-229E, a surrogate of SARS-CoV-2. The results indicate that two UV devices designed for surface disinfection, with doses of 8.07 µJ/cm 2 for the 254 nm device and 20.61 µJ/cm 2 for the 275 nm device, were efficient in inactivating 4.94 logs of surface inoculated HCoV-229E. Additionally, a 222 nm UV device with intended ceiling-based operation was effective in inactivating 1.7 logs of the virus inoculated on surface, with a dose of 6 mJ/cm 2 . A ceiling-based device designed to emit blue light at 405 nm was found to produce 89% reduction in HCoV-229E inoculated on a surface for a dose of 78 J/cm 2 . Finally, the UV based 222 nm device was found to produce a 90% reduction in the concentration of airborne HCoV-229E, at a 55 µJ/cm 2 dose. These results are indicative of the great potential of using UV based technology for the control of SARS-CoV-2. Implications : An important avenue of arresting COVID-19 and future pandemics caused by infectious pathogens is through environmental disinfection. To this effect, the study presented here evaluates commercially available UV and blue light based antimicrobial devices for their ability to kill the human coronavirus HCoV-229E, a surrogate of SARS-CoV-2, on surfaces and in air. The results indicate that two handheld UV devices produced complete inactivation of surface viral inoculum and a UVC ceiling based device produced 1 log reduction in HCoV-229E in air. These results imply the efficacy of UV technology as an antimicrobial tool, especially for rapid disinfection of indoor air.

Background: High rates of tuberculosis (TB) transmission occur in hospitals in high-incidence countries, yet there is no validated way to evaluate the impact of hospital design and function on airborne infection risk. We hypothesized that personal ambient carbon dioxide (CO2) monitoring could serve as a surrogate measure of rebreathed air exposure associated with TB infection risk in health workers (HWs)., Methods: We analyzed baseline and repeat (12-month) interferon-γ release assay (IGRA) results in 138 HWs in Cape Town, South Africa. A random subset of HWs with a baseline negative QuantiFERON Plus (QFT-Plus) underwent personal ambient CO2 monitoring., Results: Annual incidence of TB infection (IGRA conversion) was high (34%). Junior doctors were less likely to have a positive baseline IGRA than other HWs (OR, 0.26; P = .005) but had similar IGRA conversion risk. IGRA converters experienced higher median CO2 levels compared to IGRA nonconverters using quantitative QFT-Plus thresholds of ≥0.35 IU/mL (P < .02) or ≥1 IU/mL (P < .01). Median CO2 levels were predictive of IGRA conversion (odds ratio [OR], 2.04; P = .04, ≥1 IU/mL threshold). Ordinal logistic regression demonstrated that the odds of a higher repeat quantitative IGRA result increased by almost 2-fold (OR, 1.81; P = .01) per 100 ppm unit increase in median CO2 levels, suggesting a dose-dependent response., Conclusions: HWs face high occupational TB risk. Increasing median CO2 levels (indicative of poor ventilation and/or high occupancy) were associated with higher likelihood of HW TB infection. Personal ambient CO2 monitoring may help target interventions to decrease TB transmission in healthcare facilities and help HWs self-monitor occupational risk, with implications for other airborne infections including coronavirus disease 2019., Competing Interests: Potential conflicts of interest. R. R. N. and G. T. report collaboration on an NIH U01 grant evaluating TB diagnostics, outside the scope of this work, and R. R. N. is chair of the board for TB Proof, a TB advocacy organization based in South Africa. All other authors report no other conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2022. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Healthcare workers (HWs) have at least twice the risk of tuberculosis (TB) compared to the general population. There is growing emphasis on latent TB infection (LTBI) in high-risk populations. Yet we know little about HWs' perspectives of LTBI testing and treatment to inform implementation in high-incidence settings. We developed a qualitative networked approach to analyze HWs' perspectives on LTBI testing and treatment., Methods: We conducted 22 in-depth interviews with nurse and physician stakeholders, who had been recruited as part of a larger study evaluating TB transmission risk in HWs at Tygerberg Hospital, Cape Town, South Africa. We performed open coding to identify emergent themes and selective coding to identify relevant text citations. We used thematic analysis to inductively derive the CARD (Constraints, Actions, Risks, Desires) framework., Results: All HWs desired to avoid developing TB but few felt this was actionable. Despite LTBI knowledge gaps, safety and cost concerns, most HWs reported hypothetical willingness to take LTBI treatment. The CARD framework showed that desire and action related to LTBI testing and treatment was clearly framed by the interactions between constraints, administrative action, and risk. The surprise HWs described on receiving a negative LTBI (Quantiferon-Plus) result suggests LTBI testing may recalibrate HWs' perceptions regarding the futility of actions to reduce their TB risk., Conclusions: LTBI testing and treatment are acceptable to HWs and could counteract the perceived inevitability of occupational TB infection that currently may limit risk reduction action. This should be coupled with administrative leadership and infrastructural support. The CARD analytic framework is a helpful tool for implementation scientists to understand current practices within complex health systems. Application of CARD could facilitate the development of contextually-relevant interventions to address important public health problems such as occupational TB., Competing Interests: The authors have declared that no competing interests exist.

Evidence-based guidance is needed on 1) how tuberculosis (TB) infectiousness evolves in response to effective treatment and 2) how the TB infection risk can be minimised to help countries to implement community-based, outpatient-based care.This document aims to 1) review the available evidence on how quickly TB infectiousness responds to effective treatment (and which factors can lower or boost infectiousness), 2) review policy options on the infectiousness of TB patients relevant to the World Health Organization European Region, 3) define limitations of the available evidence and 4) provide recommendations for further research.The consensus document aims to target all professionals dealing with TB ( e.g TB specialists, pulmonologists, infectious disease specialists, primary healthcare professionals, and other clinical and public health professionals), as well as health staff working in settings where TB infection is prevalent., Competing Interests: Conflict of interest: G.B. Migliori has nothing to disclose. Conflict of interest: E. Nardell has nothing to disclose. Conflict of interest: A. Yedilbayev has nothing to disclose. Conflict of interest: L. D'Ambrosio has nothing to disclose. Conflict of interest: R. Centis has nothing to disclose. Conflict of interest: M. Tadolini has nothing to disclose. Conflict of interest: M. van den Boom has nothing to disclose. Conflict of interest: S. Ehsani has nothing to disclose. Conflict of interest: G. Sotgiu has nothing to disclose. Conflict of interest: M. Dara has nothing to disclose., (The content of this work is copyright of the authors or their employers. Design and branding are Copyright ©ERS 2019.)

To reduce the incidence of tuberculosis, it is insufficient to simply understand the dynamics of tuberculosis transmission. Rather, we must design and rigorously evaluate interventions to halt transmission, prioritizing those interventions most likely to achieve population-level impact. Synergy in reducing tuberculosis transmission may be attainable by combining interventions that shrink the reservoir of latent Mycobacterium tuberculosis infection (preventive therapy), shorten the time between disease onset and treatment initiation (case finding and diagnosis), and prevent transmission in key settings, such as the built environment (infection control). In evaluating efficacy and estimating population-level impact, cluster-randomized trials and mechanistic models play particularly prominent roles. Historical and contemporary evidence suggests that effective public health interventions can halt tuberculosis transmission, but an evidence-based approach based on knowledge of local epidemiology is necessary for success. We provide a roadmap for designing, evaluating, and modeling interventions to interrupt the process of transmission that fuels a diverse array of tuberculosis epidemics worldwide., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America.)

Healthcare workers (HCWs) play a central role in global tuberculosis (TB) elimination efforts but their contributions are undermined by occupational TB. HCWs have higher rates of latent and active TB than the general population due to persistent occupational TB exposure, particularly in settings where there is a high prevalence of undiagnosed TB in healthcare facilities and TB infection control (TB-IC) programmes are absent or poorly implemented. Occupational health programmes in high TB burden settings are often weak or non-existent and thus data that record the extent of the increased risk of occupational TB globally are scarce. HCWs represent a limited resource in high TB burden settings and occupational TB can lead to workforce attrition. Stigma plays a role in delayed diagnosis, poor treatment outcomes and impaired well-being in HCWs who develop TB. Ensuring the prioritization and implementation of TB-IC interventions and occupational health programmes, which include robust monitoring and evaluation, is critical to reduce nosocomial TB transmission to patients and HCWs. The provision of preventive therapy for HCWs with latent TB infection (LTBI) can also prevent progression to active TB. Unlike other patient groups, HCWs are in a unique position to serve as agents of change to raise awareness, advocate for necessary resource allocation and implement TB-IC interventions, with appropriate support from dedicated TB-IC officers at the facility and national TB programme level. Students and community health workers (CHWs) must be engaged and involved in these efforts. Nosocomial TB transmission is an urgent public health problem and adopting rights-based approaches can be helpful. However, these efforts cannot succeed without increased political will, supportive legal frameworks and financial investments to support HCWs in efforts to decrease TB transmission., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)