On December 30, 2005, the Centers for Disease Control and Prevention (CDC) released New Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Healthcare Settings. These guidelines replace all previous CDC guidelines for tuberculosis (TB) infection control in healthcare settings, and focus on preventing TB resurgence and eliminating healthcare worker (HCW) infection. As you may recall from previous AHCA memos, the State Operations Manual (SOM) directs surveyors to determine what infection control policies facilities use for persons with TB, and whether these policies conform to OSHA requirements for protecting employees and the current accepted standards of practice recommended by the CDC. Therefore, it is imperative that employers familiarize themselves with these guidelines and implement recommended practices. In particular, facilities should review and perform the new risk assessment (Appendix B) which will ultimately determine, depending on risk classification, if the facility needs to implement a respiratory protection program and comply with OSHA requirements for fit test training, etc.

The following changes and new information differentiate these guidelines from previous guidelines:

• The risk assessment process includes additional aspects of infection control.
• The term “tuberculin skin test” (TST) is used instead of purified protein derivative (PPD).
• The whole-blood interferon gamma release assay (IGRA,) Quanti FERON-TB Gold test (QFT-G), might be used instead of TST in TB screening programs for HCWs. An advantage of the QFT-G test is its specificity, thereby decreasing HCW visits for reading and interpretation of test results. Some disadvantages include higher cost, laboratory proficiency issues, and the need for the specimen to be set up within 12 hours. The Centers for Medicare and Medicaid Services also approved QFT-G for reimbursement effective January 1, 2006.
• Criteria are more clearly defined for serial testing of HCWs for TB infection.
• The term “healthcare setting” has been chosen over “healthcare facility” to broaden the potential places to apply the guidelines. Healthcare settings include inpatient and outpatient, and nontraditional facility-based settings which include long term care (LTC) facilities and home based healthcare.
• These recommendations usually apply to an entire healthcare setting rather than areas within a setting.
• New terms are introduced: airborne infection precautions (airborne precautions) and airborne infection isolation room (AII room ).
• The necessity for respirator fit testing is summarized.
• Recommendations for annual respirator training and initial and periodic respirator fit testing have been added.

Fundamentals of TB Infection Control for Long Term Care Facilities
According to the CDC guidelines, a TB infection control plan is based on a three-level hierarchy of controls: administrative, environmental, and respiratory protection. The specific details of TB infection-control programs will vary, particularly with respect to respiratory protections, based on whether patients with suspected or confirmed TB disease might be encountered in the setting or whether these patients will be transferred to another healthcare setting. In general, LTC facilities are in the latter category, and therefore would not need as in-depth respiratory protection programs as acute care and other settings to prevent TB transmission.

Aspects of administrative, environmental and respiratory controls in LTC facilities are as follows:

1. Assign responsibility for TB infection control in the setting.
2. Develop and annually review a written TB infection-control plan for transferring persons with suspected or confirmed TB disease to another healthcare setting. The plan should include separating these persons from other persons in the setting until the time of transfer, instructing continual use of surgical or procedure masks, changing the masks if they become wet, etc.
3. As previously stated, facilities need to conduct initial and ongoing TB risk assessments to demonstrate to state or federal OSHA inspectors, at the time of any safety and health inspection, whether employees are at risk for exposure to TB. Again, the CDC guidance provides a TB Risk Assessment Worksheet which can be found in Appendix B.

If the risk assessment indicates low risk for TB transmission, as is often the case in LTC facilities, a respiratory protection program is not indicated and OSHA requirements for fit testing and implementation, etc. are not applicable. However, facilities that determine employees are at higher risk for exposure to M. tuberculosis must comply with OSHA’s General Industry Respiratory Protection standard, 1910.134, including providing those employees at risk with respirators. AHCA has posted additional information on the specific requirements of the standard.

Some components of the CDC’s risk assessment include:

1. Reviewing the community profile of TB disease in collaboration with the local or state health department.
2. Consulting the local or state TB-control program to obtain epidemiologic surveillance data necessary to conduct a TB risk assessment for the healthcare setting.
3. Determining if persons with unrecognized TB disease were encountered in the setting during the previous 5 years.
4. Deciding if any HCWs need to be included in the TB screening program.
5. Conducting periodic reassessments (annually, if possible) to ensure:
1. proper implementation of the TB infection-control plan;
2. prompt detection and evaluation of suspected TB cases;
3. prompt initiation of airborne precautions of suspected infectious TB cases before transfer;
4. prompt transfer of suspected infectious TB cases;
5. proper functioning of environmental controls, as applicable; and
6. ongoing TB training and education for HCWs.
6. After learning the risk classification by completing the assessment, determine the need for a TB screening program for HCWs, and the frequency of screening (Appendix C) , based on risk classification. The three TB screening risk classifications are low risk, medium risk, and potential ongoing transmission. The classification of low risk should be applied to settings in which persons with TB disease are not expected to be encountered, and therefore, exposure to TB is unlikely. This often includes LTC facilities and is indicated when a facility has less than 3 TB patients per year.
   Some TB screening procedures for settings classified as low risk include:
1. All HCWs should receive baseline TB screening upon hire, using two-step TST or a single blood assay for M. tuberculosis (BAMT) to test for infection with TB.
2. After baseline testing for infection with TB, additional TB screening is not necessary unless an exposure to TB occurs.

Refer to Appendix C for more information.

HCWs Who Should Be Included in a TB Screening/Surveillance Program
HCWs refer to all paid and unpaid persons working in healthcare settings who have potential exposure to TB through air space shared with persons with infectious TB disease. Part time, temporary, contract, and full-time HCWs (including transport staff) should be included in a TB screening program. Examples of these staff are:

• Administrators or managers
• Dietitians and dietary staff
• Housekeepers and janitors
• Laboratory staff
• Maintenance staff
• Nurses and nurses aides
• Physical and occupational therapists
• Physicians and physician assistants
• Social workers
• Volunteers, etc.

Training and Educating HCWs
According to the CDC guidelines, HCW training and education on TB disease is essential to increase adherence to TB infection-control measures. Training and education should emphasize the increased risks posed by an undiagnosed person with TB disease and the specific measures to reduce this risk. The setting should document that all HCWs have received initial TB training relevant to their work setting and additional occupation specific education.

OSHA requires annual respiratory protection training for HCWs in facilities considered high risk for TB infection transmission. However, as stated earlier, if a risk assessment indicates low risk for TB transmission, as is often the case in LTC facilities, a respiratory protection program is not indicated and OSHA requirements are not applicable. However, LTC facilities still need written protocols for early identification of persons with symptoms or signs of TB disease and procedures for referring these patients to a setting where they can be evaluated and managed; HCWs should be trained in these procedures.

Some suggested components of an initial TB training and education program for HCWs in LTC facilities include:

• Clinical information:
• symptoms and signs of TB disease.
• diagnostic procedures, etc.
• Epidemiology of TB:
• risk factors.
• local community statistics, etc.
• Infection-control practices:
• potential for occupation exposure to TB disease in healthcare settings.
• principles and practices to reduce risk of TB transmission, etc.
• TB and immunocompromising conditions:
• relationship between TB infection and medical conditions and treatments that can lead to impaired immunity.
• pocedures for informing employee health or infection control personnel of medical conditions associated with immunosuppression.
• TB and public health:
• Roles of local and state health department’s TB control programs for TB screening, treatment, etc.
• Roles of CDC and OSHA.

All settings should conduct an annual evaluation of the need for follow-up training and education for HCWs based on the number of untrained and new HCWs, changes in the organization and services of the setting, and availability of new TB infection-control information. If a potential or known exposure to TB occurs in the setting, prevention and control measures should include retraining HCWs in the infection-control procedures established to prevent the recurrence of exposure.

TB training and education materials are available at the CDC’s TB website at http://www.cdc.gov/tb and the CDC’s TB Education and Training Resources website at http://www.findtbresources.org. Other TB-related websites and resources are in Appendix E of the guidelines.

The CDC guidelines and appendices can be read in their entirety at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm?s_cid=rr5417a1_e.