Procedure: Post-Exposure Follow-up for Tuberculosis/Airborne Pathogens


A. Purpose

This document outlines an interim, post exposure reporting and follow up process for a TB exposure incurred by either a faculty member or student in a covered occupational area. This process is based upon the CDC "Guidelines for Preventing the Transmission of Tuberculosis in Health Care Settings..." 1994. In addition, the requirements for HEPA respirators/PPE and training and education are also addressed.

These guidelines are to be in effect until the Occupational Exposure to Tuberculosis; Proposed Rule 29 OSHA acts upon C.F.R. 1910.1035. Changes will be required at that time.

B. Definitions

1) Workplaces with Inherent Exposure Potential to TB Disease

a) Healthcare facilities
b) Corrections facilities
c) Homeless shelters
d) Long term health facilities
e) Drug treatment centers
f) Ambulances/EMS vehicles


2) Exposure Potential

Exposure potential is defined as an exposure to the exhaled or expired air of a person with suspected or confirmed TB disease. Exposure to a high-hazard procedure or an individual with suspected or confirmed TB disease and with the potential to generate potentially infectious airborne respiratory secretions, i.e., aerosolized medication treatment, bronchoscopy, sputum induction, endotracheal intubation, suctioning procedures and autopsies.


C. Population at Risk for Occupational Exposure

..."all persons with direct or indirect patient care or client responsibilities. Examples include, but are not limited to: physicians, nurses, assistants, technicians, laboratory workers, morgue workers, EMS personnel, corrections personnel, students, [instructors]"...CDC, 1990.

Technical College faculty members and students in program or course areas addressed above are to be considered as Category I (high risk) for the occupational exposure to TB disease and are to be in a covered occupational area.

D. Procedures - Testing/Surveillance

1) Each student and faculty member in a covered occupational area should have a tuberculin skin test at the time of employment or prior to assignment to clinical or worksite area respectively, unless a previously positive reaction can be documented or after completion of appropriate preventative therapy or adequate therapy can be documented.

2) Any covered faculty member or student with a history of Bacillus of Calmette and Guerin (BCG) vaccination should also have the tuberculin skin test as in #1.

3) Any covered faculty member or student who exhibits a first time positive reaction to the skin test must be cleared by a physician prior to further contact with students or patients/clients. Clearance must be documented in writing. Personnel with documented, active TB disease should be also offered HIV antibody testing.

4) Covered faculty members and students with a documented history of a positive skin test (PPD) or adequate treatment of latent infection or active diseases are to be exempt from further testing unless signs and symptoms of TB disease develop.

5) Initial and follow up tuberculin skin tests should be administered and interpreted according to current CDC guidelines.

6) Periodic retesting of PPD-negative faculty members and students should be conducted to identify persons whose skin tests convert to a positive status. The frequency of retesting is risk-dependent. The schedule is every six months for persons performing high-risk procedures. In general, other covered faculty and students should be tested annually.

7) Tuberculin skin tests (initial and periodic) shall be offered to covered faculty members at no cost to the employee. Students are responsible for the cost of their skin tests.


E. Procedures - Post Exposure Follow up

1) An accidental exposure is defined in Section C.2. An exposure may occur in any clinical facility or work site where patients or clients are under treatment. The high-risk areas for exposure potential are listed in Section C.1.

2) Immediately upon identification of an accidental exposure involving a covered faculty member or student, the clinical instructor or instructor's supervisor shall be notified as well as the Technical College infection control coordinator and the authorized contact person at the clinical or work site.

3) The exposure incident shall be documented in writing with copies to the authorized person at the clinical or work site, the instructor and the Technical College infection control coordinator (ICC). (Incident Form to be provided.) Initial documentation is to be prepared the day of the incident and must be filed with the ICC within 24 hours of the incident.

4.) The effected instructor or student is to be counseled immediately after the exposure incident and referred to his or her family physician or health department to begin follow up and appropriate therapy. Baseline testing should be performed as soon as possible post-incident. The Technical is responsible for the cost of a post- incident follow up for both covered faculty members and students as specified in State Board Policy # 04-03-17.

5) Any faculty member or student in a covered occupational area with a positive skin test upon repeat testing, or after exposure should be clinically evaluated for active tuberculosis. If active tuberculosis is diagnosed, appropriate therapy should be initiated according to CDCP Guidelines or established medical protocol.

6) Any instructor or student in covered occupational area with a positive skin test, upon repeat testing or exhibiting signs and symptoms of TB, is not to have patient or client contact until such time as he or she is cleared by a physician after further testing and/or by initiation of appropriate therapy.

7) If an instructor or student in a covered occupational area is found to have clinical TB, all students or instructors within the immediate class or course shall be advised to have a PPD skin test to be cleared for further participation in the class or course. Any person exposed, as above, with a documented history of positive PPD skin tests may be recommended for a prophylactic chest X-ray.

8) Appropriate treatment protocols shall be followed per CDC Guidelines and a timetable for repeat testing shall be established.


F. Personal Protective Equipment (PPE) - HEPA or other Approved N-95 Respirators

1) Personal protective equipment (PPE) shall be utilized as follows:

a) Known or highly suspicious patient or client cases

1) High efficiency particulate air (HEPA) respirators or N.I.O.S.H.
approved N-95 respirators shall be used by faculty and students when entering a patient or clients' hospital room when the patient is known or highly suspected of having active TB disease.

2) HEPA (filter) respirator fit testing for each faculty member or student must be conducted to insure a reliable fit and face-seal prior to use of the equipment. This is required only if the HEPA respirator is to be used in lieu of other types of respirators.

3) The user should fit-check the respirator seal each time he or she uses the respirator, prior to entering a patient's or client's room.

4) Disposable or reusable HEPA or other N.I.O.S.H. approved respirators may be used. Reusable respirators must be stored to maintain the form-fit after cleaning after patient contact.


2) A covered faculty member and student with a respiratory disease or other disorder which would cause respiratory impairment/decreased pulmonary function may be required to be certified as capable of using an approved respirator by a physician. This certification is to be in writing.

3) A covered faculty member or student with a certified respiratory impairment that would prevent the use of a HEPA or other respirator should not be assigned to a known TB case or to a highly suspicious patient/client. An alternative assignment is to be made.

4) Personal protective equipment is to be provided by the Technical College for demonstration and practice lab activities. The clinical or work site may provide PPE for faculty members and students during rotations. If the PPE is not provided for actual patient/client contact, it is the responsibility of the Technical College to provide it at no cost to faculty members at no cost and to students at their cost.

G. Required Education and Training for Covered Faculty Members and Students

1) Each covered faculty member and student shall receive education and training about tuberculosis as part of the blood and airborne pathogens module. Faculty members shall receive annual refresher training thereafter. The Technical College infection control coordinator shall be responsible for monitoring and evaluating the effectiveness of this education and training process.

2) Training shall be documented as specified in the Technical College Exposure Control Plan.

3) The following shall be included in the education and training module:

a) Mode(s) of Transmission
b) Pathogenesis
c) Diagnosis and Assessment of TB
d) Latent Infection Stage Compared to the Active Disease State
e) Signs and Symptoms of Tuberculosis
f) The possibility of Reinfection in Persons with a Positive PPD
g) The Potential for Occupational Exposure and Transmission of TB
h) Principles/Practices Which Reduce risk of Exposure/Transmission
i) Review of Written Policies and Procedures.
j) The Purpose of PPD Testing and Significance of A Positive Result
k) Principles of Preventive Therapy in Latent Infection
l) Process and Steps in the Medical Evaluation of a PPD Test Conversion or Following Signs and Symptoms of TB Disease (Faculty & Students)
m) Principles of Drug Therapy for Active Tuberculosis
n) The Risk of TB in HIV or AIDS Patients or Other Immunosuppressive Disease
o) Confidentiality Secondary to Assessment and Treatment of Faculty or Student Who Develops TB Disease.
p) The Technical College's Policy on Voluntary Duty Reassignment Options for Immunocompromised Faculty Members and Students in Covered Occupational Areas.

References

II. D. 3. b. Occupational Exposure to Air Borne Pathogens/Tuberculosis


Created: March 30, 2001

Approved