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The threat of bioterrorism placed a new emphasis on tuberculosis control just as the nation threatened to slip once again into complacency over declining cases of TB. While there is no direct correlation between TB and bioterrorism, many of the protective mechanisms used to isolate patients and protect other patients and health care workers would apply to contagious bioterrorism agents.
"TB has really prepared us well to deal with smallpox and plague," says Bill Jarvis, MD, associate director for program development at the Centers for Disease Control and Prevention’s Division of Healthcare Quality Promotion. "The issues you would have [with TB] would be exactly the same as what you’d have for smallpox."
In the recent anthrax outbreak, employee health professionals began fit-testing hospital mail handlers with N95 respirators — an unanticipated use of TB controls. "Those people who have a good TB program are much more ready to adapt to a program to handle other biologic agents," says Larry Lindesmith, MD, FACOEM, FCCP, medical director of employee health and safety and an occupational and pulmonary physician at Gundersen Lutheran Medical Center in La Crosse, WI. For example, the use of N95 respirators requires not just fit-testing, but education and training as well. Employees with beards may not be able to obtain a tight fit and may need another type of respirator.
The TB protections must be adapted to fit the bioterrorism model. He notes that N95s were designed for short-term use during episodes of patient care, not for an eight-hour shift of mail handlers. "They are intended to be used for [30 minutes] at a time," Lindesmith says. "The ideal suggestion would be [for employees to] wear them for half an hour and take a five-minute break." In drafting his hospital’s bioterrorism plan, he evaluated the configuration of the TB isolation rooms. "Out of our isolation rooms listed in our TB plan, certain ones are acceptable for these other things that may occur." For example, in dealing with an organism that can be spread through airborne contact, such as smallpox, the ideal isolation room would have an anteroom that caregivers would enter before entering the patient’s room, Lindesmith says.
In treating victims of bioterrorism, air released to the outside should receive HEPA filtration, he says. "With TB, there’s no absolute requirement that the exhausted air to the outside be filtered."
Surveillance is critical to TB control, as it is in bioterrorism preparedness. In his book Timebomb (New York City: McGraw Hill; 2001), Lee B. Reichman, MD, MPH, executive director of the National Tuberculosis Center at the University of Medicine and Dentistry of New Jersey in Newark, relates a frightening tale of how multidrug-resistant tuberculosis is spreading globally.
Spawned by inadequate treatment in Russian prisons, the drug-resistant TB could become a deadly, international epidemic, he says. "One of the things that all this hysteria [about bioterrorism] is bringing to us is an increase in interest in funding of public health. You need to have public health considered a defense program rather than a social program."