OSHA - TUBERCULOSIS INFECTION CONTROL PLAN

TUBERCULOSIS

It is estimated that 10 to 15 million persons in United States are infected with Mycobacterium tuberculosis, the organism that causes TB. The increase in multiple drug-resistant TB has caused further concern. Approximately 5% of all AIDS patients also have TB. Treating patients with active infectious TB poses a potential occupational hazard to health care workers (HCWs).

The key to controlling the spread of TB in the work place is easy detection of patients with active TB, following an infection/exposure control plan and taking the proper precautions when working with patients suspected of or diagnosed with active disease. Eliminating the risk may not be possible. Adherence to the CDC guidelines will reduce the risk.

Are there any regulations regarding TB?

Yes, State laws require proper infectious control practices and reporting practices. The CDC released "Guidelines for Preventing the Transmission of Mycobacterium TB" in 1994. This document makes recommendations for reducing the risk of TB to health care workers. A copy of relevant parts of this document can be found in the appendix that follows. OSHA released draft regulations for TB in 1993, 1994 and again in 1997. On December 31, 2003, OSHA withdrew the TB standard since OSHA felt that the risk factor had decreased in the previous 10 years due to compliance with the CDC guideline. NIOSH has developed and released recommendations on types and use of respirators. OSHA can inspect for TB infection control problems under the general duty clause of the "Occupational Safety and Health Act of 1970". The information in this chapter follows the CDC Guidelines.

Mode of Transmission:

TB is a communicable disease caused by the bacterium "Mycobacterium tuberculosis". It is spread from person to person through the inhalation of airborne particles containing M. tuberculosis (less than 5 microns in size). These particles are also called droplet nuclei. These droplets are produced when a person with active TB of the lung forcefully exhales, such as when coughing, sneezing, speaking or singing. These infectious particles can remain suspended in the air and can be inhaled by someone sharing the same air. Risk of transmission increases in closed areas where ventilation is poor and if air is shared for a prolonged period of time.

TB Infection and Disease:

TB infection (positive PPD) in a person who does not have active disease (symptoms) is not considered a case of active TB. A person with TB infection who does not have active disease cannot infect others. Active TB does not develop in everyone who is infected. In the U.S., about 90% of infected persons remain infected for life and never develop symptoms of active TB. Most active cases occur in the lungs and are confirmed by chest radiograph and positive sputum culture. TB infection usually begins in the alveoli, where tubercle bacilli are initially able to multiply. Within 2-10 weeks after the initial infection with M. tuberculosis, the immune response limits further multiplication and spread of the tuberculosis bacilli. However, some of the bacilli remain dormant and viable for many years. The risk of developing active disease is greatest during the first 2 years. Persons with TB in extra pulmonary sites are usually not considered infectious to other people.

Signs and Symptoms:

The signs and symptoms of TB vary according to the location of the disease. Generally the signs and symptoms of pulmonary TB will include a persistent cough (more than 3 weeks), chest pain, coughing up sputum and sometimes coughing up blood, fatigue, feeling ill, loss of appetite, weight loss, fever, and night sweats.

Treatment of TB:

TB is usually curable if it is diagnosed early and if effective treatment is instituted without delay. TB must be treated with multiple antibiotics and for a long time compared with most other infectious diseases. Usual treatment time is 6 - 9 months. If treatment does not continue the tubercle bacilli may survive to make the person infectious again and may foster the development of drug-resistant mycobacteria. * A table of anti-tuberculosis drugs can be found in the CDC guidelines in appendix.

EXPOSURE CLASSIFICATION/RISK FACTORS

Anyone who has close contact and has shared airspace with a person who has active infectious TB is at risk for TB. The CDC classifies facilities as "high risk", "intermediate risk", "low risk", "very low risk" or "minimal risk". ALL MEDICAL FACILITIES MUST PERFORM A RISK ASSESSMENT.

The infection control program will be based on this rating.

* Detailed information on how to perform this can be found in the CDC, October 28, 1994 guideline found at the end of this chapter.

CDC Risk Assessment Classifications:

Minimal Risk: Entire facility does not admit TB patients and is not located in a community with TB (information can be obtained from public health department data).

Very Low Risk: Entire facility does not admit TB patients to inpatient areas BUT may receive initial assessment and perform diagnostic evaluations. Patients with confirmed TB will be referred to an appropriate facility. Facility is in an area with reported TB cases. No cases have been seen in facility in prior year. Depending on amount of patients seen per/year the risk classification will be upped to low, intermediate or high.

Low Risk: One to 6 active infectious TB patients are treated per year. The PPD (Mantoux test) conversion rate is the same as the conversion rate of HCWs without occupational exposure. If <1 or >6 TB patients are seen the classification will be changed accordingly.

Intermediate Risk: Exposure to 6 or more active infectious TB patients per year. The PPD (Mantoux test) conversion rate among HCWs is the same as the conversion rate in HCWs without occupational exposure.

High Risk: Frequent shared air space with known active infectious TB patients. The PPD (Mantoux test) conversion rate among HCWs greater than the conversion rate among HCWs without frequent exposure.

Note: Larger facilities may classify different area's of the facility at different risk. The CDC risk rating (of facility or section of facility) will be reviewed and assessed annually. The risk rating will be adjusted up or down according to the results of this assessment. The exposure control plan will be revised accordingly.

The initial risk assessment was performed on: ___________________________

Annual Risk Assessment (perform based on previous calendar year)

Review Date: _______________ Risk Category: __________________________

TB EXPOSURE & INFECTION CONTROL PLAN

POLICY: The key to preventing transmission is to be aware of TB and follow precautions! In general, the symptoms of active TB are symptoms that patients will likely seek medical treatment for at a medical office or clinic. The population served by some facilities may be a low to relatively high. This is determined when the risk evaluation is performed. One person will be assigned to implement facility plan. All employees will follow this plan.

The person in charge of implementing the TB infection control plan in the facility of ________________________________ is ___________________________

If this person changes write the new name and date changed here:

Name: _________________________________ Date: _______________

Early Identification of Patients with Potential TB:

All patients will be questioned during initial medical history about a history of TB disease and symptoms suggestive of TB. Any patient presenting with the following symptoms will be evaluated for disease. Evaluation of disease will include: medical history, physical examination, PPD skin test, chest radiograph and possible sputum culture or other appropriate specimen testing.

Patient with a persistent cough for more than three weeks will be evaluated for TB work-up.
Patient with pulmonary, respiratory, systemic signs or TB related symptoms will be evaluated for disease.
Patient known or suspected of having HIV with cough or fever will be evaluated.
Patient with pulmonary or systemic signs that were initially attributed to other etiologies, but which do not respond to appropriate therapy will be evaluated for TB.
Infants and children living in households with an active case of pulmonary tuberculosis, regardless of symptoms will be evaluated for disease.

Once the patient is identified, precautions listed the section "Infection Control for Medical Offices" (or appropriate health care facility) will be implemented.

TB Policy for Patient Evaluation and Referral:

________________________________________________________________

INFECTION CONTROL POLICIES

Infection Control Policy for Medical Offices and Clinics:

The following infection control policies will be implemented once a patient suspected of having TB is identified in the physician office or clinic:

Any patients with symptoms will be evaluated and diagnosed so that HCWs can identify infectious patients.
Once a patient is identified with active pulmonary TB an effort will be made to separate this patient from other patients while in the waiting room. If this is difficult to do, have the patient wear a surgical mask while waiting.
The patient will be put into an examining room as soon as possible.
HCW's entering and assisting in the examination will be kept to a minimum. They will be provided with NIOSH approved respirator masks to wear while working with the patient.
Patients with suspected active pulmonary TB will be instructed to cover the nose and mouth when coughing, sneezing, etc.
Room will be well ventilated before the next patient is put in room.
Procedure for sputum collection will not be conducted at the facility unless a specially equipped room is available.
Cough-inducing procedures and laboratory testing of sputum will not be performed by the facility or in the facility.

Infection Control Policy for In-Office Operating Rooms:

Elective operative procedures on patients with TB will be delayed until the patient is no longer infectious. If procedure must be done, it will be done in an operating room with anterooms and/or room will have a HEPA air filtration system. Doors will be closed and traffic in and out kept to a minimum.

Infection Control Policy for Dental Offices:

During initial medical history the HCW will routinely ask all patients about a history of TB disease and symptoms suggestive of TB. Patients with history and symptoms suggestive of active TB will be sent for evaluation for possible infectiousness. Elective dental treatment will be delayed until a physician confirms that the patient does not have infection. If urgent dental care must be provided the dental HCW will use respiratory protection while performing procedures on such patients.

Infection Control Policy for Home Health Care:

HCW's entering homes of patients with suspected or active TB will wear respiratory protection. The patient will be instructed to cover their mouth with a tissue or wear a surgical mask if coughing or sneezing. Precautions may be discontinued when the patient is no longer infectious.

NOTE: All HCW's having contact with patients diagnosed with or suspected of having active infectious TB will wear a NIOSH approved properly fitted high efficiency respirator.

EMPLOYEE SCREENING & EDUCATION

Employee Education:

Employee education regarding TB and TB infection control will be done upon initial employment and at least annually thereafter. Training will include:

Purpose, interpretation and value of skin testing
Procedures to prevent TB transmission (infection control plan)
Importance of compliance
Cause and transmission of TB
Distinction between TB disease and TB infection
Signs and symptoms of TB
Risk factors in health care facility
Treatment
Prognosis
Facility information on screening program
Purpose, proper selection, fit and use of PPE (respirators)
Engineering controls

Mantoux (PPD) Screening:

The Mantoux tuberculin skin test is the recommended method of skin testing to determine whether a person is infected with M. tuberculosis. A positive reaction to the tuberculin test usually means the person has been infected with M. tuberculosis. Persons who have a positive skin test and present with TB symptoms will be evaluated with a chest radiograph to rule out pulmonary TB.

For the initial TB skin test, a two-step testing procedure is recommended. Two-step testing reduces the likelihood that a boosted skin reaction will be interpreted as representing recent infection.

CDC Guidelines for Follow Up Mantoux Testing:

Minimal Risk Facilities: N/A or variable

Very Low Risk Facilities: variable (upon exposure)

Low Risk Facilities: annual

Intermediate Risk Facilities: 6 - 12 months

High Risk Facilities: 3 - 6 months

* A list of questions and answers on Mantoux testing is found at the end of this chapter

RECORD KEEPING & REFERENCES

Record Keeping:

Record keeping for PPD tests will include, date of testing, testing material and batch number used, date test was read, the size of the reaction in millimeters, interpretation, name of the person administering and/or interpreting the results. If there has been an on the job exposure, an incident report will be filled out. A written opinions of medical evaluation following an exposure must be received and documented within 15 days. If a positive skin test (TB infection) turns into active disease, the disease will be reported State Department of Health Tuberculosis Control Program upon diagnosis. Exposure records must be kept for the length of employment plus 30 years.

Write the address and phone number of your State Department of Health here:

_______________________________________________________________

Phone: __________________________________________________

References:

Core Curriculum on Tuberculosis. U.S. Department of Health and Human Services, CDC, April 1991.

Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health Care Facilities, 1994. CDC, U.S. Dept. of health and Human Services, Oct.28,1994.

Preventing the Transmission of Tuberculosis in Health-Care Facilities (draft guidelines). Federal Register, Department of Health and Human Services, Tuesday October 12, 1993.

TB The Connection HIV. U.S. Dept. of Health and Human Services, CDC, Sept 1993 Occupational Exposure to Tuberculosis; Proposed Rule. Federal Register, 29 CRF Part 1910, Oct.17, 1998.

Brown, James, PhD. TB: Keeping an Ancient Killer at Bay, MLO, November 2004.

COMMON QUESTIONS ON MANTOUX TESTING

Q. Can we use a Tine test in place of the Mantoux test?

A. No - OSHA, CDC and State guidelines ALL require the use of the Mantoux test (also called PPD).

Q. Can employees sign a declination form similar to the one that was used for Hepatitis under the Bloodborne Pathogen Standard, if they do not want to be tested?

A. The CDC guidelines do not give the employee this option - however, this document is a guideline. Since the OSHA regulation was withdrawn in 2003 - it may be up to the employer to offer such an option.

Q. Do we need to do a 2 step Mantoux?

A. OSHA, CDC and State guidelines all recommend an initial 2 step Mantoux on employees. All employees, including those with a history of BCG vaccination, are to receive a Mantoux test.

Q. How often do we have to perform follow-up Mantoux tests?

A. Follow-up testing is based upon the risk rating of your facility. Refer to your TB exposure control plan or the chart from the CDC found in the TB chapter.

Q. Which employees should be included in the Mantoux Test screening?

A. According to CDC guidelines "Health care workers who work in medical offices where there is a likelihood of an exposure to patients who have infectious TB should be included in the employer-sponsored education, training, and PPD testing programs at the appropriate risk level of the facility."

SECTION 9 - TUBERCULOSIS INFECTION CONTROL PLAN