Tuberculosis Exposure Control Plan (pdf)
OSHA
Safety and Health Topics: Tuberculosis (web link)
9.1 Purpose
9.2 Hierarchy of Control Measures
9.3 Scope
9.4 Risk Assessment for Health Care Workers
9.5 Administrative Controls
9.6 Engineering Controls
9.7 Respitory Protection
9.8 Health Care Workers Tuberculosis Screening Program
9.9 Health Care Workers with TB Infection or Active Disease
9.10 Education and Training
9.1 Purpose
To achieve early
detection, isolation, and treatment of persons with active
TB and to minimize the risk of TB transmission.
9.2 Hierarchy
of Control Measures
I Use
of administrative measures to reduce the risk of exposure
to persons with suspected or confirmed
infectious TB.
II Use
of engineering controls to prevent the spread and reduce
the concentration of infectious droplet nuclei.
III Use
of personal respiratory protective equipment. 9.3 Scope
The
plan covers all patients, classified employees, staff,
faculty, medical staff and educational appointees (including
students and volunteers) of UTHSC-H.
9.4 Risk
Assessment for Health Care Workers
An initial risk assessment to evaluate the risk
of TB transmission will be done by UT Employee Health Services
with the assistance of the IBC and EHS. This will cover all
parts of the facility. This will include all clinics
where TB patients may receive care or cough-inducing procedures
may be performed, and individual groups of health care workers
that work throughout the facility.
Each specific area and occupational category will be classified
as high, intermediate or low risk based on the number of active
or infectious TB patients admitted to the area and other risk
factors. If data is not available, all acute areas and
occupational groups likely to encounter active TB patients
will be considered as high risk.
The frequency of risk assessment and skin testing
will be determined on the basis of the most recent risk assessment.
Low risk groups will be reassessed every 12 months, intermediate
risk groups every 6 months, and high risk groups every 3 months.
Representatives of the IBC will inspect the facility, review
data, and make recommendations regarding changes in the TB
Exposure Control Plan at least annually or as necessary to
update the plan in response to documented nosocomial transmission
of TB.
Following each risk assessment, the IBC, in conjunction with
other appropriate health care workers will review all TB Control
policies to assure that they are effective and meet current
needs.
Analysis of Health Care
Workers TB Skin Test Screening Data
Results of employee
TB (PPD) testing will be kept in a retrievable aggregate database.
PPD conversion
rate will be calculated as follows:
A
= # health care workers with new positive skin tests in
each area or group
B
= # health care workers with negative skin tests in each
area or group
% Conversion = A x
100
A+B
To identify areas
where the risk of occupational PPD test conversion may be increasing,
PPD test conversion rates for each area will be compared to
rates in areas without occupational exposure to active TB and
to previous rates in the same area.
Any time a cluster
of PPD test conversions is noted, further evaluation is indicated.
The frequency
of PPD testing is determined by the risk assessment.
Areas in which
cough-inducing procedures are performed on patients who may
have active TB will, at the minimum, be considered intermediate
risk.
Review of Patient Medical
Records
The medical records of patients diagnosed with active TB will
be reviewed for the risk assessment and to determine whether
any employee exposures occurred.
Case Surveillance
Data on the number of active TB cases among patients and health
care workers will be collected, reviewed and used to:
Identify
the number of isolation rooms required.
Recognize
clusters of nosocomial transmission.
Assess
the level of potential occupational risk.
Monitor
drug susceptibility characteristics of M. tuberculosis isolates.
Observation
of Infection Control Practices
1. Compliance
is considered to be a standard of performance and will be included
in the annual performance evaluation for all employees with
potential for exposure.
2. Recommended practices
are stated in this plan, copies of which are located in each
department in the safety manual.
3. Strategies for monitoring
of compliance:
a. Follow-up
on the report of an employee's failure to comply with the
required protective measures will be the responsibility of the employee's
supervisory staff.
b. Follow-up
of problems identified through informal reports, complaints
from staff, quality assurance or safety reports, minutes from
committees, employee questionnaires, staff logs, and comments
received during evaluation of education and training programs
will be the responsibility of the affected department's supervisory
staff. Significant issues will be forwarded to the
IBC.
Noncompliance
will be reported to an employee's immediate supervisor for
evaluation and follow-up.
9.5 Administrative
Controls
1. Initial
assessment
Patients will be assessed for possible infectious
TB at the site of initial presentation (Emergency Center, Outpatient
clinics, Observation areas etc.) following the procedure for
handling suspected TB patients. Health care workers who are
the first points of contact should ask the following questions
which will help recognize and detect patients with signs and
symptoms suggestive of TB:
a. Have
you had a cough of 2 or more weeks duration?
b. Has
this cough been productive of sputum? Is it blood
stained?
c. Have
you had fever, night sweats, unintentional weight loss, lethargy
or weakness?
d. Do
you or any of your family have TB now, or a history of
TB?
• At this time, it should be
determined if a patient is a member of a high risk group.
• For those patients whose assessments
indicate suspected infectious TB, follow established TB
protocol for proper actions.
2. Physician
Referral
Referring physicians or facilities should be questioned
as to the patient's possible TB status, in order to facilitate
the patient's admission into appropriate isolation and care.
3. Bacteriologic
Screening
Harris
County TB Control will be notified of all positive AFB direct
smears and cultures.
4. Management
of Pediatric Patients with Known or Suspected Infectious
TB:
a. Pediatric
patients with suspected or confirmed TB should be evaluated
for potential infectiousness on the basis of symptoms: sputum
AFB smears, radiologic findings, and other criteria. Those
with cavitary pulmonary or laryngeal TB should be placed
in Airborne Precautions until they are determined to be non-infectious.
b. Parents
and relatives of pediatric patients suspected of having
TB should be assessed as soon as possible for the presence
of TB and should be asked to wear a mask at all times when
in the facility until their status is known.
c. Parents
should have chest x-rays and PPD tests placed and it should
be documented that they are not considered to be infectious
before they may discontinue use of a mask.
5. Management
of Patients with Suspected Tuberculosis in Ambulatory Care
Settings
and Emergency Centers:
a. Refer
to Administrative Controls initial assessment section.
b. Place
patient with suspected infectious TB in Airborne Precautions
in separate negative pressure room or demistifier tent if
available. If
separate waiting/exam room is unavailable or if patient requires
transportation to ancillary departments, patient should wear
a mask.
c. Schedule
patient to minimize exposure to other patients.
d. Patients
should be instructed to cover their mouth with tissues if
it is necessary for them to clear respiratory secretions,
and to then reapply the mask. Patients should also be
told how to dispose of the tissues.
e. If
patients are known to be non-compliant with TB medications,
institute Airborne Precautions until they are documented
to be non-infectious.
f. Patients with previously
diagnosed TB infections should be considered to be infectious
until the physician determines otherwise.
6. PPD Skin Testing
a. Administration
of tuberculin test (Mantoux):
1) 0.1
ml of PPD will be injected into either the volar or dorsal
surface of the arm. Anergy panels should be ordered
in addition to PPD testing for immunocompromised patients
where TB is suspected.
2) Tuberculin
is injected just beneath the surface of the skin.
3) Discrete,
pale elevation of the skin 6-10 mm should be produced.
b. Reading
of the skin test
1) Trained
personnel will read the test between 48-72 hours and record
results on the appropriate form which will then be placed in
the patient's chart.
2) Presence
or absence of induration is to be assessed, (not redness or
erythema), and should be recorded in millimeters.
7. Treatment
Guidelines
Patients who have confirmed active TB or are considered
highly likely to have active TB should be started on appropriate
treatment promptly, according to current guidelines.
While
the patient is in the hospital, anti-tuberculosis drugs will
be administered by directly observed therapy, in which a
health care worker observes the patient ingesting the medications.
All patients should be discharged on outpatient directly observed
therapy. Arrangements for this will be made in collaboration
with the Harris County TB Control Department at 713-599-3600.
8. Cough - Inducing
Procedures:
a. Cough-inducing
procedures should not be performed on patients who may
have infectious TB unless absolutely necessary. These cough-inducing
procedures include endotracheal intubation and suctioning,
diagnostic sputum induction, aerosol treatments (including
pentamidine therapy), and bronchoscopy. Other procedures
that may generate aerosols, e.g. irrigation of TB abscesses,
homogenizing or lyophilizing tissue, are also included
in these recommendations.
b. All
cough inducing procedures performed on patients who may
have infectious TB should be performed using local exhaust
ventilation devices, e.g. booths, or if that is not feasible,
in a negative air flow room that meets TB ventilation requirements
(i.e. isolation rooms).
c. Health
care workers should wear a hospital-approved respirator or
mask when present in rooms where cough-inducing procedures
are being performed on patients who have, or are at high
risk of having infectious TB.
d. After
completion of cough-inducing procedures, patients with known
or suspected TB should remain in the isolation room or enclosure
and not return to common waiting areas until coughing subsides.
They should be given tissues and instructed to cover their
mouth and nose when coughing. If they must recover from
their sedatives or anesthesia following procedures such as
bronchoscopy, they should be monitored in a separate isolation
room, and not in recovery rooms with other patients.
e. Before
the booth, enclosure, or room is used for another patient,
adequate time should be allowed to pass so that any droplet
nuclei that have been expelled into the air are removed.
This time will vary according to the efficiency of the ventilation
of filtration used, but is generally 20 minutes.
f. If
performing bronchoscopy in positive pressure rooms, such
as operating rooms, if unavoidable, TB infection should be
ruled out before the procedure. If bronchoscopy is
being performed for diagnosis of pulmonary disease on patients
that may have infectious TB, it should be performed in a
room that meets TB isolation ventilation requirements.
g. Before
prophylactic aerosolized pentamidine therapy is initiated,
all patients should be screened for active TB. Screening
should include medical history, PPD, and chest x-ray.
h.
Before each subsequent aerosolized pentamidine treatment,
patients should be screened for symptoms suggestive of TB. If
such symptoms are elicited, a diagnostic evaluation for TB
should be initiated.
I. For
patients with suspected or confirmed active TB, it is preferable
to use oral instead of aerosolized, prophylaxis for pneumocystic
pneumonia if clinically practical.
j. Harris
County TB Control Center should be notified (713-599-3600)
for contact investigation prior to discharge; especially when
children are in the household.
9.
Other Infection Control Measure
Any required infection control measures
must be followed to ensure compliance with the OSHA standards
and/or current guidelines for preventing the transmission of M. tuberculosis .
9.6 Engineering Controls
1.
Prevention of nosocomial transmission. Patient rooms
and areas where patients with suspected or confirmed TB are
treated should be at negative pressure to adjacent areas,
have at least 6 air changes per hour, be directly exhausted
to the outside or have air recirculated through a HEPA filtration
system with 99.7% filtration. Patient
isolation rooms are required to have negative pressure
relative to the surrounding areas. 2. Monitoring
of isolation rooms for negative pressure when used for
TB isolation should be done routinely, per current guidelines
or standards.
3. HEPA filters should
be monitored and changed routinely, per current guidelines
or standards.
4. The need for supplemental
ventilation, or air cleaning will be periodically reassessed
as a part of the risk assessment.
9.7 Respiratory Protection
1. In the following circumstances,
health care workers should wear a NIOSH approved high efficiency
particulate air (HEPA) respirator or an approved N-95 respirator:
a. when
entering rooms housing patients with suspected or confirmed
infectious TB
b. when
performing high risk procedures on patients who have suspected
or confirmed infectious TB. Examples of these include
administration of aerosolized medications, bronchoscopy,
sputum induction, endotracheal intubation and suctioning
procedures, and autopsies.
c. emergency
medical response personnel or others who must transport, in
a closed vehicle, an individual with suspected or confirmed
infectious TB.
2. Qualitative or quantitative
fit testing must be performed for each respirator wearer.
The results of such fit testing must be maintained in a retrievable
aggregate database.
3. Medical surveillance
will be performed on all potential HEPA respirator wearers.
4. Disposable HEPA respirators
should be discarded per hospital policy current guidelines.
5. Multi-user reusable
HEPA respirators should be cleaned and filters checked and/or
changed per hospital policy or current guidelines.
6. Designated user reusable
HEPA respirators should be cleaned and filters checked and/or
changed per hospital policy or current guidelines.
7. HEPA respiratory wearers
should perform check to insure proper fit prior to each use.
8. Facial hair that interferes
with the seal of the mask, must be removed.
9.8 Health Care Workers Tuberculosis
Screening Program
1. Health care workers
should have a Tuberculin PPD (Mantoux) on employment and at
appropriate intervals as determined by UT Employee/Student
Health Services.
2. Individuals with a
previous history of a positive TB skin test should not continue
to undergo skin testing. However, a baseline chest x-ray
should be on file in the employee's health record.
3. All health care workers
with a history of a positive skin test should either have a
chest x-ray on employment or when they initially convert to
a positive skin test.
4. Tuberculin PPD is
not contraindicated for pregnant employees.
5. Health care workers
who previously received BCG vaccine as a child should receive
a baseline TB skin test. If positive, the employee should
have a chest x-ray.
6. Health care workers
with immunosuppression should follow guidelines employed by
the UT Employee/Student Health Services. Because these
individuals may be at higher risk for acquisition of TB and
rapid progression to active disease, voluntary reassignment
to lower risk areas may be advisable.
9.9 Health Care Workers with
TB Infection or Active Disease
1. Health care workers
with positive PPDs and no symptoms of active diseases should
continue work as usual and be counseled to notify UT Employee/Student
Health Services if symptoms develop and to seek medical
evaluation.
2. Health care workers
with infectious TB should notify UT Employee/Student Health
Services and be excluded from work until documented to be noninfectious
and substantial improvement in symptoms. Clearance from
Student and Employee Health is required to return to work.
UT Employee/Student Health Services will monitor compliance
with medications. Noncompliant health-care workers should
be excluded from work until therapy is re-instituted and the
individual assessed to be noninfectious.
3. Health care workers
with TB at sites other than the lung or larynx usually do not
need to be excluded from work if concurrent pulmonary TB has
been excluded. (except exuding skin lesions).
4. All information provided
by health care workers regarding their health status will be
treated confidentially.
9.10 Education and Training
All health care workers should receive initial employment
and annual education about TB that is appropriate to their
job category.
The following is an outline of the materials to be covered:
1. The
basic concepts of TB transmission, pathogenesis, and diagnosis,
including the difference between latent TB infection and active
TB disease, the signs and symptoms of TB, and the possibility
of secondary inoculation in the person with a positive PPD
test. Collection of specimens for AFB cultures should
be included.
2. The
potential for occupational exposure to patients with infectious
TB, including the prevalence of TB in the community and nationwide,
situations with increased risk of exposure to TB (bronchoscopy,
autopsy, etc.) and working with people reported to have high
risk for TB.
3. Appropriate
isolation measures (negative pressure rooms etc.)
4. The
principles and practices of infection control that reduce the
risk of transmission of TB, including the hierarchy of TB infection
control measures, and exposure control plan. Include
Respiratory/Airborne Precautions, Transportation of TB patients,
and required Personal Protective Equipment.
5. The
purpose of PPD testing, the significance of a positive result
and the importance of participation in the skin test program.
6. The
principles of preventive therapy of latent TB infection, indications,
use and effectiveness, including the potential adverse effects
of the drugs.
7. The
responsibility of the employee to seek medical evaluation promptly
if symptoms develop that may be due to TB or if PPD test conversion
occurs in order to receive appropriate evaluation and therapy
and to prevent transmission of TB to patients and other employees.
8. The
principles of drug therapy for active TB. This should
include the practice of direct observed therapy in the hospital
and community.
9. The
importance of notifying the appropriate group (Student and
Employee Health, etc.) if diagnosed with active TB so appropriate
contact investigation can be instituted.
10. The
responsibilities of the institution to maintain the confidentiality
of the employee while assuring that the employee with TB
receives appropriate therapy and is non-infectious before returning
to duty.
11. The
higher risk posed by TB to individuals with HIV infection or
other causes of severely impaired cell-mediated immunity including:
a. the
more frequent and rapid development of clinical TB after
infection with Mycobacterium
tuberculosis (MTB).
b. the
differences in the clinical presentation of disease.
c. the
high mortality rate associated with MDR-TB (M. tuberculosis
organisms that are resistant to more than one anti-TB drug)
disease in such individuals.
12. The
potential development of cutaneous anergy as immune function
declines (measured by CD4 and T-lymphocyte counts).
13. The
institution's policy on voluntary work reassignment options
for immunocompromised employees.
14. Respiratory
Training to include:
a. define
HEPA respirator and why OSHA requires it's use.
b. when
to use a respirator (in room care of TB patient, bronchoscopy
etc).
c. recognize
the respirators used for TB.
d. describe how to clean and inspect the respirator.
e. describe
how long to use respirator.
f. describe
how to fit a respirator.
g. demonstrate
a respirator fit-check.
h. medical
surveillance requirement of respirator program.
I. describe
the OSHA requirements for the program.
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