Tuberculosis Exposure Control Plan 2014

8/10/2019 Tuberculosis Exposure Control Plan 2014

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TUBERCULOSIS XPOSURE ONROL LAN

THE UNVEilSTY OF TOLEDO 2014 ual Review

MEDICAL CENTE

Backgondpos

Trnsmission of TB (tuberculosis) is recognized risk in helth-cre fcilities. Trnsmission is most likel tooccur from ptients with unrecognized pulmonr or lrngel TB who re not on effective nti-tuberculosistherp nd hve not been plced in TB isoltion. Outbreks of multi-drug resistnt tuberculosis (MDRTB)hve heightened conce bout nosocomil trnsmission (mortlit 43% 93%) Increses in TB hve beenrelted to the high risk of TB mong immunosuppressed persons, prticulrl those with H infection. Ifexposed, n immunosuppressed person is t higher risk to develop ctive TB disese.

On October 8, 994, the Centers for Disese Control (CDC) published its dr rule on "uidelines forPreventing the Trnsmission of Mcobcterium Tuberculosis in Helth-Cre Fcilities. This stndrd wsenforceble under Federl Lw until the nl document ws published in December, 00 in the FederlRegister. Its purpose is to require ech emploer to fuish emploees plce of emploment which is freefrom recognized hzrds tht re cusing or re likel to cuse deth or serious hrm, b eliminting orminimizing occuptionl exposure to tuberculosis. In response to this Federl Lw, the Universit of ToledoMedicl Center Tuberculosis Exposure Pln ws written nd implemented. This pln, nd the originl text fromthe Federl Register, is vilble to ll UTMC emploees on the UT policwebsitehtt://utoledo.edu/olicies/

or in printed copies of the fection Control Mnul.

Abot th disas: The bcteri tht cuses TB is clled Mycobaceium ubeculosis t is crried in irboepricles known s droplet nuclei, tht cn be generted when persons with pulmonr or lrngel TB sneeze,cough, spek or sing. The prticles re estimted to be one to ve microns in size, nd will trvel nd stsuspended in the ir supported b ir currents. Infection occurs when susceptible person inhles dropletnuclei continingMycobaceium ubeculosis tht reches the lveoli of the lungs. The orgnism m thenspred to the rest of the bod. Usull within two to ten weeks er initil infection the immune response

limits rther spred, however, some of the orgnisms m remin dont for ers. This is known s ltentTB infection. These persons generll will hve positive Tuberculin Skin Test (TST) skin test, but re notinfectious. There is up to 0% chnce during their lifetie tht this will develop into ctive disese, withouttretment t the time of conversion. The risk is gretest during the rst two ers er infection. infectionis currentl the highest known risk fctor for the progression from ltent TB infection to ctive TB disese. Theprobbilit tht susceptible person will become infected depends primril upon the concentrtion ofinfectious droplet nuclei in the ir nd the durtion of the exposure.

Chrcteristics of the TB ptient tht increse trnsmission risk include:

Disese in the lungs, irws or lrnx Presence of cough or other forceful expirtor mesures

3 Presence of cidfst bcilli (AFB) in the sputum4. Filure of the ptient to cover the nose nd mouth when coughing Presence of cvittion on chest rdiogrph6 Anti-tuberculous chemotherp tretment filure/non-complince7 Administrtion of procedures tht cn induce coughing or cuse erosoliztion of Mcobcterium

tuberculosis (e.g. sputum induction)



+ Thid eel PPE epiat potection effectie wok pactice contol.

lthough copletely eliinating the k of TB taniion ay be ipoible adheence to theeguideline will geatly educe the ik.

E. Risk Assssmnt (to ealuate the ik of TB taniion in all pa of the intitution and to bae thePlan on thi ik aeent)

The algoith fo Suppleent One will be ued to ae eployee fo ik. TST eult of eployee will be ecoded in the indiidual eployee health ecod. Reult willalo be ecoded by Faily Medicine in a etieable aggegated databae. Identiing infoationwill be handled condentially.

F. Piodic Rassssmnt of th Tbclosis Expos Contol Plan

The Tubeculoi Expoue Contol Plan will be eiewed biannually and a needed to ealuate iteffectiene and to dene action neceay to iniie the ik of TB taniion (Suppleent Two).

Infection Peention and Contol will conduct a ik aeent bi-annually o oe fequently ifinceaed cae ae identied.

Facilitie Maintenance and the Safety and Health Depaent will eet annually to eiewentilation and will epo nding to the Infection Peention and Contol Coitee nnual epo fo Facilitie Maintenance will be epoed to the Infection Peention and Contol

Coitee on the tatu of hopital entilation

G Ealy Dtction of Patints with TB

diagnoi of TB hould be conideed fo any patient with any of the following ypto

Peitent cough > week duation. Coplaint of bloody putu unexplained weight lo o anoexia. Chet Xay exa with pulonay caitation o hila/ediatinal adenopathy with o without

pleual/peicadia! effuion. Finding of apical/uppe lobe inltate. Cough and fee if the patient alo ha a ignicant eaction to a tubeculin kin tet (ee Suppleent

Six) a hitoy of a ignicant eaction to a tubeculin kin tet a hitoy of peiou tubeculoi o ahitoy of expoue to infectiou tubeculoi.

co-exiting TB infection hould be ealuated in a patient that i iunouppeed (e.g. )with pulonay ign o ypto that ae initially acibed to othe etiologie. The ealuationhould be epeated if the patient doe not epond to appopiate theapy fo the peued etiology ofthe pulonay abnoalitie.

Diagnotic eaue fo identiing TB hould be intituted aong uch patient. Thee eaue ayinclude

Hitoy and phyical exainationTST

1tet

Chet adiogaph icocopic exaination and cultue of putu o othe appopiate pecien.Biopy and/o bonchocopy ay be indicated fo oe patient.Conide Quantifeon TB Gold Tet (QFT-Gi which eaue the patient iune yte eactionto M.Tb

TST tsts a to b ad btwn and hos aft placmnt

Blood sampls fo QFT-G mst b pocssd within 1 hos QFTG is an altnativ to TST



+ Results of FB seas of sputu will be aailable within 48 hous of specien collection Statseas will also be aailable depending on cicustances.

+ Patients with high suspicion of o coned TB will be epoted to the appopiate health depatentiediately by the Infection Peention and Contol Depatent to assue identication andealuation of contacts can be initiated

H. Managmnt of Patints in Otpatint Facilitis with

. Tiage of patients ust include igoous effots to detect patients with actie TB poptly. Eployees who ae the st points of contact will be tained to ask appopiate questions which

will help ecognie and detect patients with signs and syptos suggestie of TB (seeSuppleent Thee)

patient haing signs o syptos of TB should be ealuated poptly to iniie tie spent inthe outpatient aeas. hen possible, the patient should be scheduled fo the end of the day o when the least nube

of patients ae pesent to aoid exposing othe patients. If thee is a delay, o if the pocedue is lengthy, the pocedue should be postponed until the

patient is deeed noncontagious by his/he physician.

3. iboe Pecautions (iboe Infection isolation ) ust be ipleented This includes: Poptly eoing patient fo waiting oo. Placing patient in iboe Infection Isolation () oo (if aailable), o in a piate oo

with the doo shut and P lte on Placing an isolation ask on patient and instuct the patient to keep the ask on until the patient

is in the oo. Giing the patient tissues and instuct the patient to coe thei nose and outh when coughing

o sneeing if ask ust be eoed to facilitate espiatoy cleaance.

4 Ventilation in geneal use aeas (waiting oos) and special aeas (teatent o isolation oos)should be as descibed fo siila patient aeas (see Suppleent Fou)

5 Cough inducing pocedues ust be done in a oo eeting TB isolation equieents (seeSuppleent Fou)

I Managmnt of Hospitalizd Patints with

. ditting Physicians Physician ofces ust alet the appopiate depatents (e.g. ditting, Eegency Roo) to

the fact that thei patient is suspected of haing TB

Ealy Detection of TB Eployees who ae the st points of contact should be tained to ask appopiate questions

which will help ecognie and detect patients with signs and syptos suggestie of TB (see

Suppleent Thee)

3 ditting a patient with infectious o potentially infectious TB The depatent whee the patient st entes the facility (ie. ditting, Clinic o Eegency

Roo) ust ask the patient iediately with an isolation ask, and the patient ust be takeniediately to an isolation oo.

If a patient is aditted though ditting o as a diect adit and thee is a delay in theaailability of negatie pessue oos, the patient will be placed in a piate oo with thedoo shut.



+ ditting pesonnel ae not tained in espiato use; theefoe ay not be put at isk to gatheinfoation fo a potentially infectious patient ditting will st poide the patient with aask o tissue with instuctions to coe outh and nose

+ The patient should be taken to a piate oo, pefeably with negatie pessue but ay beplaced in a piate oo with instuctions to keep thei outh and nose coeed with the tissueo ask

ditting will then gathe infoation oe the phone to the isolation oo and will equestassistance with signatues fo the patient's cae poide tained in espiato use

4 Readitting patients with peiously diagnosed TB When patients with peiously diagnosed TB ae eaditted befoe conation of coplete

cue, they should be placed in iboe fection Isolation until infectiousness has been uledout

. Tanspoing a patient in iboe Infection Isolation Patient ust wea a as The tanspoe does not need to wea a espiato outside of the isolation oo as long as the

patient weas a as

6 Patient Roo Placeent

ny patient suspected o known to hae actie TB should be placed in an Roo (seeSuppleent Fou fo specications) The pupose of an isolation oo is to: Isolate patients who ae likely to hae infectious TB, fo othe people Peent escape of doplet nuclei fo the oo Poide an enionent that will allow a eduction of the concentation of doplet nuclei

though engineeing contols If egatie Pessue Isolation Roos ae not aailable, patients ay hae to be placed into a

oo with a potable P Filte

7 Initiation of iboe Infection Isolation: The patient has signs and syptos suggestie of TB FB sea is positie

iboe Infection Isolation can be initiated by the Medical Diecto of Infection Contol,Infection Contol Depatent, the attending physician, physician consultants, edical esidentso piay cae nuse

8 Teination of iboe Infection Isolationiboe Infection Isolation ay only be teinated by the physician if the following citeia aeet:

Fo patients known to hae TB o known to hae TB in the past with new syptos Infectious TB is unlikely and anothe diagnosis is ade that explains the syndoe Patient has thee consecutie negatie FB sputu sea esults, and Patient has eceied standad antitubeculosis teatent (iniu of two weeks), and

Patient has deonstated clinical ipoeent

The patient is on effectie teatent (TB eican Thoacic Society Guidelines) Clinically, the patient is esponding to teatent, o Mycobacteial cultue shows FB othe than TB

Fo patients aditted to ule out disease: Thee negatie seas

t least 8 hous apat t least one collected duing ealy oing



+ In ost cases, patients with negatie sputu sea esults ay be eleased fo in twodays

9. Labeling+ The oo ust be labeled by placing the iboe Infection Isolation sign on the doo

0. Maintaining ppopiate Ventilation (see Suppleent Fou) Doo to the isolation oo ust eain closed If the isolation oo has an anteoo the doos

to both oos ust be kept closed Isolation oo pessue ust be onitoed daily

a) Fo oos with electonic onitos, check each tie the oo is enteedb) Fo oos without electonic onitos, call Facilities Manageent to daily soke test the

oo iing" the Isolation Roo

a) Upon dischage of patient o teination of (iboe with Respiato) Pecautions, theisolation oo ust be allowed to ai" to achiee a 99.9% eoal efciency pio toenteing the oo without a espiato o aditting anothe patient This aiing tie canbe found in Suppleent Fou

Diagnostic and teatent pocedues

Must be pefoed in the isolation oo o appopiate negatie pessue oo Tests that cannot be pefoed in the patients oo should be delayed until the patient is out ofisolationa) Only unde an unusual edical ugency should the patient be tanspoted outside of the

isolation ooContact the Infection Contol Pactitione, o desiate, befoe any decision to beakisolation is ade outside of a edical eegencyThe pocedue ust be scheduled if possible at a tie when the eceiing depatent isleast cowded, weighing the isk of tansission to othe patients, isitos, and staf

Visitos e to be kept to a iniu, should keep thei isits shot, and leae the oo if the patient

begins coughing Should wea a ask while in the oo May oluntaily wea an 9 espiatoy but ust hae instuctions on how to wea it

3. H o iunosuppessed patients Must be kept in iboe Infection Isolation fo pulonay o layngeal infections with any

ycobacteial species due to the potential fo ixed infection with TB Isolation ay be teinated by the physician if the following citeia ae et:

Infectious TB is unlikely and anothe diagnosis is ade that explains the syndoe Patient has thee consecutie negatie FB sputu sea esults, and Patient has eceied standad antitubeculosis teatent (iniu of two weeks), and Patient has deonstated clinical ipoeent

The patient is on effectie teatent (TB eican Thoacic Society Guidelines) and Clinically, the patient is esponding to teatent, o Mycobacteial cultue shows FB othe than TB

Fo patients aditted to ule out disease o suspected: Thee negatie seas ae needed to discontinue isolation o one bonchoscopy/lung biopsy

4 Pediatic patientsWith suspected o coned TB should be ealuated fo potential infectiousness no diffeently thanadults, based on syptos, FB seas, and adiologic ndings

6



. ulturig Patiets with Active TB• Hspitalized patiets with active TB wh are effective treatmet as per America Thracic

Sciet Guidelies shuld be mitred fr relapse with sputum smears ever tw weeksa) Failure t take medicatis ad the presece f drug resistat TB are the tw mst

cmm reass fr the patiet remaiig ifectius.

6 Multi-drug Resistat TB Patiets with multidrug resistat TB shuld be maitaied i A Precautis thrughut their

hspital sta because f the tedec fr treatmet failure ad relapse.

7. Patiet Educati Patiets i Airbe Ifecti Islati shuld be educated abut the trasmissi f TB ad the

reass fr islati precautis b their caregiver. Patiets shuld be taught t cver their muths ad ses with a tissue whe cughig r

seezig, eve while i the islati rm, t ctai drplets b their caregiver.

8. itiati f Treatmet Patiets wh have crmed active TB r are csidered highl likel t have active TB shuld

be started apprpriate treatmet prmptl accrdig t curret guidelies (see SupplemetSeve)

Ati-tuberculsis drugs shuld be admiistered b directl bserved therap (DOT) i which ahealth care wrker bserves the patiet igestig the medicatis

9. Discharge Plaig Befre a patiet is discharged, the Outcme Maagemet Departmet shuld

a) llabrate with public health authrities t esure ctiuati f therapb) rm appitmet with a prvider wh will fllw the patiet util treatmet is

cpleted.c) rm sufciet medicati t take util the utpatiet appitmetd) Place it case maagemet, such as utreach prgram f the health departmet

0. Patiets that are ifectius at discharge shuld l be discharged t facilities with Airbe

Ifecti Islati capabilities, r t hme The shuld t be discharged t a hme withimmucmprmised perss

. Respiratr Prtecti Respiratrs will be used fr respiratr prtecti IOSH has deteied that the fllwig

categries f respiratrs are effective agaist TB (Tpe 00, Tpe 99, Tpe 9). The miimallaccepted level f respiratr prtecti fr TB is Tpe 9 (9)

Respiratrs must be w i all settigs where there are patiets with TB r suspected t haveTB. Such settigs wuld iclude Airbe Islati rms r exam rms, brchscp rthracic surger a kw r suspected TB patiet, etc.

A saf altnativ to th N-95 spiato is th PAPR (Powd Ai Potctiv Rspiato)

Ths may b won by any pson, spcially thos with a bad o hav not bn abl to

b t tstd with th N95 o N100 spiato fo oth asons. On tim taining isqid pio to waing th PAPR

All emplees required t wear a respiratr must be qualied. This must iclude A cdetial medical evaluati (medical questiaire lled-ut b emplee ad evaluated

b Famil Medicie) and t tstd

Fit testig will be cducted b either Famil Medicie, b the ursig Educatrs i ursigOrietati r Health & Safet Departmets (i accrdace with stated prcedure i the FederalRegister) (9 FR 9 0. 34). Refer t UT respiratr prtecti prgram lie at:http:// w.utled.edu/depts/safet/dcs/S08-034.pdf

Oth taind individals may assist ths dpatmnts whn ndd



Qualied emplees will have their ceicati kept i their emplee health leEmplees wh fail t be qualied fr the 9, ma t wear a 9 respiratr ad mat be put at risk f expsure t TB. A alterate chice wuld be the pwered airrespiratr (PAPR)The curret chice f respiratr fr UTM is the 9 (see istructis, Supplemet Eight)r the (P APR)Hds ad respiratrs are gveed uder the Respiratr Prtecti Prgramhttp:// w.utled.edu/depts/safet/dcs/S08034.pdf

leaig aer patiet discharge. ursig will leave the islati sig the dr ad the PA device ruig util aer the

rm is cleaed Evirmetal Services Staff will wait e hur befre eterig rm withut respiratr

prtecti Evirmetal Services Staff ma eter prir t e hur if the 9 mask r PAPR is w ad

the dr is kept shut. Staff will use the apprved hspital disifectat fr cleaig the rm

J Cough Inducing Pocdus

1. Prcedures that ivlve istrumetati f the lwer respiratr tract r iduce cugh ma icreasethe prbabilit f drplet uclei beig expelled it the air (eg. edtracheal auctiig aditubati, aersl treatmets icludig petamidie, brchscp)

Aerslized Petamidie (AP) All patiets shuld be screeed fr active TB befre prphlactic AP therap is iitiated Scree shuld iclude medical histr, TST, ad chest radigraph. Fr each subsequet treatmet, patiets shuld be screeed fr smptms suggestive f TB. If

such smptms are elicited, a diagstic evaluati fr TB shuld be iitiated. Fr patiets with suspected r crmed TB, it is preferable t use ral prphlaxis fr PP if

cliicall practical

Brchscp If brchscp is used fr diagsis f pulmar TB, it must be perfrmed i a rm that

meets A vetilati requiremets If l psitive pressure rms are available, TB shuld be ruled-ut befre the prcedure All patiets havig a brchscp shuld be treated as if the have TB except where dig s

wuld be verl prhibitive t patiet care (i.e., all brchscpies which ca be perfrmed iegative pressure rm shuld be) IU patiets wuld t fall it this categr ad wuld becsidered i the verl prhibitive t patiet care categr, ad based this ,ma chse tperfrm the brchscp i a patiet rm, uder egative pressure. ugh iducigprcedures shuld t be perfrmed patiets wh ma have ifectius TB uless abslutelecessar

. All cughiducig prcedures must be de i a egative pressure islati rm r uder lcalexhaust (bth r special eclsure).

3. Aer cmpleti f prcedure, patiet must remai i Airbe Ifecti Islati Rm r uderlcal exhaust util cughig subsides

4 Befre the ext patiet is allwed it this area, suciet time must be alltted t allw thevetilati t expel drplet uclei frm the air (see Supplemet Fur)



K Edcation and Taining

. All employees of TMC will receive eduction bout TB nnully tht is relevnt to theiroccuptionl group

Trining will be conducted before initil ssignment during new employee orienttion

3. Trining my include the following elements:

The bsic concepts of M tuberculosis trnsmission, pthogenesis, nd dignosis, includinginformtion conceing the difference between ltent TB infection nd ctive TB disese, thesigns nd symptoms of TB, nd the possibility of reinfection

The potentil for occuptionl exposure to persons who hve infectious TB, includinginformtion conceing the prevlence of TB in the community nd fcility, the bility of thefcility to properly isolte ptients who hve ctive TB, nd situtions with incresed risk ofexposure to M tuberculosis

The principles nd prctice of Infection Prevention nd Control tht reduce the risk fortrnsmission of M tuberculosis, including informtion conceing the hierrchy of TB InfectionControl mesures nd the written policy nd procedures of the fcility Site-specic controlmesures should be provided to HCW's working in res tht require mesures in ddition tothose of the bsic TB Infection Control progrm

The purpose of TST skin testing, the signicnce of positive TST test result, nd theimportnce of prticipting in the skintest progrm The principles of preventtive therpy for ltent TB infection The HCW's responsibility to repor positive TST (performed elsewhere) or signs nd symptoms

suggestive of TB to Fmily Medicine The responsibility of TMC to mintin the condentility of the HCW who hs TB while

ensuring the HCW is free of TB before retuing to duty The higher risks ssocited with TB infection in persons with H infection or other severely

impired cell-medited immunity TMCs policy on voluntry work ressignment options for immunocompromised HCW'S

L. Halth a Woks onsling Scning and Evalation

Counseling the HCW regrding TB Becuse of the incresed risk of rpid progression from ltent to ctive TB in H positive or

other severely compromised persons, Fmily Medicine will evlute ech employee withpositive TST or Quntiferon during their nnul review to determine if they hv mediclcondition or re receiving medicl tretment tht my led to severe cell-medited immunityThis is done with medicl surveillnce questionnire

Employees t risk for H infection should know their sttus nd will be encourged to seekvoluntry testing This will llow the employee to seek pproprite preventtive mesures ndto consider voluntry work ressignments This should be personl decision HumnResources will mke resonble ttempts to offer ltetive job ssignments, ie work setting

with the lowest possible risk of occuptionl exposure to TB Immune sttus nd voluntry job ressignment will be treted condentilly

Screening HCW's for ctive TB Any HCW with persistent cough (greter thn two weeks), especilly in the presence of other

signs nd symptoms comptible with TB, such s weight loss, night swets, bloody sputum,norexi, or fever, should be evluted promptly for TB nd my not retu to work until TB isexcluded or rendered non-infectious



3. Screening HCW's for ltent TB infection At the time of employment, ll HCW'S, including those with history of BCG vccintion will

receive twostep Mntoux TST ( single step Mntoux TST will be provided if there isdocumenttion from the employee of negtive TST within the lst yer), or my be tested withthe Qunitferon blood test.

Annul Tuberculosis screening hs been mended bsed on the risk ssessment of the hospitl,nd the regionl results, reported by the locl helth deprtment.

4 Evlution nd mngement of HCW's with positive TST tests (see Supplement Six) All HCW's with newly recognized positive TST tests must be evluted promptly for ctive T'B

with chest rdiogrph nd clinicl evlution. HCW's TST test converts to positive, history of possible exposure must be tken in n

ttempt to determine the potentil source of TB Routine chest rdiogrphs re not required for symptomtic TST converters, except for initil

evlution, or unless symptoms develop tht my be due to TB. HCW's with ctive TB my not retu to work until on effective therpy, coughing is resolved,

nd three consecutive rst moing AFB smers re negtive Fmily Medicine must ensuretht the HCW is mintined on dequte therpy nd remins AFB smer negtive. If treted by privte physicin, Fmily Medicine must communicte with the physicin to ensure

ppropriteness of tretment, nd to monitor symptoms nd job duties HCWs with ctive TBwill be reported to the Public Helth Deprtment ccording to locl lws HCW's with positive TST tests will be evluted by Fmily Medicine or through their PCP. If

preventive therpy is dvised, the recommended durtion of therpy is months for personswith H infection nd persons with bnorml chest rdiogrphs consistent with old TB; otherpersons should receive therpy for months s directly observed therpy of regimen ofrifpentine nd isonizid or per most current Americn Thorcic Society recommendtions

Further informtion vilble t:http://wwwodh.ohiogov/�/medaODH/ASSES/Files/heath 20statistics 20-

20dsease 20 20tb/County 20Rate 20Table 202012.ashx

M. Additional Considations fo Slctd Aas

Operting Rooms Elective opertive procedures on ptients with ctive pulmonry or lryngel TB should be

delyed until the ptient is no longer infectious. Procedures should be perfoed in operting rooms with nterooms If there re no nterooms,

the doors to the operting room must be kept closed nd trfc in nd out minimized Theprocedure should be performed t the time when other ptients re not present (i.e. end of dy)nd when miniml number of personnel re present

A bcteril lter should be plced on the ptient endotrchel tube or t the expirtory side ofthe brething circuit of the nesthesi mchine.

The ptient must be recovered in the operting room When redy to trnsp, the ptient mustwer n isoltion msk, or if intubted, the endotrchel tube must hve bcteril lter

MorgueIf utopsies/dissections re being done: The morgue must be under negtive pressure, with the ir vented to the outside of the hospitl

ddition, there must be t lest totl ir exchnges per hour Respirtors must be wo during utopsies on ptients who my hve hd TB.

Emergency Deprtment As p of the trige process, ll ptients must be ssessed for clinicl nd historicl signs or

symptoms for TB

0



4. Clinicl Lbortory+ The lbortory should conform to criteri specied by CDC nd ccordnce ith locl

nd stte ls nd regultions, system is in plce to report ny positive results from nypositive specimen to clinicins ithin 4 hours of receipt of the specimen

5. Kobcker Center Ptients determined to hve ctive TB infection ill be trnsferred to fcility ith negtive

ventiltion cpbilities until they meet the criteri for discontinuing Airboe isoltion

6 Endoscopy+ Employees must er respirtory msk during ll bronchoscopy procedures All

bronchoscopies must tke plce in negtive pressure room

7. Rehb Hospitl Ptients determined to hve ctive TB infection ill be trnsferred to fcility ith negtive

ventiltion cpbilities until they meet the criteri for discontinuing Airboe isoltion.

Prepared by: Sandra J. Hensley, Infection Control Practitioner and Kristen Woodman, Infection Control Coordinator

Reference:

1) Federal Register/vol.59, No. 208/Friday, October 28, 994/Notices(2) MMWR November 4, 2005o.54/No RR-123) MMWR Guidelines for Preventing the Transmission of Mycobacterium in Health Care Settings, 2005, MMR December 30,2005/Vol 54o. RR17

Additional infation and specics can be found in Safety and ealth procedure Airboe Pathogens Control Plan, and in InfectionControl policy #31 :DIS206, TB Isolation.

Approved by:

-

� I tc '-7 [

Director, Sfety & Helth

Dte

Dte



Supplement 1

Peiodic Reassessment of The Tubeculosis Pevention Pogam

(eveysix months and as necessay)

Infection Pevention and Contol Depatment

. Review the number of TB ptients seen, by re (inptient nd outptient) This is to be used to:

Estimte the need for dditionl isoltion rooms

Recognize clusters of nosocomil trnsmission.

Assess level of potentil occuptionl risk

Review the drug-susceptibility ptes of TB ptients seen t the fcility

. Review smple of TB ptients seen t the fcility to evlute infection control prmeters by reviewingthe lst months of dt from the Ptient Sfety et Dtbse

Were pproprite criteri used for discontinuing isoltion?

Ws there dely in isolting the ptient?

Ws n pproprite isoltion room used?

Ws the ptients door nd chrt lbeled ppropritely?

Ws ptient trnsported out of isoltion room except for medicl emergencies?

Family Medicine

Anlyze HCW TST nd Quntiferon results, by re (or by occuptionl group for persons not ssigned to specic re, such s respirtory therpists.)

Conversion rtes should be clculted t 6 month intervls to estimte the risk of TST test conversion for echre in the fcility nd for ech occuptionl group not ssigned to specic re This rte should becompred to pst history nd to res without occuptionl exposure

Bsed on the results of the TMC risk ssessment for number of cses of TB nd employee conversion, TMCflls into the low ctegory nd nnul testing continues to be risk specic Employees will be screened t hirend er exposureEngineeing and Maintenance

Perform review of ventiltion (see Supplement four) to include Direction of ir ow in res where TB trnsmission is potentil problem (witing rooms, procedure

rooms, etc). Assessment of the ventiltion system used in egtive Pressure Isoltion rooms to include pressure

redings, ir exchnges, venting time nd inspection of system nd fns Rooms pssing inspection should be lbeled with sticker s certied. The lbel should contin the dte

ceried, ir exchnges per hour, nd time required to vent the room



Spplmnt

Fist Point of Contact Tiag

Qstions to Ask Patints to Dtct Tbclosis

Exposure Symptoms Have you ever been tod by a doctor that you had . Do you have night sweats?TB? . Have you ost weight that wasn't from dieting?

Have you ever ived with or worked with anyone . Do you cough up bood?with TB?

Have you ever had a skin test that your doctor said4 Have you coughed for more than two weeks?

shows that you had TB? The test may havebeen caed a TST or Tin Tst

If the patient answers yes to

) at east on question in both the Expos and Symptoms coumns,

2) at east two questions in the Symptoms coumn,

or

mask the patient immediatey. This patient may have tubercuosis



Supplement

THE TB ISOLATION ROOM

TB isoation rooms shoud be singe patient rooms.

The room must be maintained under negative pressure (a pressure differentia of 000 inch of water andan inward veocity of 00 feet per minute are minimum acceptabe eves)

Doors must be kept cosed to maintain negative pressure egative pressure shoud be checked daiy on rooms in use for egative Pressure Isoation by means

of a smoke tube or air veocity measurement device as foows:

Rooms with eectronic monitors Prior to patient being admited or shory aer admission, the primary nurse wi activate the monitor

by tuing the key With room door cosed, monitor shoud have a green ight on. Primary care nurse is responsibe to ensure this ight is on. If ight dispays red, maintenance must be caed immediatey (Pease aow - minutes for room

pressure to baance aer opening and cosing door). A empoyees entering this room shoud aso be made aware of the monitor and to report to theprimary care nurse any probems

egative pressure rooms are under the inuence of a singe dedicated exhaust fan, which is monitoredby the Faciities Maintenance department.

Faiures are reported immediatey, by Faciities Maintenance, to Safety & Heath, the unit invovedand to Infection Contro. Foow up to faiure wi be to remove any patient with TB or rue out TB to another area capabe of

PA tration or dedicated exhaust with negative pressure capacity.

3 There must be a minimum of ACH for isoation and treatment rooms constructed aer 0/8/94Rooms before this time must be at a minimum of 6 ACH, but shoud be increased to ACH when

feasibe. However, the air wi not usuay be changed the indicated number of times per hour, as the air owpattes in the room may not permit compete mixing of the suppy and room air in a pars of theroom A mixing factor is required to account for this. The factor is appied as an actua mutipierto determine the actua suppy air fow (ACH x mixing factor actua required suppy ACH). Roomsshoud be designed to achieve the owest mixing factor. A quaitative measure can be made withsmoke tubes at various paces in the room. (ASAE Joua, Juy 968:pp 33-4).

4. Air from the TB isoation room must be: exhausted to the outside, or recircuated into the genera ventiation using PA ters in the exhaust ducts before the air is

retued to the genera ventiation

When HEP A ters are used in the genera ventiation, a reguary schedued maintenance program isnecessary.a. A quantitative eakage and ter performance test using the diocta phthaate (DOP) penetration

test shoud be performed at the initia instaation, when the ter is changed, and annuay.b A manometer or pressure sensing device shoud be instaed in the ter system to provide an

accurate means of objectivey determining the need for ter repacement.

Rooms with an anteroom are preferred since they increase the effectiveness of the isoation room bysering as an airock. The anteroom must have positive pressure in reation to the isoation room



6 Aer a patient is discharged from Airborne Infection Isoation, the isoation room must be vented a setamount of time to achieve a 999% reduction in airboe contaminants (see Suppement ve). This timeis specic to each isoaton room and shoud be cacuated by the Faciities Management Depament

Additiona Ventiation Conces

. Genera use areas (e.g. waiting rooms, radioogy suites)

A singe pass, non-recircuating system with air exhausted to the outside or a recircuation systemwith the air passed through PA ters before recircuation to the genera ventiation system may beused.

PA tration P A ters must be carefuy instaed and meticuousy maintained to ensure adequate function. Such ters, when changed, must be regarded as infectious A respirator must be wo, and care must be taken so as not to aerosoize contents The ter must be red pastic bagged and seaed.

3 Portabe PA ter (Private Room Ony) If monitored negative pressure rooms are not avaiabe, a portabe PA ter unit is to be ordered

from Centra Service Unit shoud be positioned at the foot of the patient's bed, as cose as possibe to the center/midde ofthe room

A negative pressure procedures aso appy to those rooms

4. egative pressure must be veried daiy when a patient with active pumonary or aryngea M.Tb. isoccupying the room. Veri and document the reading on the monitoring device at the door or Veri and document that a tissue hed at the gap at the bottom of the door is puing in.

urse taking care of the patient shoud perform this assessment and document in patient chart in theisoation section of nursing record egative Pressure Operating

5



Suppmnt 4

Air Changs Pr Hour And Tim In Minuts Rquird For Rmova

Ecincis Of 90%, 99%, Or 99.9% Of Airborn Contaminants

[This table is prepared according to the formula* t1 =(in (C2/C1)/(QN) x 60, which is an adaptation f theformula for the rate of purging airboe contaminants

1with t1=, and C2/C1= -(removal efciency/00).]

Air Minutes required for a Air Minutes required for aChanges removal

ecienc

of: Changes removalefcienc

of:per Hour 90% 99% 999% per Hour 90% 99% 999%

38 76 44 5 9 8 8 69 38 07 6 9 7 63 46 9 38 7 8 6 44 35 69 04 8 8 5 35 8 55 83 9 7 5 6 3 46 69 0 7 4 7 0 39 59 25 6 7

8 7 35 5 30 5 9 49 5 3 46 35 4 8

0 4 8 4 40 3 7 0 3 5 38 45 3 6 9 3 35 50 3 6 84 0 0 30

*Where t1=initial time point t2=time (minutes) required for removal efciency C=initialconcentration of contaminants C2nal concentration of contaminants Q=air ow rate (cubic feet perhour) V=room volume (cubic feet) QN=air changes per hour

The times given assume perfect mixing of the air within the space (ie. mixing factor ) However, perfectmixing normally does not occur, and the mixing factor could be as high as 0 if air distribution is very poor. (Adiscussion of mixing is provided in reference Industrial Ventilation: A Manual of Recommended Practice 5.The required time is determined by multiplying the appropriate time from the table by the mixing factordetermined for the booth or room. The factor and required time should be included by the manufacturer of thebooth or enclosure as part of the operating instructions for the enclosure and these instructions should befollowed.

1Mutchler, JE Principles of ventilation In: IOSH. The industrial environmentits evaluation and control

Washington, DC.: IOSH, 973.2 IOSH: Guide to industrial respiratory protection, Cincinnati, Ohio: US DS, CDC, IOSH. 987: DS

(IOSH) publication o. 876.

6



Supplement 5

Summary o Interpretation O Tuberculin Skin Tet (TST)

. A eaction of5 mm is classied as positive in: Pesons with infection o isk factos fo H infection with unknown H status Pesons who have ecent close contact* with pesons with active B. Pesons who have abnomal chest adiogaphs consistent with old healed B

A eaction of 0 mm is classied as positive in all pesons who do not meet any of the citeia above butwho have othe wok isk factos fo B including

ig Rik Group Intavenous dug uses known to be seonegative Pesons with othe medical conditions that have been epoed to incease the isk of pogessing fom

latent B infection to active B, including silicosis, gastectomy, jejuno-ileal bypass sugey, being0% o moe below ideal body weight, chonic enal failue, diabetes mellitus, high dosecoicosteoid and othe immunosuppessive theapy, some hematologic disodes (e.g. leukemias andlymphomas), and othe malignancies

Locally identied high isk populations Childen who ae in one of the high isk goups listed above Health cae wokes who povide sevices to any of the high isk goups.

ig-Prevalence Group Foeign-bo pesons fom high pevalence counties in Asia, Afica, and Latin Ameica Pesons fom medically undeseved low income populations

a) Residents of long-tem cae facilities (eg coectional institutions, nusing homes)b) Pesons fom high isk populations in thei communities, as detemined by local public health

authoities

3 Induation of5 mm is classied as positive fo pesons who do not meet any of the above citeia

4. Recent convetes ae dened on the basis of induation: ? 0 mm incease within a -yea peiod is classied as positive fo pesons ? 5 mm inceases unde ceain cicumstances (# I above)

5. hese guidelines ae meant to be in compliance with, not supesede, the most ecent ecommendations ofthe Ameican hoacic Society.

*Recent close contact implies household contact o unpotected occupational exposue simila in intensityand duation to household contact

7



Supplement 6

Regimen Options For The Treatment Of TB In Children And Adults

Total Inital reatment Phase Continuation reatment ase

Duration of Interval and.

Interva and

Option Incation Therapy

rqs Duration Druqs Duration omments

1 Pulmonary and 6 months INH Daily for 8 INH Daily or two or EMB orSM should be continued until

extrapulmonary RIF weeks RIF three times susceptibility to INH and RIF isTB in adults and PZA weekly2 for 16 demonstrated.children EMB weeks3

In areas where primary INH resistanceor SM

is <4%, EMB orSM may not benecessary for patients with noindividual risk factors for drugresistance.

2 Pulmonary and 6 months INH Daily for 2 INH Two times Regimen should be directly observedextrapulmonary RIF weeks then RIF weekly2 for 16

After the initial phase, EMB orSMTB in adults and PZA two times weeks.3children EMB weekly2 for

should be continued until susceptibility

orSM 6 weeksto INH and RIF is demonstrated,unless drug resistance is unlikely.

3 Pulmonary and 6 months INH 3 times Regimen should be directly observed.extrapulmonary RIF weekly2 for

Continue all four drugs for 6 months4TB in adults and PZA 6 months3children EMB

This regimen has been shown to be

or SMeffective for INH resistant TB

4 Smear and 4 months INH Follow NH Daily or two or Continue all four drugs for 4 monthsculture negative RIF options 1, RIF three times

If drug resistance is unlikely (primarypulmonary TB in PZA 2 or 3 for 8 PZA weekly2 for 8adults EMB weeks EMB weeks

INH resistance <4% and patient has no

or SM orSMindividual risk factors for drugresistance) EMB or SM may not benecessary and PZA may bediscontinued after 2 months

1 EMB = Ethambutol; isoniazid PZA pyrazinaminde; RIF = rifampin; SM = streptomycin2 All regimens administered intermitently should be directly obsered3 For infants and children with miliary TB bone and joint TB or TB meningitis, treatment should last 12 months. For adults withthese forms of extrapulmonary TB response to therapy should be monitored closely. If response is slow of suboptimal treatmentmay be prolonged on a case-by-case basis.4 Some evidence suggests that SM may be discontinued aer 4 months if the isolate is susceptible to all drugs5 Avoid treating pregnant women with SM because of the risk of ototoxicity to the fetus

Note: For all patients if drug-susceptibility results show resistance to any of the rstline drugs, or if the patient remainssymptomatic or smear or culture positive aer 3 months consult a TB medical expert

osaeSheule .

Dail Do aximum doe} 2 ies weekose (axim dose} 3 timesweekl ose (maxium do e)

r

u

s

Chilen* Adult· ·· Cildren* ult Chilren ult ··Isoniazid 10-20 mg/kg 5 mg/kg 20-40 mg/kg 15 mg/kg 20--40 mg/kg 15 mg/kg

300

m

300

m

(900

mq

900 m

900

m 900 m

Rifampin 10-20 mg/kg 10 mg/kg 10-20 mg/kg 10 mg/kg 10-20 mg/kg 10 mg/kg600

m 600

m

600

m 600 m 600

m

600 m

Pyrazinamide 1530 mg/kg 1530 mg/kg 5070 mg/kg 50-70 mg/kg 50-70 mg/kg 50-70 mg/kg2

m

2

m 4 m

4

m

3

m

3

m

Ethambutol 15-25 mg/kg 15-25 mg/kg 50 mg/kg 50 mg/kg 2530 mg/kg 25-30 mg/kg

Streptomycin 20-40 mg/kg (1 15 mg/kg 20-40 mg/kg (1 20-40 mg/kg (1 2040 mg/kg (1 20-40 mg/kgm

1

m m m

m

1

m

*1 eas f age o nde

8



Supplement 7

Instuctions on the PFR (Paticulate Filte Respiato) N95 Respiato

. You must quali medically and pass ttesting to wear this respirator

Always wear the size that you were tted to. You may not wear any other size The size is located onthe underside of the respirator.

3 The PR 95 Respirator is disposable. You should dispose of this respirator when:+ The respirator becomes soiled or damaged. When the respirator becomes moist from your breath.+ You are no longer able to achieve a good "t".+ Aer 8 hours of use.

4. The respirator is considered medical waste and must be disposed of in a red bag.

5. Each time you put on the respirator, you must+ Position it on the face

+ One band on upper nec, one band on top of head in front of ears+ o hair, scars, etc that may brea seal, especially at coers of respirator.+ osepiece is centered and contoured.

+Determine an acceptable t+ Chin is cupped in respirator+ Respirator spans from bridge of nose to chin.+ Straps are not overly tight.

+ Chec for "blow-by"+ Exaggerate inhaling and exhaling with the chin down+ If air is felt escaping through the sides of the mas, reposition the mas and chec again for

"blow-by".

9



Suppemet

Periodic isk Assessmet of the Tubercuosis Exposure Cotro Pa

ate idicates previous six moth period)

Da Pains ihEmlo

TST LucasCoun_

cass of UTMC Risk ssssmnciv T Convrsions aciv T

Lucas/Sannual/nnual

Jan 99 Vry LoJun 99 Vry LoJan 3 LoJun LoJan LoJun /36 LoJan LoJun 4/57 LoJan 3 Lo

Jun 3 7/9 LoJan 4 LoJun 4 4/9 Vry LoJan 5 LoJun 5 /6 LoJan 6 LoJun 6 9/39 LoJan 7 4 LoJun 7 4/5 LoJan 8 LoJun 8 7/3 Lo

Jan 9 Vry LoJun 9 3 3/8 LoJan LoJun 3/9

Vry LoJan Vry

LoJun 45

Vry

LoJan Vry

LoJun LoJan 3 4/49 LoJun 3 Lo

Reference list:

Centers for Disease Control and Prevention. (11) CDC issues recommendations on use of newtreatment option for latent TB infection Retrieved omh://www.cdcgov/nchhs/newsrooatentTBPressReleasehtml

Centers for isease Control and Prevention (1) Tuberculosis ( TB), Infection control and prevention:Infection control health care settings Retrieved omhttp://wcdc.gov/tb/topic/infectioncontrol/default.htm

Ohio Department of Health Tuberculosis disease data Retrieved omhttp//w.odhohiogovealthstats/disease/tb/tb l aspx

Centers for Disease Control and Prevention Treatment of Tuberculosis American Thoracic Society, CDC and Infectiousiseases Society of America. MM W 3 ;5(noR-l l) htt//wthoracicorstatements/resources/tb opi/rr521 l pdf

Tuberculosis Exposure Control Plan 2014

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