II. HIERARCHY OF CONTROL MEASURES

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1 TITLE/DESCRIPTION: Tuberculosis Control Program - Exposure Control Plan DEPARTMENT: All Patient Care Departments PERSONNEL: All Patient Care Personnel EFFECTIVE DATE: 4/83 REVISED: 10/96, 12/04, 6/08, 3/12, 5/14, 1/15 I. PURPOSE A. To achieve early detection, isolation, and treatment of persons with active Tuberculosis (TB) to minimize the risk of TB transmission. II. HIERARCHY OF CONTROL MEASURES A. Use of administrative controls to reduce the risk of exposure to persons with infectious TB. B. Use of environmental controls to prevent the spread and reduce the concentration of infectious droplet nuclei. C. Use of respiratory protection controls. III. RESPONSIBILITY A. The Director, Infection Prevention and Control/Employee Health will provide the supervisory responsibility for the TB Control Program. IV. RISK ASSESSMENT A. General 1. The risk assessment and annual evaluation of the TB Control Plan will be performed by the Infection Prevention and Control. 2. A risk assessment will be done for: a. The facility as a whole b. All departments where TB patients may receive care or coughinducing procedures which may be performed. c. Individual groups of healthcare workers (HCW) that work throughout the facility. B. Case Surveillance 1. Data on the number of active TB cases among patients and HCWs are collected, reviewed, and used to: a. Identify the number of isolation rooms required b. Recognize clusters of healthcare-associated transmission c. Assess the level of potential occupational risk. 2. Analysis of HCW tuberculin skin test (TST) Screening Data a. Results of employees TST are kept in a retrievable aggregate database. b. TST conversion rates are calculated in accordance to the risk. c. TST conversion rates for each area are compared to rates in areas without occupational exposure to Mycobacterium tuberculosis and to previous rates in the same area to identify areas where the risk of occupational TST conversions may be increased.

2 d. Any time a cluster of TST conversions is noted, further evaluation is indicated. e The frequency of TST are determined by the risk assessment. f. Areas in which cough-inducing procedures are performed on patients who may have TB will at the minimum implement the medium risk protocol. 3. Review of TB patient Medical Records a. The medical records of all culture positive TB patients admitted to the facility will be reviewed. 4. Observation of Infection Prevention and Control Practices a. Compliance is considered to be a standard of performance and is included in the annual performance evaluation for all employees with potential for exposure. b. Recommended practices are stated in this plan and located in policies and procedures. c. Strategies for compliance monitoring. (1) 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. (2) Follow-up of problems identified through informal reports, complaints from staff, patient safety reports, employee questionnaires, staff logs, and comments received during evaluation of education and training programs will be the responsibility of the affected departments supervisory staff. (3) Monitoring will be done during the normal Infection Prevention and Control surveillance rounds by the Infection Prevention and Control Director. (4) Noncompliance will be reported to an employee's immediate supervisor by all employees who observe an employee's failure to comply with the required protective measures. (5) Incidents of noncompliance will be investigated by the noncompliant employee's immediate supervisor/manager to determine the cause and corrective measures to be implemented. C. Engineering Evaluation 1. The TB Engineering Evaluation will be reviewed as a part of the risk assessment annually. D. Periodic Reassessment 1. Follow-up risk assessment will be performed annually. 2. TB Control Plan will be reviewed annually. V. DETECTION OF PATIENTS WHO MAY HAVE ACTIVE TB A. Consideration of TB Diagnosis B. Patient Screening 1. In order to promptly identify patients at risk of transmitting TB who receive services as inpatients or outpatients, systematic screening of all patients is used. 2. As a result of screening procedures, patients with suspected or confirmed TB are to be isolated in an Airborne Precaution isolation room.

3 3. To be effective, screening involves the participation of many healthcare workers, including reception and admitting personnel as well as nurses and physicians. 4. The scope of screening activity includes all initial entry areas of SMC for patients such as ambulatory care, Emergency Department, and admitting department. LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 Initial contact with a coughing patient - encourage patient to cover cough. Tissues are available in all waiting areas. Signs are posted in waiting areas encouraging use of tissue when coughing. Health assessment for risk factor history - if risk factors present, remove patient from traffic area to designated holding area as soon as possible. Medical assessment for TB - diagnostic testing, admission, and isolation decisions. Follow-up assessment to verify or exclude TB - laboratory confirmation and Board of Health reporting for cases; exposure follow-up if indicated. C. Patients with signs/symptoms 1. Persistent cough > 2 weeks duration 2. Bloody sputum 3. Night sweats 4. Weight loss 5. Anorexia 6. Fever/chills 7. Fatigue D. Groups with a higher prevalence of TB infection 1. Medically underserved populations, including some African-Americans, Hispanics, Asians and Pacific Islanders, American Indians, and Alaskan Natives 2. Homeless persons 3. Current or past prison inmates 4. Alcoholics 5. Injecting drug-users 6. Elderly 7. Residents of long-term care facilities 8. Contacts to persons with active TB 9. Foreign born persons from Asia, Africa, the Caribbean, and Latin America. E. Groups with a higher risk to progress from latent TB infection to active disease 1. HIV Infection 2. Silicosis 3. Abnormal chest x-ray showing fibrotic lesions 4. Diabetes mellitus 5. Prolonged corticosteroid therapy 6. Immunosuppressive therapy 7. Hematologic and reticuloendothelial disease 8. End stage renal disease 9. Intestinal bypass

4 10. Post gastrectomy 11. Chronic malabsorption syndrome 12. Carcinoma of the upper oropharynx and upper GI tract 13. Being l0% or more below ideal body weight 14. Persons who have been infected within the past two years 15. Children <14 years of age F. Diagnostic Measures for Identifying TB 1. History and physical examination 2. PPD test 3. Chest x-ray 4. Smear and culture of sputum or other appropriate specimen 5. Bronchoscopy or biopsy, if indication 6. Laboratory Response in AFB Testing a. AFB smear results of sputum available within hours of specimen collection G. Additional Considerations 1. Patients having positive or history of positive TST, previous TB, exposure to TB, and those in a high risk groups have a higher probability of TB. 2. Active TB is strongly suggested if a chest x-ray is suggestive of TB, the sputum smear is positive for AFB, or symptoms are suggestive of TB. 3. Immunosuppressed patients with pulmonary signs and symptoms initially ascribed to other etiologies should be evaluated for co-existing TB initially and the evaluation repeated if the patient does not respond to appropriate therapy for the presumed etiology of the pulmonary abnormalities. 4. Other organisms, such as Pneumocystis carinii or Mycobacterium avium complex may occur simultaneously and TB should be sought in the diagnostic evaluation of all patients with symptoms compatible with TB. 5. Persons with HIV infection or other conditions associated with severe suppression of the cell-mediated immunity may be present with atypical clinical or radiographic presentation and/or the simultaneous occurrence of other pulmonary infections. 6. Impaired responses to TST a. Overgrowth of cultures with M. avium complex when both MAI and M. tuberculosis are present. H. Public Health Department Reports 1. All patients with suspected or confirmed TB should be reported to the county (or state) health department within 24 hours of diagnosis as required by state law. 2. Immediately report all patients with suspected or confirmed TB to the health department so that the identification and evaluation of TB contacts can be initiated. VI. MANAGEMENT OF PATIENTS IN AMBULATORY CARE SETTINGS AND EMERGENCY ROOMS A. Triage patients at first point of contact in order to detect active TB patients. 1. Teach HCWs to recognize signs and symptoms of TB. 2. Screen patients by asking appropriate questions to detect possible TB.

5 VII. B. Promptly evaluate patients with signs or symptoms of TB to minimize time spent in Ambulatory Care areas. 1. Utilize Airborne Precautions in negative pressure room while conducting diagnostic evaluations for suspected TB. 2. Place patient in the Emergency Department's PEDS room or PACU12 which are negative pressure rooms. 3. Patient shall be given a surgical mask to wear while in the ambulatory setting and instructed to keep it on at all times. 4. Patients shall be given tissues and instructed to cover their mouths and noses when coughing or sneezing, if they must remove their mask to facilitate respiratory clearance. C. Immediately institute Airborne Precautions for known TB patients noncompliant with prescribed drug therapy. D. Avoid scheduling active TB patients at same site/time with severely immunocompromised or HIV+ patients. If this is not feasible, physically separate the patient in a different area. E. Design and maintain ventilation of areas serving patients diagnosed with TB or high risk for TB to reduce risk of TB transmission. 1. Ventilate waiting or treatment rooms with a minimum of 6 air exchanges per hour (12 air exchanges per hour for new construction). 2. HEPA filters facilitate in-room air disinfection and recirculation. 3. Cough induction should be performed in a negative pressure area, allowing adequate time for expelled air to be filtered and removed prior to use for another patient. MANAGEMENT OF HOSPITALIZED PATIENTS WITH TB A. Evaluation for TB 1. Pulmonary TB should always be included in the differential diagnosis of persons with signs and symptoms suggestive of TB and appropriate diagnostic measures should be used. 2. Tuberculin Skin Testing (TST) 5TU (intermediate strength purified protein derivative, Mantoux). B. Administration of Tuberculin ml of 5TU TST injected into either the volar or dorsal surface of the forearm. 2. Tuberculin should be injected just beneath the surface of the skin intradermally. 3. Discrete, pale elevation of the skin 6-l0 mm in diameter should be produced. C. Reading of the Skin Test 1. By well-trained, designated personnel between hours after injection. 2. Presence or absence of induration is basis for interpretation, not redness or erythema. 3. Transverse diameter of induration should be recorded in millimeters. 4. Establish appropriate definition of a positive reaction depending on the risk of TB in patient's risk group. Determination of TST Reaction: TST Reaction Determination of Reaction Negative Positive

6 5 mm induration No known risk factors for MTB HIV-infected persons Recent contacts of infectious TB Persons with fibrotic changes on chest radiograph consistent with prior TB Patients with organ transplants and other immunosuppressed patients 10 mm induration 15 mm induration No known risk factors for MTB Recent arrivals from high-prevalence countries Injection drug users Residents and employees of high-risk congregate settings Mycobacteriology laboratory personnel Persons with conditions that increase risk for progressing to TB Children <5 years of age, or children and youth exposed to adults at high risk No known risk factors for MTB D. Initiation of Treatment 1. Patients with confirmed active TB or highly likely to have active TB shall be started on appropriate treatment promptly, based on analysis of susceptibility surveillance data of TB isolated. 2. Inpatients should be administered antituberculosis drugs by directly observed therapy. E. Initiation of Airborne Precaution Isolation 1. All patients with suspected or confirmed TB shall be evaluated for potential infectiousness and those with pulmonary or laryngeal TB should be placed in Airborne Precautions until they are determined to be non-infectious. 2. When patients with previously diagnosed TB who are readmitted before confirmation of complete cure, shall be placed in Airborne Precaution until infectiousness has been ruled out. F. Airborne Precaution Isolation Practice 1. Patients in Airborne Precautions shall be educated about TB transmission and the reasons for isolation. 2. They shall also be taught to contain secretions from coughing or sneezing. 3. Patients in Airborne Precautions shall remain in isolation room with closed door. 4. Transporting the TB patient outside isolation room shall occur only when medically essential procedures cannot be performed in the isolation room.

7 5. A surgical mask must be worn by the patient when outside the isolation room; timing of transport shall be planned to occur when the procedure can be performed rapidly and the patient does not have to wait in a crowded area. 6. If treatment and procedure rooms do not have a separately ventilated area or meet ventilation recommendations for Airborne Precautions, the patient shall remain masked and be returned promptly to the isolation room. 7. Healthcare workers entering the Airborne Precautions room shall be minimized and all who enter must wear an N-95 respirator. 8. All employees who enter the room must have been properly face-fitted with the N-95 respirator. 9. Face fit employee who may be at risk and require respiratory protection with N-95 respirators include but are not limited to: a. Nursing b. Transportation c. Patient Care Techs d. Respiratory Therapy e. Security f. Case Managers g. Physical Therapy h. Electro-Diagnostics i. Environmental Services j. Radiology k. Pastoral Care G. Airborne Precaution Isolation Room 1. Isolate patients who are likely to have infectious TB. 2. Prevent the escape of droplet nuclei from the room, preventing entry of M.tuberculosis into the hall and other areas. 3. Provide an environment that will allow the reduction of the concentration of droplet nuclei through various engineering controls. H. Characteristics of the Isolation Room 1. Single patient room. 2. Maintained under negative pressure and monitored daily when used. 3. Door open only when patient or personnel must enter or leave room. 4. Designed to achieve the best possible ventilation air flows, with a minimum requirement of 6 air exchanges per hour (12 air exchanges per hour for new construction). 5. Air from isolation room should be exhausted to the outside in accordance with federal, state, and local regulation. (TDH - exhaust through the roof and 25 feet from air intake). 6. If it is impossible to vent the exhaust to the outside from rooms or areas used to treat patients with known or suspected infectious TB, HEPA filters must be used in the exhaust duct to the general ventilation system to remove infectious organisms and particulates the size of droplet nuclei from the air before the air is returned to the general ventilation system. 7. An anteroom may increase the effectiveness of the isolation room by serving as an airlock to minimize the potential for droplet nuclei to escape into the corridor when the patient room door is opened.

8 9. There should be enough negative pressure rooms to appropriately isolate all patients with suspected or confirmed active TB. I. Discontinuation of Airborne Precautions 1. Patients who have been receiving treatment for their active TB may be removed from Airborne Precaution Isolation when there is clinical improvement and one of the following: 3 spontaneously produced sputa collected on consecutive days are AFB smear negative (concentrated specimen). A positive AFB sputum is culture negative. 2. Patients with active TB shall be monitored for relapse with sputum smears on a regular basis. 3. Patients with multidrug-resistant TB should be in isolation throughout their hospital stay. 4. Orders for discontinuation of isolation should come from the Infection Prevention and Control Department and /or the patient's physician. 5. In situations where there is disagreement with isolation decisions, the Chair of the Infection Prevention and Control Committee, or a designee should be consulted for resolution. 6. The room should be aired (for approximately 60 minutes) with the door closed, after any TB patient is discharged before another patient can be admitted to the room. J. Discharge Planning 1. Plans to be initiated and in place before discharge a. Confirmed appointment with provider who will follow the patient. b. Sufficient medication to take until outpatient appointment c. Placement into case management, such as directly observed therapy or outreach programs of the local health department. 2. Discharged infectious patients should be discharged only to facilities with TB isolation capability or to home. 3. If high-risk persons reside in the home, either they or the patient should be relocated until patient is no longer infectious. VIII. ENGINEERING CONTROL RECOMMENDATIONS Ventilation at Springhill Medical Center accomplishes the dilution and removal of contaminants from the air and provides for room air flow, velocity (cfm) and patterns that meet current federal, state and local regulations. Prevention of nosocomial transmission requires patient rooms and areas where patients with suspected or confirmed TB are treated be at negative pressure to adjacent areas, have at a minimum 6 air exchanges per hour (12 air exchanges per hour for new construction), be directly exhausted to the outside or to have air recirculated through a HEPA filtration system with 99.7% filtration; ultraviolet germicidal irradiation can be used as a supplement, but can not be used instead of proper ventilation. A. Portable System 1. Air that is recirculated within the same room. These are usually "portable" systems of 2 types: a. Portable unit available in Central Sterile

9 b. Enclosed chamber around a bed/stretcher stored in Emergency Management Pod NOTE: These are useful and acceptable for patient treatment or isolation in areas where negative air pressure is not or cannot be made available. B. Negative pressure patient isolation room/areas are as follows: Emergency Department Room 31, PACU, ICU 1005, 3211, 3313, 2411, 4201, 1304, 1312, and Bronch Lab. 1. General Ventilation reduces the concentration of contaminants in the air. 2. Single Pass System exhausts 100% of the room air to the outside. 3. The supply air is air from the outside that has undergone appropriate heating and cooling or is from a central system supplying a number of areas. 4. Recirculating System only a small portion of the total room or area exhaust is discharged to the outside. This volume of exhaust air is then replaced with fresh outside air. 5. The resulting mixture is then recirculated to the rooms or areas serviced by the system. 6. Ventilation Rates of a minimum of 6 air changes per (12 air exchanges per hour for new construction), for isolation and treatment rooms are maintained. 7. Room Air Flow Patterns are designed to prevent stagnation of the air and prevent "short circuiting" of the supply to the exhaust (i.e. passage of air directly from the air intake to the air exhaust). 8. The supply and exhaust locations should first direct the clean air to areas where HCWs are likely to work, across the infection source, and then to the exhaust. 9. Facility Air Flow Direction is designed and balanced to provide air flow patterns from more clean to less clean (or less-contaminated to morecontaminated) areas. 10. The pressure differential is necessary to maintain negative pressure in a room; it is very small and can be altered by small changes in the ventilation system such as opening and closing the isolation room corridor doors or windows. All doors and windows must remain appropriately closed in both the isolation room and other areas except when needed to enter or leave an area. 11. Monitoring of negative pressure rooms is required by use of smoke tubes, tissue test, or by use of an air velocity measuring device with alarms on a daily basis when in use. 12. They are designed to prevent dissemination of droplet nuclei generated by infectious TB patients. 13. Alternative methods for achieving negative pressure include an anteroom with positive pressure with respect to the isolation room and neutral with respect to the corridor; use of a small exhaust fan to exhaust air to the outside either through the building, or through a window or outside wall when the existing ventilation system is incapable of achieving the desired negative pressure. (NOTE: This is an interim measure only-provides no fresh air and suboptimal dilution). 14. Corridor general ventilation system is balanced to create a higher pressure in the corridor than in the room.

10 IX. 15. Exhaust from Airborne Precaution Rooms should be exhausted directly to the outside of the building, away from people and animals, in accordance with federal, state, and local regulations. 16. Exhaust from isolation rooms must be exhausted above the roof at least 25 feet from an air intake source. 17. If direct exhaust to the outside is impossible, air should only be exhausted within the facility through a properly designed, installed and maintained HEPA filter. C. HEPA Filtration 1. HEPA filtration is used to remove contaminants from the air. HEPA filters remove at least 99.7% of particles 0.3 microns in diameter. 2. The filtration described in this section is in excess of the standard filtration in the main air conditioning system and is specifically for the purpose of eliminating TB aerosols/particles. 3. Air that is recirculated to other areas of the facility (in exhaust ducts prior to return and recirculation of air). NOTE: Installation, maintenance and monitoring must be performed; special installation of filters, inspection and chemical testing to detect leaks, measurement of airflow, and special precautions during filter removal are required. All procedures done by trained personnel wearing masks. 4. Ducts with contaminated air must all be labeled. 5. Air that is recirculated back into the same room: (in exhaust ducts, then recirculated back into the room). NOTE: This is typically used where increasing airflow to achieve the required number of air exchanges is difficult or impossible to achieve. D. Monitoring system: Accustat Alarm 1. Installation, Maintenance and Monitoring of the HEPA filtration System will be done by the Engineering Department and/or contractor on initial installation, after any modification of air duct system. The HEPA filtration System is selfmonitoring. 2. Daily monitoring of the Negative Pressure by the department/unit staff when the room is in use. 3. Monitoring and Maintenance of the Ventilation System is the responsibility of the Engineering Department and/or contractor. RESPIRATORY PROTECTION CONTROLS A. A NIOSH N-95 approved respirator shall be worn by employees when caring for patients with TB or suspected TB, when assisting with cough-inducing procedures on patients with TB or suspected TB, and when entering the room of a patient with TB. B. The N-95 respirator is used at Springhill Medical Center. Respiratory protective devices used for TB should meet the following criteria: C. Ability to filter particles 0.3 micron in size in the unloaded state with a filter efficiency of equal to or greater than 95% D. The hospital shall make available to the HCW a N-95 respirator for use in caring for patients with TB or suspected TB. E. The Respiratory Protection Program consists of annual respirator fit testing for the employee according to the OSHA standard. F. The fit check shall be checked by the wearer each time he/she puts on the respirator.

11 G. The HCW shall wear the respirator when he/she enters the room of a patient with TB or suspect TB, when assisting with cough inducing procedures on patients with TB or suspect TB, and when assisting with bronchoscopy or other such procedures. H. 3M and Kimberly Clark PFR N-95 Particulate Filter Respirators are used at SMC. Respirators are available in different sizes or models. See Appendix 1 and 2 with directions on use. I. Reusable Powered Air Respirators (PAPR) with high efficiency filters are available through Patient Care Services. X. TRANSPORTATION OF AIRBORNE PRECAUTION PATIENTS A. Patients with pulmonary TB should not be transported unnecessarily to other areas or department, or leave the isolation room. For example, a TB patient needing a chest x- ray should have a portable done in the isolation room when possible. B. If the isolated patient's recuperation and treatment would be compromised by examinations, procedures, and treatments performed in the patient's room, then the patient may be transported from the isolation room to other departments with appropriate respiratory protection procedures for both staff and patient. C. The receiving department and transportation service should be notified in advance. D. The sending unit notifies the receiving procedure department staff that an Airborne Precaution patient is being transported to them and will require immediate placement upon arrival in the procedure room. E. If suspected or known TB patients are transported, the patient should wear a mask (surgical, not a respirator). F. The patient is instructed to keep the mask on (over nose and mouth) at all times during the transport to and from the procedure room. G. If the patient is on mechanical ventilation, a mask on the patient is not needed due to the microbial filter on the Ambu bag used in transport. H. The transporter wears a N-95 respirator when entering the Airborne Precaution room to begin/end the transport process. I. Elevators are cleared of passengers and non-essential persons when used to transport TB patients. J. Employees who transport, or are present during the vehicular transport, of patients with confirmed or suspected TB are to wear respiratory protection while in the enclosed vehicle (ambulance, helicopter). XI. RADIOLOGY SCREENING FOR TUBERCULOSIS A. Posterior-anterior and lateral chest radiographs are routinely evaluated by the radiologist for presence of pulmonary tuberculosis. B. The primary physician is notified immediately by the radiologist if active pulmonary TB is suspected. C. Inpatient chest x-rays are portable and done in the Airborne Precaution patient room. D. If portable x-ray results are inadequate and additional views are needed, the patient is transported to Radiology per transportation requirement stated above. E. Whenever possible, procedures done in Radiology for TB patients are scheduled last to facilitate adequate ventilation of the procedure room following the procedure. XII. COUGH INDUCING PROCEDURES A. General Guidelines Procedures that involve instrumentation of the lower respiratory tract or induce cough may increase the probability of droplet nuclei being expelled in the air.

12 B. These cough-inducing procedures include endotracheal intubation and suctioning, diagnostic sputum induction, aerosol treatments (including Pentamidine therapy) and bronchoscopy. C. Other procedures that may generate aerosols (e.g., irrigation of tuberculous abscesses, homogenizing or lyophilizing tissue), are also included in these recommendations. D. Do not perform on patients who may have infectious TB unless absolutely necessary. E. Use local exhaust ventilation devices or a room that meets the ventilation requirements for Airborne Precautions on patients with infectious TB. F. During cough-inducing procedures HCWs will wear respiratory protection, N-95 Respirator. G. Keep patients in the isolation room or enclosure until coughing subsides. H. Give tissues and instructions to cover their mouth and nose when coughing. I. Post sedatives or anesthesia, monitor in a negative pressure isolation room and not in recovery areas with other patients. J. Before the room is used for another patient, adequate time should be allowed to pass so that any droplet nuclei that have been expelled in the air are removed. K. Additional Considerations for bronchoscopy 1. If performing bronchoscopy in positive pressure rooms (such as Operating Rooms) is unavoidable, TB should be ruled out before the procedure. 2. If bronchoscopy is being performed for diagnosis of pulmonary disease that may include TB, it should be performed in a room that meets TB isolation ventilation requirements. L. Special Considerations for the Administration of Aerosolized Pentamidine (AP) 1. All patients should be screened for active TB before prophylactic AP therapy is initiated. 2. Screening should include medical history, TST and a chest radiograph. 3. Before each AP treatment, patients should be screened for symptoms suggestive of TB, such as development of productive cough. 4. For patients with suspected or confirmed TB, it is preferable to use oral prophylaxis for PCP if clinically practical. XIII. EDUCATION AND TRAINING OF HEALTH CARE WORKERS A. All health-care workers will receive education about Tuberculosis (TB) that is appropriate for their job category. B. Specific information and training about occupational hazards and required protective measures will be provided to new employees before the initial assignment and annually to all employees. C. This training will occur through specific department programs, orientation, General Review, and through ongoing in-service educational programs. D. All employees will be competent in age-related issues concerning TB and isolation practices. E. Although the level and detail of this education may vary according to the job description, the following elements will be included in the education of all health-care workers: basic concepts of TB, the potential for occupational exposure, the principles and practice of infection prevention and control, the purpose of the skin test program, preventive therapy, drug therapy, medical evaluation, contact investigation, confidentiality, the higher risk to immunocompromised persons, and work reassignment options.

13 XIV. HEALTHCARE WORKER COUNSELING, SCREENING AND EVALUATION A TB screening and prevention program for Health-Care Workers (HCW) is necessary for protection of both HCWs and patients. Personnel with positive TST, TST conversions, or symptoms suggestive of TB shall be identified, evaluated to rule out active TB, and provided options for therapy or preventive therapy if indicated. 1. Counseling the HCW regarding TB a. All HCWs should know if they have a medical condition or are receiving a medical treatment that may lead to severely impaired cell-mediated immunity b. All HCWs shall be counseled about the potential risks, in severely immunocompromised persons, associated with taking care of patients with some infectious diseases, including TB. c. Options shall be made available for severely immunocompromised HCWs to voluntarily transfer to areas and activities in which there is the lowest possible risk of exposure to M. tuberculosis. d. The Director, Infection Prevention and Control/Employee Health and Employee Health Nurse shall, in consultation with the HCW's personal physician, evaluate the risk of acquisition of TB by the immunocompromised HCW and provide counseling for the HCW regarding their risk of infection. e. Reasonable attempts shall be made to offer alternative job assignments to an employee with a documented condition compromising cell-mediated immunity who works in a high risk setting for TB. f. The confidentiality of the worker shall be maintained. 2. Initial Screening of Health Care Workers a. Initial tuberculosis screening evaluation, periodic screening and follow-up are provided at no cost to employees through Employee Health. b. An initial two-step TST is required of all new employees at the time of employment. Two step testing is used to detect boosting phenomena that might be misinterpreted as skin test conversions. c. If documentation is provided to Employee Health that the employee has had a negative skin test within the past twelve (12) months, that test may be utilized as the initial step in the two-step testing procedure. d. Interferon-Gamma Release Assay (IGRA) such as QuantiFERON TB Gold (QFTG) testing may be performed on employees. e. Exempt HCWs with a history of a positive TST, adequate treatment for disease, or adequate preventive therapy unless they develop signs or symptoms suggestive of TB. f. Information on TST and results is periodically summarized by the Employee Health Department and presented to the Infection Prevention and Control Committee. g. This information is used to assess the efficacy of the respiratory protection program and to assess the incidence of unknown exposures which lead to skin test conversions. h. Employees are determined to be in high risk or non-risk categories of potential TB exposure depending on the expected level of contact with TB patients and the expected duties performed within the employees' job classification.

14 i. These employees perform or are present during high-hazard procedures such as cough-inducing procedures, Bronchoscopy Procedures, and Respiratory Therapy procedures (sputum induction). j. Employees of SMC in high risk areas will receive TST annually. k. Employees whose normal job duties do not place them in high risk category, but who at some point, have participated or been present in a high-hazard task will be temporarily considered high risk for that period of time. 3. Evaluation and management of health-care workers with positive TST. a. If a HCW's TST converts to positive, Employee Health will evaluate personnel individually to determine the likely means of exposure. b. The drug susceptibility pattern of the M. tuberculosis of known source patients should be determined if possible in order to determine appropriate preventive therapy for the HCW with the TST conversion. c. Employees with new significant TST reactions will be referred to the Mobile County Health Department for further evaluation and treatment; if necessary. d. HCWs with positive TST shall have a chest radiograph as part of the initial evaluation of their TST; repeat chest radiographs are not needed unless symptoms develop that may be due to TB. e. Employees who have previously documented positive TST results will be periodically evaluated by Employee Health. Annual evaluation forms with signs and symptoms must be completed by the employee. f. TST conversions that are determined to be occupationally related are recorded on the OSHA Log. g. All HCWs, including those with a history of a positive TST, should be reminded periodically that they should be evaluated promptly for any pulmonary symptoms suggestive of TB. 4. Work Restrictions. a. Active TB 1. Any HCW with persistent cough (>2 weeks duration), especially in the presence of other symptoms or signs compatible with TB, such as weight loss, night sweats, bloody sputum, anorexia, or fever, shall be evaluated promptly for TB. 2. HCWs with pulmonary or laryngeal TB shall be excluded from work until medical clearance. 3. Before returning to work, the HCW shall provide proof of: a. Receiving adequate therapy. b. Three consecutive daily negative sputum AFB smears. c. That the cough is resolved. 4. After work duties are resumed and while the HCW remains on antituberculosis therapy, the HCW shall provide proof that they are: a. Maintained on effective drug therapy for the appropriate time period b. Remain AFB sputum smear negative. 5. HCWs 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.

15 XV. 6. HCWs with TB who discontinue treatment before the recommended course of therapy has been completed shall be excluded from work until: a. Treatment is resumed b. Adequate response to therapy is documented c. Again have negative sputum smears on three consecutive days. 7. Employee Health will be advised confidentially of the TB diagnosis and shall verify the appropriateness of the treatment and monitor symptoms and job duties. b. Latent TB 1. HCWs receiving preventive treatment for latent TB infection shall be allowed to continue usual work activities. 2. HCWs with TB infection who cannot take or do not accept or complete a full course of preventive therapy shall not be excluded from work, but they shall be counseled about the risk of developing active TB and shall be instructed on a regular basis to seek evaluation promptly if symptoms develop that may be due to TB, especially if they have exposure to high risk patients (i.e., patients at high risk for developing TB if they become infected with M. tuberculosis, such as patients who are HIV infected). PROBLEM EVALUATION A. Investigating TST Conversions and Active TB in HCWs 1. Administer TST to HCWs in the same area or group who may have had similar exposure to determine if there is additional evidence of transmission. 2. The contact investigation will extend to possibly exposed patients, if indicated. 3. Initiate problem evaluation, if indicated. If a problem with patient detection, TB isolation practices, or environmental controls are identified, implement the appropriate interventions and follow the high-risk protocol until there have been two consecutive three-month periods with no evidence of transmission. 4. Continue following the high-risk protocol in that area and consult with the public health department or other persons with expertise in TB control, if no specific problem can be identified. 5. Improve environmental controls as needed if transmission appears to be occurring in TB isolation or procedure rooms. 6. Take the following steps if a HCW develops TB: a. Perform contact investigation that includes HCWs, patients, and visitors who had significant exposure to the HCW. b. Immediately notify the public health department for consultation and to allow for investigation of community contacts not exposed in the healthcare facility. c. The public health department is to notify facilities when HCWs with TB are reported by physicians so that appropriate contact investigation can be done in the facility. Sharing of such information is by law strictly limited to a need to know basis in order to protect the HCW. B. Investigating Possible Patient to Patient Transmission of TB 1. Conduct surveillance of active TB cases in patients. If surveillance suggests the possibility of patient-to-patient transmission, such as:

16 a. High proportion of TB patients had prior admission in the past year b. Sudden increase in patients with drug-resistant TB c. Multiple patients with identical and characteristic drugsusceptibility or DNA fingerprint patterns take the following steps: 2. Review HCW TST and patient surveillance data for the suspected areas to detect additional patients or HCWs with TST conversions or active disease. 3. Look for possible exposures of the new TB patients to other patients with TB during prior admissions: a. Admitted to same room or area b. Received same procedure c. Were in same treatment area on the same day. 4. Take the following steps if the above suggests transmission has occurred: a. Conduct a problem evaluation to determine possible causes of the transmission: 1. Problem with patient detection 2. Problem with institutional barriers to implementation of appropriate Airborne Precautions practices 3. Problems with environmental controls b. Determine which additional patients or HCWs may have been exposed and evaluate with TST. c. Consult with the public health department for assistance in community contact investigation. C. Investigating contacts of persons with TB who were not recognized and isolated appropriately 1. Take the following steps when a patient is seen in the institution without being recognized as having TB and promptly isolated, but is subsequently diagnosed as having infectious TB: a. Identify HCWs and other patients who were exposed to the patient 1. Interview patient and appropriate personnel 2. Review patient's medical record to determine which areas and persons may have been exposed to the patient prior to appropriate isolation, such as 3. Outpatient clinics 4. Hospital rooms 5. Treatment, radiology and procedures areas 6. Persons providing direct care 7. Other personnel such as therapists, clerks, transportation personnel, environmental service, social workers b. Contact investigation follows a concentric circle, expanding from closest, to less close contacts, if transmission to the former is found. c. Administer a TST to all HCWs and patients with documented exposure as soon as possible after exposure. d. If initial test is negative, a second test should be administered 8-12 weeks after the exposure was terminated. e. Promptly evaluate exposed persons with TST conversion or with symptoms suggestive of TB clinically and with chest radiographs.

17 f. Persons with previously known positive TST who have been exposed to an infectious patient do not require a repeat TST or a chest radiograph unless they have symptoms of TB. g. Conduct an investigation to determine why TB was not recognized in the patient or, if recognized, why the patient was not isolated promptly so that appropriate protective actions could be taken. XVI. COORDINATION WITH PUBLIC HEALTH DEPARTMENT A. Report suspected/diagnosed TB cases, when known, to facilitate appropriate community contact investigation, follow-up and continuation of therapy. B. Implement coordinate discharge plan involving patient, HCW and Health Department. C. The confidentiality of HCW will be maintained as prescribed by state and local laws. D. Appropriate contact investigations or patients and HCW's with active TB will be coordinated by health care facility and Health Department. E. Forward all AFB and sputum smear/culture results to Health Department as they become available. F. Health Department may provide assistance to facilitate in planning and implementing TB control programs, TB screening, outbreak investigations or engineering expert referral. XVII. ADDITIONAL CONSIDERATION FOR SELECTED AREAS A. Operating Rooms 1. Elective procedures on patients with TB should be delayed until the patient is no longer infectious. 2. If procedures must be performed, they should be done in OR rooms with door closed and traffic at a minimum. 3. Procedures should be done when other patients are not present in the operating suite (e.g., end of day) and when minimum number of personnel is present. 4. This applies to pulmonary and non-pulmonary sites. 5. A bacterial filter placed on the patient endotracheal tube or at the expiratory side of the breathing circuit of the anesthesia machine may be useful in reducing the risk of contamination of anesthesia equipment or discharge of tubercle bacilli into the ambient air when anesthesia is being administered to a patient with possible TB. 6. The pulmonary TB patient should be monitored during recovery in the Recovery Room meeting TB isolation room ventilation requirements. 7. Personnel present when operative procedures are performed on patients who have infectious TB should wear N-95 respirators rather than standard surgical masks alone. B. Autopsy 1. Autopsies are not performed at SMC. C. Emergency Medical Services 1. When emergency medical response personnel or others must transport patients with confirmed or suspected active TB, a surgical mask should be placed on the patient. 2. Because of the inability to ensure administrative and environmental controls in emergency transport situations and vehicles, the HCW should wear respiratory protection.

18 3. Emergency-response personnel should be included in a comprehensive TST screening program. 4. They should also be included in the follow-up of contacts of a patient with infectious TB. D. Laboratories 1. Laboratories processing specimens for mycobacterial studies (e.g., AFB smears and cultures) should conform to criteria previously specified by CDC/NIOSH Biosafety in Microbiological and Biomedical Laboratories. 2. The laboratory director is responsible for the determination and documentation of the appropriate Biosafety level required by the activities and occupational hazards in the laboratory and the maintenance of the appropriate associated safety compliance procedures. 3. Specific laboratory workplace control measures to prevent or minimize occupational exposure to TB. 4. Laboratory waste contaminated with M. tuberculosis is decontaminated prior to leaving the laboratory then incinerated.

19 Appendix 1

20 Appendix 2