Safety Manual:
Prevention of Tuberculosis (TB) Transmission Plan

The purpose of this tuberculosis infection control plan is to prevent the transmission of tuberculosis in the workplace and to comply with Occupational Safety and Health Administration requirements. 

This plan applies to all NKY Health staff. 

Staff shall be trained regarding the hazards and control of tuberculosis. Trainings are the responsibility of the Employee Health Nurse and will be given:

• Upon initial employment.

• At the time of a staff's  Tuberculin skin test (TST) conversion or diagnosis of active infectious Mycobacterium tuberculosis (MTB).

• At the time of new MTB infection control information.

• At the time of any NKY Health changes in organization or services provided.

• At the time of any changes to this NKY Health Tuberculosis Exposure Control Plan.

At a minimum, the following subjects will be discussed:

• The cause and transmission of Mycobacterium tuberculosis (MTB).

• Definition of infectious and non-infectious MTB.

• The distinction between MTB disease and Latent Tuberculosis Infection.

• The purpose and interpretation of TST or Quantiferon-Gold, including the significance of a skin test conversion.

• The signs and symptoms of MTB.

• The reporting mechanism of the signs and symptoms.

• The purpose of preventive therapy.

• The risk factors for MTB disease development.

• The potential infectiousness of employees with infectious MTB disease.

• The treatment of MTB and the origin and prognosis of multi-drug resistant TB.

• The purpose of surveillance and the recommended follow-up of positive TSTs.

• Site specific protocols, including the purpose and proper use of controls.

• The purpose, proper selection, fit, use and limitations of personal protective equipment.

• The engineering controls in use in the person’s work area.

• The critical role Directly Observed Preventive Therapy plays in preventing the emergence of multiple drug resistant strains of MTB. 

After the training, employees will complete a Tuberculosis Exposure Control Training Record form. This form will be filed with other OSHA-required training records and retained indefinitely by the Employee Health Nurse. Training records for NKY Health employees are maintained in a learning management system and/or personnel files.

Clinical Services has primary responsibility for the implementation and management of this plan. Assistance will be required from the Clinic Managers and employees in the following areas:

• Client’s medical record reviews

• Implementation and follow-up of client and employee tuberculin skin testing

• Data collection of conversion rates in the community

Early identification of clients with infectious MTB is critical to the success of this plan. Clinical Services will offer tuberculin skin testing and follow-up to NKY Health employees at risk for exposure to infectious MTB. Clinic Managers and staff will be responsible for the management of this section of the plan.  

This plan is based on three levels of control: 

• Administrative

• Environmental

• Respiratory protection

AFB:  acid fast bacilli

BCG: Bacillus Calmette Guerin

CDC: Centers for Disease Control and Prevention

DOPT: Directly Observed Preventative Therapy

DOT: Directly Observed Therapy

HIV: Human Immunodeficiency Virus

LTBI: Latent Tuberculosis Infection

MTB: Mycobacterium Tuberculosis

NIOSH: National Institute for Occupational Safety and Health

N-95 Respirator: An air-purifying, particulate respirator capable of filtering particles 1.0 μm 95 percent efficiently  

OSHA: Occupational Safety and Health Administration

Particulate Respirator: Respirator certified by NIOSH to prevent penetration by particles 0.3 μm to 1.0 μm

QFT: Quantiferon-Gold

TST: Tuberculin Skin test by Mantoux using purified protein derivative 

The purpose of this program is to ensure the protection of all employees from respiratory hazards through proper use of respirators. Respirators are to be used only where engineering control of respiratory hazards is not feasible, while engineering controls are being installed or in emergencies. 

NKY Health has authorized Clinical Services to make necessary decisions to ensure success of the respirator program. These decisions will include equipment purchases and appropriate training (fit testing). Clinical Services will develop written detailed instructions covering the basic elements in this program and is authorized to amend these instructions as necessary. The District has expressly authorized Clinical Services to monitor and to halt any operation of the District where there is danger of serious injury. 

Clinical Services will develop written standard operating procedures governing the selection and use of respirators, using the OSHA standard for respiratory protection, 29CFR.1910.134. Other recognized authorities will be consulted if there is any doubt regarding proper selection and use. Only Clinical Services may amend these procedures.

Respirators will be selected by Clinical Services on the basis of hazards to which the employee is exposed. All selections will be made by Clinical Services. Clinical Services has chosen NIOSH-certified disposable, particulate respirators labeled N-95, N-99 or N-100 and Positive Air Pressure Respirators (PAPR) for use by NKY Health employees.

At least one employee at each clinic site will be instructed and trained in the proper use of respirators and their limitations. When necessary, at-risk employees of Environmental Health and Safety will also be instructed and trained. Training will provide the employee an opportunity to handle the respirator, have it fitted properly, test the face piece- to-face seal, wear it in normal air for a familiarity period, and finally to wear it in a test atmosphere.

Every respirator wearer will receive fitting instructions, including demonstrations and practice in how the respirator should be worn, how to adjust it and how to determine proper fit. Training will be done before an employee is assigned to a task requiring respirator use and at least annually thereafter. Training will be provided by Clinical Services.

Tight fitting respirators cannot be worn when conditions prevent a good face seal. Such conditions may be:

• A growth of beard or sideburns.

• A skullcap that projects under the face piece.

• Temple pieces on glasses. 

• The absence of one or both dentures.

• Changes in the employee’s physical condition that could affect respirator fit (facial scarring, cosmetic surgery, an obvious change in body weight).

• Changes in the employee’s physical condition that could affect respiratory function.

• Changes in the model, type or size of the respirator.

To ensure proper protection, the face piece fit will be checked by the wearer each time the respirator is worn. The manufacturer’s fitting instructions will be followed.

Each employee required to wear N-95 respirators will have a supply for his/her use only. Disposable respirators may not be shared.

Disposable respirators will be stored in manila envelopes or paper bags plastic bags when not in use. The envelope/bag will be labeled with employee’s name. Envelopes/Bags will be stored so that they will not be crushed or bent out of shape. Disposable respirators may be reused if the straps are intact, the respirator does not seem soiled, wet, splashed with body fluids or blood, the respirator’s shape has not been compromised and comfortable breathing is possible. The respirator will be replaced if any of these situations occur.

Appropriate surveillance of work conditions and degree of employee exposure to stress will be maintained. Clinic managers and coordinators will have primary responsibility for this surveillance. There will be regular inspections of all clinic sites by Clinical Services to determine the continued effectiveness of and compliance with the respiratory protection programs.

Records of medical evaluation must be retained and made available in accordance with 29 CFR 1910.1020.

Records of fit testing:

• Name or identification of the employee

• Type of fit test performed

• Specific make, model, style and size of respirator tested

• Date of test

• Pass/ fail results of the qualitative test

Cx

Fit test results will be retained until the next fit test is done.

Employees will not be assigned to tasks requiring respirator use until it has been determined that they are physically and mentally able to perform the task while using the respirator.

See the mandatory OSHA Respirator Medical Evaluation Questionnaire found in Appendix C of CFR 1910.134.

Who needs to be FIT tested:

·         TB case managers

·         Back up TB case managers

·         Front Office Associate/Interpreters

Process for FIT testing:

1.       Request Respiratory Questionnaire from Employee Health Nurse (EHN)

2.       Respiratory Questionnaire completed and returned to EHN

3.       The EHN reviews the questionnaire and completes the screening

4.       If needed the EHN may send the employee to St. Elizabeth Business Health for further screening

5.       FIT testing performed by EHN

6.       Performed yearly

The purpose of this section is to give site specific information to prevent the transmission of MTB in the workplace.

In April 2015 and October of 2019, an assessment for risk factors for the possible transmission of MTB was conducted. All worksites of the District were included in the assessment. Based on these assessments, the following designations for risk have been assigned:

• The District office site is classified as low risk. 

• The clinic sites at Grant County Health Center, Boone County Health Center, Kenton County Health Center and Campbell County Health Center are classified as medium risk. 

Sites are will be re-assessed annually. 

in 2019. review of data for these sites has shown no evidence of client-to-client or client-to-employee transmission. Normally, clients with known or suspected active MTB disease are not seen at clinical sites. Counseling, testing and treatment are accomplished by home visits. Non infectivity is determined by three consecutive negative AFB smears and/or cultures and response to therapy.

Clerical Responsibilities

When a client presents for services not MTB-related who is symptomatic for tuberculosis:

1. Offer tissues; instruct client to cover mouth

2. Inquire:

   • Are you coughing?

   • How long have you had a cough?

   • Have you lost weight?

   • Do you have a fever?

If all questions are answered yes, or cough has lasted longer than three weeks, the staff will take client immediately to an exam room and notify a nurse.

Nursing Responsibilities

When a client presents for services not MTB related with symptoms of tuberculosis, the nurse will obtain a brief history from client. If tuberculosis is a possibility, the nurse will:

1. Continue to isolate client from other clients

2. Request that client wear a surgical mask

3. Request that the client cover mouth and nose when coughing or sneezing with tissues supplied by the nurse.

4. Instruct all employees to wear an N-95 respirator when in the room with client or during any face-to-face contact. Offer tuberculin skin test and sputum testing if indicated.

5. Counsel and refer for appropriate follow-up.

Client evaluation at a Clinic Site

Infectious MTB disease

• Only if absolutely necessary will a known/suspected client with active MTB be seen at a clinic site.

• Known or suspected clients with HIV/AIDS will be scheduled and the visit completed prior to scheduled visit for client with active MTB disease. It is preferable to schedule known/suspected HIV/AIDS clients on a different day.

• Client will wear a surgical mask during the entire visit. These masks are to be supplied to client at initial contact visit and instructions given for use.

• Employees in contact with client will wear N-95 respirators or PAPRs.

Non-infectious (three (3) consecutive negative AFB smears and/or cultures): No respiratory protection is required.

Client with LTBI: No respiratory protection is required.

A TB skin test (TST) or a TB blood sample (QFT) is a test that looks to see if you have been infected with TB.  A TB-4 screening determines a person's risk of exposure to see if a TST or QFT is needed.  

Frequency of retesting will depend on the risk of developing a new infection:

• Staff who may frequently be exposed to patients with MTB disease will be screened yearly or more often if requested. The screening will determine the need for retesting. 

• TB case managers and the TB coordinator will be tested yearly. 

• Staff with known exposure will be screened and retested.

• Staff who are working in the clinical areas, but who are not routinely caring for patients with MTB infections, will be screened every year to determine the need for testing. 

• Staff who are working in the administrative offices and who do not have clinical responsibilities are not required to be retested; however, annual testing is available for free to these staff should any desire to be tested. A TB screening will determine the need for testing. 

According to the Center for Disease Control and Prevention, "Annual TB testing of health care personnel is not recommended unless there is a known exposure or ongoing transmission".  See CDC link here.

See additional information regarding TB testing in the State of KY by going to this link.

Who needs annual TB screening (see TB-4 Risk Assessment Form):  

• Clinic staff, including clerk interpreters

• TB case managers/TB coordinator

• Dental employees

• WIC/Nutrition employees who visit the hospital (St. Elizabeth requirement)

• Anyone with a history of a previous positive TB skin test or positive BAMT

• Anyone with a history of BCG vaccine 

• Health Educators who are in contact with high risk individuals (ex: HIV case managers, etc.).

• Clinic Clerks

• WIC/Nutrition employees

Employees with previous positive test/LTBI diagnosis need TB risk assessment and symptoms check-list completed annually.

All periodic skin testing will be staggered so that all staff in one area will not be tested at the same time.  Staff who are required to test annually (TB coordinator, TB case managers, and WIC/Nutrition staff who visit the hospitals) will be tested during their birth month. 

Initial interview, directly observed therapy, specimen collections:

Clients with active MTB disease:

• Infectious: Client will wear a surgical mask, supplied by District employee, during the entire visit. Employees will wear a N-95 respirator during entire visit.
  
  If NKY Health employee is assisting the client with a sputum specimen collection, the procedure will preferably be conducted outside in open air, away from other persons. The employee will wear a N-95 respirator during the procedure.

• Non-infectious (Three (3) consecutive negative AFB smears and/or cultures): No respiratory protection is required.

Client with LTBI: No respiratory protection is required.

NKY Health maintains active surveillance for tuberculosis and TB skin test (TST) conversion among clients and NKY Health staff. Surveillance of staff will be managed by Clinical Services. Generally, Clinical Services staff will perform the testing. Data on the occurrence of Mycobacterium tuberculosis (MTB) bacteria and TST conversions among clients and staff will be collected and analyzed to estimate the risk of MTB transmission in the facility and to evaluate the effectiveness of infection control and screening practices.

Annual Kentucky MTB Cases and Case Rates are included in this plan. 

At the time of hire, all NKY Health staff will receive a Two-Step TB Skin Test (TST ) unless one of the following reasons not to perform the test exists:

• Documented history of MTB disease and treatment.

• Previous documented positive test result for MTB disease.

• Documented completion of adequate treatment for LTBI.

• History of reaction associated with the test (ulceration or anaphylactic shock).

• The staff has a history of BCG vaccination, which may mean that the Employee Health Nurse decides to use Quantiferon-Gold instead.

Exceptions to the two-step TST for new hires:

•  If a new hire has had a TB skin test in the previous 12 months before employment, they can provide proof of documentation as “step one” and the “step 2” TB skin test will then be administered within 2-3 weeks of date of hire and read within 48-72 hours by the Employee Health Nurse (EHN).

• Any employee who has not had at least one TB skin test in the previous 12 months of employment will have a two-step TB skin test initiated.

•  Step 1 of the skin test will be administered within the first week of hire and read by the EHN within 48-72 hours.

•  Step 2 repeats the skin test 7-14 days after the first administered skin test and is read 48-72 hours later by the EHN.

Employees with previous positive test/LTBI diagnosis need TB risk assessment and symptoms check-list completed annually.

For staff who do not qualify for a TST, a symptom screen will be used to identify staff with symptoms of MTB. For those who will be tested using TST, unless the staff has a documented history of a TST within one year, all initial and periodic screening will be done using the two step procedure. 

In addition to periodic screening, clients and staff will be evaluated if they have been exposed to a potentially infectious MTB client for whom infection control procedures outlined in this Plan have not been properly done or if there is a TST conversion of NKY Health staff. The following procedures will be followed:

1. Administer a symptom screen to all potentially exposed employees.

2. Administer a TST to those who had previously negative TST results; baseline two step TST should not be performed in contact investigation.

3. Repeat the TST and symptom screen eight to 10 weeks after the end of the exposure, if the initial TST result is negative.

4. If either TST result or symptom screen is positive, promptly evaluate (including chest radiograph) the exposed person for MTB disease.

Staff with positive TST, with skin-test conversions on repeat testing or after exposure, will be clinically evaluated for active tuberculosis. Staff with symptoms suggestive of tuberculosis will be evaluated regardless of skin test results. If tuberculosis is diagnosed, appropriate therapy will be instituted by a physician knowledgeable and experienced in managing MTB disease in accordance with the recommendations of the American Thoracic Society, the CDC and the Infectious Diseases Society of America. Staff diagnosed with active tuberculosis will be offered HIV antibody testing and counseling.

Staff who have positive TSTs or TST conversions, but do not have clinical tuberculosis, will be evaluated for LTBI treatment according to the Kentucky Public Health Practice Reference protocol for tuberculosis. Staff with positive TSTs will be offered HIV antibody testing and counseling.

Conversion of a staff's TST to positive after previously documented negative TSTs must be recorded on the OSHA 300/300A form. A case of MTB disease in an employee with previously documented negative TSTs or symptom screens must be recorded on the OSHA 300/300A form. Both of these situations are privacy concern cases.  

All persons with a history of MTB or positive TST are at risk for contracting tuberculosis in the future. These persons should be reminded periodically that they should promptly report any pulmonary symptoms. If symptoms of MTB should develop, the person should be evaluated immediately.

Routine chest films are not required for asymptomatic, tuberculin-positive employees. After the initial chest X-ray is taken, employees with positive TSTs do not need a repeat chest X-ray unless symptoms develop that may be due to MTB.

Staff with active pulmonary or laryngeal tuberculosis pose a risk to clients and other staff while they are infectious; therefore, stringent work restrictions for these staff are necessary. They will be excluded from work until adequate treatment is instituted, cough is resolved and sputum is free of bacilli on three consecutive AFB smears. Staff with current tuberculosis at sites other than the lung or larynx usually do not need to be excluded from work if concurrent pulmonary tuberculosis has been ruled out. Staff who discontinue treatment before the recommended course of therapy has been completed will not be allowed to work until treatment is resumed, an adequate response to therapy is documented and negative sputum smears on three consecutive days are documented.

Staff who are otherwise healthy and receiving treatment for LTBI will be allowed to continue usual work activities. 

Staff who cannot take or do not accept or complete a full course of preventive therapy will have their work situations evaluated to determine whether reassignment is indicated. Work restrictions may not be necessary for otherwise healthy employees who do not accept or complete preventive therapy. These staff will be counseled about the risk of contracting disease and will be instructed to seek evaluation promptly if symptoms develop that may be due to tuberculosis, especially if they have contact with high-risk clients (i.e. clients at high risk for severe consequences if they become infected).

County Population # of Cases Case Rate

Boone 135,968 3     2.2

Campbell   93,076 1     1.1

Grant   24,941 0         0

Kenton 169,064 2     1.2

District 423,049 6             1.4

County Population # of Cases Case Rate

Boone 133,581 2 1.5

Campbell 93,584 0 0.0

Grant 25,069 0 0.0

Kenton 166,998 2 1.2

District 419,232 4 1