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In our last week’s blog post, we learnt the basics of tuberculosis in older adults. This week we will focus on the management of tuberculosis in the nursing homes. We will look into the action plans of what to do at each stage of the disease.
Trends and fatality in nursing homes
Older adults carry a high tuberculosis burden. In Singapore, latent tuberculosis infection reaches up to 30 percent in older age groups, which increases the pool for reactivation in care facilities.
Nursing home residents have higher tuberculosis incidence than many other congregate settings. A CDC multi-state survey reported 39.2 cases per 100,000 among residents.
Outbreaks in long-term care lead to severe outcomes. In a Taiwan facility outbreak, nine people developed tuberculosis over 13 months. Five resident cases died during treatment, highlighting high all-cause mortality once disease occurs in frail elders. Poor ventilation and airway suctioning were key transmission drivers.
Older age and residence in long-term care are linked to higher mortality among tuberculosis patients in Singapore surveillance data. Tuberculosis-specific deaths were 2.7 percent among treated cases, with long-term care residence associated with death.
Across jurisdictions, the share of tuberculosis cases in older adults is rising, which increases risk in nursing homes.
How latent tuberculosis becomes active tuberculosis
Latent infection progresses when immunity weakens. Ageing, diabetes, chronic kidney disease, malnutrition, corticosteroids, anti-TNF drugs, and untreated HIV drive reactivation. Risk is highest in the first years after infection, but it persists for life. Treating latent infection reduces progression.
Progression of tuberculosis
1. Initial exposure
A person breathes in droplets containing Mycobacterium tuberculosis.
Bacteria reach the lungs and settle in the alveoli.
The immune system responds by sending white blood cells to surround the bacteria.
At this point, most people do not develop symptoms.
2. Latent tuberculosis infection (LTBI)
The bacteria remain alive but inactive inside granulomas (small immune “capsules”).
People with latent tuberculosis have no symptoms and are not infectious.
Latency can last for years or decades. About 5–10 percent of healthy individuals eventually progress to active disease. In older adults, reactivation risk rises with immune decline or chronic illness.
3. Progression to active tuberculosis
When the immune system weakens (ageing, diabetes, malnutrition, immunosuppressive therapy), the granulomas break down.
Bacteria begin to multiply.
This reactivation can happen months, years, or even decades after the original infection.
4. Early active tuberculosis
The bacteria multiply in the lungs.
Symptoms gradually appear: cough, fever, night sweats, weight loss.
At this stage, the person becomes infectious if tuberculosis is pulmonary.
Without treatment, the disease worsens over weeks to months.
5. Advanced active tuberculosis
Lung tissue is progressively destroyed, leading to cavitations (holes in lung tissue).
Coughing up blood, severe breathlessness, and wasting (cachexia) develop.
Bacteria may spread beyond the lungs (extrapulmonary tuberculosis) to sites like lymph nodes, spine, kidneys, or brain.
In older adults, this spread is more common.
6. End-stage tuberculosis
Severe lung damage causes respiratory failure.
Disseminated or miliary tuberculosis spreads throughout the body, overwhelming organs.
Without treatment, mortality is high. Death can occur within months to two years from onset of active disease, depending on the person’s health and extent of disease.
How nursing home can respond at various stages?
1) Resident or staff with symptoms suggestive of pulmonary tuberculosis
- Act on the same day. Place the person in a single room with the door closed. Prefer negative pressure. If unavailable, add a portable HEPA unit and maximize natural ventilation. Put a surgical mask on the resident during transport.
- Staff use fit-tested N95 or PAPR for all entries and specimen collection. Use eye protection and gowns if aerosol-generating care such as suctioning is required.
- Notify public health and arrange urgent sputum collection for smear, NAAT, and culture. Avoid delays. Limit movement to medically necessary reasons. Log all contacts.
- Prepare for hospital transfer if airborne isolation cannot be maintained onsite. Coordinate transport with the receiving facility.
2) Confirmed infectious pulmonary tuberculosis, smear-positive or NAAT-positive
- Maintain airborne precautions. N95 or PAPR for staff. Continue a surgical mask for the resident when out of the room. Use dedicated equipment. Keep a strict entry log.
- Isolation continues until local public health clears discontinuation, often after clinical improvement and documented non-infectiousness based on treatment response and serial sputum results. Follow public health orders.
- Launch a contact tracing with public health. Prioritise roommates, direct-care staff, and anyone sharing airspace for prolonged periods. Test using IGRA or TST, then repeat per guidance for recent exposure.
- Review environmental controls. Target improved ventilation and reduce crowding.
3) Suspected or confirmed pulmonary tuberculosis, smear-negative but NAAT pending or negative
- Continue airborne precautions until tuberculosis is ruled out or an alternative diagnosis is made. Decisions should follow clinician and public health advice.
- If NAAT negative and clinical suspicion falls, public health may de-escalate. Document the rationale. Avoid prolonged isolation beyond what is needed, to protect psychosocial wellbeing.
4) Extrapulmonary tuberculosis without pulmonary involvement
- Airborne isolation is not typically required unless there are cough, laryngeal disease, or drainage procedures that aerosolise secretions. Use standard precautions and procedure-specific protection. Confirm with public health.
5) Latent tuberculosis infection in residents or staff
- No isolation is needed. The person is not infectious. Offer preventive treatment according to national guidance and drug interactions. Counsel on symptoms and adherence. Monitor for hepatotoxicity, which is more common in older adults.
- For staff, follow current guidance on baseline screening and post-exposure testing. Routine annual testing is not recommended unless there was exposure or ongoing transmission.
6) Facility-wide actions during and after a case
- Activate your written tuberculosis infection control plan. Include rapid triage of cough, airborne precautions, and pathways for transfer.
- Audit PPE use and N95 fit-testing for all clinical staff. Provide PAPR access for those not fit-testable.
- Review ventilation performance in resident rooms and common areas. Add HEPA units where needed. Reduce resident crowding.
- Train staff to recognize atypical tuberculosis in elders, such as weight loss, low-grade fever, or functional decline without a clear cause. Link to a fast diagnostic pathway with sputum collection onsite.
- Maintain tight documentation, including isolation start and stop dates, clinical criteria, and public health communications. Use the least restrictive isolation that still protects others, as required by regulatory guidance.
Conclusion
Undermanagement of tuberculosis in a nursing home can result in avoidable deaths, prolonged outbreaks, and regulatory consequences. Older adults are at higher risk of disease progression, poorer outcomes, and increased mortality once infection occurs. Rapid detection, strict airborne isolation, and consistent use of personal protective equipment are essential to protect both residents and staff. Close collaboration with public health authorities ensures quicker containment of outbreaks. Addressing latent infections through preventive treatment helps reduce the reservoir of future cases. Effective management requires precision and timely action, which ultimately saves lives.