Program to Control Exposures

TB disease in persons over the age of 65 constitutes a large proportion of TB cases in the United States. Many of these individuals have latent TB infection; however, with aging these individuals' immune function starts to decline, placing them at increased risk of developing active TB disease, and employees in long-term care facilities at an increased risk of occupational exposure to TB.

Potential Hazard

Exposure to Mycobacterium tuberculosis and Multidrug-resistant (MDR) TB:

Mycobacterium tuberculosis: TB is caused by the bacteria Mycobacterium tuberculosis and is spread by airborne droplets generated when a person with TB disease coughs, speaks, sings, sneezes, etc. Infection occurs when a susceptible person inhales droplet nuclei containing the bacteria, which then become established in the body. 

Additional hazard is now present because of multidrug-resistant (MDR) TB. MDR organisms are resistant to the drugs that are normally used to treat TB, such as isoniazid and rifampin. The course of treatment when treating MDR TB increases from 6 months to 18-24 months, and the cure rate decreases from nearly 100% to less than 60%. Mortality among patients with MDR-TB can be high.

Possible Solutions

Implement an effective control program which minimizes exposures to TB. Not all controls discussed in this eCAT are required by OSHA.

Enforcement Procedures OSHA's enforcement procedures are addressed in the OSHA Directive CPL 2.106, Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis.  Except for specific standards (e.g., 1019.139, 1910.145) enforcement for TB is based on the OSHA General Duty Clause Section 5(a)(1) which provides: "Each employer shall furnish to each of his employees  employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees." OSHA Directive CPL 2.106 uses the 1994 CDC document, Recommendations for Preventing the Transmission of TB for Health Care found in Appendix A, to support it's policy.

The CDC guidelines outline an effective TB infection control program including:

• Early identification, isolation, and treatment of persons with TB, (e.g., provide and practice early patient screening in the ED, to identify potentially infectious patients, and prevent employee exposures.
  
  

• The use of engineering and administrative procedures to reduce the risk of exposure. 
  
  

• The use of respiratory protection. 

The directive using the CDC guidelines addresses protection from the following types of TB exposures:

• Exposure to the exhaled air of an individual with suspected or confirmed pulmonary TB disease.
  
  

  • A suspected case is one in which the facility has identified an individual as having symptoms consistent with TB. The CDC has identified the symptoms to be: productive cough, coughing up blood, weight loss, loss of appetite, lethargy/weakness, night sweats, or fever.

• Employee exposure without appropriate protection to a high hazard procedure performed on an individual with suspected or confirmed infectious TB disease and which has the potential to generate infectious airborne droplet nuclei. 
  
  

  • Examples of high hazard procedures include aerosolized medication treatment, bronchoscopy, sputum induction, endotracheal intubation and suctioning procedures, emergency dental, endoscopic procedures, and autopsies conducted in hospitals.

The following are examples of feasible and useful abatement methods, which are addressed by the directive:

• Early Identification of Patient/Client,Medical Surveillance, Case Management of Infected Employees, Worker Education and Training, Engineering Controls.

Screening, Medical Surveillance, Case Management

Potential Hazard

Exposure to TB because of ineffective:

• Identification and screening of residents. 

• Exposure Control Plan.

• Medical surveillance of employees.

• Case management.

Possible Solutions

Screening of Residents: Promptly implementing early screening or other practices allows for early identification of residents with infectious TB so that appropriate controls can be initiated before occupational exposure occurs.

• TB warning symptoms:
  
  

  • Productive cough, coughing up blood, weight loss, loss of appetite, lethargy/weakness, night sweats, or fever [CDC's 1994 Guidelines for determining TB Infectiousness].

• Early Detection of Tuberculosis, Questionnaire: A two-part  screening questionnaire, to help in identifying those with TB or suspected TB.

Medical Surveillance of employees according to Directive CPL 2.106  includes: 

• Medical surveillance at no cost to the employees,
  
   

• Medical surveillance for all current potentially exposed employees and for all new employees prior to exposure. 
  
  

• Medical surveillance consists of: employee medical evaluation and management, post-exposure follow-up and administering periodic and baseline TB skin testing. Only skin testing is addressed here. See OSHA Directive CPL 2.106 for further information.
  
  

• TB Skin Testing: 
  
  

  • Mantoux tuberculin skin test detects TB infection and helps monitor, identify and address conversion rates:
    
    

    • Baseline TB testing a two-step test method is required on initial skin test, provided they have not had a negative skin test with in the last year.
      
      

    • Frequency of skin testing is determined by the risk assessment of your particular facility.
      
      

      • Retesting required every three months, for high risk facilities.
        
        

      • Six months for workers in intermediate facilities.
        
        

      • Yearly testing for low risk personnel. 
        
        

      • See the CDC guidelines pp. 8-17, for definitions of risk categories.

Case Management of Infected Employees

Exposure to the adverse affects of TB infection can occur due to inadequate case management.

According to Directive CPL 2.106 effective case management of infected employees includes:

• Protocol for New Converters [Directive CPL 2.106 Appendix A].
  
  

  • An employee's conversion to a positive TB skin test is followed as soon as possible by appropriate; physical, laboratory, and radiographic evaluations to determine whether the employee has infections TB disease [CDC guidelines].
    
    

• Work Restrictions for Infectious Employees [Directive CPL 2.106 Appendix A].

Training and Education

Potential Hazard

Exposure to TB due to lack of training or education (employees are not aware of the tasks or procedures that may involve risks of exposure to TB).

OSHA Directive CPL 2.106, L.4., Training and education of employees about TB hazards includes: 

• Mode of TB transmission, its signs and symptoms, medical surveillance and therapy, and site specific protocols including the purpose and proper use of controls [Appendix A, pg. 36-37].
  
  

• Employee education about recognizing and reporting to a designated person, any patients or clients with symptoms suggestive of infectious TB, as well as post exposure protocols to be followed in the event of an exposure incident [Appendix A, pg. 23]. 

Isolation

Potential Hazard

Exposure to TB because of:

• Failure to promptly isolate and mask those patients with suspected infectious TB.
  
  

• Adequate transfer procedures were not provided and/or used.

Possible Solutions

Provide adequate isolation for those patients with TB or suspected TB.

Isolation of residents who have suspected or confirmed TB is required by  OSHA Standard 1910.139(a)(1). 

Transferring of patients: Facilities who have determined a resident has suspected infectious TB, and do not intend to provide treatment for TB patients:

• May choose to promptly transfer a patient to a facility that provides service to individuals who need isolation.
  
  

  • It is recommended that the facility's exposure control plan have in place procedures for transferring infectious individuals such as:
    
    

    • Masking and segregation of the individual until transfer can be arranged. 
      
      

    • The time to transfer should be as soon as feasible.
      
      

    • Temporary isolation can be provided by placing a portable stand-alone HEPA filtration unit (vented to the outside) in an unused exam room, booth tent or other enclosure if the time to get someone transferred may take an extended period.

Isolation Rooms

Potential Hazard

Exposure to TB because of isolation room failure:

• Equipment failure, not working properly.

• Isolation doors left open or excessive traffic in room.

Possible Solutions

Facilities that choose to provide service to residents with confirmed or suspected TB need to provide appropriate isolation rooms [OSHA Directive CPL 2.106, L.1.e.5 (1996, February 9)]:

• Use respiratory acid-fast bacilli (AFB) isolation rooms [1910.139(a)(1)].

	A switch outside the room equipped with an indicator light flipped to the "on" position is one way to indicate the negative pressure has been activated in the room.
	Isolation rooms are maintained at negative pressure to prevent the escape of aerosolized M. tuberculosis from the infected patient's room into outside corridors and unprotected employees and patients.
	CDC 1994 guidelines specifes the following:
	Keep doors closed except for the purpose of entering or exiting to help maintain negative pressure in room.
	Limit access to these rooms to specific employees.
	Combine tasks to prevent excessive traffic in the room. For example: Rather than having the dietary aide bring in food, the nurse could combine tasks by bringing in food with medications and bedding as she performs morning care for the patient.
	Locate air intake ducts away from doors.
	Regularly inspect HEPA filters and other devices used in isolation rooms to demonstrate installed effectiveness.
	To monitor and check for negative room pressure the smoke trail method can be used. Explanation of smoke trail testing procedures can be found in: Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis, Appendix B, OSHA Directive CPL 2.106 (1996). Occupational Exposure to Tuberculosis proposed rule Federal Register #62:54159-54309 Appendix G, (1997, October 17).
	Vent isolation room air to the outdoors away from intake vents and employees. If the air from these areas cannot be vented to the outside, filter air before it can be recirculated back into other areas of the facility through a HEPA filter.

Additional Information:

In September of 1999, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Committee on Healthcare Safety recommended that JCAHO update its Environment of Care Standard for Utility Systems Management, including the Comprehensive Accreditation Manual for Long Term Care to include and address issues of improperly designed and maintained ventilation systems (including inappropriate pressure relationships, air exchange rates, and filtration efficiencies).

 

Warning Signs and Tags

Potential Hazard

Exposure to TB because of inadequate signs or labels, such as:

• Isolation and treatment rooms not labeled properly.
  
  

• Exposure to TB through unlabeled contaminated ducts, fans, filters.

Possible Solutions

Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis [OSHA Directive CPL 2.106, L.4.].

Employees must receive adequate information about the hazards of TB through the use of labels and signs, as indicated in 1910.145 Accident Prevention Signs and Tags. OSHA requires that signs must be posted at the entrance to:

	Rooms or areas used to isolate an individual with suspected or confirmed infectious TB (TB isolation rooms for example).
	Rooms or areas where procedures or services are being performed on an individual with suspected/confirmed TB.
	Warning signs shall be posted outside the Respiratory isolation or treatment room. The sign must include a signal word (e.g. "STOP", HALT", or "NO ADMITTANCE") or biological hazard symbol and a descriptive message (e.g., "Respiratory Isolation, No Admittance Without Wearing a Type N95 or More Protective Respirator", or "See nurses' station before entering this room") [1910.145(f)(4)]. The precaution sign must remain posted at the entrance to the room after the room has been vacated by someone who was infectious at the time they left the room, and respirators must be used if entering the room, until the area is ventilated for the time necessary to obtain 99.9% removal efficiency [CDC Guidelines]. Discrepancy Between the Joint Commission and OSHA posting requirements for Isolation Rooms. Interpretation and Compliance Letter, (1996, November 5).
	Employers must use biological hazard tags on air transport components (e.g., fans, ducts, filters), that may reasonably contain air infected with M. tuberculosis to warn employees, temporary employees, or contractors of possible hazards of contamination [OSHA Directive CPL 2.106, L.4. (1996)].
	Example wording for warning label: "Contaminated Air--Respiratory Protection Required."

 

Respiratory Protection

Potential Hazard

Exposure to TB due to:

• Improper use or fit of respirator, or improper reuse of damaged or soiled respirators.
  
  

• Ineffective respiratory protection program.

Possible Solutions

The standard at 1910.139(a)(2) states that the employer is responsible to establish and maintain a complete respiratory protection program that assures respirators are properly selected, fitted, used, and maintained and updated as necessary. NOTE: The OSHA Directive CPL 2.106,L.2.(1996, February 9), cited the then existing 1910.134 as the standard requiring respiratory protection against TB. In 1998, the old 1910.134 was redesignated as 1910.139 and applied only to TB.

	NIOSH offers a sample respiratory protection program in Step 3, of TB Respiratory Protection Program Administrator's Guide called: ABC Health Care Facility Respiratory Protection Program.
	The directive CPL 2.016, L.2.a. specifies the CDC guidelines for standard performance criteria for respirators for exposure to TB. These criteria include: wearing NIOSH-approved high-efficiency particulate air (HEPA) filtered respirator, or Class N95 or more protective respirator whenever the employee: Enters rooms housing individuals with suspected or confirmed infectious TB. Is present during the performance of high hazard procedures or services for an individual with suspected or confirmed infectious TB. Transports an individual with suspected or confirmed TB in a closed vehicle.
	Requirements for a minimal acceptable program are found in 1910.139(b), and include among other things:
	Employee instruction on correct fit and use of respirators [1910.139Fit Testing is covered in the OSHA Technical Manual. Employees must be fit tested before using their respirators and whenever a change occurs (i.e., different size, model, or respirator design or facial shape).  Providing respiratory protection for persons who wear glasses may be a problem; a proper seal must be maintained [1910.139(e)(5)(ii)]. Respirators cannot be worn with facial hair which interrupts the facial seal.
	Standard operating procedures for storing, reusing, and disposing of respirators [1910.139(f) CPL 2.106, L.2.a.3].
	For example, a disposal container could be provided on the cart outside the room to store soiled reusable respirators until they can be cleaned for reuse.
	Respirators shall be regularly cleaned and disinfected. Those used by more than one worker shall be thoroughly cleaned and disinfected after each use [1910.139(b)(5)]. Disposable respirators can be reused (by the same HCW), as long as the functional and structural integrity of the respirator is maintained. The outside of the filter material should be inspected before each use: If the filter material is physically damaged or soiled, the filter should be changed or discarded. Health care facilities' policies specify whether cleaning or sterilizing an item is necessary [CDC Guidelines].

Additional Information

• Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis [OSHA Directive CPL 2.106 (1996, February 9)]. 

• TB Respiratory Protection Program in Health Care Facilities Administrator's Guide. Step 7: Inspect, Clean, Maintain, and Store Respirators.

• OSHA Respiratory Protection Advisor.

• Respiratory Protection Technical Links Page.

 

Housekeeping/Cleaning

Potential Hazard

Exposure to TB through improper housekeeping or venting procedures when cleaning TB contaminated rooms.

Possible Solutions

[OSHA Directive CPL 2.106 Appendix A, CDC, Supplement 5-Decontamination-Cleaning, Disinfecting, and Sterilizing (1994)] addresses cleaning practices when cleaning the room of a person who has infectious TB. 

• Normal cleaning procedures can be used, (i.e., an EPA approved germicide/disinfectant. It does not need to be tuberculocidal for routine cleaning of a TB isolation room).
  
  

• Personnel should follow isolation practices and wear a Class N95 or more protective respirator, while cleaning rooms of an infectious patient.
  
  

• After the room is vacated by an infectious patient, the precaution sign must remain posted at the entrance to the room, and respirators must be used if entering the room, until the area is ventilated for the time necessary, using the CDC's recommendations, for removal efficiency of 99.9%.
  
  

• For final cleaning of the isolation room after a patient has been discharged, PPE is not necessary if the room has been ventilated for the appropriate amount of time.

Recordkeeping

Potential Hazard

Exposure to TB because exposure conversion trends are not being monitored.

Possible Solutions

OSHA Recordkeeping Standards:

• Beginning January 1, 2002, the new recordkeeping requirements go into effect. Section 1904.11 of the revised rule outlines the new factors in determining work relationship of TB for recordkeeping purposes including:

• If any employee has been occupationally exposed to anyone with a known case of active tuberculosis and subsequently develops a tuberculosis infection as evidenced by a positive skin test or diagnosis by a doctor you must record the case on the OSHA 300 log.
  
  

• Under the following circumstances the employer can line out or erase the log if evidence is obtained that the employee's TB case was not caused by an occupational exposure:

  • The worker is living in a household with a person who has been diagnosed with active TB.

  • The Public Health Department has identified the worker as a contact of an individual with a case of active TB unrelated to the workplace; or

  • A medical investigation shows that the employee's infection was caused by exposure to TB away from work, or proves that the case was not related to the workplace TB exposure. 
    

• You do not have to record on the log a positive TB skin test result obtained at a pre-employment physical as this exposure did not occur at your worksite.
  

Additional Information

• 1904 Recording and Reporting Occupational Injuries and Illnesses. New Recordkeeping regulatory text PDF only.

• Recordkeeping. OSHA Publication 3169

• New record keeping forms OSHA 300, 300A 301.

• 1910.1020, Access to Employee Exposure and medical records, (prior designation 1910.20).