Occupational Exposure to Tuberculosis TB

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Occupational Exposure to Tuberculosis (TB)

• John Furman
• Division of Occupational Safety Health

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Purpose of the Presentation

• Discuss DOSHs current enforcement procedures for
  workplace exposure to tuberculosis (TB).
• Discuss the new CDC guidelines for preventing
  transmission of TB in healthcare (published
  December 30, 2005)
• Understand the implications to investigations of
  healthcare facilities

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DOSH Enforcement

• No OSHA/DOSH TB control rule
• WRD 11.35 establishes enforcement of CDC TB
  control guidelines
• Safe workplace standard
• Hazard specific requirements
• OSHA enforcement directive CPL 2.106
• Currently enforcing 1994 CDC guidelines
• 2005 guidelines may be implemented without
  penalty

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Why did CDC revise TB guidelines?

• 1994 guidelines widely implemented in health-care
  facilities
• Advisory Council for the Elimination of
  Tuberculosis (ACET) requested revision of 1994
  guidelines based on decrease in TB incidence
  rates
• New Guidelines for Preventing the Transmission of
  Mycobacterium tuberculosis in Health-Care
  Settings, MMWR Vol. 54/No. RR-17
• Published December 30, 2005

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Why does OSHA/DOSH need to remain involved?

• TB remains a public health concern
• Infection rates greater than US average in
  certain high risk populations
• MDR-TB a growing concern
• HCWs face increased exposure risks
• 10 HCWs diagnosed with TB disease in 2005
• Recent cases of HCWs as exposure sources

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WRD 11.35

• Enforcement Procedures and Scheduling for
  Occupational Exposure to Tuberculosis, OSHA
  Instruction CPL 2.106, issued 1996
• References CDCs Guidelines for Preventing the
  Transmission of tuberculosis in Health-Care
  Facilities MMWR Vol. 43/No. RR-13, 1994
• Provides uniform inspection procedures

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WRD 11.35, Applicability

• Scope of workplaces
• Health Care Facilities
• Correctional Institutions
• Long-term Care Facilities for Elderly
• Homeless Shelters
• Drug Treatment Centers

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Incidence of TB

• 2005 TB rates
• US average rate was 4.9/100,000
• Washington rate 4.0/100,000
• cases TB disease holding steady at 253/yr
• King (127), Pierce (27), Snohomish (24) with
  most cases
• 3 cases of MDR-TB reported

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Risk Factors

• Foreign born
• Unemployed
• Homeless
• Excess alcohol
• HIV-AIDS positive
• Injecting drug use

• Other drug use
• Health care worker
• Previous diagnosis
• Resident of correctional facility
• Resident of long-term care facility
• Migrant worker

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HCW

• All paid and unpaid persons working in health
  care settings
• WISHAct applies only to the employer, employee
  relationship
• DOH, JCAHO, CMS et al expect that all HCWs are
  included in the TB medical surveillance program

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2005 GuidelinesSummary of Changes

• The scope of settings in which the guidelines
  apply has been broadened to include laboratories
  and additional outpatient and nontraditional
  facility based settings.
• These recommendations generally apply to an
  entire health-care setting rather than areas
  within a setting.
• The risk assessment process includes the
  assessment of additional aspects of infection
  control

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Summary of Changes

• A written TB control plan is required
• Blood assay for M. tb, QuantiFERONTB Gold, may
  be used instead of TST in TB screening programs
  for HCWs.
• Criteria for serial screening of HCWs are more
  clearly defined. This may decrease the number of
  HCWs who need serial TB screening.

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Summary of Changes

• New terms, airborne infection precautions,
  airborne infection isolation room (AII room),
  tuberculin skin testing (TST), are introduced.
• Information on ultraviolet germicidal irradiation
  (UVGI) and room-air recirculation units has been
  expanded.
• AFB specimens may be taken 8-24 hours apart with
  one being an early morning specimen.

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Summary of Changes

• Training recommendations have been expanded
• Competency of those administering and reading
  TSTs
• Recommendations for annual respirator training,
  initial respirator fit testing, and periodic
  respirator fit testing have been added.
• The evidence of the need for respirator fit
  testing is summarized.

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Expanded Scope

• New Terminology Health-care-associated settings
• used to broaden the potential places where
  guidelines apply
• Inpatient settings
• Patient rooms
• Emergency depts.
• Intensive care units
• Surgical suites
• Laboratories Lab procedure areas
• Bronchoscopy suites
• Sputum induction or inhalation therapy rooms
• Autopsy suites
• Embalming rooms

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Scope (cont.)

• Outpatient settings
• TB treatment facilities
• Medical offices
• Ambulatory-care settings
• Dialysis units
• Dental care settings
• Non-Traditional facility-based settings
• Emergency Medical Services (EMS)
• Long term care settings (hospices skilled
  nursing facilities)
• Settings in Correctional facilities (prisons,
  jails, detention centers)
• Home-based healthcare outreach settings
• Homeless shelters

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New TB Screening Blood Test

• D) QFT-G Blood test
• QuantiFERONTB Gold test (QFT-G) (Cellestis
  Limited, Carnegie, Victoria, Australia)
• A blood assay for M. tuberculosis (BAMT).
• Whole-blood interferon gamma release assay (IGRA)
• Might be used instead of TST in TB screening
  programs for HCWs

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QFT vs. TST

• Pros of using QFT-G (BAMT)
• Cost effective alternative
• Only 1 visit for blood draw
• Results can be available in lt24 hours after
  testing
• Greater specificity for M. tuberculosis with BAMT
  
• Antigens used are not present in most NTM or
  used for BCG
• Can be used to screen persons vaccinated with BCG
  
• Not subject to boosting effect
• Not subject to placement and reading errors

• Cons of using QFT-G (BAMT)
• Possible errors in collecting or transporting
  blood specimens
• Incubation must be done w/in 16 hours of
  collection
• Lab-based errors in running or interpreting the
  assay
• Cost prohibitive?

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Appendix B TB Risk Assessment Worksheet

• Elements considered in Risk Assessment Process
• Incidence of TB (community facility)
• Risk Classification
• Screening of HCWs for M. TB infection
• TB Infection-Control Program
• Implementation of TB infection control plan based
  on review by infection control committee
• Lab processing of TB related specimens, tests,
  results based on laboratory
• Environmental controls
• Respiratory Protection Program
• Reassessment of TB Risks

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Risk Classification
Potential ongoing transmission Evidence of ongoi
ng transmission regardless of setting

• Low
• lt200 beds
• lt3 pts/yr
• gt200 beds
• lt6 pts/ yr
• Outpatient, nontraditional facility-based
• lt3pts/yr

• Medium
• lt200 beds
• gt3 pts/yr
• gt200 beds
• gt6 pts/ yr
• Outpatient, nontraditional facility-based
• gt3 pts/yr

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New Screening Frequency Recommendation

• Risk TB Screening Frequency
• Classification
• Low Baseline, further screening
• 
  is not necessary unless
• 
  unless exposure
• Medium Baseline, annual
  screening
• Potential Baseline, every
  screening
• ongoing
  every 8-10 weeks
• transmission

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Special Notes on Risk Classifications

• Classification of medium risk might need to be
  assigned, even if a facility meets the low-risk
  criteria when
• Settings serve communities w/ high incidence of
  TB disease
• Settings that treat populations at high risk
  (e.g., HIV patients)
• Settings that treat patients w/ drug-resistant TB
  disease
• A classification of potential ongoing
  transmission should be applied to a specific
  group of HCWs or to a specific area of the
  health-care setting in which evidence of ongoing
  transmission is apparent, if such a group or area
  can be identified.
• Conduct investigation (screen workers every 8-10
  wks until corrected)
• Classification should be temporary
• The setting should be reclassified as medium risk
  and recommended screening should be annual.

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Criteria for HCW screening

• All HCWs who share the air must be included
  in the medical surveillance program.
• HCWs whose duties do not include contact with
  patients or TB specimens may not need to be
  included in the serial TB screening program
• In certain settings, this change will decrease
  the number of HCWs who need serial TB screening

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TST/BAMT Positive HCWs

• Remote infection
• Initial and annual symptom screen
• Additional evaluations as indicated
• Education re symptoms and duty to report
• Baseline positive or conversion
• Symptom screen and CXR
• Additional evaluations as indicated
• Consider prophylaxis

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Airborne Infection Isolation (AII Room)

• New Terminology AII Room
• Airborne infection isolation room (AII room) is
  introduced instead of the term negative pressure
  room or AFB Isolation room
• Another term used
• Airborne infection precautions - used instead of
  airborne precautions

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AII Room (cont.)

• Use of other national consensus guidelines AIA,
  ASHRAE
• 6 ACH (existing) 12 ACH (new)
• Minimum of 2 ACH of outdoor air
• Monitoring devices
• Differential air flow rates and leakage
• Pressure differential from 0.001 to 0.01 in water
• Maintenance schedules

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Information on UVGI

• Information on ultraviolet germicidal irradiation
  (UVGI) and room-air recirculation units has been
  expanded.
• Information on effectiveness of UVGI added
• Discussion of studies conducted which examine
• Air mixing
• Relative humidity
• Ventilation rates

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Respiratory Protection

• Expanded section on respiratory protection
• Reference to OSHA Respiratory protection standard
  requirement for Respiratory protection program
• Selection criteria CDC/NIOSH approved
  respirator
• Medical screening/evaluation of those assigned
  respirators
• Annual training recommended

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Respiratory Protection

• WAC 296-842 applies to all respirator use at
  work.
• OSHA not enforcing annual fit test requirements
• DOSH will enforce 296-842 using state funds only

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DOSH Inspection Focus

• Assignment of responsibility
• Written TB control plan
• TB risk assessment
• Medical surveillance
• Early detection and isolation
• Engineering controls
• Respiratory protection
• HCW training and education
• Respiratory etiquette
• Coordination with local health department

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Current Enforcement

• OSHA currently working on update to PCPL 2.106
• Formally still enforcing 1994 CDC guidelines
• Consult with DOSH ONC re facilities who have
  implemented 2005 guidelines
• Enforce DOSH Respirator rule re bio-agents

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• QUESTIONS?