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TB Infectious Control

TB Infectious Control

Policy

It shall be the policy of this agency to adhere to the OSHA standards related to respiratory protection and the current CDC guidelines for tuberculosis infection control.

The agency does not admit TB patients to service and per CDC guidelines considers to be at low to medium risk.  Yearly the agency as part of the annual evaluation and Infection control assessment will re-evaluate the risk based on current CDC guidelines, the risk definitions below and the local health department TB reported statistics.  This evaluation will determine if the policy requirements for employee TB testing will be adjusted.

Purpose:         

This plan is designed to prescribe practices relating to the management of Mycobacterium Tuberculosis to minimize the risk of exposure and transmission of this disease to home care staff, patients, and others.  It shall be available for review by all staff.

Definitions:

  1. High Risk:
    1. The Agency PPD test conversion rate is significantly greater than previous conversion rates and epidemiological investigation suggests agency-acquired transmission or M. Tuberculosis, or
    2. A cluster of PPD conversions has occurred and epidemiological investigation suggests Agency acquired transmission of M. Tuberculosis, or
    3. Evidence of ongoing transmission of M. Tuberculosis.
  1. Intermediate Risk:
  1. The Agency cares for three (3) or more TB patients per year,
  2. The PPD test conversion rate is the same as previous conversion rates for the Agency,
  3. No clusters of PPD test conversions have occurred, and
  4. No person-to-person transmission of M. Tuberculosis has been detected.
  1. Low Risk:
  1. The Agency cares for less than three (3) TB patients per year,
  2. The PPD test conversion rate is the same as previous conversion rates for the Agency,
  3. No clusters of PPD test conversions have occurred, and
  4. No person-to-person transmission of M. Tuberculosis has been detected.
  1. Very Low Risk:
  1. The Agency does not admit patients with active TB; patients who may have active TB are referred to a collaborative agency, and
  2. The Agency provides services to communities of counties where TB cases have been reported during the previous year.
  1.  Minimal Risk:
  1. The Agency does not admit TB patients; patients who may have active TB are referred to a collaborative agency and
  2. The agency provides services to communities or counties where no TB cases have been reported during the previous year.

Procedures and Responsibilities:

  1. The administration of this plan shall be the responsibility of the Agency Administrator and/or the most appropriate designee.
  2. The agency will follow current CDC guidelines for TB monitoring & testing.
    1. The 2-step Mantoux PPD test shall be required for all Agency field staff with patient contact upon hire (or a negative 2-step test completed within 12 months of hire) and a TB questionnaire every year unless they have a positive result from the Mantoux test, in which case a chest x-ray is conducted.  Following CDC guideline, no follow-up chest X-Ray is required, only an annual TB Verification/Attestation/ TB questionnaire
  3. Agency staff and patients will be screened for exposure to TB.
    1. All Agency staff members who have not previously converted to a positive Mantoux PPD will be screened for exposure to TB when being hired and as indicated by CDC guidelines, using the Mantoux 2-step PPD test administered and interpreted by a physician, ARNP, or trained personnel.
    2. If the Agency staff being screened for exposure to TB when being hired does not have documentation of a PPD within the past six (12) months, a 2-step Mantoux test will be administered.
    3. Agency staff members who have converted to a positive Mantoux PPD will not be given a Mantoux PPD test on hire but will be requested to submit a baseline negative chest x-ray report.  The employee will complete a TB assessment and be assessed for symptoms of TB. If symptoms are noted or develop at any time, a chest x-ray will then be obtained. A TB questionnaire will be required every year.
    4. The patient’s physician will be notified immediately when a patient exhibits signs and symptoms of TB on initial assessment to the Agency or at any time during the patient’s admission.
    5. Patients with suspected or confirmed TB will be reported immediately to the local health department.
    6. The population considered at high risk includes the following (CDC definition):
  1. African Americans
  2. Alcoholics
  • Asian and Pacific Islanders
  1. Intravenous
  2. (IV) drug users
  3. American Indians
  • Elderly persons
  • Alaskan Natives
  1. People from areas of the world where TB is prevalent (Asia, Africa, Caribbean)
  2. Hispanics
  3. Persons with pulmonary signs or symptoms
  • Persons with HIV infection or with risk factors for HIV infection
  • People living in the same household as members of these groups
  • Current or past inmates

 

Policies for Care of Patients with Suspected TB Infections

  1. Home care for patients with suspected TB infections shall provide for early identification of active TB.  Symptoms include, but are not limited to the following:
    1. productive cough
    2. coughing up blood
    3. weight loss
    4. loss of appetite
    5. lethargy
    6. weakness
    7. night sweats
    8. fever.
  2. TB patients are not admitted to our Agency.  If a patient’s TB infection is discovered while the patient is receiving services from the Agency, we will continue to care for the patient unless they prefer to be transferred to another Agency.
  3. Care of patients with suspected or confirmed infections shall be available and shall include:
    1. Precautions to prevent exposure until communicability has been eliminated by chemotherapy
    2. Instructing patients to cover coughs and sneezes
    3. Instructing patients who are on TB medications about the importance of taking medications as prescribed unless adverse effects are seen.
  4. Individuals with suspected or confirmed TB should, to the extent possible, be isolated from other residents in an area with the maximum possible ventilation, as follows:
    1. In a facility other than the home, regulations require the isolation of patients in an acid-fast bacilli (AFB) isolation room and, in areas where high-hazard procedures are performed on such individuals, negative pressure and appropriate means to release exhaust must be maintained.
    2. Since this is not possible in the home, the use of an approved particulate respirator is appropriate.
    3. A warning sign should be posted outside of the patient’s room, e.g. “Special Respiratory Isolation” or “AFB Isolation” or a description of the necessary precautions.
  5. The Agency shall make provisions for the performance of instructions regarding cleaning, disinfecting, or sterilizing as follows:
    1. Generally, critical items should be sterilized (needles, instruments, or items introduced into the bloodstream or sterile areas of the body).
    2. Semi-critical items should be sterilized or cleaned with high-level disinfectants (non-invasive flexible items such as stethoscopes or BP cuffs).
    3. Non-critical items should be cleaned with detergents or low-level disinfectants (crutches, bed boards, nursing bags, etc.)
    4. The selection of chemical disinfectants depends on the intended use, the level of disinfection required, and the structure and material of the item to be disinfected.

Policies for Care of Staff with Suspected TB Infections

  1. The Agency shall manage staff with newly recognized conversions or a positive Mantoux PPD, and staff diagnosed with active TB.
    1. Agency staff who convert or who test positive on the Mantoux PPD test shall:
  1. Be requested to obtain a chest x-ray to determine if clinically active TB is present.
  2. If symptomatic, the staff will be excluded from work until a physician’s written statement of non-infectious status is obtained.
    1. When the Agency has staff with newly recognized conversions or a positive PPD:

The positive Mantoux PPD, medical evaluation, and treatment will be documented in the staff member’s employee medical record.

    1. A chest x-ray will be conducted every five years on all employees having a positive Mantoux reading.
    2. When Agency staff members are diagnosed as having active TB the Agency shall:
  1. Exclude the staff member from work until a written statement of non-infectious status from the physician and the staff member has been shown to have three (3) consecutive daily AFB smears that are negative.
  2. When the staff member returns to work, the Agency requires documentation from the staff member’s health care provider that he/she is maintained on effective therapy and remains AFB sputum smear negative.
  • If the staff member discontinues therapy before the course has been completed, they must be excluded from work.
    1. Staff members with active TB sites other than the lung or larynx usually do not need to be excluded from work.
  1. The Agency shall provide training and education of staff.
    1. Agency staff will receive training and education in TB infection control and the use of respiratory protection on hire and annually.
    2. Staff training and education will include:
  1. The basic concepts of TB transmission, pathogenesis, and diagnosis.
  2. The potential for occupational exposure to persons with infectious TB.
  • The principles and practices of infection control reduce the risk of TB transmission.
  1. The purpose of Mantoux PPD testing and the importance of the skin test program.
  2. The principles of preventative therapy for latent TB infection.
  3. The responsibility of the staff member is to seek medical evaluation promptly.
  • The principles of drug therapy for active TB.
  • The importance of notifying the Agency if diagnosed with active TB.
  1. The responsibility of the Agency is to maintain the confidentiality of the staff member who converts or develops active TB.
  2. The higher risk posed by TB to the immune-compromised individual or those with HIV.
  3. education specific to home care:
    1. Cough-producing procedures performed on patients with infectious TB should not be done in the home unless necessary.
    2. Such procedures should be done in a health care facility in a room or booth with the recommended ventilation for such procedures.
    3. If these procedures must be done in a patient’s home, they should be performed in a well-ventilated area away from other household members.
    4. If feasible, the home care staff should consider opening a window to improve ventilation or collecting the specimen while outside the dwelling.
    5. The home care staff collecting these specimens should wear respiratory protection during the procedure.
    6. The home care staff should instruct patients with suspected or confirmed TB to cover their mouths and noses with a tissue when coughing or sneezing.
    7. The home care staff should instruct patients on TB medications and the importance of taking their medications as prescribed.
    8. The home care staff should instruct patients at risk for developing TB in the importance of having pulmonary symptoms evaluated promptly for early detection of and treatment for TB.

Requirements for the Selection and Use of Respiratory Protective Devices

All employees who come in contact with TB or other airborne infectious disease/hazard clients will be fit tested for the OSHA/HEPA mask as follows:

  1. The office will have on hand a (HEPA) Respirator, Model N 95, 9970, or another Disposable.
  2. A sample sensitivity test on a field employee will be conducted to ensure that the Fit test is appropriate for each employee.
  3. A Fit test is conducted as per the manufacturer-recommended guidelines or 3M Respirator Training (see link at bottom of this page) on employees who will be coming in contact with TB  or other airborne infectious disease/hazard clients.  Since the Agency does not admit active TB clients, it is assumed that this will not be a regular occurrence.
  4. Once successful completion is achieved, the respirator fit is deemed adequate.

The agency will have at least one person who has been fit tested to be able to provide care to someone who may be or is positive for TB or other airborne infectious disease/hazard. The agency administration will determine and arrange a site for fit testing of employees as needed.

  1. The Agency shall provide for employee use of a NIOSH-approved N95, or similar respirator equipped with high-efficiency particulate air (HEPA) filters, the minimally acceptable level of respiratory protection.
  2. If disposable respirators are used, their reuse is permitted as long as the respirator maintains its structural and functional integrity.  The Agency must address the circumstances in which a disposable respirator will be considered to be contaminated and not reusable.
  3. Whenever respirators are required to be used, the Agency must have a complete respiratory protection program in place, as follows:
    1. Respirators are recommended under the following circumstances:
  1. When employees enter the homes or rooms of individuals with suspected or confirmed infectious TB disease.
  2. When employees perform high-hazard procedures on individuals who have suspected or confirmed TB disease including, but not limited to:
    1. Aerosolized medication, e.g. Pentamidine.
    2. Sputum induction.
    3. Endotracheal intubation.
    4. Suctioning procedures.
    5. When transporting an individual with suspected or confirmed TB disease in a closed vehicle.
    6. During performance of cough-inducing procedures in a well-ventilated area away from other household members.
    1. The Agency will use only respiratory protective devices certified by NIOSH such as N95 or similar for protection against TB.
    2. Respiratory protective devices used for TB shall meet the following criteria:
  1. They will have a NIOSH filter category rating of 95, 99, or 100.
  2. They will be able to be qualitatively or quantitatively fit-tested to manufacturer’s specifications for most health care workers.
    1. Agency staff will be medically screened for conditions which would prohibit wearing respiratory protection prior to being fit tested.
    2. Field employee will be fit tested prior to use.
    3. Agency staff will be required to wear respiratory protection when entering the homes of patients with suspected or confirmed TB.
    4. Respiratory precautions may be discontinued when the patient is no longer infectious.
    5. Agency staff unable to wear respiratory protection for medical reasons or because they are unable to obtain a proper fit in the fit test will not be assigned to care for patients with suspected or confirmed TB during the time, they are infectious.
  1. The Agency shall provide the wearer of the respirator mask with education and training in:
    1. The need for wearing their respective mask and the potential risks of not wearing it.
    2. How to properly use the respirator mask and the capabilities, and limitations of the mask.
    3. Inspecting, donning, fit checking, and correctly wearing the respirator masks, with the chance to handle it, learn how to don and wear it properly and check its important parts.
    4. The recognition of an inadequately functioning respirator mask.
    5. The manufacturer’s instructions for storage, inspection, cleaning, and maintenance of the respirator masks.
  2. The Agency will evaluate the effectiveness of the respiratory program.
    1. Both the written operating procedures and the administration of the program will be revised as necessary based on the results of the annual evaluation.
    2. The evaluation of the program will include work practices and employee acceptance of the respirator use by eliciting comments about such subjective areas as the comfort of the respirator and its interference with duties.

Protocol for Discard of (HEPA) Respirator mask:

The (HEPA) Respirator mask should be discarded under the following situations:

  1. If the employee can no longer breathe with the mask on.
  2. If the employee can taste or smell unusual chemicals with the mask on.
  3. If the employee notices the mask to be warped, bent, wet, or damaged in any way.
  4. Note:  These masks should be discarded in a double red bag along with other hazardous materials

Fit Testing

Tight-fitting respirators must seal to the wearer’s face in order to provide expected protection. This includes disposable respirators (also called “filtering facepieces”). Therefore, fit testing is required in the US by the Occupational Safety and Health Administration (OSHA) before a user wears a mandatory respirator on the job and must be assessed at least annually. In addition, fit tests should be performed:

  • Whenever a different size, style, model or make of respirator is used.
  • When any facial changes occur that could affect fit, such as significant weight fluctuation or dental work.

OSHA doesn’t require fit test administrators to be certified, just to know how to conduct a test, recognize invalid tests, and properly clean and maintain equipment. There are two kinds of tests: qualitative and quantitative.

Qualitative Fit Test (QLFT)

A qualitative fit test (QLFT) may only be used to fit test:

  • Negative-pressure, air-purifying respirators, as long as they’ll only be used in atmospheres where the hazard is at less than 10 times the permissible exposure limit (PEL).
  • Tight fitting facepieces used with powered and atmosphere-supplying respirators.

QLFT is pass/fail and relies on the user’s senses using one of four OSHA-accepted test agents:

  • Isoamyl acetate (banana smell); only for testing respirators with organic vapor cartridges.
  • Saccharin (sweet taste); can test respirators with a particulate filter of any class.
  • Bitrex® (bitter taste); can also test respirators with particulate filters of any class.
  • Irritant smoke (involuntary cough reflex); only for testing respirators with level 100 particulate filters.

 

Each QLFT method uses seven exercises performed for 1 minute each:

  • Normal breathing.
  • Deep breathing.
  • Moving head side to side.
  • Moving head up and down.
  • Talking.
  • Bending over (or jogging in place if fit test unit doesn’t permit bending at the waist).
  • Normal breathing again.

 

Quantitative Fit Test (QNFT)

A quantitative fit test (QNFT) can be used to fit test any tight-fitting respirator. It involves using an instrument to measure leakage around the face seal and produces a numerical result called a “fit factor.” There are three OSHA-accepted QNFT test protocols:

  • Generated aerosol uses a non-hazardous aerosol such as corn oil generated in a test chamber.
  • Condensation nuclei counter (CNC) uses ambient aerosol and doesn’t require a test chamber.
  • Controlled negative pressure (CNP) uses a test that creates a vacuum by temporarily cutting off air. (There is also a fourth method, which is an abbreviated version of this one.)

 

In addition, OSHA stipulates that fit testing of employees must occur at least annually; whenever a different size, style, model or make of respirator is used; and when any physical change occurs that could affect fit (such as, for example, significant weight fluctuation, dental work, or other facial changes).

 

User seal check procedure: https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134AppB1

 

Link for 3M Fit Testing procedure: https://www.3m.com/3M/en_US/respiratory-protection-us/support/center-for-respiratory-protection/fit-testing/