PENN EXPOSURE CONTROL PLAN

APPENDIX D

Tuberculosis (TB) Infection Control Plan

This document makes recommendations for reducing the risk of transmitting Myobacterium Tuberculosis (M. Tuberculosis) to healthcare workers (HCWs), patients, volunteers, visitors, and others in University healthcare settings. Designated personnel (PRINCIPAL INVESTIGATORS / AREA SUPERVISORS) are responsible to conduct a risk assessment for their area to determine the risk for nosocomial or occupational transmission of M. Tuberculosis and implement an appropriate TB infection control plan. HCWs refers to all paid and unpaid persons working in healthcare settings who have the potential for exposure to M. Tuberculosis. This may include but is not limited to: physicians, dentists, nurses, aides, dental workers, technicians, workers in laboratories and morgues, emergency medical personnel, students, part-time personnel, temporary staff not employed by the University, and persons not directly involved in patient care but who are potentially at risk for occupational exposure to M. Tuberculosis (e.g. volunteer workers and dietary, housekeeping, maintenance, clerical and janitorial staff).

TB Screening Protocol

1. Introduction to TB
   
   TB is a disease caused by a bacterium, M. tuberculosis. TB is spread primarily by airborne droplets coughed up from the lungs of persons with active disease. Once inhaled, the organism establish infection in the lungs and then disseminate throughout the body before the immune response brings the primary infection under control. Most infected persons have no symptoms of disease. Following infection a small percentage of individuals will develop symptoms. About ten percent of persons who become infected will develop an active case of TB during their lifetimes.
   
   The risk of developing active disease is enhanced by a number of factors, including HIV infection, pharmacologic immunosuppression (e.g. cyclosporin, steroids), underlying medical conditions such as diabetes mellitus and sudden weight loss.
   
   For decades the prevalence of TB in the United States was declining. In the mid 1980's, however, the number of TB cases increased, fueled by the development of the epidemic of HIV infection in this country. Those areas seeing the largest caseloads of HIV infection are the same areas experiencing the largest increases in TB cases. In 1992 pulmonary TB was made an AIDS-defining illness. In 1993 the number of cases of TB in this country decreased from the previous year. This decline may be due to reporting of TB cases as AIDS-defining illnesses, rather than reporting through TB control channels or to greater success in having patients complete a course of treatment.


2. The prevalence of TB in this region
   
   Between 1989 and 1992 Philadelphia saw a forty percent increase in the number of cases of pulmonary TB; however, TB has declined by nearly half in subsequent years. One hundred forty-seven cases were reported in 2002. Philadelphia accounts for approximately 40% of Pennsylvania’s total case in 2002.
   
   The statewide rate of TB is approximately 3.2 cases per 100,000 population. This is lower that the national rate of 8.0 cases per 100,000 population. Philadelphia County, in contrast, has a case rate of 9.7 per 100,000, although there are segments of the community with much higher rates.
   
   In the mid-1980’s and early 1990s there was an increase in the prevalence of multi-drug resistant (MDR) TB in the United States. Like the trend in cases overall, the trend in MDR cases has been reversed as well. MDR-TB was never very prevalent in Philadelphia or in Pennsylvania despite a substantial occurrence of this phenomenon in nearby jurisdictions such as New Jersey and New York City. In recent years less than one percent of newly diagnosed cases of TB in Philadelphia have been MDR. However, nearly eight percent of the cases in Philadelphia are resistant to Isoniazid, an important drug in the arsenal against TB. This level of Isoniazid resistance indicates that the potential for multi-drug resistance still exists. The inability to use first line drugs makes treatment for TB more complicated and of longer duration. In areas where the level of Isoniazid resistance exceeds 4%, four-drug initial therapy is necessary.


3. Risk assessment
   
   It is important to realize that TB is spread most exclusively from patients who have pulmonary infection and who cough infectious organisms into the air, which may be inhaled by others. Rarely, a person with a soft tissue TB infection may spread organisms through aerosols from drainage at their infected site. Workers in front line positions involved in patient contact may encounter TB among individuals who have not yet been diagnosed. Personnel with outpatient contact should be aware of this problem. Laboratory personnel who handle the organism, M. tuberculosis, may also be at risk. An ongoing employee tuberculin screening program is available to monitor healthcare workers who may be at risk of becoming occupationally infected with TB.


4. TB control measures
   
   TB control involves a hierarchy of interventions. Those interventions are:
   
   1. administrative controls
   2. source control
   3. environmental controls
   4. personal protective equipment.

   Administrative Controls

   Administrative controls include the education of staff and development of policies and practices for the rapid identification and isolation of individuals suspect of having TB.
   

   Management Of Patients To Prevent TB Exposures

   1. Rapid identification, isolation of the patient and initiation of treatment is the best way to control TB and prevent its spread.
   2. Professional staff should be aware of the presence of a cough in patients. Any patient complaining of a cough should be questioned regarding symptoms and risk factors for TB. Any individual suspected of having TB on the basis of symptoms described or on the basis of chest x-ray findings should be immediately given a mask to wear. The patient should be referred to their personal healthcare provider, HUP's Emergency Room or walk-in clinic for more careful evaluation as soon as possible. If an isolation room is available the suspect patient should be placed in a closed room and all health care workers entering the room should wear appropriate respiratory protection.
   3. If a patient has a productive cough of more than two weeks duration a mask should be placed on the patient. Patients at particular risk of TB include those on immunosuppressive medications (e.g. cyclosporine, steroids), HIV infected persons, persons born in countries with high endemic rates of TB, alcoholics and those with kidney failure, pulmonary disease and other conditions.
   4. If a cough is not identified by questioning or evaluation proceed with the appropriate workup for the patient.

   Source Control

   Source control is a very important aspect of TB control. The "source" is the coughing patient with active pulmonary or laryngeal TB. The ultimate means of source control is to have a patient with active TB successfully complete a course of therapy. It is now recommended that all patients with TB receive directly observed therapy, which involves the observed administration of all of a patient's medication. Factors such as homelessness, substance abuse, psychiatric disorders, as well as other problems may impair the patient's ability to complete therapy. It should be noted that TB medications are provided free by county health departments in the Commonwealth of Pennsylvania. Therefore, inability to pay for medication should not be a factor in non-compliance with taking anti-tuberculous medications. Attempts should be made to identify other factors that may interfere with a patient's ability to take proper medication.
   
   While waiting for anti-TB therapy to take effect, the source control can be effected by having a patient wear a mask or simply cover his/her mouth while coughing. The mask may be a paper surgical mask. Patients known or suspected to have TB should be restricted in their movements in University treatment facilities.
   
   

   Environmental Controls

   Environmental controls are utilized to decontaminate the air in high-risk areas such as patient treatment rooms and treatment waiting rooms areas.
   
   Treatment rooms must have negative air pressure to adjacent areas and a minimum of six air changes per hour in existing facilities. New facilities must have at least twelve air changes per hour in treatment areas. Negative pressure inside the treatment room permits air to be drawn into the room and prevents its escape to adjacent areas. This protects persons outside the room from exposure to infectious aerosols that may be generated inside the room by a patient with active TB. The room air is changed a minimum of six times each hour and exhausted from the building without internal recirculation. Exhaust air must be subjected to HEPA filtration if it is to be recirculated. Doors and windows to the room must be kept closed in order to maintain the negative pressure gradient.
   
   If the number of air changes noted above is not attainable, alternative methods, such as local HEPA filtration should be considered. Contact EHRS at 215-898-4453 for assistance in evaluating the ventilation requirements of your facility.
   
   

   Respiratory Protection

   The last line of defense against the spread of TB is the use of personal protective equipment. Respiratory devices are employed to prevent the inhalation of infectious droplets. They should be used in situations where the patient has not yet received sufficient treatment to be rendered non-infectious and when environmental controls may not provide adequate protection.
   
   Appropriate respiratory protection must be provided at no cost to staff that are at-risk. Before wearing a respirator, personnel must:

    

   1. Go to Occupational Medicine at HUP for medical evaluation.
   2. Contact EHRS (215-898-4453) for training in respirator selection, fit testing and use.


5. What to do in the event of an exposure
   
   If you believe you have been exposed to TB in the course of your duties at the University, you should discuss this with your supervisor for possible referral to the Occupational Medicine for TB screening. EHRS investigates occupational exposures to TB to determine if there have been any unprotected exposures. In instances of unprotected exposure, the exposed individuals are identified by EHRS and instructed to report to Occupational Medicine & Health Service for testing. Individuals who become infected with TB (develop a positive skin test reaction) following an exposure are not able to transmit TB unless they develop an active case of TB. Students who are exposed in the course of their studies should be evaluated in Student Health (215-662-2850).


6. Screening of employees for TB
   
   Every employee who is at-risk of occupational exposure to TB must be screened on an annual basis. Persons working in high exposure areas or occupations should be screened twice yearly.
   
   The program of tuberculin screening is administered by Occupational Medicine at the University of Pennsylvania Medical Center (215-662-2354).
   
   
   Should an employee be found to have a positive skin test for TB, further evaluation will be necessary, including, if needed, a chest radiograph. If the tuberculin skin test is positive, preventive medicine may be indicated to reduce the risk of developing active disease. A decision whether to take the medicine should be made in conjunction with advice provided by Occupational Medicine and the employee's personal physician. Standard guidelines from the American Thoracic Society are employed in the decision to recommend prophylaxis following TB infection.¹


7. Individual Responsibilities
   
   
   1. Responsibilities of the primary University health care provider:
      
      1. Prompt referral of patients suspected or proven to have active pulmonary TB.
      2. Notification of EHRS of any potential exposure of employees to TB.
   2. Responsibilities of EHRS:
      
      
      1. Training University personnel who may be at-risk of occupational exposure to TB.
      2. Training and fit-testing of personnel who may require respiratory protection.
      3. Ensuring appropriate referral of employees suspected of having occupational exposure to a patient with active pulmonary TB or when an unsuspected TB exposure episode has occurred.
      4. Development of "contact" lists when an exposure episode has occurred, so that Occupational Medicine may perform appropriate screening.
   3. Responsibilities of the Occupational Medicine:
      
      
      1. Periodic (at least annual) screening of at-risk University employees for TB.
      2. Screening of University personnel following an unsuspected TB exposure episode.
      3. Maintenance of centralized medical records allowing employee tracking.
      4. Notification of EHRS if any University employee is found to have active TB.
   4. Responsibilities of Student Health Services:
      
      
      1. Pre-admission screening of University students for TB.
      2. Screening of University students following an unsuspected TB exposure episode.
      3. Maintenance of centralized medical records allowing student tracking.
      4. Notification of EHRS if any University student is found to have active TB


8. Important Telephone Numbers
   
   Should you have questions about TB control, please call the telephone numbers listed below for additional information.
   
   Office of Environmental Health and Radiation Safety 215-898-4453 Occupational Medicine 215-662-2354 Student Health Service 215-662-2850<

¹ American Thoracic Society Treatment of Tuberculosis Infection in Adults and Children
Am J Respir Crit Care Med Vol 149. pp 1349-1374, 1994.