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					 PALM BEACH COUNTY
 HEALTH DEPARTMENT


TUBERCULOSIS EXPOSURE
    CONTROL PLAN

 The Palm Beach County Health Department
 Tuberculosis Exposure Control Committee
   reviewed and updated the TB Exposure
     Control Plan on December 17, 2003


     Boubker Naouri, MD, MSc, MPH
   Tuberculosis Exposure Control Officer
Contents
                                                                  Page

  I.     Policy and Purpose                                         2

  II.    Administrative Responsibility                              3

  III.   Tuberculosis Exposure Control Committee                    3

  IV.    Tuberculosis Exposure Control Officer                      4

  V.     Risk Assessment                                            5

  VI.    Case Management of Clients with suspected or Confirmed

         diagnosis of Tuberculosis                                  5

  VII. Outreach Programs                                            6

  VIII. Reporting of Active Tuberculosis (TB) Cases                 6

  IX.    Engineering Controls                                       6

  X.     Isolation of Infectious Clients                            7

  XI.    Respiratory Protection for Health Care Workers             8

  XII. Employee Educational Program                                 8

  XIII. Responsibilities                                            9

  XIV. Health Care Workers Medical Surveillance                     10

  XV. Problem Evaluation                                            10

  XVI. References                                                   12

  XVII. Appendices                                                  13

                                     1
               PALM BEACH COUNTY HEALTH DEPARTMENT (PBCHD)

                   TUBERCULOSIS (TB) EXPOSURE CONTROL PLAN


     I.        POLICY AND PURPOSE

It is the policy of the Palm Beach County Health Department (PBCHD) to provide care to
patients with tuberculosis (TB) in a manner that minimizes the risk of transmission of TB
to others. Early diagnosis, timely and effective treatment to individuals with active
pulmonary TB; effective use of administrative, work practice and engineering controls;
the use of respiratory protection; and a comprehensive health care worker (HCW)
surveillance program are key components of this policy.

   1. GOALS

             Ensure that all persons who have or are suspected of having infectious
              Mycobacterium tuberculosis are identified and promptly placed in Acid Fast
              Bacilli (AFB) isolation and started on appropriate chemotherapy.
             Ensure that clients remain on appropriate chemotherapy until completion of a
              recommended course of therapy until cured to prevent a return to
              infectiousness.
             Ensure that persons who are not infected with TB are protected from exposure
              to infectious Mycobacterium tuberculosis by appropriate precautions wherever
              there is a potential for TB transmission.
             Provide expert advice or provide referrals to experts for information about
              appropriate infection control measures.

The PBCHD TB Exposure control plan (TECP) is based upon “Guidelines for Preventing
the Transmission of Mycobacterium tuberculosis in Health Care Facilities, 1994”
published by the Centers for Disease Control and Prevention, U.S. Department of Health
and Human Services. The TECP encompasses the Florida Department of Health Bureau
of TB and Refugee Health Technical Assistance: TB 4, January 1, 2001 (Appendix I);
PBCHD policies and procedures related to TB (Appendices II, III, IV, V).

   2. PURPOSE

The purpose of the TECP is to prevent or eliminate the risk of exposure to TB to
employees in the work setting. The original plan went into effect on June 1, 1995. The
TECP is in effect for the entire PBCHD and is an overall plan to protect the HCW and
clients from transmission of TB. This TECP will be reviewed annually per PBCHD
PPGM# A-II.4.5.2 (Appendix II) by the TB Exposure Control Committee (TECC) to
insure that appropriate measures are in place to prevent the transmission of TB to HCW.




                                              2
Copies of the TECP are available in the offices of:

           The Division Directors
           Center Directors
           Center Senior Community Nurse Supervisors
           TB Control Program sites
           Medical Director
           Clinic Nursing Supervisor of the TB Control Program

     II.     ADMINISTRATIVE RESPONSIBILITY

The TECC (see following pages) has the responsibility to develop, monitor the
implementation of, and evaluate the policies within the written TECP. The Senior
Community Health Nurse Supervisor in each of the Centers is delegated the responsibility
for supervision of implementation of the TECP in his/her assigned unit.

The use of engineering controls to prevent the transmission of TB and reduce the
concentration of infectious droplet nuclei is under the administrative responsibility of the
TB Control Program Manager. The TECC has the responsibility for selecting the primary
means of respiratory protection for HCW. Educational programs to address the issue of
prevention of transmission of TB are determined by the TECC.

The expected outcome of the TECP committee will be the utilization of safe work
practices for and by employees.

     III.    TB EXPOSURE CONTROL COMMITTEE (TECC)

   1. TB exposure control committee purposes

The TECC has as its purposes to:

           Protect employees from exposure to TB thorough the appropriate use of
            TECP.
           Assure a safe and healthy environment for HCW who care for clients with TB.

   2. TECC goals

           Ensure that all persons who have or are suspected of having infectious
            Mycobacterium tuberculosis are identified and promptly placed in AFB
            isolation and started on appropriate chemotherapy.
           Ensure that clients remain on appropriate chemotherapy until completion of a
            recommended course of therapy until cured to prevent a return to
            infectiousness.



                                             3
              Ensure that persons who are not infected with TB are protected from exposure
               to infectious Mycobacterium tuberculosis by appropriate precautions wherever
               there is a potential for TB transmission.
              Provide expert advice or provide referrals to experts for information about
               appropriate infection control measures.

    3. Meetings

The TECC shall meet not less than four (4) times a year and will meet at other times as
needed and determined by the TECC Chair or Committee members.

    4. TECC structure

                       Role                                                 Appointed By
Chair                                               PBCHD Director
Deputy Chair                                        Chair
Standing Member (Site TECC Representatives)         Director in charge of building(s) at each site.
Standing Member (Safety and Loss Prevention         Safety and Loss Prevention Committee Charter
Committee Chair)
Sub-Committee Chair (Site TECC Committee            Director in charge of building(s) at each site.
Chairs)
Sub-Committee Member                                Center, Division and Program Directors at each site
Recorder                                            Chair, Sub-Committee Chair
Team Leader                                         Chair, Sub-Committee Chair
Team Members                                        Sub-Committee Chair
Quality Advisor                                     Duty Position
Infection Control Advisor                           Duty Position



        IV.     THE TB EXPOSURE CONTROL OFFICER

    1. Role description

The TB Exposure Control Officer (ECO) is the TB Control Program Manager in the
service of PBCHD. This person has expertise in TB exposure practice, exposure
surveillance, data collection and analysis, documentation, and reporting.

    2. Functions

The ECO is responsible for the following activities:

              Collecting, correlating, and analyzing TB Exposure data of clients and
               HCW’s.
              Receiving reports of suspected or known cases of TB.



                                                4
           Determining TB and other data to be collected and surveillance measures to be
            implemented.
           Reporting unusual problems or occurrences to the TECC.
           Making recommendations for staff compliance with the TECP.
           Serving as the Chair of the TECC.
           Scheduling the quarterly and other meetings of the TECC as needed and
            preparing the meeting agenda.

           V. RISK ASSESSMENT

The TECC and each PBCHD Health Center have taken measures to assess the risk factors
involved in the transmission of Mycobacterium tuberculosis at each site. The outcomes
of these measures have been used to assess the level of risk for TB transmission to
HCW’s in TB Control and AIDS program clinical areas, the building which adjoin or
house them, and the other PBCHD buildings where clinical services are performed. The
classification of risk has been determined using the criteria on the Risk Level Scoring
Sheet (Appendix VII). Risk factors for the PBCHD health centers are assessed annually
by the TECC.

        VI. CASE MANAGEMENT OF CLIENTS WITH SUSPECTED OR
            CONFIRMED DIAGNOSIS OF TB

   1. Early identification

Early identification of clients with active TB takes place during the initial or reopened
encounter to the PBCHD clinics. Triage measures are implemented to take a health
history, to ask relevant questions to facilitate identification of TB, and to detect signs and
symptoms of active TB in clients. The PBCHD cough screen (Appendix VIII) form #
PBCHD-MRC146 (6/97), is provided to assist in this assessment.

If there is a suspected or known case of TB, the client is immediately placed in a
designated isolation room, given a Sub Micron Molded Surgical Mask, tissues, and tissue
disposal bag. The client is immediately referred to the appropriate TB clinic for isolation
purposes. The client is instructed in the rationale for the use of the mask, how to wear the
mask, and the use of tissue to cover his mouth and nose when coughing or sneezing. TB
precautions are initiated immediately with the client. Clients with known TB have
appointments scheduled to avoid contact with high-risk groups, including severely
immunocompromised clients.

   2. Evaluation and treatment

Suspected or confirmed cases of active TB are referred to TB clinic for evaluation.
Tuberculosis Skin Testing and radiological examination, as well as other diagnostic
measures, are initiated when in the PBCHD. Clinical policies and protocols are in place
for prescribing first and second line medications according to the health status of the


                                              5
client. Client education includes verbal and written instructions about medication and its
side effects, isolation, and other health care measures to implement at home to prevent
transmission of TB to other family members. Clients are taught to discontinue isolation
precautions when they are no longer infectious. All new TB suspects and cases are
candidates for and receive directly observed therapy (DOT). Those clients who require
hospitalization are referred to local hospitals or A.G. Holley Hospital for treatment.

   3. Monitoring response to treatment

Clients are given appointments to the PBCHD TB clinics, for follow-up purpose. In these
subsequent visits, the client’s health status and medication compliance are monitored and
appropriate laboratory tests on sputum and blood are performed. When treatment
regimens are completed, clients are scheduled for follow-up visits at designated interval.

       VII. OUTREACH PROGRAMS

Some HCWs are assigned to a client caseload in outreach services for Palm Beach
County. For the prevention of transmission of TB, it is mandatory for HCW to wear a
National Institute of Occupational Safety and Health (NIOSH) approved Type N95 or
more protective respirator and to implement the same exposure control protocol for
dealing with active cases as would be used in the ambulatory health care setting. This is
imperative when providing DOT, outreach case finding, contact follow-up, or when
dealing with non-compliant suspected or confirmed active TB clients.

      VIII. REPORTING OF ACTIVE TB CASES

There is a public health protocol in place to report new, confirmed TB cases.

        IX. ENGINEERING CONTROLS

Engineering controls are in effect in PBCHD TB Control and AIDS Program clinical
areas. In addition to the use of HEPA filters and ultraviolet lights in some clinical areas,
several areas have respiratory isolation rooms in place. Doors to these rooms are kept
closed when clients are present and for a posted, specified time after they leave the room.

HCW entering these rooms must wear a Type N95 particulate respirator when a client
who is TB infectious, suspected TB infectious or undergoing cough inducing or
pentamidine treatment is present and for a minimum of the posted, specified time after
the client leaves the room. The specified time is determined by an Environmental
Specialist from the Indoor Air Quality Section of the Division of Environmental Health &
Engineering. The specified time is posted by the nursing supervisor of the respective TB
Control/AIDS clinics.




                                             6
   1. Respiratory Isolation Rooms

Respiratory isolation rooms are used to perform all clinical services (except x-ray where
not available) for patients that have been determined to be TB infectious or suspected TB
infectious. All cough inducing procedures and pentamidine treatments are performed in
the respiratory isolation rooms.

The isolation rooms are designed to meet the CDC standard of 12 air changes each hour.
Room air is exhausted to the outside, and the room is maintained in a negative pressure
mode. These rooms maintain these standards and are checked on a yearly basis and
adjusted accordingly. In addition, they are tested daily, using the “tissue test” or “smoke
test”.

Daily documents (Appendix IX) will be maintained in each PBCHD TB/AIDS Clinic and
summary report prepared by the clinic-nursing supervisor is forwarded to the TECC twice
a year. If changes are required, the ECO is responsible for notifying and following up
each request for completion and compliance of the engineering controls for these rooms.
The clinic supervisor is responsible for requesting and arranging for the annual airflow
checks performed by Environmental Health and Engineering.

Each center with respiratory isolation rooms must have center specific procedures for the
use of each respiratory isolation room.

   2. Cough-inducing procedures

Cough-inducing procedures are not performed on known TB clients unless absolutely
necessary. Cough-inducing procedures are explained to clients for sputum collection and
appropriate collection devices are provided. If additional instruction is needed by clients,
who already have initiated cough-induction, HCWs must wear a respirator when entering
the room. Clients are required to remain in the cough-inducing (respiratory isolation)
room until they have stopped coughing. After the client leaves the room, the room is not
to be entered or used again for a minimum of posted, specified time to allow for
therapeutic ventilation of the room. HCWs are not permitted to enter these rooms for
cleaning purposes until the required ventilation process have been completed.

         X. ISOLATION OF INFECTIOUS CLIENTS

PBCHD HCWs shall screen any clients who are coughing using the Coughing Screen
Worksheet (Appendix VIII). If a client is determined to be at risk for TB, the patient must
immediately put on a surgical mask then be ushered into a designated respiratory isolation
room. If none is available, they are to be sent to wait outside. Whenever possible, the
client will be transported by the route that will minimize the number of people exposed to
their coughing.




                                             7
Each TB clinic has an appropriately engineered respiratory isolation room. Suspect and
infectious cases of TB will be asked to wear a mask and placed in the respiratory isolation
exam room. All procedures, except x-ray if not available, are performed in the isolation
room. HCWs wear a respirator when entering the room. After the client leaves the room,
the room is not entered or used again for the posted specified time to allow for therapeutic
ventilation of the room. HCWs are not permitted to enter these rooms for cleaning
purposes until the required ventilation process has been completed.

As previously stated, staff will wear respirators when in the home or respiratory isolation
room (detention, hospital, hospice, nursing home, etc.) of TB suspected or infectious
cases. The respirator will be correctly applied before entering the home/room and
removed after exiting the home/room.

        XI. RESPIRATORY PROTECTION FOR HEALTH CARE WORKERS

See Appendices IV and V for the Policy and Procedure for Respiratory Protection for
Occupational Exposure to Tuberculosis.

       XII. EMPLOYEE EDUCATIONAL PROGRAM

All PBCHD employees receive annual TB education and training. The educational
program includes knowledge of individual work roles, functions, and responsibilities and
a required TB Exposure Control Plan curriculum. Thereafter, a review of required
content and update of TB information and training are provided on an annual basis. The
TB Control Program Manager and site Sr. Community Health Nursing Supervisor are
responsible for reviewing and updating epidemiological, technical, and site specific
materials.

HCWs are given access to an educational manual and multiple learning aids. This manual
contains the goals and purposes of the PBCHD TB exposure control Plan and the
educational program described below.

   1. Educational Program Objectives

At the completion of the program the learner will:

          Know the incidence of TB in the US, Florida and PBC
          Know the pathophysiology and methods of transmission of TB
          Identify the signs and symptoms of active TB
          Understand how TB is transmitted
          List measures to prevent the transmission of TB
          Relate how early identification of clients with TB is made
          Discuss the management of the client with TB
          Describe the occupational risks of TB
          Understand counseling services available to the employees


                                             8
          Understand where employees can seek appropriate resource people within
           PBCHD

   2. Educational Program Content

          Epidemiology
          Transmission
          Pathogenesis - signs and symptoms
          Screening
          Prevention
          Diagnosis
          Treatment
          Risk to employees

Counseling services and other resources will be available to employees.

     XIII. RESPONSIBILITIES

   1. Center Directors

The Center Directors are responsible for providing information and training to employees
at the sites listed below.

          Lantana
          Delray Beach
          C.L. Brumback, Belle Glade
          West Palm Beach Health Center, West Palm Beach
          Jupiter Auxiliary, Jupiter
          Broadway Health Center, Riviera Beach.

The TB Control Program Manager or his designee will provide training for staff at the
different sites.

   2. Center Senior Community Health Nursing Supervisors

The Center Senior Community Health Nursing Supervisors will be responsible for the
following for their assigned sites/staff.

          Maintaining an up-to-date list of staff requiring training
          Scheduling periodic training seminars for employees
          Maintaining appropriate training documentation such as “Sign-in-Sheets”/
           Quizzes etc.




                                            9
   3. Supervisors and Employees

Supervisors are responsible for assuring the mandatory attendance of all training sessions
by staff and compliance with the appropriate medical surveillance procedures.
Employees are responsible for attending the TB training sessions, participating in the site-
specific medical surveillance program, and implementing TB exposure control protocols.

      XIV. HEALTH CARE WORKERS MEDICAL SURVEILLANCE

The counseling and screening program for HCW is a responsibility of the center director.
This is especially important in the PPD testing program. HCW are tested upon
employment (Appendix X). New employees without documentation of a negative PPD
within the previous 12 months are to receive a two-step PPD. PPD testing is done every
three (3) months to one (1) year on HCW with negative PPD, depending on the latest risk
assessment. New employees with a positive PPD test result or with documentation of
having had a positive PPD are x-rayed and counseled concerning symptoms of TB, and a
symptom screening questionnaire is done every three (3) months to one (1) year,
depending on the risk assessment. No further x-rays are obtained unless symptoms of TB
disease develop. In addition, HCW’s with negative PPDs are tested whenever they have
been exposed to a TB infectious client and appropriate precautions were not observed at
the time of exposure. If a HCW’s PPD test converts to positive, the center director will
maintain confidentiality and initiate counseling for the HCW. The center director is
responsible for providing further TB diagnostic testing to rule out the diagnosis of active
TB in the HCW.

Each Center Senior Community Health Nursing Supervisor is to provide to the TECC a
roster (Appendix XI) of staff PPD tests (including staff symptom screen results) annually
in March for low risk facilities and biannually in March and September for intermediate
risk facilities.

       XV. PROBLEM EVALUATION

The TECC is responsible for investigating the following situations within the PBCHD:

          The occurrence of PPD test conversions
          Situations in which clients or health care workers with active TB are not
           promptly identified and isolated, thus exposing other persons in the facility to
           TB
          The occurrence of possible person-to-person transmission of TB
          The occurrence of other TB-related problems

The TECC will be responsible for investigating PPD test conversions in HCW. The
possible source or transmission factor is to be detected and steps taken promptly to
evaluate the HCW for active TB. On the basis of an initial evaluation, additional



                                             10
diagnostic measures should be taken as indicated. History of possible exposure should be
obtained and investigated according to public health guidelines.

If a HCW develops infectious TB or an infectious TB client goes unrecognized, the case
should be evaluated to determine the likelihood of possible occupational transmission, to
identify possible causes, and to implement standard interventions. Contacts who have
intense exposure to the HCW/client should be identified and evaluated for TB exposure
and disease.

Other TB related problems would be investigated by the TECC as they occur.




                                            11
                                  REFERENCES



Dept. of Health. Technical Assistance: TB 4, Tuberculosis Infection Control,
Tallahassee, FL, January 2001.

Dept. of Health and Rehabilitative Services. TB 101. Tallahassee, FL May 1994

CDC. Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in
Health-Care Facilities, 1994. Atlanta, US Department of Health and Human
Services 1994.

Occupational Safety and Health Administration (OSHA). Occupational Exposure
to Tuberculosis; Proposed Rule, 1997. Washington D.C., U.S. Department of Labor.




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                                  APPENDICES




   I. Technical Assistance: TB4
  II. Tuberculosis Exposure Control Procedure
 III. Cough Screen Procedure
 IV. Respiratory Protection for Occupational Exposure to Tuberculosis Policy
  V. Respiratory Protection for Occupational Exposure to Tuberculosis Procedure
 VI. Tuberculosis Exposure Control Committee Charter
VII. Risk Level Scoring Tools
VIII. Cough Screen Form (2 sides)
 IX. Airflow Checklist
  X. Initial Employee PPD Screening Log
 XI. PPD Log




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