NORTHERN ZONE SAN MATEO COUNTY FIRE AGENCIES (Brisbane, Colma, Daly City, Pacifica and San Bruno) EMS - POLICY MANUAL

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1 POLICY STATEMENT Purpose: To provide a comprehensive exposure control plan which maximizes protection against occupational exposure to tuberculosis/respiratory conditions for all members of the Northern Zone, San Mateo County Fire Agencies, and the public we serve. Scope: This policy applies to all personnel who have a potential for occupational exposure to Tuberculosis and specific identified respiratory syndromes such as SARS (Severe Acute Respiratory Syndrome). Northern Zone Fire Agencies recognize that employees providing prehospital emergency medical care may be exposed to patients who have tuberculosis/or other diseases spread by respiratory transmission. The goal of this program is to provide all personnel with the best available protection from occupationally acquired tuberculosis. Northern Zone Fire Agencies have established a written Tuberculosis/Respiratory Exposure Control Plan. Sections not found in this policy but needed for clarification and/or compliance can be found in the existing Communicable Disease Policy, EMS PO 1-1. Northern Zone Fire Agencies have developed this policy with information obtained from the Occupational Safety and Health Administration, U.S. Department of Labor, Department of Industrial Relations, and the Occupational Safety and Health Administration, State of California. This organized group of fire agencies will develop plans leading to compliance for any deficient areas identified by this program. Although this policy contains specifics for Tuberculosis, its intended use is for all respiratory means of transmission contact. Therefore, follow the reporting requirements for suspected respiratory contact transmissions. IMPLEMENTATION This Tuberculosis/Respiratory Exposure Control Plan is applicable to all personnel providing fire, rescue or emergency medical services, effective November 1, It consists of a policy statement, TB definition, employee TB surveillance, criteria for determining suspected active TB patients, methods of exposure control, disposal procedures, post-exposure DATE 11/01/98 DATE 11/10/2010 PAGE 1 of 11 EMS PO 1-2

2 management/evaluation and follow-up, training and recordkeeping, and additional definitions. This plan will be reviewed annually and updated as needed. DEFINITON OF TUBERCULOSIS General: Tuberculosis ( TB ) is a disease caused by a bacterium called Mycobacterium Tuberculosis. TB bacilli are spread from person to person by means of airborne particles, called droplet nuclei, which can be generated when persons with infectious TB sneeze, cough, speak or sing. The particles are so small (1-5 microns in diameter) that normal air current can keep them airborne for hours, and can spread throughout a room or building. Infection occurs when a susceptible person inhales droplet nuclei containing TB bacteria, and the bacteria become established in the lungs and then spread throughout the body. Two to ten weeks after initial infection with droplet nuclei containing TB bacteria, the body s immune response usually limits further multiplication and spread of TB bacteria. However, in a small proportion of cases (usually 1%), initial infection rapidly progress to clinical illness or active. For another group (approx. 5-10%), active TB develops after an interval of months, years or decades. The risk of progression to active TB is markedly increased for persons infected with the Human Immunodeficiency virus (HIV). Although there are some situations in which active TB cases are not infectious, it should be presumed that any active TB case is infectious unless there is evidence to the contrary. TB SURVEILLANCE Class A Exposure Risk employees shall be provided with a TB skin test at hire and at least every six months. The following job classifications have been identified as having potential occupational exposure risk: Firefighter Firefighter/Paramedic Fire Engineer Fire Captain DATE 11/01/98 DATE 11/10/2010 PAGE 2 of 11 EMS PO 1-2

3 Class B Exposure Risk employees shall be provided with a TB skin test at hire and at least every 12 months. The following job classifications have been identified as having limited potential occupational exposure risk: Fire Chief Battalion Chief Fire Marshal Fire Education Specialist EMS Coordinator Training Chief Class C Exposure Risk persons shall show evidence of a TB skin test within the last 12 months. The following persons have been identified as having some potential temporary occupational exposure hazard: Persons participating in Fire Agency Ride-Along programs If there is documentation of a previous positive TB skin test for the employee, additional tests need not be provided. Each Northern Zone Fire Agency shall ensure that: 1. All TB skin tests are administered by a licensed healthcare professional in accordance with the recommendations of the U.S. Public Health service current at the time the TB skin test is administered. Paramedics who have been trained by Seton s Occupational Health Nurse and who have received a certification shall be recognized to observe skin tests. Licensed and certified paramedics will observe all skin test reactions for zero induration within hours. All employees who have skin tests other than zero induration will be immediately referred to Seton Medical Center occupational health. 2. Written notification of the TB skin test results, and its interpretation, are promptly provided to each employee tested. Notification shall include the following statement: HIV infection and other medical conditions may cause a TB skin test to be negative even when TB infection is present. 3. Anergy testing is provided on request, or when medically indicated, to any employee who receives a negative TB skin test result. DATE 11/01/98 DATE 11/10/2010 PAGE 3 of 11 EMS PO 1-2

4 IDENTIFICATION OF TB PATIENTS Confirmed Active TB Patient: If a patient, family member, treating facility, convalescent hospital, or other healthcare facility offers verbal or written information indicating active TB, the patient shall be considered a confirmed active TB case. Suspected Active TB Patient: Any person complaining of a productive cough or over two weeks duration accompanied by any of the following secondary symptoms 1. fever 2. chills 3. night sweats 4. lethargy or weakness 5. loss of appetite 6. weight loss 7. coughing up blood DATE 11/01/98 DATE 11/10/2010 PAGE 4 of 11 EMS PO 1-2

5 Methods of Exposure Control The following procedures shall be adhered to during every pre-hospital emergency medical response when there is a risk of exposure to confirmed or suspected active TB patient. Disposable gloves shall be worn prior to making patient contact. NIOSH-approved N-95 or HEPA filtered air purifying respirator/mask or higher level of respirator/mask or higher level of respiratory protection shall be worn in the following conditions: 1. When performing any high-risk procedure on a suspected or confirmed active TB patient or when in a room where such a patient is undergoing a high-risk procedure. High-risk procedures include the following: endotracheal intubation bag-valve-mask ventilation suctioning aerosolized inhalation treatment any other respiratory care procedure which can aerosolize TBcontaminated fluids 2. While occupying rooms with suspected or confirmed active TB patient and if in a room which had been occupied within the past hour. 3. When in the presence of an unmasked suspected or confirmed active TB patient. 4. When transporting a suspected or confirmed TB active patient in an ambulance unless the patient is masked and the required ventilation method is achieved. The patient compartment must have a negative atmospheric pressure as well as being able to dilute and remove the contaminated air. DATE 11/01/98 DATE 11/10/2010 PAGE 5 of 10 EMS PO 1-2

6 Suspected or confirmed active TB patients without respiratory difficulties should be asked to wear a surgical mask to prevent droplet generation from coughing and sneezing. Such patients should be provided with tissues and instructed to cover their mouth and nose when coughing or sneezing if they find it necessary to temporarily remove the surgical mask to clear their airway. Additional disposable personal protective equipment (eye and face protection, gowns, and gloves) shall be worn if the tasks being performed and situation indicates. If a suspected or confirmed active TB patients are in closed rooms, ventilation should be increased by opening door, windows and possibly forced ventilation as well. Disposal Procedures The Center of Disease Control has indicated that once impacted on a HEPA respirator, biological particles are not readily returned to the air, thus respirator filters can remain safe and functional for weeks to months. However, it will be the policy of each Northern Zone Fire Agency to dispose of the HEPA respirator after use. Disposal of used HEPA respirators shall be according to procedures outlined in Bloodborne Pathogen Exposure Control Plan. POST-EXPOSURE MANAGEMENT, EVALUATION AND FOLLOW-UP GENERAL: In addition to the procedures and guidelines of the Exposure Control Plan, the following procedures and guidelines will also be followed when a possible TB exposure incident has occurred. Definition of an Substantial Exposure Incident: An event in which an employee sustains substantial exposure to a confirmed active TB patient, or to a suspected active TB patient which is later confirmed by the receiving hospital, without the usage of all applicable exposure control measures required. In determining whether the event involves substantial exposure, the following factors shall be taken into account: DATE 11/01/98 DATE 11/10/2010 PAGE 6 of 10 EMS PO 1-2

7 1. The infectiousness of the patient; 2. Proximity of the employee to the patient; 3. The extent to which the employee was protected from exposure; and 4. The length of the exposure event. Initiating the Reporting Process; The immediate supervisor shall be notified as soon as possible after the exposure incident. The following steps will be taken; 1. The immediate supervisor will notify the Exposure Control Officer and the Battalion Chief or his/her Fire Department designee. 2. The immediate supervisor will utilize the Procedure for Determining Exposure for medical follow-up if the criteria are met; and 3. Complete an Exposure Incident Report Form EMS-501 (copy of form follows on next page) PROCEDURE FOR DETERMINING EXPOSURE The following procedure shall be utilized for determining exposure levels so that the appropriate medical evaluation and follow-up can be initiated. 1. Exposure Level Determination: Level 3 Exposure: Level 2 Exposure: Level 1 Exposure: High Risk for transmission. Any substantial exposure incident in which personnel are subjected to confined atmospheres where persons with suspected or confirmed active TB, are present. Any incident in which the employee feels an exposure potentially occurred but does not meet the criteria of a Level 2 Exposure. This is an optional requirement. DATE 11/01/98 DATE 11/10/2010 PAGE 7 of 11 EMS PO 1-2

8 MEDICAL EVALUATION AND FOLLOW-UP 1. The immediate supervisor will determine the appropriate exposure level using the definitions outlined above and shall take following actions: Persons who meet the criteria for a Level 2 Exposure shall have immediate medical evaluation at the request of the receiving hospital physician no later than 72 hours after discovery of the condition. Persons who meet the criteria for a Level 2 Exposure will not have immediate medical follow-up unless so directed by a receiving hospital physician or upon the recommendation of the County Health Officer. 2. Any employee who exhibits a TB skin test conversion as a result of an occupational exposure shall be provided with medical evaluation for TB and, where medically appropriate, preventive therapy for TB. 3. Any employee known to have been subject to an occupational exposure incident shall be provided within one week from the date of the exposure incident and again 12 weeks after the exposure incident, medical evaluation for TB and, where medically appropriate, a TB skin test and preventive therapy for TB. 4. Each Northern Zone Fire Agency shall ensure that all employees who undergo preventive therapy for TB are provided all medical evaluation and services necessary to complete therapy. TRAINING All employees of the Northern Zone Fire Agencies shall be provided TB prevention training before assignment to work which is reasonably anticipated to involve exposure to a TB patient, and repeat training at least annually. TB prevention training program shall be conducted utilizing the following curriculum: 1. Appropriate in content and vocabulary for the level, skills, and ability of the employees; 2. An opportunity for interactive questions and answers with the person conducting the training; DATE 11/01/98 DATE 11/10/2010 PAGE 8 of 11 EMS PO 1-2

9 3. Identification of individuals at increased risk for TB, especially those with HIV infection; 4. Modes of TB transmission and the differences between TB infection and disease; 5. Symptoms and consequences of TB; 6. Explanation of this TB Exposure Control Plan, including employer/employee responsibilities, and procedures to prevent TB exposure; 7. Use and limitations of all methods utilized to prevent TB exposure; 8. TB surveillance, including the criteria used to determine whether a TB skin test result is positive, and the effect of HIV infection and other medical conditions on the interpretation of the result; and 9. Preventative therapy, medical treatment, the difficulty of treating drug-resistant TB, and the role of incomplete medical treatment in the development of drug-resistant TB. Respirator training shall consist of at least the following: RECORDKEEPING 1. The use and limitations of the N-95 or HEPA respirator 2. How to wear, adjust, and determine proper fit of the designated respirator 3. Each employee shall complete and pass a documented fit test conducted by a trained fit-tester using approved testing procedures. Sales Representatives from ProMedix (phone # ) can perform fit testing. Paramedic Coordinator shall ensure that Seton Medical Center -Employee Occupational Health* documents all TB skin test, including; 1. The name or other identifier of the person tested; 2. The date of the test; 3. The result of the test in millimeters of induration; DATE 11/01/98 DATE PAGE 9 of 11 EMS PO 1-2

10 4. The interpretation of the result. * Seton Medical Center Employee/Occupational Health Department 1900 Sullivan Avenue, 8 th floor Daly City, Ca (650) Fax (650) Each Northern Zone Fire Department shall document the following and forward to North Zone Paramedic JPA Coordinator: 1. All exposure incidents, including: the name or other identifier of the employee exposed; the date and location of the incident; a detailed description of the incident; all follow-up evaluation and treatment; and, steps taken to prevent such incidents in the future. 2. All training, including the employee s name, training dates, and training provider; 3. Employees HEPA respirator fit test record and respiratory questionnaire. Training documentation shall be maintained for at least three years. TB skin test conversions from known TB skin test negative to positive and diagnosed cases of TB shall be recorded on the log of occupational injuries and illnesses (Cal/OSHA 200 Log). All documentation required shall be made available promptly upon request to the Cal/OSHA, the California Department of health Services and the NIOSH for examination and copying. ADDITIONAL DEFINITIONS ANERGY TESTING: A skin test to assess the competence of the body s immune system by evaluating delayed-type hypersensitivity. The test shall include mumps and at last one additional DTH skin test antigen, unless an equally effective testing procedure is used. DATE 11/01/98 DATE 11/10/2010 PAGE 10 of 11 EMS PO 1-2

11 HEPA ( High Efficiency Particulate Air ): percent efficient against 0.3-micrometer monodisperse particles. HIV: The human immunodeficiency virus, the cause of Acquired Immudondeficiency Syndrome (AIDS). LICENSED HEALTHCARE PROVIDER: A person whose legally authorized scope of practice allows him or her to provide the medical evaluation or preventive therapy. SOURCE CASE: Either a suspect or confirmed active TB case. DATE 11/01/98 DATE 11/10/2010 PAGE 11 of 11 EMS PO 1-2