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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).

Hazards found in a Tuberculosis Area Air Intake Duct Door Warning Sign Negative Pressure Switch Housekeeping Practices Exposure Control Plan PPE/N95 Respirator Disposal Container for Reusable Respirator Respiratory Protection Program Combined Tasks Filtered/Clean Air Ductwork Hepa Filter  Warning Label for Contaminated Air Contaminated Air Ductwork Employee Servicing System Employee Servicing System

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


 

Identification , Screening, Medical Surveillance

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. 

 

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.

 

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.
  • 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.
  • Doors should be kept closed except for the purpose of entering or exiting to help maintain negative pressure in room.
  • Access to these rooms could be limited to specific employees.
 

  • Tasks could be combined 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.
  • Air intake ducts should not be located by the door.
  • Negative pressure must be checked daily to assure that HEPA filters and other devices used in isolation rooms function effectively.
  • Isolation room air should be vented to the outdoors away from intake vents and employees. If the air from these areas cannot be vented to the outside, HEPA filters must be used to filter air before it can be recirculated back into other areas of the facility.

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).

 

 

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

Communication of Hazards: Warning Signs and Tags

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:

  • 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)].
    • 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.
  • 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)].
  • Example wording for warning label: "Contaminated Air--Respiratory Protection Required."

 

 

Training and Education

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

 

Respiratory Protection

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)]. 

  • 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.
  • Requirements for a minimal acceptable program are found in 1910.139(b), and include:
    • 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. 
      • 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.
  • Standard operating procedures for storing, reusing, and disposing of respirators [1910.139(f)].
  • 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 [1910.139(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.

Additional Information

 

 

Housekeeping/Cleaning

Hazard

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.

 

 

Recordkeeping

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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