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The Center for Disease Control and Prevention (CDC) has identified nursing homes and long-term care facilities as a high risk setting for exposure to Tuberculosis (TB). In 1990, the CDC found that the risk of TB infection for nursing home employees was three times higher than the rate experienced for other employed adults of similar age, race, and sex. *Note OSHA is currently involved with rulemaking for Tuberculosis
which may influence the following recommendations (OSHA Unified
Agenda).
Common
safety and health topics:
For additional information:
Exposure
Control Plan (ECP)
TB disease in persons over the age
of 65 constitutes a large proportion of TB cases in the United States. Many of these
individuals have latent TB infection; however, with aging these individuals' immune
function starts to decline, placing them at increased risk of developing active TB
disease, and employees in long-term care facilities at an increased risk of occupational
exposure to TB. |
Hazard
Exposure to Mycobacterium Tuberculosis
due to an effective ECP:
Mycobacterium Tuberculosis: TB is caused by the bacteria Mycobacterium
tuberculosis and is spread by airborne droplets generated when a person
with TB disease coughs, speaks, sings, sneezes, etc. Infection occurs when a susceptible
person inhales droplet nuclei containing the bacteria, which then become established in the
body.
Example Controls
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Exposure
Control Plan
(ECP):
Control of exposure to TB can be readily addressed in a
facility's ECP. It is recommended employers identify employees with occupational exposure to TB and
develop an Exposure Control Plan to help prevent exposure to TB in their specific
facilities.
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Nursing homes or long-term care facilities for the elderly have been identified by the CDC and OSHA as having a high-risk situation for the
transmission of TB.
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To assist employers in establishing a baseline risk
assessment for TB in a particular facility the CDC offers:
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Identification
, Screening, Medical Surveillance
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Hazard
Exposure to TB because
of ineffective
Example
Controls
Screening
of Residents: Promptly implementing early screening or other
practices allows for early identification of residents with TB or suspected TB so that
appropriate controls can be initiated before occupational exposure
occurs.
Medical
Surveillance of employees: OSHA requires medical surveillance for all those employees who have occupational exposure
to TB. Medical surveillance includes: employee medical evaluation and management,
post-exposure follow-up and administering periodic and baseline TB skin testing. Only skin
testing is addressed here.
- TB
Skin Testing:
- Mantoux tuberculin skin test detects TB infection which help 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 to yearly,
for intermediate or low risk facilities.
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Isolation |
Hazard
Exposure to TB because:
- Failure to promptly isolate and mask those
patients with suspected infectious TB.
- Adequate transfer procedures were not provided and/or used.
Example Controls
Provide adequate isolation for those
patients with TB or suspected TB.
Isolation of patients who have suspected or
confirmed TB is required by OSHA [OSHA Directive CPL
2.106
(1996, February 9)].
Transferring of patients:
Facilities who have determined a patient 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.
- The facility's exposure control plan needs to have
in place procedures for transferring such individuals.
Proper precautions must be taken before transfer
takes place, 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.
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Isolation Rooms |
Hazard
Exposure to TB because of isolation room
failure:
- Equipment failure, not working properly.
- Isolation doors left open or excessive traffic in room.
Example
Controls
Facilities that choose to provide service
to residents with TB or suspected TB, need to provide appropriate isolation
rooms [ OSHA Directive CPL
2.106
(1996, February 9)]:
- Facilities must use Acid-fast bacilli (AFB) isolation rooms.
Additional Information:
In September of 1999, the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) Committee on Healthcare Safety recommended
that JCAHO update its Environment of Care Standard for Utility
Systems Management, including the
Comprehensive Accreditation Manual for Long Term Care to include and address issues of improperly designed and
maintained ventilation systems. (including inappropriate
pressure relationships, air exchange rates and filtration
efficiencies).
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Warning
Signs and Tags |
Hazard
Exposure to TB because of inadequate signs or labels,
such as:
- Isolation and treatment rooms not labeled properly.
- Exposure to TB through unlabeled contaminated
ducts, fans, filters.
Example Controls
Enforcement
Procedures and Scheduling for Occupational Exposure to Tuberculosis
[OSHA Directive CPL 2.106 (1996, February 9)].
Employees should 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 should be posted at the
entrance to:
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- Rooms or areas used to isolate an individual with
suspected or confirmed infectious TB (TB isolation rooms for
example).
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- Rooms or areas where procedures or services are
being performed on an individual with suspected/confirmed TB.
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- 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)].
- CDC's
recommendations specify that 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.
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- 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 (1996, February
9)].
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- Example wording for warning
label: "Contaminated Air--Respiratory Protection Required."
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Training and Education
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Hazard
Exposure to TB due to
lack of training or education (employees are not aware of the tasks or
procedures that may involve risks of exposure to TB).
Example Controls
Employers must train employees regarding the tasks that may involve risk of occupational exposure
to TB and plan for methods to control these hazards [Enforcement
Procedures and Scheduling for Occupational Exposure to Tuberculosis
OSHA Directive CPL 2.106 (1996, February 9)] For example:
- The employee needs to be educated about the risks
associated with transporting a patient with infectious TB.
- If transporting the
patient outside the facility (e.g. in an ambulance), the patient
should be instructed to wear a mask, and personnel transporting
the patient should wear respiratory protection.
Additional Information
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Respiratory Protection
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Hazard
Exposure to TB due to:
- Improper use or fit of
respirator, or improper reuse of damaged or
soiled respirators.
- Ineffective respiratory protection program.
Example Controls
Employees must be protected from
exposure to the exhaled air of an individual with suspected or confirmed
TB. [1910.139]. Note: OSHA only issues citations when a TB hazard is
present, not for the absence of a certain means of control.
Respiratory Protection for M. Tuberculosis states that the employer
is responsible to establish and maintain a complete respiratory protection
program that assures
respirators are properly selected, fitted, used, and maintained and
updated as necessary [1910.139(a)(2)].
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- Employees must wear a NIOSH approved high efficiency particulate air
(HEPA)
filtered respirator, or Class N95 or more protective respirator
whenever the employee:
- Enters an AFB isolation room or area in use for TB
isolation.
- 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.
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- Requirements for a minimal
acceptable program are found in 1910.139(b),
and include:
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Employee instruction on
correct fit and use of respirators [1910.139(e)(5)(i)].
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.
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Fit
Testing is covered in the OSHA Technical Manual. Employees
must be fit tested before using their respirators and whenever
a change occurs (i.e., different size, model, or respirator
design or facial shape).
- Providing respiratory
protection for persons who wear glasses may be a problem; a
proper seal must be maintained [1910.139(e)(5)(ii)].
- Respirators
cannot be worn with facial hair which
interrupts the facial seal.
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- Standard operating procedures for
storing, reusing, and disposing of respirators [1910.139(f)].
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- 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.
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Respirators shall be regularly cleaned and disinfected. Those
used by more than one worker shall be thoroughly cleaned and
disinfected after each use [1910.139(b)(5)].
- Disposable respirators
can be reused (by the same HCW), as long as the functional and
structural integrity of the respirator is maintained. The
outside of the filter material should be inspected before each
use:
- If the filter
material is physically damaged or soiled, the filter should
be changed or discarded.
- According
to the CDC, health care facilities policies should specify
whether cleaning or sterilizing an item is necessary to
decrease the risk for infection.
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Additional
Information
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Housekeeping/Cleaning
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Hazard
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Exposure to TB
through improper housekeeping or venting procedures when cleaning TB
contaminated rooms. |
Example
Controls
CDC, Supplement
5-Decontamination-Cleaning, Disinfecting, and Sterilizing
(1994) describes appropriate cleaning practices when
cleaning the room of a person who has infectious TB.
- Normal cleaning procedures
can be used, (i.e., an EPA approved germicide/disinfectant. It does not need to be tuberculocidal for routine cleaning of a TB isolation
room).
- Personnel should
follow isolation practices and wear a Class N95 or more protective
respirator, while
cleaning rooms of an infectious patient.
- After the room is vacated by
an infectious patient, the precaution sign must
remain posted at the entrance to the room, and respirators must be used if entering the
room, until the area is ventilated for the time necessary, using the CDC's
recommendations, for removal efficiency of 99.9%.
- For final cleaning of the isolation room after a
patient has been discharged, PPE is not necessary if the room has been ventilated for the
appropriate amount of time.
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Recordkeeping
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Hazard
Exposure to TB
because exposure conversion trends are not being monitored.
Example Controls
Comply with OSHA
Recordkeeping Standards:
- 1904, Recording and Reporting
Occupational Injuries and Illnesses.
- OSHA 200 Log-Tuberculosis infection and active
tuberculosis disease are recordable illnesses on the OSHA 200
log, because nursing home employees have a presumption of
work-relatedness to TB infection.
- 1910.1020, Access to Employee
Exposure and medical records, (prior designation 1910.20).
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