Official reprint from UpToDate®

www.uptodate.com ©2018 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Tuberculosis transmission and control

Author: Kimon C Zachary, MD

Section Editor: C Fordham von Reyn, MD
Deputy Editor: Elinor L Baron, MD, DTMH

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2018. | This topic last updated: Oct 25, 2018.

INTRODUCTION — The transmission of tuberculosis (TB) in health care facilities is an important public health concern;
careful infection control measures are required to reduce health care-associated transmission [1,2].

Issues related to control of TB transmission will be reviewed here. Other issues related to TB are discussed in detail
separately. (See related topics.)

TB TRANSMISSION — Person-to-person transmission of TB occurs via inhalation of droplet nuclei (airborne particles 1 to 5

microns in diameter). Coughing and singing facilitate formation of droplet nuclei [3-7]. (See "Tuberculosis: Natural history,
microbiology, and pathogenesis".)

Factors associated with risk for TB transmission via droplet nuclei include [8,9]:

● Presence of active untreated pulmonary or laryngeal TB

● Presence of cavitary disease

● Presence of sputum with positive nucleic acid amplification (NAA) test result for Mycobacterium tuberculosis (MTb)
complex

● Presence of sputum with positive smear for acid-fast bacilli (AFB)

● Presence of sputum with positive MTb culture (even if sputum is AFB smear negative)

● Short time (<9 days) to positive MTb culture

Procedures that can result in the dispersal of droplet nuclei–associated risk for TB transmission include [1]:

● Endotracheal intubation

● Bronchoscopy

● Sputum induction

● Chest physical therapy

● Administration of aerosolized drugs

● Irrigation of a tuberculous abscess

● Autopsy on a cadaver with untreated TB disease

Patients with isolated extrapulmonary TB are not contagious; such patients require careful evaluation for presence of
pulmonary or laryngeal TB since patients with both extrapulmonary disease and pulmonary or laryngeal disease may be
infectious.

Immunocompromised patients with extrapulmonary TB should be presumed to have pulmonary TB until proven otherwise
with negative sputum samples for AFB smear and culture, even if chest radiography is normal.

COMPONENTS OF TUBERCULOSIS INFECTION CONTROL — Hospital-based infection control programs are critical for
limiting nosocomial transmission of TB. Important measures for a successful program include designating responsibility for
TB infection control and having a written TB infection control plan [1]. Components of infection control include use of
airborne infection isolation and respiratory protection as discussed in the following sections.

Health care workers (HCWs) should be educated regarding TB symptoms, transmission, and prevention. Those who care for
patients with respiratory illness should also be trained in effective use of respiratory protection and undergo annual TB
screening.

Airborne infection isolation — Hospitalized patients with known or suspected active pulmonary TB should be placed in an
airborne infection isolation (AII; previously called negative pressure isolation [NPI]) room, if possible.

An AII room is a single-occupancy patient care room with a ventilation system that generates negative pressure, allowing air
to flow into the room but not out of the room into the corridor or to other occupied areas (since air will naturally flow from
areas with higher pressure to areas with lower pressure), thereby preventing infectious droplets from escaping the room. The
doors and windows of AII rooms must be kept closed to maintain negative pressure, and the pressure should be verified at
least daily.

At least 6 air exchanges per hour are recommended (for construction prior to 2001); for renovations or newer construction,
12 or more exchanges per hour are considered standard [1,10,11].

Air should be exhausted to the outdoors (where the droplet nuclei are diluted in the outdoor air), far removed from any intake
vents, people, or animals (in accordance with applicable federal, state, and local regulations on environmental discharges). If
recirculation to general ventilation is unavoidable, air must be passed through a high-efficiency particulate air (HEPA) filter
installed in the exhaust ducts to remove infectious droplets from the air before it is returned to the general circulation [1].

Anterooms are useful for maintaining negative pressure. If an anteroom is present, an individual entering the patient's room
should open the anteroom door, enter the anteroom, and close the anteroom door. Then the individual should open the AII
room door, enter the AII room, and close the AII room door. The anteroom door and the AII room door should not be open
simultaneously. All individuals entering the room must wear appropriate respiratory protection [1]. (See 'Use of masks'
below.)

Patients should be educated about the purpose of the isolation room and be instructed to cover their nose and mouth when
coughing or sneezing, even while in the isolation room. Procedures should be performed in the AII room whenever possible
to minimize exposure of the patient to others in the hospital. If the patient must leave the room, he or she should wear a
surgical mask [12]. (See 'Use of masks' below.)

Entry of visitors and HCWs should be restricted to minimize TB transmission.

Use of masks — N95 masks should be available outside AII rooms in several sizes to optimize fit and ensure usage.

Health care workers — HCWs should wear respiratory protection in the following circumstances:

● While in the room of a patient with known or suspected active infectious TB

● While accompanying a patient with known or suspected active infectious TB, such as during transit

● While present during a procedure for a patient with known or suspected active infectious TB that induce coughing or
aerosolization, such as:

• Endotracheal intubation

• Bronchoscopy

• Sputum induction

• Chest physical therapy

• Administration of aerosolized drugs

• Irrigation of a tuberculous abscess

• Autopsy on a cadaver with untreated TB disease

Appropriate respiratory protection consists of an N95 mask or a powered air-purifying respirator (PAPR). These are designed
to protect the user from exposure to aerosolized droplets within the environment.

N95 masks filter particles ≥1 micrometer in diameter with at least 95 percent efficiency given flow rates up to 50 liters per
minute. N95 masks must fit to a person's face with less than 10 percent seal leakage. HCWs should be fit tested in order to
determine the most appropriate N95 mask size [1]. HCWs who are unable to use an N95 mask due to poor fit (for example,
individuals with beards or those whose facial structure precludes a tight seal) should use a PAPR.

The optimal interval for repeat N95 mask fit testing is uncertain. The Occupational Safety and Health Administration (OSHA)
requires annual fit testing [13], although this standard was designed to protect workers against industrial aerosols. Evidence
for annual N95 mask fit testing in health care settings is limited, and good TB control outcomes have been reported by a
program that did not perform annual fit testing [14].

Patients — Patients with known or suspected TB should be instructed to cover the mouth and nose with tissues when
coughing or sneezing. Patients should wear a surgical mask when outside AII rooms; surgical masks are designed to prevent
the release of respiratory secretions of the person wearing the mask from entering the environment. Patients need not wear
a mask while inside AII rooms [1,12].

Patients with known or suspected TB do not require an N95 mask, since these are designed to protect the user from
exposure to aerosolized droplets within the environment.

Visitors — Visitors should wear N95 masks while visiting patients with known or suspected active TB; health care workers
should provide instructions on how to use the mask. (See 'Health care workers' above.)

Contact investigation — Contact investigation for known or suspected infectious cases should be initiated as soon as
possible to identify secondary cases of active and latent TB or, in some situations, a source case; such investigations of
patient family members and other close contacts in the community identified by the patient or others are generally
performed in collaboration with public health officials [15,16].

Within a health care facility, contact investigation may be warranted if a patient with infectious TB received care prior to
institution of infection control measures. Contact investigation is also warranted if a health care worker is newly diagnosed
with active, potentially infectious TB and may have exposed others while working prior to diagnosis. In addition, identification
of nosocomial TB transmission should prompt review of institutional TB control policy and practices.

An individual with acid-fast bacilli (AFB) smear-positive TB is generally considered to have been infectious beginning three
months prior to the first smear-positive sputum or three months prior to the onset of symptoms, whichever is earlier. For
individuals with AFB smear-negative TB, the contagious period is considered to have begun one month prior to onset of
symptoms [1].

Patients and health care workers with potential exposure should be screened by symptoms and tuberculin skin test (TST) or
interferon-gamma release assay (IGRA), unless baseline positive TST or IGRA has been documented previously. If initial
screening is negative, testing should be repeated 8 to 10 weeks following the end of the exposure.

In one study including than 4400 contacts of patients with culture-confirmed pulmonary TB in the United States and Canada,
the risk of TB disease over the course of five years was 4 percent; 75 percent of cases were identified within three months of
the index patient's diagnosis [17].

Assessing compliance — Several studies have been performed to assess compliance with infection control programs for TB
in health care facilities. One prospective study including two institutions found that, over a two-year period, 19 percent of
patients with pulmonary TB were not isolated on their first hospital day and, of patients placed into TB isolation, only 8
percent proved to have TB [18]. Individuals entering airborne isolation rooms did not wear masks in up to 4 percent of cases,
and approximately half of individuals wore surgical masks rather than N95 masks even though N95 masks were available.

In another report including three institutions, patients determined to be at risk for active TB were placed in rooms that were
not designed for negative pressure in 19 percent of cases. In addition, some patients were placed in rooms designed for
negative pressure although the negative pressure was not activated or functional (11 percent of cases) [19].

These studies highlight the need for regular review of compliance with established infection control policies for the control of
TB.

Surveillance — Surveillance should include review of TB incidence and affected groups in the community, with tabulation of
cases over at least the previous five years. Collaboration with local or state public health can facilitate this. Lapses in
infection control should be identified and corrected. Drug susceptibility data for TB cases should be reviewed. Health care
workers with risk for exposure to TB should undergo annual serial testing for TB infection.

Clues suggestive of potential patient-to-patient transmission include a high proportion of cases with prior hospitalizations in
the previous year, a sudden increase in cases (especially multidrug-resistant TB), or multiple TB patients with identical drug-
susceptibility patterns (or DNA genotype, if available). Surveillance data in relevant regions should be reviewed for an
increase in TST or IGRA conversion.
Where IGRAs are used for serial testing, studies in HCWs have demonstrated unusually large numbers (up to 6 to 8 percent)
of false test conversions [20,21]. In such cases, careful review of risks for TB exposure in converters should be performed; if
no risk is discovered, the test should be repeated. These same studies showed high rates of reversions to negative in health
care workers who reported no new TB risk. In circumstances where unsuspected conversions occur, causes for breakdown
of infection control interventions should be sought, the possibility of further exposures (patients and HCWs) should be
pursued, and the local and/or state public health department should be notified [1]. (See "Use of interferon-gamma release
assays for diagnosis of latent tuberculosis infection (tuberculosis screening) in adults", section on 'Serial testing'.)

CLINICAL APPROACH

Assessing risk for tuberculosis — Care for patients with known or suspected active pulmonary TB begins with clinical
assessment for the likelihood of active pulmonary TB, which should be suspected in the following circumstances:

● Birth and/or travel to a TB-endemic region of the world

● Contact with known, infectious TB cases

● History of prior positive tuberculin skin test (TST) or interferon-gamma release assay (IGRA)

● Cough of ≥2 to 3 weeks' duration, with at least one additional symptom, including fever, night sweats, weight loss, or
hemoptysis

● HIV infection and unexplained cough and fever

● Unexplained illness including respiratory symptoms of ≥2 to 3 weeks' duration in the setting of increased risk for TB (as
summarized below)

● Community-acquired pneumonia that has not improved after seven days of treatment in the setting of increased risk for
TB (as summarized below)

● Incidental findings on chest radiography suggestive of TB in the setting of increased risk for TB (as summarized below),
even in absence of symptoms

Factors associated with increased risk for TB infection include:

● Recent exposure to a person with a case of infectious TB

● History of a positive test result for M. tuberculosis

● Illicit drug use

● Birth in or travel to a region where TB incidence is high

● Residents and employees of high-risk congregate settings such as homeless shelters and prisons

● Membership in a medically underserved, low-income population

Medical risk factors for progression to active TB include:

● HIV infection

● Diabetes mellitus

● Immunosuppression (including biologic agents such as tumor necrosis factor-alpha inhibitors)

● Chronic renal failure

● Hematologic malignancy

● Head/neck cancer

● Weight >10 percent below ideal body weight

● Silicosis

● Gastrectomy or jejunoileal bypass

Risk factors for TB are discussed further separately. (See "Epidemiology of tuberculosis", section on 'Risk factors' and
"Clinical manifestations and complications of pulmonary tuberculosis" and "Diagnosis of pulmonary tuberculosis in adults".)
Diagnostic evaluation — Diagnostic evaluation for pulmonary TB includes history and physical examination (with attention to
TB risks if any) and chest radiography and sputum acid-fast bacilli (AFB) smear and culture and at least one specimen sent
for nucleic acid amplification (NAA) testing [22-24]. A series of at least three sputum specimens should be collected in 8- to
24-hour intervals (with at least one specimen obtained in the early morning). (See "Diagnosis of pulmonary tuberculosis in
adults".)

If the patient is unable to produce an adequate sputum sample, sputum induction or bronchoscopy should be pursued. Such
procedures should be performed with proper respiratory protection for health care workers, and bronchoscopes must be
disinfected properly. (See 'Health care workers' above and "Flexible bronchoscopy in adults: Overview", section on 'Infection
control'.)

Clinical triaging — Diagnostic evaluation for TB may be performed in the outpatient or inpatient setting [2,25]. Hospitalization
with airborne infectious (ie, respiratory) isolation is appropriate if social or clinical circumstances preclude outpatient
management or if there is public health risk for transmission [1,2,25]. Assessments of the patient's social circumstances (eg,
living, employment, school, access to health care resources) by public health personnel can be used to determine whether
isolation is warranted. There is no need to hospitalize on the basis of suspected infectiousness if the patient poses no
danger to public health. Consultation and expert assistance is available from state health departments and from United
States Centers for Disease Control and Prevention (CDC)-supported Regional Training and Medical Consultation Centers [26].

Outpatient management — During diagnostic evaluation, outpatients should be instructed to remain at home without
visitors and away from other family members. Individuals particularly susceptible to TB (such as small children and
immunocompromised individuals) should not visit or live with patients who may be infectious. These types of decisions are
usually made in conjunction with the local public health authority, which should be notified at the time TB is suspected. (See
"Diagnosis of pulmonary tuberculosis in adults", section on 'Reporting and public health'.)

Inpatient management

Initiating airborne precautions — Components of airborne precautions include implementation of airborne isolation

and use of masks. Patients with known or suspected active pulmonary TB should be placed in an airborne infection isolation
(AII) room, if possible [27]. The approach to assessing TB risk is described in the preceding section. (See 'Assessing risk for
tuberculosis' above.)

If an AII room is not available, patients should wear a surgical mask and be placed in an enclosed area; contact with others
(especially with young children or immunocompromised patients) should be avoided. Patients should be referred to a facility
with an AII room if possible [1,12]. If an area other than an AII room is used, it should not be used again for at least one hour
after the patient has departed. (See 'Airborne infection isolation' above.)

Health care workers and visitors should wear an N95 mask while in contact with a patient with known or suspected active
TB, as described above. (See 'Health care workers' above and 'Visitors' above.)

Patients with known or suspected TB should wear a surgical mask when outside AII rooms. (See 'Patients' above.)

Discontinuing airborne precautions — Airborne precautions (including use of AII room and masks) may be
discontinued when infectious TB is deemed clinically unlikely and one or more of the following criteria applies [28-30]:

● An alternative diagnosis explaining the clinical syndrome has been established.

● Demonstration of three consecutive negative AFB sputum smear results.

● Demonstration of two negative-sputum Xpert MTB/RIF results (algorithm 1) [29]. Three sputum specimens are still
required for AFB smear and culture in such cases, since recovery of organisms is needed for drug susceptibility testing
and Xpert MTB/RIF does not detect all patients with pulmonary TB.

For circumstances in which a diagnosis of TB is established, airborne precautions (including use of AII room and masks)
may be discontinued after antituberculous therapy has been administered for at least two weeks (with evidence of clinical
improvement) and three subsequent negative sputum AFB smears [1]. In general, cough frequency is reduced after two
weeks of appropriate antituberculous therapy, which considerably diminishes the potential for airborne transmission [31].
Xpert MTB/RIF results should not be used to determine when a patient with laboratory-confirmed pulmonary TB may be
released from AII.

The Xpert MTB/RIF assay has been approved by the US Food and Drug Administration (FDA) for use in place of serial acid-
fast sputum smears to aid in decisions regarding whether continued airborne infection isolation is warranted for patients
with suspected TB [32,33]. Sputum quality is critical to the performance of this test. Further guidance regarding this
indication has been issued by the National Tuberculosis Controllers Association (NTCA) and the Association of Public Health
Laboratories (APHL) [29]. Other issues related to use of the Xpert MTB/RIF are discussed further separately. (See "Diagnosis
of pulmonary tuberculosis in adults".)

Use of Xpert MTB/RIF for guiding decisions regarding airborne infection isolation is based on results of studies
demonstrating that negative Xpert MTB/RIF results from one or two sputum specimens are highly predictive of the results of
two or three negative acid-fast sputum smears [30,34,35]. When compared with the results of two or three serial fluorescent-
stained acid-fast sputum smears, a single Xpert MTB/RIF assay result detected approximately 97 percent of patients who
were AFB smear positive and culture confirmed as infected with M. tuberculosis complex (MTBC); two serial Xpert MTB/RIF
assay results detected 100 percent of AFB smear–positive, MTBC culture–positive patients [34]. These findings confirm
results of other reports [22,23,36,37].

"Ruling out" infectious TB must include appropriate clinical judgment. Sputum AFB smears are relatively insensitive,
especially in regions with low TB prevalence where individuals tend to present for care earlier in the course of illness. The
Xpert MTB/RIF assay detects 95 to 100 percent of AFB smear-positive cases but only 50 to 70 percent of smear-negative,
culture-positive cases of pulmonary TB [38,39]. Therefore, clinical judgment remains paramount, even with negative Xpert
MTB/RIF results.

Discharge planning — Suspected or confirmed cases of TB should be reported promptly to the local or state public
health department (in accordance with public health regulations) to expedite contact investigation, to assure adequate
medication is provided and case management is initiated, and to plan outpatient follow-up. (See 'Contact investigation'
above.)

Careful follow-up for subsequent clinical evaluation is required; this usually requires engagement with local public health
officials. Clinical care should be arranged with a provider who has expertise with management of TB. The patient should be
provided with an adequate supply of medication (not just the prescriptions) to last until the outpatient appointment. Directly
observed therapy (DOT) should be arranged if feasible. (See "Adherence to tuberculosis treatment" and 'Contact
investigation' above.)

In some circumstances, infectious patients (eg, patients with AFB smear–positive sputum) may be discharged to home (at
the discretion of the clinician and local public health authorities), provided there are no household members who are
immunocompromised or younger than four years of age [1]. Infectious patients should remain at home as much as possible;
when receiving visitors or leaving home, patients should wear a surgical mask. (See 'Patients' above.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Tuberculosis transmission and control".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they
answer the four or five key questions a patient might have about a given condition. These articles are best for patients who
want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer,
more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your
patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the
keyword(s) of interest.)

● Beyond the Basics topic (see "Patient education: Tuberculosis (Beyond the Basics)")

SUMMARY

● Transmission of tuberculosis (TB) in health care facilities is an important public health concern. Person-to-person
transmission of TB occurs via inhalation of droplet nuclei. Individuals with active untreated pulmonary or laryngeal
disease may be contagious, particularly when cavitary disease is present or when the sputum is acid fast-bacilli (AFB)
smear positive. Patients with sputum smear-negative, culture-positive pulmonary TB can also transmit infection. (See
'TB transmission' above.)

● Hospital-based infection control programs are critical for limiting nosocomial transmission of TB. Components of
infection control include use of airborne infection isolation (AII) and use of masks. (See 'Components of Tuberculosis
infection control' above.)

● Care for patients with known or suspected active pulmonary TB begins with clinical assessment for the likelihood of
active pulmonary TB, which should be suspected in the circumstances outlined above. (See 'Assessing risk for
 tuberculosis' above.)

● Diagnostic evaluation for TB may be performed in the outpatient or inpatient setting. Hospitalization with airborne
precautions is appropriate if social or clinical circumstances preclude outpatient management or if there is public health
risk for transmission. (See 'Clinical triaging' above.)

● Hospitalized patients with known or suspected active infectious pulmonary TB should be placed in an AII room if
possible; if an AII room is not available, patients should wear a surgical mask and be placed in an enclosed area. An AII
room is a single-occupancy patient care room with a ventilation system that generates negative pressure, allowing air to
flow into the room but not out of the room, thereby preventing infectious droplets from escaping the room. (See
'Airborne infection isolation' above and 'Initiating airborne precautions' above.)

● Health care workers and visitors should wear an N95 mask while in contact with a patient with known or suspected
active TB. N95 masks are designed to protect the user from exposure to aerosolized droplets within the environment.
(See 'Health care workers' above and 'Visitors' above.)

● Patients with known or suspected TB should wear a surgical mask when outside AII. Surgical masks are designed to
prevent the release of respiratory secretions of the person wearing the mask from entering the environment. Such
patients should not wear an N95 mask and need not wear a surgical mask while inside AII. (See 'Patients' above.)

● Diagnostic evaluation for pulmonary TB includes chest radiography, sputum AFB smear and culture, and nucleic acid
amplification (NAA) testing. A series of at least three sputum specimens should be collected in 8- to 24-hour intervals
for smear and culture (with at least one specimen obtained in the early morning and sent for NAA testing). (See
'Diagnostic evaluation' above.)

● Airborne precautions (including use of AII room and masks) for a patient with suspected infectious TB may be
discontinued after the diagnosis of infectious TB has been ruled out (algorithm 1) or after a diagnosis of TB has been
established with initiation of antituberculous therapy followed by clinical response to treatment (usually four to seven
days) and three subsequent negative AFB smears. Discontinuation of airborne precautions should follow applicable
public health regulations. (See 'Discontinuing airborne precautions' above.)

● Suspected or confirmed cases of TB should be reported promptly to the local public health department in order to
assure case management, expedite contact investigation, and plan outpatient follow-up. Clinical care should be
arranged with a provider who has expertise with management of TB. The patient should be provided with an adequate
supply of medication (not just prescriptions) to last until the outpatient appointment. Directly observed therapy should
be arranged if feasible. (See 'Discharge planning' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 8000 Version 28.0

GRAPHICS

Approach to the use of Xpert MTB/RIF assay to make decisions regarding need for airborne infection isolation in adults

The Xpert MTB/RIF assay has been approved by the United States Food and Drug Administration for use in place of serial acid-fast sputum smears to
aid in decisions regarding whether continued airborne infection isolation is warranted for patients with suspected tuberculosis. The approach described
above should not be used alone to rule out tuberculosis; Xpert-negative or AFB smear-negative sputum may contain viable organisms and represent
infectious tuberculosis. Interpretation of Xpert results must be made in the context of clinical and radiographic findings. In addition, at least three
sputum specimens should be obtained for AFB smear and culture, which must be performed for detection of Mycobacterium tuberculosis complex and
antimicrobial susceptibility testing.
Negative Xpert results with positive AFB smear results should prompt consideration of nontuberculous mycobacteria infection (refer to related
UpToDate content).
Procedures must comply with state and local public health regulations; for questions, contact your local public health authority.
Institutional infection control, in collaboration with the tuberculosis laboratory and public health authority, should collect and analyze data to determine
and evaluate the effectiveness of the methods used to determine discharge from AII and modify this protocol as necessary.

TB: tuberculosis; AII: airborne infection isolation; AFB: acid-fast bacilli.

* First morning sputum specimen is preferred to maximize diagnostic yield. Protocols for sputum collection are provided in the reference below. Sputum quality is
critical for the performance of this assay. Spontaneously expectorated sputum obtained following deep coughing or sputum obtained following an approved
procedure for sputum induction with deep inhalation of aerosolized hypertonic saline and deep coughing may be used. Saliva is not acceptable.
¶ An invaild Xpert result represents a failure of the assay; this is estimated to occur in 1 to 2 percent of specimen runs; in such cases, the presence or absence of M.
tuberculosis complex cannot be determined.
Δ In such circumstances, a positive results suggests TB is likely, a negative result suggests infectious TB is not likely, and an invalid result indicates that the likelihood
of infectious TB cannot be determined based on Xpert results. In such cases, AFB smear results and clinical judgment should be used to make decisions regarding
likelihood of infectious TB and timeframe for discontinuation of AII.

Modified from: National Tuberculosis Controllers Association and Association of Public Health Laboratories: Consensus statement on the use of Cepheid Xpert MTB/RIF
assay in making decisions to discontinue airborne infection isolation in healthcare settings. Available at:
http://www.tbcontrollers.org/docs/resources/NTCA_APHL_GeneXpert_Consensus_Statement_Final.pdf (Accessed on April 27, 2016).

Graphic 108299 Version 2.0