occupational exposure to tuberculosis tb

1. Occupational Exposure to Tuberculosis (TB) John Furman Division of Occupational Safety & Health

3. 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

4. 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 Why revise the guidelines when 1994 guidelines widely implemented in healthcare settingsWhy revise the guidelines when 1994 guidelines widely implemented in healthcare settings

5. 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

6. WRD 11.35 Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis, OSHA Instruction CPL 2.106, issued 1996 References CDC�s Guidelines for Preventing the Transmission of tuberculosis in Health-Care Facilities [MMWR Vol. 43/No. RR-13], 1994 Provides uniform inspection procedures

7. WRD 11.35, Applicability Scope of workplaces Health Care Facilities Correctional Institutions Long-term Care Facilities for Elderly Homeless Shelters Drug Treatment Centers

8. 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 TB recordkeeping began in 1953, 2004 had the lowest rates ever since that timeTB recordkeeping began in 1953, 2004 had the lowest rates ever since that time

9. 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

10. 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

11. 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

12. Summary of Changes A written TB control plan is required Blood assay for M. tb, QuantiFERON�TB 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.

13. 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. [Change in criteria for serial testing; reduction in # of HCW required to be serial tested] [Info added to UVGI and air circulation info} [Change in criteria for serial testing; reduction in # of HCW required to be serial tested] [Info added to UVGI and air circulation info}

14. 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.

15. 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

16. 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 Ambulatory care settings in old guidelines included TB treatment facilities & emergency departments; in these guidelines it is separate and part of �outpatient settings�; Dialysis units are included w/ recommendations to use AII rooms for patients w/ TB or transfer to a hospital w/ AII room that can perform dialysis & recommendation for use of N95 respirators for staff In our old CPL we mention that �coverage of non-hospital healthcare settings(i.e., doctos�offices, clinics, etc.) includes only personell present during the performance of high hazard procedures on suspect or active TB patients.� Medical offices and dental settings were included under the umbrella of �Other health cares settings�Ambulatory care settings in old guidelines included TB treatment facilities & emergency departments; in these guidelines it is separate and part of �outpatient settings�; Dialysis units are included w/ recommendations to use AII rooms for patients w/ TB or transfer to a hospital w/ AII room that can perform dialysis & recommendation for use of N95 respirators for staff In our old CPL we mention that �coverage of non-hospital healthcare settings(i.e., doctos�offices, clinics, etc.) includes only personell present during the performance of high hazard procedures on suspect or active TB patients.� Medical offices and dental settings were included under the umbrella of �Other health cares settings�

17. New TB Screening Blood Test D) QFT-G � Blood test QuantiFERON�TB 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 A Food and Drug Administration (FDA)--approved in-vitro assay This is the most recent blood test developed�the first was QFT which was Approved in 2001; QFT-G replaces QFT and uses syntehtic proteins as antigens instead of PPD (which is used by QFT)A Food and Drug Administration (FDA)--approved in-vitro assay This is the most recent blood test developed�the first was QFT which was Approved in 2001; QFT-G replaces QFT and uses syntehtic proteins as antigens instead of PPD (which is used by QFT)

18. QFT vs. TST Pros of using QFT-G (BAMT): Cost effective alternative Only 1 visit for blood draw Results can be available in <24 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?

19. 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 Important questions on each of these elements of a risk assessment programs are written out in a Q&A format to facilitate review of program and determination of risk � Ex. For risk classification : how many beds the facility has? How many TB patients encountered in previous year? Separate questions to be considered by inpatient facilities than those to be considered by outpatient facilities or Nontraditional facilities Important questions on each of these elements of a risk assessment programs are written out in a Q&A format to facilitate review of program and determination of risk � Ex. For risk classification : how many beds the facility has? How many TB patients encountered in previous year? Separate questions to be considered by inpatient facilities than those to be considered by outpatient facilities or Nontraditional facilities

20. Risk Classification Low <200 beds <3 pts/yr >200 beds <6 pts/ yr Outpatient, nontraditional facility-based <3pts/yr Medium <200 beds >3 pts/yr >200 beds >6 pts/ yr Outpatient, nontraditional facility-based >3 pts/yr

21. 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 Decrease in freq of TB screening] [Criteria to determine screening freq changed] HCWs whose duties do not include contact with patients or TB specimens DO NOT NEED to be included in the serial TB screening program. Decrease in freq of TB screening] [Criteria to determine screening freq changed] HCWs whose duties do not include contact with patients or TB specimens DO NOT NEED to be included in the serial TB screening program.

22. 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.

23. Criteria for HCW screening All HCW�s 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

24. 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

25. 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 Negative pressure isolation rooms are now referred to throughout the document as AII roomsNegative pressure isolation rooms are now referred to throughout the document as AII rooms

26. 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

27. 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

28. 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

29. 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

35. 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

36. 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

37. QUESTIONS?