Tuberculosis — Healthcare

Scope

Various OSHA standards require employers to provide safeguards for workers exposed to TB. The standards generally apply to all occupational exposures.

Regulatory citations

• 29 CFR Part 1904 — Recording and Reporting Occupational Injuries and Illnesses
• 29 CFR 1910.132 — Personal Protective Equipment (PPE)
• 29 CFR 1910.134 — Respiratory protection
• 29 CFR 1910.145 — Specifications for Accident Prevention Signs and Tags
• 29 CFR 1910.1020 — Access to Employee Exposure and Medical Records
• 29 USC 654(a)(1) — General duty clause of the Occupational Safety and Health Act

Key definitions

• Air changes per hour (ACH): Air change rate expressed as the number of air exchange units per hour. ACH is the number of times per hour that the total volume of air in an enclosure or room is replaced with clean air from the ventilation system or other air supply system.
• Airborne infection isolation room (AIIR): A room designed to maintain Airborne Infection Isolation (AII). AIIRs are single-occupancy patient-care rooms used to isolate persons with suspected or confirmed infectious TB disease. Environmental factors are controlled in AIIRs to minimize the transmission of infectious agents that are usually spread from person to person by droplet nuclei associated with coughing or aerosolization of contaminated fluids. AIIRs should be maintained under negative pressure (so that air flows under the door gap into the room), at an air flow rate of 6–12 ACH, and there should be direct exhaust of air from the room to the outside of the building or recirculation of air through a HEPA filter.
• Bacille Calmette-Guerin (BCG): A vaccine for TB that is used in most countries where TB disease is endemic.
• Baseline TB screening; Screening HCWs for LTBI and TB disease at the beginning of employment. TB screening includes a symptom screen for all HCWs, and tuberculin skin tests (TSTs) or blood assay for Mycobacterium tuberculosis (BAMT) for those with previous negative test results for M. tuberculosis infection.
• Baseline TST or baseline BAMT: The TST or BAMT is administered at the beginning of employment to newly hired HCWs. If the TST method is used, for HCWs who have not had a documented negative test result for M. tuberculosis during the preceding 12 months, the baseline TST result should be obtained by using the two-step method. BAMT baseline testing does not need the two-step method.
• Blood assay for Mycobacterium tuberculosis (BAMT): A general term that refers to recently developed in vitro diagnostic tests for the presence of infection with M. tuberculosis. This term includes, but is not limited to, interferon gamma release assays (IGRA).
• Boosting: In some persons who had remote infections with M. tuberculosis or other mycobacteria or who had previous BCG vaccinations, the ability to react to tuberculin may wane over time. When given a TST years after infection, these persons may have a false-negative reaction. However, the TST may stimulate the immune system, causing a positive or boosted reaction to subsequent tests. Giving a second TST after an initial negative TST (two-step testing) can reduce the likelihood that a boosted reaction to a subsequent TST will be misinterpreted as a recent infection.
• Healthcare setting: Any setting in which healthcare is delivered and workers might share air space with persons with TB disease or come in contact with clinical TB specimens. This term is broader than the term “facility,” which refers to a building or set of buildings. Examples of healthcare settings are inpatient settings (e.g., patient rooms), outpatient settings (e.g., TB treatment facilities and dental clinics), and non-traditional facility-based settings (e.g., medical settings in correctional facilities).
• Infection control program: A multi-disciplinary program that includes activities to ensure that recommended practices for the prevention of infections are implemented and followed by workers to prevent the spread of infection to patients and other personnel.
• Latent TB infection (LTBI): Infection with M. tuberculosis without exhibiting symptoms or signs of disease. Persons with LTBI do not feel sick and do not have any symptoms. They are infected with M. tuberculosis, but do not have active TB disease. The only sign of TB infection is a positive reaction to the TST or a positive BAMT. Persons with latent TB infection are not infectious and cannot spread TB infection to others. Latent TB is often treated to prevent TB disease, although clinicians also take into account the individual’s age, the duration of the latent infection, if known (progression to disease is much more likely within the first two years following infection), and the potential side effects from medication.
• Multidrug-resistant TB (MDR TB): TB that is resistant to at least two of the best anti-TB drugs, currently isoniazid and rifampin. Extremely drug-resistant TB (XDR TB) is a relatively rare type of MDR TB. XDR TB is defined as TB that is resistant to isoniazid and rifampin, as well as to any fluoroquinolone, and to at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin). Because XDR TB is resistant to first-line and second-line drugs, patients are left with treatment options that are much less effective.
• TB disease: A condition caused by infection with M. tuberculosis or other mycobacteria that has progressed to causing clinical or subclinical illness, meaning there are signs or symptoms of disease or other indications of disease activity (e.g., the ability to culture reproducing TB organisms from respiratory secretions). M. tuberculosis can attack any part of the body, but the disease is most commonly found in the lungs (pulmonary TB). Pulmonary TB disease can be infectious, whereas extra-pulmonary disease (occurring somewhere other than the lungs) is infectious only in rare circumstances.
• TB skin test (TST): TST is the standard method of determining whether a person is infected with M. tuberculosis. The TST is performed by injecting tuberculin PPD into the inner surface of the forearm. The skin test reaction should be measured by trained personnel between 48 and 72 hours after administration.

Summary of requirements

Employers are required to:

• Provide respirators to each employees when such equipment is necessary to protect the health of such employees. In such cases, the employer must establish and maintain a respiratory protection program.
• Conduct a hazard assessment to determine the need for personal protective equipment (PPE), document a hazard assessment certification, and provide and ensure the use of necessary PPE, along with PPE training.
• Post signs informing employees about any hazards that are of a nature such that failure to designate them may lead to accidental illness to employees or the public, or both.
• Keep injury/illness records. Covered employers must keep injury and illness records using the OSHA Form 300 Log, the Form 300A Summary, and the Form 301 Incident Reports, or equivalent forms.
• Certify and post the annual summary of injuries/illnesses. This must be posted from February 1 through April 30.
• Submit injury and illness data electronically to OSHA or OSHA’s designee, if required, by March 2 every year, if applicable.
• Keep exposure/medical records. Employers with employees exposed to biological agents (including bacteria like tuberculosis) must keep exposure records. Exposure records must be kept for 30 years. Medical records must be kept for the duration of employment plus 30 years.
• Report to OSHA. All employers, even those who may be exempt from other recordkeeping requirements, must promptly report to OSHA all work-related: fatalities, in-patient hospitalizations, amputations, and losses of an eye.

When conducting a TB-related inspection, OSHA directive CPL 02-02-078, “Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis,” June 30, 2015, explains that OSHA officers may evaluate whether the employer has implemented appropriate abatement measures to reduce the hazard. The directive adds that OSHA may cite under the General Duty Clause if any one of the following are found to be deficient:

• TB infection control program,
• TB risk assessment,
• Medical surveillance,
• Case management of infected employees,
• Employee education and training, and
• Engineering controls.

Directive CPL 02-02-078 summarizes some widely accepted standards of practice and refers OSHA officers to the Centers for Disease Control and Prevention (CDC) “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings,” December 30, 2005. Employers should consult the 2005 guidelines, along with any more recent guidelines. The CDC indicates that its “Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC,” May 17, 2019, updates the recommendations for screening, testing, and treatment of U.S. healthcare personnel.

In addition, according to OSHA, healthcare employers should take specific precautions to prevent the spread of TB, including the following:

• Avoid unprotected contact with potentially infected persons. When making first contact with all individuals who may have TB, visually screen for signs and symptoms of potential TB illness.
• Obtain input from employees during the development of a hazard analysis and a TB control strategy.
• Provide training in infection control procedures. Workers should be aware of potential hazards on the job and how to prevent accidental transmission. Employers should provide training on the facility’s policies and procedures regarding TB. Train workers on TB procedures, aerosol treatments, power washing, and any other practices that could increase the risk of exposure.
• Monitor health symptoms if possible exposure to TB has occurred. Workers should monitor their health for symptoms of TB infection for 10 days following known exposure and call their state or local health department immediately if they develop any illness signs or symptoms.
• Install and properly maintain appropriate air-handling systems in healthcare facilities.
• Booths used for source control should be instantaneously exhausted so that 100 percent of airborne particles are removed.
• Place patients with suspected active TB infection in an airborne infection isolation room (AIIR).
• Use HEPA filters in general-use areas, e.g., waiting rooms and emergency rooms, when recirculating indoor air. In isolation rooms these filters can only be used as a supplemental control and are not a replacement for negative pressure ventilation.
• Use UV irradiation as an additional control where exposure to TB bacilli risk is particularly high. UV radiation cannot be considered a substitute for ventilation requirements due to the low efficacy of these systems. UV irradiation may be used on recirculating air in general-use areas.
• Implement policies and practices to minimize potential exposures. When patients with active TB are known to be admitted, airborne precautions should be implemented before arrival, upon arrival, and throughout an affected patient’s presence in the healthcare setting. These patients should be placed in an isolation room with hazard signage on the door. Avoid transporting patients outside of the isolation room unless necessary and limit the numbers of healthcare workers caring for patients and visitors allowed to see the patients. Special considerations should be employed for high-risk procedures such as cough-inducing and aerosol-generation procedures, intubation, and bronchoscopy.
• Track all healthcare workers and support staff who care for or enter the rooms of confirmed or suspected active TB patients.