Evaluations www.careandcompliance.com/eval We deeply value your feedback, and will utilize it in the ongoing development of our courses and services. HIV/AIDS, BLOODBORNE PATHOGENS, AND TUBERCULOSIS Introduction to Bloodborne Pathogens WHAT ARE BLOODBORNE PATHOGENS? • • Infectious microorganisms in human blood that can cause disease in humans. Include, but are not limited to, hepatitis B (HBV), hepatitis C and human immunodeficiency virus (HIV). Adapted from www.osha.gov WHO IS AT RISK? • Workers in many occupations, including caregivers, housekeeping personnel, nurses and other healthcare personnel may be at risk of exposure to bloodborne pathogens. Adapted from www.osha.gov EXPOSURE CONTROL PLAN • • • • • • • • Must implement an exposure control plan Describe how an employer will use a combination of engineering and work practice controls Ensure the use of personal protective clothing and equipment Provide training Medical surveillance Hepatitis B vaccinations Signs and labels Among other provisions… Adapted from www.osha.gov HIV and AIDS WHAT IS HIV? • • Human immunodeficiency virus. The virus that can lead to acquired immune deficiency syndrome, or AIDS. WHAT IS HIV? • HIV damage a person’s body by destroying specific blood cells, called CD4+ T cells, which are crucial to helping the body fight diseases SYMPTOMS • • • Within a few weeks of being infected with HIV, some people develop flu-like symptoms that last for a week or two, but others have no symptoms at all. People living with HIV may appear and feel healthy for several years. However, even if they feel healthy, HIV is still affecting their bodies. SYMPTOMS May experience flu-like symptoms 2-6 weeks after becoming infected • • • • Chills Rash Night sweats Muscle aches • • • • Sore throat Fatigue Swollen lymph nodes Ulcers in the mouth STATISTICS • • • The CDC estimates that about 56,000 people in the United States contracted HIV in 2006. Around 34 million people worldwide living with HIV Over 25 million have died since the first cases were reported in 1981 AIDS • • AIDS is the late stage of HIV infection The person’s immune system is severely damaged and has difficulty fighting diseases and certain cancers. PROGRESSION TO AIDS • • Before the development of certain medications, people with HIV could progress to AIDS in just a few years. Currently, people can live much longer - even decades - with HIV before they develop AIDS. This is because of “highly active” combinations of medications that were introduced in the mid 1990s. HIV complications • Cardiovascular Health • Hepatitis • Opportunistic Infections • Oral Health Issues HIV complications • Cancer • Dementia • Kidney disease • Other complications HIV Transmission TRANSMISSION • • • HIV can be detected in several fluids and tissues of a person living with HIV. Finding a small amount of HIV in a body fluid or tissue does not mean that HIV is transmitted by that body fluid or tissue. These specific fluids must come in contact with a mucous membrane or damaged tissue or be directly injected into the blood-stream for transmission to occur. WHICH BODY FLUIDS? These body fluids have been shown to contain high concentrations of HIV: • Blood • Semen • Vaginal fluid • Breast milk • Other body fluids containing blood WHICH BODY FLUIDS? The following are additional body fluids that may transmit the virus that health care workers may come into contact with: • Fluid surrounding the brain and the spinal cord • Fluid surrounding bone joints • Fluid surrounding an unborn baby TRANSMISSION • • In the United States, HIV is most commonly transmitted through specific sexual behaviors (anal or vaginal sex) or sharing needles with an infected person. It is less common for HIV to be transmitted through oral sex or for an HIV-infected woman to pass the virus to her baby before or during childbirth or after birth through breastfeeding or by prechewing food for her infant. TRANSMISSION • • It is possible to acquire HIV through exposure to infected blood, transfusions of infected blood, blood products, or organ transplantation This risk is extremely remote due to rigorous testing of the U.S. blood supply and donated organs. TRANSMISSION • Some healthcare workers have become infected after being stuck with needles containing HIVinfected blood or, less frequently, when infected blood comes in contact with a worker's open cut or is splashed into a worker's eyes or inside their nose. HIV IS NOT SPREAD BY • • • • • Air or water Insects, including mosquitoes Saliva, tears, or sweat Casual contact like shaking hands or sharing dishes Closed-mouth or “social” kissing THE RISK TO DIRECT CARE PROVIDERS • • • The risk of direct care provider being exposed to HIV on the job is very low Especially if they carefully follow standard precautions Casual, everyday contact with an HIV-infected person does not expose direct care providers or anyone else to HIV. THE RISK TO DIRECT CARE PROVIDERS • • • For direct care providers on the job, the main risk of HIV transmission is through accidental injuries from needles and other sharp instruments that may be contaminated with the virus Even this risk is small. The risk of infection from a needle-stick is less than 1%. HIV Screening and Testing ANTIBODY SCREENING TEST • • • Most common HIV test is the antibody screening test. This test can be performed with blood sample or oral fluid. This tests the antibodies your body produces to fight against HIV. Blood tests can detect HIV as soon as 3 weeks after being infected. FOLLOW-UP DIAGNOSTIC TESTS • • Follow-up diagnostic test – these tests are performed after someone tests positive on his/her first test. HIV tests are usually very accurate, but a follow-up test is typically performed to confirm the results of the first test mostly for insurance/health care provider purposes. Treatment and Support TREATMENTS • • Many people with HIV, including those who feel healthy, can benefit greatly from current medications used to treat HIV infection. These medications can limit or slow down the destruction of the immune system, improve the health of people living with HIV, and may reduce their ability to transmit HIV. MEDICATIONS • • • • Can be expensive Can be very effective Complicated dosing schedules In some cases, virus develops a resistance to the medication HAART Highly Active Anti-Retroviral Therapy MEDICATIONS Class Description Examples Non-nucleoside reverse transcriptase inhibitors (NNRTIs) NNRTIs disable a protein needed by HIV to make copies of itself. efavirenz (Sustiva), etravirine (Intelence) and nevirapine (Viramune) NRTIs are faulty versions Nucleoside reverse of building blocks that HIV transcriptase needs to make copies of inhibitors (NRTIs) itself. Protease inhibitors (PIs) PIs disable protease, another protein that HIV needs to make copies of itself. Abacavir (Ziagen), and the combination drugs emtricitabine and tenofovir (Truvada), and lamivudine and zidovudine (Combivir) atazanavir (Reyataz), darunavir (Prezista), fosamprenavir (Lexiva) and ritonavir (Norvir) MEDICATIONS Class Description Examples Entry or fusion inhibitors These drugs block HIV's entry into CD4 cells enfuvirtide (Fuzeon) and maraviroc (Selzentry) Integrase inhibitors Works by disabling integrase, a protein that HIV uses to insert its genetic material into CD4 cells raltegravir (Isentress) THERE IS NO CURE • • • No one should become complacent about HIV and AIDS. While current medications can dramatically improve the health of people living with HIV and slow progression from HIV infection to AIDS, existing treatments need to be taken daily for the rest of a person’s life, need to be carefully monitored, and come with costs and potential side effects. At this time, there is no cure for HIV infection. TREATMENT AND SUPPORT Hepatitis B HEPATITIS B • • Hepatitis B is a contagious liver disease that results from infection with the Hepatitis B virus. It can range in severity from a mild illness lasting a few weeks to a serious, lifelong illness. HEPATITIS B TRANSMISSION • Hepatitis B is spread when blood, semen, or other body fluid infected with the Hepatitis B virus enters the body of a person who is not infected. HEPATITIS B TRANSMISSION • • • • • • From an infected mother to her baby during birth Sex with an infected partner Sharing needles, syringes, or other drug-injection equipment Sharing items such as razors or toothbrushes with an infected person Direct contact with the blood or open sores of an infected person Exposure to blood from needlesticks or other sharp instruments ACUTE OR CHRONIC Acute Hepatitis B • Short-term illness that occurs within the first 6 months after exposure. • Can—but does not always—lead to chronic infection. Chronic Hepatitis B • Long-term illness that occurs when the virus remains in a person’s body. • Estimated 800,000 to 1.4 million persons have chronic Hepatitis B virus infection in the U.S. HEPATITIS B VACCINE • • • The Hepatitis B vaccine series is a sequence of shots that stimulate a person’s natural immune system to protect against HBV. After the vaccine is given, the body makes antibodies that protect a person against the virus. These antibodies are then stored in the body and will fight off the infection if a person is exposed to the Hepatitis B virus in the future. HEPATITIS B VACCINE • • • • Safe and effective Usually given as 3-4 shots over a 6-month period Recommended for health care workers (including caregivers) at risk for exposure to blood or bloodcontaminated body fluids on the job Employers must offer at not cost if a job puts you at risk for exposure to blood or blood-contaminated body fluids on the job Hepatitis C HEPATITIS C • • A contagious liver disease that results from infection with the Hepatitis C virus. It can range in severity from a mild illness lasting a few weeks to a serious, lifelong illness. CAN BE ACUTE OR CHRONIC • • • Acute Hepatitis C virus infection is a short-term illness that occurs within the first 6 months after someone is exposed to the Hepatitis C virus. For most people, acute infection leads to chronic infection. Chronic Hepatitis C is a serious disease than can result in long-term health problems, or even death. HOW IS HEPATITIS C SPREAD? • • • Spread when blood from a person infected with the Hepatitis C virus enters the body of someone who is not infected. Today, most people become infected with the Hepatitis C virus by sharing needles or other equipment to inject drugs. Before 1992, when widespread screening of the blood supply began in the United States, Hepatitis C was also commonly spread through blood transfusions and organ transplants. HOW IS HEPATITIS C SPREAD? People can become infected with the Hepatitis C virus during such activities as: • Sharing needles, syringes, or other equipment to inject drugs • Needlestick injuries in health care settings • Being born to a mother who has Hepatitis C HOW IS HEPATITIS C SPREAD? Less commonly, a person can also get Hepatitis C virus infection through: • Sharing personal care items that may have come in contact with another person’s blood, such as razors or toothbrushes • Having sexual contact with a person infected with the Hepatitis C virus IS THERE A VACCINE? • • • At this time there is not a vaccine for hepatitis C. Vaccines are available only for Hepatitis A and Hepatitis B. Research into the development of a vaccine is under way. Diabetes and Hepatitis DIABETES AND HEPATITIS • • CDC has investigated multiple outbreaks of viral hepatitis among residents in long-term-care (LTC) communities Attributed to shared devices and other breaks in infection-control practices related to blood glucose monitoring DIABETES AND HEPATITIS Insulin pens and insulin cartridges • Do not use to administer to multiple residents • Not designed for, and are not safe for, use on more than one person DIABETES AND HEPATITIS Glucometers • Assigned to individual residents • Decontaminate regularly and any time contamination is suspected • Maintain supplies and equipment within individual resident rooms if possible DIABETES AND HEPATITIS • • • • Unused supplies and medications taken to the bedside should not be used for another resident Never share fingerstick sampling Select single-use lancets that permanently retract upon puncture Dispose of in sharps container DIABETES AND HEPATITIS • • Any trays or carts used to deliver medications or supplies to individual residents should remain outside resident rooms. Do not carry supplies and medications in pockets. DIABETES AND HEPATITIS • • • • Prepare medications in a centralized medication area Multiple dose insulin vials should be assigned to individual residents and labeled appropriately. Store unused and used diabetes equipment and supplies separately Never reuse needles, syringes, or lancets. How to Protect Yourself GET VACCINATED! • Get the hepatitis B vaccine AT HOME… • In your personal life the best way to protect yourself from bloodborne pathogens is to avoid engaging in activities that lead to their transmission, such as unprotected sex. AT WORK… • At work you can protect yourself by applying the principles of standard precautions during any activity that may lead to exposure to blood or other potentially infectious body fluids IF YOU ARE EXPOSED… • If you experienced a needlestick or sharps injury or were exposed to the blood or other body fluid of a resident during the course of your work, immediately follow these steps: IF YOU ARE EXPOSED… 1. 2. 3. 4. 5. Wash needlesticks and cuts with soap and water Flush splashes to the nose, mouth, or skin with water Irrigate eyes with clean water, saline, or sterile irrigants Report the incident to your supervisor Immediately seek medical treatment Standard Precautions STANDARD PRECAUTIONS • • Replaced Universal Precautions Includes elements of Universal Precautions and Body Substance Isolation STANDARD PRECAUTIONS Two key elements: All blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents Should be applied to all residents, regardless of infectious status STANDARD PRECAUTIONS Applies to all: • Blood • Body fluids • Secretions • Excretions (except sweat) • Nonintact skin • Mucous membranes STANDARD PRECAUTIONS Two key elements: All blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents Should be applied to all residents, regardless of infectious status STANDARD PRECAUTIONS Hand Hygiene • When • How STANDARD PRECAUTIONS Hand Hygiene: When • • • • • • Before having direct contact with residents After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings After contact with a resident’s intact skin If hands will be moving from a contaminated-body site to a cleanbody site during resident care After contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident After removing gloves STANDARD PRECAUTIONS Hand Hygiene: Visibly Soiled • When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids • Wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water STANDARD PRECAUTIONS Hand Hygiene: Not Visibly Soiled • If hands are not visibly soiled, or after removing visible material with nonantimicrobial soap and water, decontaminate hands • The preferred method of hand decontamination is with an alcohol-based hand rub • Alternatively, hands may be washed with an antimicrobial soap and water. STANDARD PRECAUTIONS Hand Hygiene: Spores • Wash hands with nonantimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile or Bacillus anthracis) is likely to have occurred STANDARD PRECAUTIONS Respiratory Hygiene STANDARD PRECAUTIONS Respiratory Hygiene • Cover the mouth/nose when coughing or sneezing STANDARD PRECAUTIONS Respiratory Hygiene • Post signs at entrances and in strategic places STANDARD PRECAUTIONS Respiratory Hygiene • Provide tissues and notouch receptacles for disposal of tissues STANDARD PRECAUTIONS Respiratory Hygiene • Provide resources and instructions for performing hand hygiene in or near common areas STANDARD PRECAUTIONS Respiratory Hygiene • During periods of increased prevalence of respiratory infections in the community, offer masks to coughing residents and other symptomatic persons STANDARD PRECAUTIONS Resident Placement • • Include the potential for transmission of infectious agents when selecting a resident's room/apartment Place residents who pose a risk for transmission to others (e.g., uncontained secretions, excretions or wound drainage) in a single-resident room when available STANDARD PRECAUTIONS Care of the Environment STANDARD PRECAUTIONS CLEAN then DISINFECT STANDARD PRECAUTIONS CLEANING DISINFECTING SANITIZING Removes germs Kills germs Lowers # of germs • Removes germs, dirt, and • Uses chemicals to kill impurities from surfaces germs on surfaces or or objects objects • Uses soap (or detergent) • Done after cleaning and water • Physically remove germs from surfaces • Does not necessarily kill germs • Works by either cleaning or disinfecting surfaces or objects to lower the risk of spreading infection STANDARD PRECAUTIONS Clean in disinfect properly: • Always follow label directions • Wash surfaces with a general household cleaner to remove germs • Rinse with water • Follow with an EPA-registered disinfectant to kill germs STANDARD PRECAUTIONS Bleach is a good alternative: • Add 1 tablespoon of bleach to 1 quart (4 cups) of water. For a larger supply of disinfectant, add ¼ cup of bleach to 1 gallon (16 cups) of water • Apply the solution to the surface with a cloth • Let it stand for 3 to 5 minutes • Rinse the surface with clean water Regulated Waste REGULATED WASTE “Liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.” STANDARD PRECAUTIONS Sharps containers • Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are: • Puncture resistant • Leakproof on sides and bottom • Labeled or color-coded STANDARD PRECAUTIONS Sharps containers, during use: • Easily accessible to personnel • Located as close as is feasible to the immediate area where sharps are used or can be reasonably anticipated to be found (e.g., laundries) • Maintained upright throughout use • Replaced routinely and not be allowed to overfill. REGULATED WASTE Regulated Waste • Regulated waste shall be placed in containers which are: • Closable • Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping • Labeled or color-coded • Closed prior to removal to prevent spillage or protrusion of contents Personal Protective Equipment PERSONAL PROTECTIVE EQUIPMENT • • "Personal Protective Equipment" is specialized clothing or equipment worn or used by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment. PERSONAL PROTECTIVE EQUIPMENT Gloves • For touching blood, body fluids, secretions, excretions, contaminated items • For touching mucous membranes and nonintact skin PERSONAL PROTECTIVE EQUIPMENT Gown • When contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated PERSONAL PROTECTIVE EQUIPMENT Mask/Eye Protection • During procedures and activities likely to generate splashes or sprays of blood, body fluids, secretions, and excretions PERSONAL PROTECTIVE EQUIPMENT Resuscitation barrier device • When performing CPR with mouth-tomouth resuscitation PERSONNEL PROTECTIVE EQUIPMENT • • • • Must be provided by the employer Must be readily available to appropriate personnel Maintain appropriate sizes, etc. Provide training in use, donning, and removing ACTIVITY: AGREE or DISAGREE Agree or Disagree When assisting a resident in your Community that you know does NOT have HIV, you still should take precautions as if they were infected with HIV. Agree or Disagree Every resident should be tested for HIV/AIDS before they are admitted into your Assisted Living Community. Agree or Disagree Residents in your Community that have HIV or AIDS should NOT be allowed to have sexual relationships with another resident within the Community. Agree or Disagree All of your residents and employees MUST be tested for Tuberculosis. Tuberculosis WHAT IS TUBERCULOSIS? • Abbreviated as TB for tubercle bacillus or Tuberculosis. • TB bacteria usually attacks the lungs, but can attack any part of the body including the kidney, spine, and brain. WHAT IS TUBERCULOSIS? • Research shows that TB is the second most common cause of death worldwide. • If untreated, or not treated effectively, tuberculosis can be fatal. CAUSES • Tuberculosis is caused by the infectious agent known as Mycobacterium tuberculosis (Mtb). • Discovered by Dr. Robert Koch in 1882. RISK FACTORS For someone to develop active TB disease, the following two events must take place: • The bacteria enters the body and causes an Mtb infection. • The immune system cannot stop the TB bacteria from growing and spreading after the initial infection. ACTIVE VS. LATENT There are two types or forms of TB: • Active • Latent TRANSMISSION • Tuberculosis is primarily an airborne disease. • According to the CDC, “The TB bacteria are put into the air when a person with active TB disease of the lungs or throat coughs, sneezes, speaks, or sings.” TRANSMISSION A person CANNOT get TB by: • Touching bed linens or toilet seats • Shaking someone’s hand • Sharing food/drink • Sharing toothbrush • Kissing SYMPTOMS • The symptoms of TB can range from no symptoms or very mild illness (latent TB) to significant symptoms with massive involvement (active TB). • TB may also lie dormant for years and reappear after the initial infection is contained. SYMPTOMS Early symptoms of active TB can include: Cough Loss of appetite Shortness of breath Paleness Weight loss Joint pain Fatigue Chills Fever Swollen glands Night sweats Abdominal swelling General discomfort DIAGNOSTIC TEST • What is PPD and what other test may be performed to detect or diagnose TB? PREVENTION • What is the BCG vaccine and who is recommended to receive this vaccine? • What are the risk factors involved? TREATMENTS What are the common challenges regarding TB treatments? • Long-term antibiotic therapy • Risk of liver damage • Costs • Co-morbid conditions such as mental illness Strategies to Ensure Quality of Care for Our Residents 117 STRATEGIES TO ENSURE QUALITY OF CARE Successful treatment of tuberculosis has benefits both for the individual resident and the community in which the resident resides. The goals for treatment are: • To minimize the transmission of TB to other persons • To cure the individual resident of TB STRATEGIES TO ENSURE QUALITY OF CARE • What are some ways we can ensure quality of care for our residents? STRATEGIES TO ENSURE QUALITY OF CARE Awareness • It is important that people are aware that TB is not an ancient disease as it is often considered to be. TB is killing more people than ever before in history and remains one of the world’s deadliest infectious diseases. Healthcare workers, organizations, community members all need to assist in raising awareness. OSHA REQUIREMENTS Implement effective control programs to minimize exposure to Tuberculosis which include: • Early Identification • Isolation • Treatment STOP TB POLICIES AND PROCEDURES • One essential strategy to ensure quality of care for our residents is to develop and implement effective policies and procedures in our assisted living and residential care communities. STAFF TRAINING Effective staff training is the key to providing the highest quality of care to our residents. • Educate staff to be aware of the causes and risks • The use of protective equipment • Injury and illness prevention • Resident rights and confidentiality Strategies to Ensure Confidentiality and Personal Rights 124 STRATEGIES TO ENSURE CONFIDENTIALITY • Confidentiality is not an option, it’s a requirement! CONFIDENTIALITY/PERSONAL RIGHTS Resident • What are the resident’s personal rights? • How can we ensure highest quality of care while maintaining confidentiality and resident rights? CONFIDENTIALITY/PERSONAL RIGHTS Care Staff • Identify how to respond when care staff are diagnosed with HIV or have latent TB. Any Questions? Comments? Quiz QUESTION #1 HIV is transmitted in ________________. a. b. c. d. Air, water, and some foods Blood and some bodily fluids Blood only None of the above QUESTION #1 HIV is transmitted in ________________. a. b. c. d. Air, water, and some foods Blood and some bodily fluids Blood only None of the above QUESTION #2 Hepatitis B is a non-contagious liver disease that results from infection with the Hepatitis B virus. a. b. True False QUESTION #2 Hepatitis B is a non-contagious liver disease that results from infection with the Hepatitis B virus. a. b. True False QUESTION #3 Personal protective equipment only includes: gloves and masks. a. b. True False QUESTION #3 Personal protective equipment only includes: gloves and masks. a. b. True False QUESTION #4 When a resident’s equipment has been contaminated with blood or other bodily fluids, you must first: a. b. c. d. Rinse with water Clean Disinfect None of the above QUESTION #4 When a resident’s equipment has been contaminated with blood or other bodily fluids, you must first: a. b. c. d. Rinse with water Clean Disinfect None of the above QUESTION #5 Sharps or Needlesticks injuries can occur ____________. a. b. c. d. When a person uses them During disassembly Due to improper disposal All of the above QUESTION #5 Sharps or Needlesticks injuries can occur ____________. a. b. c. d. When a person uses them During disassembly Due to improper disposal All of the above QUESTION #6 HIV is NOT spread by: a. b. c. d. Saliva, tears or sweat Casual everyday contact with an HIV-infected person Casual contact like shaking hands or sharing dishes All of the above QUESTION #6 HIV is NOT spread by: a. b. c. d. Saliva, tears or sweat Casual everyday contact with an HIV-infected person Casual contact like shaking hands or sharing dishes All of the above QUESTION #7 An exposure control plan must include information regarding how an employer will use a combination of engineering and work practice controls to prevent or reduce occupational exposure to bloodborne pathogens. • • True False QUESTION #7 An exposure control plan must include information regarding how an employer will use a combination of engineering and work practice controls to prevent or reduce occupational exposure to bloodborne pathogens. • • True False QUESTION #8 TB is a life-threatening infection that primarily affects the: a. b. c. d. Brain Blood Lungs Heart QUESTION #8 TB is a life-threatening infection that primarily affects the: a. b. c. d. Brain Blood Lungs Heart QUESTION #9 According to the CDC, “The TB bacteria are put into the air when a person with active TB disease of the lungs or throat _______________.” a. b. c. d. Coughs Sneezes Speaks All of the above QUESTION #9 According to the CDC, “The TB bacteria are put into the air when a person with active TB disease of the lungs or throat _______________.” a. b. c. d. Coughs Sneezes Speaks All of the above QUESTION #10 Symptoms of active TB include: a. b. c. d. Cough Weight loss Night sweats All of the above QUESTION #10 Symptoms of active TB include: a. b. c. d. Cough Weight loss Night sweats All of the above Evaluation www.careandcompliance.com/eval If you have not completed your evaluation please take time to complete when time permits, your feedback is greatly appreciated.