• Program to Control Exposures
• Identification, Screening, Medical Surveillance
• Training and Education
• Isolation

• Isolation Rooms
• Warning Signs and Tags
• Respiratory Protection
• Housekeeping/Cleaning
• Recordkeeping

Exposure to TB because of ineffective:

• Identification and screening of residents
   
• Exposure Control Plan
  
  
• Risk Assessment
  
  
• Medical surveillance of employees
  
  
• Case management

The protocol for early identification of individuals with active TB starts with the following elements:

• Assignment of responsibility for the TB infection control program.
• Conduct a risk assessment, and periodically reassess risk.
• Develop and follow a TB infection control plan for your facility.

Screening of Residents: Prompt implementation of early screening procedures, and staff training to help them identify potentially infectious individuals, will allow for early identification of patients with infectious TB and the initiations of appropriate controls before occupational exposure occurs to staff and other patients.

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

Exposure Control Plan (Non-mandatory): Control of exposure to TB can be readily addressed in a facility's Exposure Control Plan (ECP). An ECP helps employers prevent exposure to TB in their facilities. Exposure Control Plan. (sample) Please adapt to fit your facility.   Risk Assessment: Nursing homes or long-term care facilities for the elderly have been identified as having a high-risk situation for the transmission of TB. The degree of risk of occupational exposure of a worker to TB will vary based on a number of factors discussed in detail by the CDC and (Directive CPL 2.106 Appendix A, PDF 141 pages, pg. 4-5). To assist employers in establishing a baseline risk assessment for TB in a particular facility the CDC offers: Elements of a risk assessment for TB in Health Care Facilities Protocol for conducting a TB risk assessment:  Figure 1  Figure 1a  Figure 1c

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, OSHA Directive CPL 2.106 Appendix A, PDF, pages 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. [Appendix A, PDF, page 40 sec 4] . TB test skin conversions protocol.
  
  
• Work Restrictions for Infectious Employees [Directive CPL 2.106 Appendix A -  PDF, page 41].

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's Respiratory Protection Standard 1910.134(c)(1)(viii), Requires training of employees in the respiratory hazards to which they are potentially exposed during routine and emergency situations.
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, - PDF, pages 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, PDF, page 23].

OSHA's Respiratory Protection Standard 1910.134(c)(4) also requires employers to provide respirator training, medical evaluations, fit-testing, written program, and recordkeeping at no cost to the employee.

• Tuberculosis. Slide presentation, OSHA Office of Training and Education. (1996, March 20). This presentation will provide an overview of CPL 2.106 - Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis. Although this slide presentation is outdated and does not reflect  respiratory protection now being covered under 1910.134, it does offer general abatement information and an overview of CPL 2.106.

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.

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

OSHA Directive CPL 2.106, states individuals with suspected or confirmed infectious TB disease must be placed in a respiratory acid-fast bacilli (AFB) isolation room. High hazard procedures on individuals with suspected or confirmed infectious TB disease must be performed in AFB treatment rooms, AFB isolation rooms, booths, and/or hoods. (AFB isolation refers to a negative pressure room or an area that exhausts room air directly outside or through HEPA filters if recirculation is unavoidable).

Transferring of patients: The CDC recommends that 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.

Exposure to TB because of isolation room failure:

• Equipment failure, not working properly.



• Isolation doors left open or excessive traffic in room.

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)].  Individuals with suspected or confirmed infectious TB disease must be placed in a respiratory acid-fast bacilli (AFB) isolation room. AFB isolation refers to a negative pressure room or an area that exhausts room air directly outside or through HEPA filters if recirculation is unavoidable.

• Use respiratory acid-fast bacilli (AFB) isolation rooms:

	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 and CPL 2.106 Appendix A, PDF, specifies 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).
	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.

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.

Communication of Hazards: Warning Signs and Tags

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/ Appendix A - PDF, see chart on page 72. 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."

Exposure to TB due to:

• Improper use or fit of respirator, or improper reuse of damaged or soiled respirators.
  
  
• Ineffective respiratory protection program.

OSHA's Respiratory Protection standard 1910.134 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 regularly.

• Respiratory Protection Program Guidelines. OSHA CPL 2-254A (2000, July 14), 18 pages. This instruction sets forth guidelines for establishing and implementing an OSHA respirator program to ensure that all OSHA employees are protected from exposure to respiratory hazards.

Employer must also provide a medical evaluation to determine the employee's ability to use a respirator [1910.134(e)].

• 1910.134 App C, OSHA Respirator Medical Evaluation Questionnaire (Mandatory).

	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 1910.134(b), and include among other things:
	Employee instruction on correct fit and use of respirators [1910.134(k)]. Every respirator wearer shall receive fitting instructions including demonstrations and practice in how the respirator should be worn, how to adjust it, and how to determine if it fits properly. Fit Testing is covered in the OSHA Technical Manual and OSHA CPL 2-2.29 (1980, October 27). Employees must be fit tested before using their respirators and annually or whenever a change occurs (i.e., different size, model, or respirator design or facial shape) [1910.134(f), 1910.134(e)(5)]. 1910.134 App A, Fit Testing Procedures (Mandatory). Providing respiratory protection for persons who wear glasses may be a problem; a proper seal must be maintained [1910.134(g)(1)(ii)]. Respirators cannot be worn with facial hair that interrupts the face-to facepiece seal or valve function [1910.134(g)(1)(i)].
	Standard operating procedures for storing, reusing, and disposing of respirators [1910.134(h) 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 [1910.134(h)(1)(i)-(iv)]. 1910.134 App B-2, Respiratory Cleaning Procedures (Mandatory). 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- Appendix A].

Additional Information: Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis [OSHA Directive CPL 2.106 (1996, February 9)]. Respiratory Protection Program Guidelines. OSHA CPL 2-254A (2000, July 14), 18 pages. This instruction sets forth guidelines for establishing and implementing an OSHA respirator program to ensure that all OSHA employees are protected from exposure to respiratory hazards. Inspection procedures for the Respiratory Protection Standard. OSHA CPL 2-0.120 (1998, September 25), 10 pages. This instruction establishes agency interpretations and enforcement policies, and provides instructions to ensure uniform enforcement of the Respiratory Protection Standard, 29 CFR 1910.134. 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 Safety and Health Topics Page.

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

[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).
  
  
  • Products are available if Tuberculocidal cleaning is desired for certain processes. The United States Environmental Protection Agency (EPA) Office of Pesticides Program. provides lists of registered anti-microbial products at Antimicrobial Chemical/Registration Number Indexes.
  
  
• 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.

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

OSHA Recordkeeping Standards:

• On January 1, 2002, the new recordkeeping requirements went 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.

• Recordkeeping. OSHA Publication 3169.
• Recordkeeping forms: The OSHA Form 300, Log of Work-Related Injuries and Illnesses has been revised. The forms, which are required for employers to use in recording injuries and illnesses, have changed in several important ways for 2004. The new forms must be in use by January 1, 2004.
• New Recordkeeping Rule Factsheet. Highlights of the OSHA Recordkeeping Rule.
• 1910.1020, Access to Employee Exposure and medical records, (prior designation 1910.20).