TB Infection Control Manual PDF
TB Infection Control Manual PDF
TB Infection Control Manual PDF
Infection Control
a practical manual for preventing tb
clinics
sputum induction
airborne infection
isolation rooms
emergency departments
homeless shelters
Tuberculosis
Infection Control
A PRACTICAL MANUAL FOR PREVENTING TB
CLINICS
SPUTUM INDUCTION
AIRBORNE INFECTION
ISOLATION ROOMS
EMERGENCY DEPARTMENTS
HOMELESS SHELTERS
The Francis J. Curry National Tuberculosis Center is a joint project of the San Francisco
Department of Public Health and the University of California, San Francisco, funded by
the Centers for Disease Control and Prevention under Cooperative Agreement U52 CCU
900454.
Permission is granted for nonprofit educational use and library duplication and distribution.
Suggested citation:
Francis J. Curry National Tuberculosis Center, 2007: Tuberculosis Infection Control: A
Practical Manual for Preventing TB, [inclusive page numbers].
This publication is available on the Francis J. Curry National Tuberculosis Center website:
www.nationaltbcenter.ucsf.edu
Feedback and comments related to this product are welcome, please email:
tbcenter@nationaltbcenter.ucsf.edu
Table of Contents
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Part I: Tuberculosis (TB) Infection Control Overview . . . . . . . . . . . . . . . . . . . . . . .1
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Guidelines and Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Environmental Controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Using Ventilation to Reduce the Risk of Spreading TB. . . . . . . . . . . . . . . . . 15
Natural Ventilation and Fans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Using Directional Airflow to Reduce the Risk of Spreading TB . . . . . . . . . . . 18
Central Ventilation Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Using Negative Pressure to Reduce the Risk of Spreading TB . . . . . . . . . . 26
Using Ultraviolet Germicidal Irradiation (UVGI) to Reduce the Risk
of Spreading TB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Upper Air UVGI And High-efficiency Particulate Air (HEPA) Filter Units . . . . . 38
Part II: Infection Control In Specific Settings and Procedures . . . . . . . . . . . . . .47
Clinics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
Facility Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Employee Categories at Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Administrative Controls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Environmental Controls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Respiratory Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
TB Infection Control Plan Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Sputum Induction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73
About Sputum Induction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Administrative Controls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Environmental Controls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Respiratory Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Performing Sputum Induction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Summary of Sputum Induction Environmental Controls. . . . . . . . . . . . . . . . 86
Airborne Infection Isolation Rooms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87
Designing a New State-of-the-Art Airborne Infection Isolation Room (AI IR) . 89
Assessing an Existing AI IR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Upgrading or Converting an Existing Room . . . . . . . . . . . . . . . . . . . . . . . .101
TABLE OF CONTENTS
J.
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
ii
Acknowledgements
The following individuals are gratefully acknowledged for their invaluable participation and
guidance in this project:
Janet Abernathy, RN, BSN
Manager, Clinical Quality
San Ramon Regional Medical Center
San Ramon, CA
Masa Narita, MD
TB Control Officer
Public Health Seattle & King County
Seattle, WA
Robert G. Smith
Senior Health Educator
Homeless Health Care Los Angeles
Los Angeles, CA
ACKNOWLEDGEMENTS
iii
The following organizations were instrumental in creating the original products which
were incorporated into this Manual:
Alameda County Public Health Department
Boston Public Health Commission
Broad Street Solutions, San Diego
California Department of Health Services
California Office of Statewide Health Planning and Development
Cardio-Pulmonary Department, San Mateo County General Hospital
Catholic Healthcare West
Centers for Disease Control and Prevention
Contra Costa Regional Medical Center
Department of Emergency Medicine, Olive View-UCLA Medical Center
Division of Tuberculosis Control, Los Angeles County Department of Health
Services
Fresno County Human Services System
Harvard Medical School, The Cambridge Hospital, and Massachusetts
Department of Public Health, Boston
Homeless Health Care Los Angeles
Housing Authority of Portland, Oregon
Institute for Medical Quality
Institutional Consultation Services, Francis J. Curry National Tuberculosis Center
Kaiser Permanente, Walnut Creek
Missouri Department of Health, Section of Vaccine-Preventable and Tuberculosis
Disease Elimination, Jefferson City, Missouri
Oldham Engineering, Berkeley, CA
Oregon Health Division
Palo Alto Medical Foundation
Austin/Travis County Health Department
Sacramento County Department of Health and Human Services Public Health
Promotion and Education
San Diego County Health and Human Services
San Francisco Department of Health
San Joaquin County Public Health Services
San Mateo County General Hospital
School of Public Health, University of California at Berkeley
Ted Jacobs Engineering Group, Oakland, California
Texas Department of Health
The Bromeen Group
The Cotton Group
The Salvation Army Bell Shelter, Bell, California
iv
Abbreviations
Organizations
AIA
ANSI
ASHRAE
Cal/OSHA
CDC
CMC
CNTC
FDA
MMWR
NIOSH
OSHA
OSHPD
Terms
ACH
LTBI
AFB
Acid-fast bacilli
M. tb
Mycobacterium tuberculosis
AIDS
MDR
Multidrug-resistant
AIIR
NAAT
BAMT
NTM
Nontuberculous mycobacteria
BCG
PIN
CFM
PPD
DOT
QFT-G
FPM
RIPT
HCW
Healthcare worker
RTMCC
HEPA
TB
Tuberculosis
HIV
TST
HVAC
UV
Ultraviolet
ICP
UVGI
IGRA
VAV
INH
Isoniazid
" W.G.
LEV
XDR
Extensively drug-resistant
ABBREVIATIONS
vi
Tuberculosis
Infection Control
Overview
PREFACE
.....................
INTRODUCTION . . . . . . . . . . . . . . . 7
GUIDELINES AND
REGULATIONS . . . . . . . . . . . . . . . 10
ENVIRONMENTAL
CONTROLS . . . . . . . . . . . . . . . . . . 15
CHAPTER TITLE
Preface
About the Francis J. Curry National
Tuberculosis Center
One of four regional tuberculosis training and medical consultation centers (RTMCC)
funded by the Centers for Disease Control and Prevention (CDC), the Francis J. Curry
National Tuberculosis Center (CNTC) is a joint project of the San Francisco Department of
Public Health and the University of California, San Francisco. CNTC creates, enhances,
and disseminates state-of-the-art resources and models of excellence to control and
eliminate tuberculosis (TB) nationally and internationally. Committed to the belief that everyone deserves the highest quality of care in a manner consistent with his or her culture,
values, and language, CNTC 1) develops and delivers versatile, culturally appropriate
trainings and educational products, 2) provides technical assistance, and 3) provides
medical consultation.
PREFACE
high-risk institutions, including health-care facilities, and shelters. While the ICS no longer
exists, their work is an integral part of this document.
This manual was developed in an effort to compile all of the information into one cohesive
document, making it easier to:
Understand how TB is spread
Understand how ventilation, filters, and UVGI can help reduce the spread of TB
Evaluate and improve ventilation
Use filters and UVGI to reduce the risk that TB will spread
In addition, this manual provides facility-specific procedures for TB infection control, making it easier to:
Understand the special needs and requirements of each facility type
Sustain TB control measures to ensure their effectiveness
Make informed decisions regarding planning, funding, and selection of ventilation
equipment, filters, and UVGI
Learn the essential elements of a safe sputum induction program
Learn the design and regulatory requirements for airborne infection isolation rooms
(AIIRs)
PREFACE
Review the table of contents to get an overview of the manual contents. Note the
titles of the appendices for future reference.
2.
Read the introduction. This section contains information on how TB is spread and
drug resistance.
3.
Read Guidelines and Regulations. This section contains information from the CDC,
AIA, OSHA, and Cal/OSHA.
4.
Read the Environmental Controls section to understand how filters, UVGI, and
ventilation should be implemented..
5.
For detailed information, read the section that corresponds to your needs or setting:
Clinics (page 49)
Sputum Induction (page 73)
AIIRs (page 87)
Hospital Emergency Departments (page 113)
6.
As you read this manual, refer to the Glossary for definitions of terms used in the
document, and Resources and References to see which works were referenced in
a passage, and to learn about resources from which you can obtain additional
materials.
Introduction
How Tuberculosis (TB) Is Spread
TB is caused by bacteria (a type of germ) called Mycobacterium tuberculosis (M. tuberculosis). A person who has TB disease in his or her lungs or larynx (throat) can release tiny
particles called droplet nuclei into the air by coughing, sneezing, singing, shouting, talking, or breathing.
These particles are invisible to the naked eye and are approximately 1 to 5 microns in size.
( A micron is approximately one-hundredth the width of a human hair.) Droplet nuclei can
remain airborne in room air for a long period of time, until they are removed by natural or
mechanical ventilation.
In order for TB to spread, there must be a source patient who has infectious TB disease
and a susceptible host (a person to inhale droplet nuclei containing M. tuberculosis). Anyone who shares air with a person with infectious TB disease of the lungs or larynx is at
risk, although TB is not usually spread by brief contact. TB is spread when another person inhales one or more of these particles and becomes infected with TB.
INTRODUCTION
TB Disease
Most TB disease occurs in the lungs, but about 15% occurs in other parts of the body
(e.g., bone, eye, and brain). General symptoms of pulmonary TB include:
Cough
Fever
Night sweats
Fatigue
Unexplained weight loss
Hemoptysis (bloody sputum)
Without treatment, a person with TB disease will get sicker. A person with untreated pulmonary TB disease of the lungs or larynx will also become more contagious. Untreated
TB can become a life-threatening disease; however, with effective and complete treatment, TB can be cured.
A person with a cough lasting 3 or more weeks along with any other symptoms of TB
disease (fever, night sweats, fatigue, unexplained weight loss, hemoptysis [bloody sputum]) should be evaluated by a healthcare provider as soon as possible. If TB disease is
diagnosed or suspected, treatment will be prescribed.
When TB is Infectious
With rare exceptions, TB is infectious only when it occurs in the lungs or larynx. TB that
occurs elsewhere in the body is usually not infectious, unless the person also has TB in
the lungs or larynx at the same time.
In general, a person with suspected or confirmed TB disease of the lungs or larynx should
be considered infectious until the person has:
1.
Had three negative acid-fast bacilli (AFB) sputum smear results obtained 8-24 hours
apart, with at least one being an early morning specimen (an AFB sputum smear is
a type of medical test used in the diagnosis of TB); and
2.
3.
A person who has met all three of the above conditions must continue to take TB medications as prescribed and continue to receive medical care for TB.
Drug-resistant TB
Drug-resistant TB is a growing global problem and is more difficult and expensive to treat
and cure. Like regular drug-susceptible TB, drug-resistant TB is airborne and is just as
contagious. In addition, there is often a delay in recognizing drug-resistant TB that can
lead to prolonged exposure, making it easier for TB to spread.
Drug resistance is divided into two types: primary resistance and secondary (or acquired)
resistance. Primary resistance occurs when a person gets infected with TB that is already
resistant. We would know this because they were never treated for TB before. Secondary
resistance occurs during treatment for tuberculosis, because the doctor prescribes inadequate treatment, patients with TB stop their treatment prematurely, or take their medicine sporadically.
Preventing drug-resistance is very important. When medications are not taken as prescribed or the treatment regimen is inadequate (such as therapy with a single drug), drugresistant organisms emerge and take over. Therefore, patient adherence to a prescribed
course of therapy and treatment with multiple drugs are essential factors in preventing the
emergence of drug resistance.
Consultation with
medical and
nursing experts
who are
knowledgeable and
experienced in
MDR TB
case /contact
management is
essential.
INTRODUCTION
ASHRAE
The American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE),
Inc. published a handbook in a series of four volumes, one of which is revised each year
to ensure that no volume is older than 4 years. The 2004 Handbook covered HVAC Systems and Equipment, and the 2003 Handbook addressed HVAC Applications.
11
12
TA B L E 1 .
GUIDELINES
OSHPD 1
CAL/OSHA 2
CDC 3
ASHRAE 4
AIA 5
Room designation
Negative-pressure
isolation room
Atmospheric
isolation
Airborne infection
isolation room
Airborne infection
isolation room
Airborne infection
isolation room
Applies to
All
All
10
12
Prefer 12,
minimum >6 for
facilities existing
pre-1994; >12 for
post 1994 new &
renovated
>12
12
May be reduced if
room unoccupied
In-room HEPA
recirculation
allowed?
Yes
Yes,
if used to achieve
12 ACH in existing
pre-1994 facilities
No
No
No
Yes
Yes, if used to
achieve 12 ACH in
existing pre-1994
facilities
No
No
HEPA-filtered
recirculation to
other areas?
No
Yes
Only if unavoidable
No
Single pass
recommended
No
Exhaust to outside,
if not possible
recirculate to air
handling unit
exclusively serving
AIIR
Minimum outside
air change rate
(OSA ACH)
Section 5142
requires employers
to maintain the
minimum amount of
outside air required
by the building code
at the time the system
was permitted.
Minimum exhaust
air excess airflow
(offset)
75 CFM
Not addressed
See page 64 of
CDC guidelines
Not addressed
Not addressed
0.001" W.G.
Not addressed
0.01" W.G.
0.01" W.G.
0.01" W.G.
Minimum room
pressure
differential
1 2001 California Mechanical Code. Title 24, Part 4, Chapter 4: Ventilation Air Supply.
2 California Division of Occupational Safety and Health (Cal/OSHA). Interim Tuberculosis Control Enforcement Guidelines, revised March 1, 1997. Policy and
Procedure C-47.
3 Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR
2005; 54 (No.RR-17),
4 American Society of Heating, Refrigerating and Air Conditioning Engineers. Chapter 7: Healthcare Facilities. In: 2003 HVAC Applications handbook. Atlanta:
American Society of Heating, Refrigerating and Air Conditioning Engineers, Inc., 2003.
5 American Institute of Architects, 2006 Guidelines for Design and Construction of Hospitals and Health Care Facilities published by the American Institute of
Architects Academy of Architecture for Health, with assistance from the Department of Health and Human Services (DHHS).
13
REGULATIONS
GUIDELINES
OSHPD 1
CAL/OSHA 2
CDC 3
ASHRAE 4
AIA 5
Minimum air
velocity under
door
100 FPM
Not addressed
Not addressed
Not addressed
Not addressed
Air distribution
Supply high,
exhaust low,
specific
arrangement
Not addressed
See figure 3 on
page 63 of CDC
Guidelines
Upper-air or in-duct
UVGI allowed?
Not addressed
Not addressed
No
Not addressed
Not addressed
Anteroom
required?
Yes
No
No
May be desirable
Noted as general
option, required for
PE isolation rooms
for airborne
infection isolation
Minimum
anteroom ACH
10
Not addressed
Mechanical 10 ACH
10
10
Minimum
anteroom outside
air change rate
(OSA ACH)
Section 5142
requires employers
to maintain the
minimum amount of
outside air required
by the building code
at the time the
system was
permitted
Defers to
ANSI/ASHRAE
Std 62.1-2004
Defers to ASHRAE
& 100% exhaust to
outside
Positive to isolation
room, neutral to
corridor
Not addressed
Positive or negative
Not addressed
Positive or negative
Continuous,
alarmed
Test annually
Anteroom
pressurization?
Monitoring of
negative pressure
14
Not addressed
Environmental Controls
In this manual, the term environmental controls refers to the use of engineering technologies to help prevent the spread and reduce the concentration of infectious droplet
nuclei in the air.
Due to funding and other restrictions, public health clinics, community health clinics, and
homeless shelters frequently make use of locations that were not originally designed for
use as clinics or shelters. As a result, if a location has an existing ventilation system, it may
not have sufficient safeguards to prevent the spread of TB, or it may not be operational.
Some settings have no ventilation system at all.
Additional risks faced by clinics, shelters, and hospital emergency departments, are deficiencies in AIIR environmental controls. When deficiencies occur, suspected or known TB
patients may be placed in AIIRs that have inadequate environmental controls, such as low
air change rates or positive pressure, placing others at risk of exposure.
This section outlines the environmental controls for designing, implementing, and maintaining an effective ventilation system at both a facility level and at an AIIR level. See part
2 for more specific information on different settings.
ENVIRONMENTAL CONTROLS
15
16
FIGURE 1.
Propeller Fans
STANDING FAN
CEILING FAN
WINDOW FAN
DESK FAN
ENVIRONMENTAL CONTROLS
17
In the homeless shelter setting, this principle can help protect staff from an unidentified TB
patient. For example, use of directional airflow can help reduce the chance that TB will
spread from a client to a staff member doing intake interviews. If the air direction is known,
the staff member should sit near the fresh air source, and the clients should sit near the
exhaust location.
In a room in which large numbers of people may congregate, such as a dormitory or a
waiting room, anyone could be a source of TB, and TB could spread to others in the room.
Therefore, the direction of air movement is less critical. It is more important to achieve
good air mixing in all locations so that particles are more quickly diluted and removed.
18
ENVIRONMENTAL CONTROLS
19
1.
Hold two incense sticks together and light them. (CNTC recommends that two
sticks be used side-by-side)
2.
As soon as the incense starts to burn, blow out the flame. Now the incense
should produce a continuous stream of smoke.
3.
4.
Observe how quickly the smoke dissipates. This is a subjective test that may
require some practice. It does not give a definite result but is useful for comparing rooms to each other. For example, it may take 5 seconds for smoke to dissipate in one room but 10 seconds in another.
5.
Repeat smoke tests for different common conditions at your facility. For example, if doors are kept open during the day but closed at night, the tests should
be done under both conditions.
20
DISADVANTAGES
Air that is introduced directly from the outdoors, without the benefit
of filters or ductwork, may bring in unwanted elements, such as
traffic exhaust and noise, rain, dust, odors, pollen, and insects
Keeping windows and doors open may adversely affect security,
comfort, and privacy. This is especially true at night and in the winter
ENVIRONMENTAL CONTROLS
21
CASE STUDY
Check Ventilation
Lynn wanted to improve ventilation in her building. Her first step was to check the existing ventilation.
Using incense, she noted that air mixing seemed satisfactory near doors and open windows as
smoke seemed to disperse quickly. In the corners, away from doors and open windows, however, air
movement seemed slow.
To match nighttime conditions, Lynn closed the doors and windows and repeated the tests. Air
movement was slow throughout the facility.
During both sets of tests, Lynn noticed that most air moved upward and from the front of the building
toward the back.
Lynn looked at the two exhaust fans. Both had a considerable buildup of lint and dust. She turned
them on and held a piece of paper against each grille. In the mens room the paper was pulled against
the grille. But in the womens room there was no pulling effect, and Lynn noticed that she could not
hear the fan running.
22
Based on these simple checks, Lynn now had a good idea of the ventilation in her building:
During the day, when doors and windows were kept open, air movement was good except in
the corners of the rooms
At night, when doors and most windows were closed, air movement was slow
How could Lynn improve the situation with her limited budget? She got out the vacuum cleaner and
thoroughly cleaned the two exhaust grilles. She noticed an immediate improvement in airflow at the
grille in the mens room, but the fan in the womens room still was not working.
Improvements
Near the corners on the back wall were two blocked-up windows. It occurred to Lynn that if she were
to install a fan in each of these windows, it should produce an air current throughout the building,
regardless of whether the doors and windows were open.
She measured the windows and bought a through-the-wall fan at her local hardware store for each
window. Staff from an affiliated job-training program installed the fans in the windows as part of a
training exercise. Lynn made sure that the window fans exhausted air out the back of the building.
While they were at her building, Lynn asked the crew to look at the exhaust fan in the womens room.
They found the problem, a broken electrical wire, and repaired it.
The Results
Lynn did some final incense tests that night, with the fans on and the doors closed. Air movement
was greatly improved throughout the facility. However, some clients complained about a slight draft
and were provided with extra blankets.
She repeated the tests the next morning with the windows and doors open and was pleased to see
that airflow was now satisfactory, even in the corners.
Feeling very proud of herself, Lynn wrote and posted a one-page policy summarizing her environmental control efforts:
Keep all fans (toilet exhaust and through-the-wall fans) on at all times
The next month, Lynn was happy to share her experience, and her policy, with her peers at a meeting
of the local homeless shelter directors organization. The members agreed that, while TB transmission at Welcome Home could still occur, the risk had been reduced. Furthermore, the increased fresh
air had improved the indoor environment for her staff and clients.
ENVIRONMENTAL CONTROLS
23
24
Configurations
Forced-air systems come in many different configurations. A ventilation unit can be located
in an attic, a basement, or a closet, or it can be suspended from the ceiling in the room
itself. The basic components of the system are usually the same and may include some
or all of the following:
Filters to clean air before recirculation
A fan to move the air through the unit
A furnace for heating
An air conditioning section for cooling
These components can be installed in a single unit or can be housed in separate sections.
A system may also include other parts, such as:
A thermostat and controls to turn the fan on and off and to control the temperature
Ductwork, diffusers, and/or grilles to distribute and collect air
FIGURE 2.
FAN SECTION
BURNER SECTION
to
other
rooms
ceiling
ROOM
mixed air
returned to system
floor
supply air
mixes with room air
Recirculating Systems
Some buildings have a mechanical system that recirculates all air returned to the systemthat is, 100% recirculation (See Figure 2).
In a 100% recirculating system, air is supplied to a room to provide ventilation and/or
heating or air conditioning. This air mixes with room air and then is drawn back (returned)
to the unit, where it is filtered and/or heated or cooled before being sent back to the room.
Even in a building with a recirculating air system, some rooms will exhaust rather than
return air. Typically, bathrooms, shower rooms, institutional kitchens, and similar spaces
will have a separate fan to exhaust air directly outdoors. See Using Exhaust Fans on
page 18 for more information.
ENVIRONMENTAL CONTROLS
25
Negative pressure
is created by
exhausting more air
from a room than is
supplied to the
room so infectious
particles are
contained within a
room by a
continuous air
current being pulled
into the room under
the door.
Negative pressure is created by exhausting more air from a room than is supplied to the
room so infectious particles are contained within a room by a continuous air current being
pulled into the room under the door. Therefore, when the negative pressure room is used
as designed, airborne particles generated in the room cannot escape to the corridor.
Negative pressure is created by setting (or balancing) a ventilation system so that more air
is mechanically exhausted from a room than is mechanically supplied. This creates a ventilation imbalance, called an offset. The room makes up the offset by continually drawing
in air from outside the room. Probably the most common examples of negative pressure
are residential bathrooms. Often a bathroom will have an exhaust fan but no supply.
26
FIGURE 3.
Air Filtration
FILTER EFFICIENCY
LINT FILTER
PLEATED FILTER
M. tb droplet nuclei
size range
(1 to 5 microns)
100%
HEPA = 99.97%
% Removal
80%
60%
Pleated = 50%
MERV 7 or 8
40%
20%
Lint = 0%
0%
0
10
ENVIRONMENTAL CONTROLS
27
Pleated filters are readily available from hardware stores in sizes that fit most ventilation
systems.
Pleated filters are slightly more expensive than lint filters. They also cause more of an
obstruction, which will reduce airflow slightly.
28
FI GUR E 4.
In-duct UVGI
airflow
direction
UV lamps
An appropriately designed, installed, and maintained in-duct UVGI system should effectively disinfect most recirculated air and, therefore, significantly reduce the risk of TB exposure. For TB control purposes, such
a system would be almost equivalent to a 100% outside air system.
service door
with
inspection
window
In-duct UVGI is a useful option for a recirculating air system that serves
areas at high risk for TB transmission as well as areas with lower risk.
airflow
direction
ENVIRONMENTAL CONTROLS
29
DISADVANTAGES
in-duct UVGI lamps, unlike HEPA filters, do not cause a significant obstruction to airflow in the system. Therefore, they can remove most infectious
particles from air but do not significantly reduce the amount of airflow.
UVGI lamps are a more specialized type of equipment than almost all other components of a mechanical system and require specialized expertise to install
and maintain.
In-duct UVGI is usually less expensive to install and operate than a 100%
outside air system.
30
FIGURE 5.
ceiling supply
air difuser
Components: Thermostats
Room thermostats are electrical devices that control ventilation systems. They are usually mounted on a wall near a return air grille.
Many different types of thermostats are available, ranging from the very simple to programmable units with many functions. Most designs include three basic components:
A switch that allows the thermostat to control the unit
A thermometer that measures and displays room temperature, and
An adjustable set point that allows the user to input the desired room temperature.
More expensive thermostats allow the user to program the fan, furnace, and air conditioning individually and to have different set points for weekdays and weekends.
ENVIRONMENTAL CONTROLS
31
32
ENVIRONMENTAL CONTROLS
33
An appropriately
designed, installed,
and maintained
in-duct UVGI
system should
effectively disinfect
most recirculated
air and, therefore,
significantly reduce
the risk of TB
exposure from
recirculated air.
Ventilation Rate
Provide a ventilation rate of at least 12 ACH in rooms frequented by patients or clients.
Dilution ventilation is the most effective environmental control against TB transmission.
Generally, the incremental cost of increasing ventilation capacity in a new ventilation system installation is not significant compared with the total cost of the installations design
and construction. 12 ACH is the minimum rate recommended by ASHRAE for waiting
rooms in health facilities. Given the rates of TB among the homeless, a shelter has comparable risk to a hospital waiting room.
34
Air Distribution
Provide supply and return air in each room, rather than collecting air from several
rooms at a single location. This will reduce the possibility of air currents carrying
infectious particles to other areas
Design the ventilation system for good air mixing. Adequate air supply and air mixing
will greatly reduce the risk of TB transmission by diluting and removing infectious
particles. Diffuser characteristics, such as size and air diffusion pattern, should be
selected to suit the room in which diffusers are installed and the individual diffuser
location within the room
If the system will include ceiling diffusers, you can enhance air mixing by using the
louvered face type, rather than the perforated face type
If sidewall air supply grilles are used, the diffusers should be the double deflection
type, with two sets of air deflection blades. The front set of blades is vertical; the
second set behind these is horizontal. The louvers should be adjusted to provide
even airflow patterns in each room
Return registers should be located in the same room and as far away as possible
from supply diffusers so that supply air can fully mix with room air
In-Duct UVGI
In-duct (or return-duct) UVGI may be used in a ventilation system to disinfect air removed
from a group setting before recirculation.
DISADVANTAGES
Maintenance required
ENVIRONMENTAL CONTROLS
35
CASE STUDY
The existing forced-air heating system consisted of a furnace in a janitors closet, a single
return grille on the wall outside the closet, six ceiling supply grilles, and a thermostat
The return grille and duct were extremely dusty. Dan removed the grille and cleaned out the
dust with a vacuum cleaner
He opened the filter section. The filter was a flat lint-type. It was also extremely dusty and was
incorrectly installed in the filter track. Dan measured the lint filter ( 25" x 14" x 1") and discarded
it. He bought three replacement pleated filters from a nearby hardware store. They cost about
$5 each. He wrote the date on one of the filters and placed it in the furnace
The thermostat had an adjustable temperature setting and three fan settings: OFF, AUTO, and
FAN ON. It was set to AUTO so the fan would come on only when the temperature dropped
below 68F. Dan set the controls to FAN ON, and the fan in the unit came on immediately. The
improvement in ventilation was obvious
The furnace had no outside air intake and there was no obvious way to connect one because
the unit was not close to an outside wall. To let in natural ventilation, Dan decided to keep at
least two windows open whenever the building was occupied
Dan used some incense sticks to evaluate air movement. He was happy to see that air movement
was brisk throughout the shelter. He also confirmed airflow at each diffuser and at the grille
What steps should Dan take to ensure that routine maintenance is done for the Central
Ventilation System?
36
Effectiveness of UVGI
UVGIs effectiveness increases with:
Intensity of the radiationdepends on the wattage, condition, and age of the
lamp (the intensity of a lamp fades over time and also, to a lesser extent, as dust
accumulates on the lamp)
Length of exposure timedepends on how quickly air containing infectious particles moves past the lamp
Proximity of infectious particles to the UVGI lampdepends on the placement and number of lamps used
UVGIs effectiveness decreases with:
Relative humidityUVGI is not recommended for rooms in which the relative
humidity of the air is greater than 70%
ENVIRONMENTAL CONTROLS
37
Hazards of UVGI
Although UVGI can cause temporary harm to the eyes and skin, newer fixture designs
and compliance with guidelines on the use of UVGI should make it possible to use this
control measure safely and effectively.
Precautions should be taken to alert and protect the people using the room(s) in which the
UVGI is used. Facility staff should also receive appropriate education.
Upper-Air UVGI
F IG UR E 6 .
UV lamp fixture
suspended
from ceiling
38
Upper-air UVGI lamps are mounted high on walls or hung from the ceiling
Metal baffles on the fixtures are needed to ensure that the radiation is directed only
outward and upward, away from where people are in the room below
Upper-room air is irradiated and disinfected. Cleaned air mixes with the air in the
lower part of the room and dilutes infectious particles
The clinical effectiveness of upper-air UVGI as a means to reduce the risk of TB transmission
is uncertain and cant be measured. It varies depending on many factors, including the age
of the lamps, placement of the lamps, room configuration, and room airflow patterns.
Care must be taken in the design, installation, and maintenance of UVGI because of
safety concerns, because effectiveness can vary, and because every installation is unique.
UVGI Radiometer
Radiation levels are measured with a device called a radiometer. The radiometer should
be calibrated specifically to measure UVGI radiation.
Radiation levels at the lamps should be much greater than radiation levels in the occupied
room. Because of the difference in radiation levels, two separate meters may be required,
one to verify that the radiation levels at the lamps are high, and another to verify that radiation levels in the occupied room are low.
ENVIRONMENTAL CONTROLS
39
Planning an Installation
Before installing UVGI fixtures, address the following items:
Locate UVGI fixtures so that radiation in the upper-air is uniform, continuous, and
complete
In the installation contract, include measurements of radiation levels after installation
Take these measurements before the job is accepted and payment is made. Submit
a written report to the owner
Until readings have been taken in the occupied zone to ensure that radiation
levels are below the NIOSH REL, the installation is not complete, and the lamps
should not be used. Readings should be taken in a number of locations corresponding to where people will be exposed
Take radiometer readings at each lamp to ensure that the radiation intensity
meets the manufacturer's specifications
40
Non-reflective paint may need to be added to ceilings and walls. Some ceiling paints
can reflect too much radiation down to the occupied room below. If meter readings
indicate excessive radiation in the occupied area, the ceiling may need to be painted
with non-reflective paint. This should be included in the budget for the planned
installation. Paint containing titanium dioxide is recommended for reducing reflection
from surfaces
Post warning signs, in all appropriate languages, on the UVGI fixtures and on the
walls. The signs should carry the following or a similar message:
CAUTION
Ultraviolet Energy
Turn off lamps before entering the upper part of the room.
( The upper part of the room is the space above the UVGI fixtures.)
Staff, patients, or shelter clients may have concerns regarding health hazards from
UVGI. To address these concerns, provide education on the purpose, benefits, and
risks associated with upper-air UVGI. (OSHA requires staff training.) Also, consider
posting an information sheet on the wall of the room
The on/off switch for the lamps should be accessible to appropriate staff members
but not located where patients or clients may turn off the fixtures
Routine Upkeep
Designate a staff member to be the in-house monitor for UVGI fixtures. This person
should be trained in the basic principles of UVGI operation and safety and should be
responsible for cleaning, maintaining, and replacing the lamps. This may include
regular maintenance by the engineering department, but a record should be kept of
this work
Check and clean lamps and fixtures every 3 months. Turn off the lamps before they
are cleaned; clean with a cloth dampened with water or alcohol
ENVIRONMENTAL CONTROLS
41
Replace lamps once a year or as recommended by the manufacturer. The violet blue
glow emitted by a lamp is not an indicator of the lamps effectiveness. Take radiometer readings at each new lamp to ensure that radiation levels meet the manufacturer's recommendations. Dispose of used lamps as recommended by the lamp manufacturer
Keep a record of all maintenance and monitoring, including radiometer readings and
dates. This will help determine the average life of the lamps. Lamps should be purchased close to your planned replacement time, as prolonged storage may result in
a loss of radiation intensity
DISADVANTAGES
Potentially hazardous to staff and people who use the rooms in which
they are located
Effectiveness uncertain
Only addresses TB; does not remove dust and other particles
HEPA filter units are readily available machines that can be used anywhere to provide
clean air. Use this section to get an overview of HEPA filter units and to learn how to use
them effectively, to determine what type and size of unit is suitable for your facility, and to
help plan routine upkeep of HEPA filter units.
HEPA filter units allow anyone to improve air quality in any room almost immediately. No
detailed engineering knowledge is required to install or maintain HEPA units. These units
are especially useful in settings that may have inadequate or no ventilation and limited
funds for upgrades.
High efficiency filters, such as HEPA filters, remove essentially all particles in the size range
of droplet nuclei from the air that passes through them. These filters are used in self-contained units to provide a source of clean air. A HEPA filter unit will provide cleaned air to
dilute infectious particles and will also remove airborne particles.
HEPA filter units are available in a variety of sizes and configurations, but all consist primarily of:
A HEPA filter to remove small particles from the air
A prefilter to remove coarser particles and thereby prolong the life of the HEPA filter
A fan to circulate air past the HEPA filter and into the room
Controls, such as an on/off switch and fan speed control
42
The most common types of units are portable, freestanding devices. Ceiling-mounted
and wall-mounted units are also available. Portable units have the advantage of greater
flexibility and ease of installation and service. Permanent units are less vulnerable to tampering and theft, less likely to be in the way, and cant be easily moved to a location where
they will be less effective.
The size of HEPA filter units is based on the amount of air they deliver, usually expressed
in CFM. Most units include a switch that can be used to vary the airflow.
FI GUR E 7A.
Small, portable units deliver 150 to 250 CFM. Most units include a threeposition fan speed switch but no other controls. Small units are useful for
offices, on-site clinic rooms, and other smaller areas.
Small units are light enough to be easily carried around and placed on a
desktop or other surface. These units are readily available from hardware
stores and similar retail outlets.
Some small units may use high efficiency filters that do not meet the precise
requirements for HEPA filters. ( A HEPA filter must remove 99.97% of particles equal to or greater than 0.3 micron in diameter.) However, TB droplet
nuclei are significantly larger than particles used to test HEPA filters, so
near-HEPA filters will remove the majority of particles in the size range of
TB droplet nuclei.
FI GUR E 7B.
These units usually have wheels so they can be moved from room to room.
Controls include a fan speed switch and often a warning light to indicate
when filter replacement is recommended.
Options may include a lockable cover for the controls to prevent tampering
and an internal UVGI lamp. Because the HEPA filter removes all infectious
particles in the TB droplet nuclei size range, the UVGI offers no added
benefit.
Larger units are available from specialized medical equipment suppliers.
ENVIRONMENTAL CONTROLS
43
TA B LE 2 .
44
800 ft 3
80 CFM
100 CFM
1,000 ft 3
100 CFM
130 CFM
1,500 ft 3
150 CFM
190 CFM
2,000 ft 3
200 CFM
250 CFM
4,000 ft 3
400 CFM
500 CFM
8,000 ft 3
800 CFM
1,000 CFM
Room volume (first column) is room length times width times ceiling height. For
example, a room that is 8 feet wide by 8 feet long with a 10-foot-high ceiling will
have a volume of 640 cubic feet. A tape measure is required to measure room
dimensions
Six (6) ACH (second column) is the minimum recommended air change rate
The required airflow in CFM to achieve this air change rate is calculated as follows:
( Room volume x 6 ACH) / 60 minutes per hour = airflow in CFM)
The listed minimum airflow (third column) is the minimum rated airflow of a HEPA
filter unit. The recommended 25% safety factor is included. Most HEPA filters include
a switch that adjusts the airflow from a fixed minimum (low setting) to a fixed maximum (high setting). Because of the increased noise, people tend to use the units at
the low setting. Therefore, the low setting should be the basis for unit selection
Example: Assume an 800-cubic-foot room volume. A unit that lists airflows as
100/150/200 CFM would be preferable to a unit that lists airflows of 50/100/150
CFM because it will provide the recommended airflow at the low (quieter)
setting
DISADVANTAGES
Can be portable
ENVIRONMENTAL CONTROLS
45
CASE STUDY
Room volume
=
=
=
=
=
=
4,560
________________________
76 CFM
760 x 6
4,560 cubic feet per hour
The actual airflow may be less than advertised. To compensate, Catherine adds a 25% safety factor
to get a required airflow of 95 CFM.
76 CFM x 1.25
95 CFM
Most units have an adjustable speed setting. They become noisier at the higher speeds. Catherine
plans on running the unit at low speeds during interviews, so she decides to select a HEPA filter unit
with a low-speed setting of at least 95 CFM.
46
Infection Control in
Specific Settings and
Procedures
CLINICS . . . . . . . . . . . . . . . . . . . . . . 49
SPUTUM INDUCTION
........
73
AIRBORNE INFECTION
ISOLATION ROOMS . . . . . . . . . . 87
EMERGENCY
DEPARTMENTS
.............
HOMELESS SHELTERS
CHAPTER TITLE
113
. . . . . 131
47
Clinics
CHAPTER TITLE
49
CLINICS
Patients who are at high risk for TB often receive care at public health and community clinics prior to diagnosis and treatment. Clinic funding does not generally allow
for facility renovation or installation of special ventilation. Furthermore, clinic staffing
does not always include experienced infection control, occupational health, or mechanical engineering personnel, which often places clinic staff and other patients at
increased risk of exposure to TB.
To help reduce the risk of exposure to TB, clinics should have a TB infection control
plan (ICP) in place that is part of the overall infection control program. This section of
the manual describes the problems faced by clinics, how to develop and maintain an
effective TB ICP, and how to reduce the risk of TB exposure for clinic staff.
50
Low-risk facilities
are free to select
these more
protective options,
if desired.
51
TA B LE 3 .
Risk classifications for health-care settings that serve communities with high incidence of
tuberculosis (TB) and recommended frequency of screening for Mycobacterium tuberculosis
infection among health-care workers (HCWs)*
Risk classification
Setting
Low risk
Medium risk
< 3 TB patients/year
> 3 TB patients/year
< 6 TB patients/year
> 6 TB patients/year
Outpatient; and
nontraditional
facility-based
< 3 TB patients/year
>3 TB patients/year
TB treatment
facilities
Settings in which
persons who will be treated have been demonstrated to
have latent TB infection (LTBI) and not TB disease
a system is in place to promptly detect and triage persons
who have signs or symptoms of TB disease to a setting in
which persons with TB disease are treated
no cough-inducing or aerosol-generating procedures are
performed
Settings in which
persons with TB disease
are encountered
criteria for low risk is not
otherwise met
Laboratories
Potential
ongoing transmission
Evidence of ongoing
M. tuberculosis transmission,
regardless of setting
No**
Every 12 months
As needed in the
investigation of potential
ongoing transmission
TST or BAMT
for HCWs upon
unprotected
exposure to
M. tuberculosis
Perform a contact investigation (i.e., administer one TST as soon as possible at the time of exposure, and, if the TST result is
negative, place another TST 810 weeks after the end of exposure to M. tuberculosis)
* Health-care workers (HCWs) refers to all paid and unpaid persons working in health-care settings who have the potential for ex posure to
M. tuberculosis through air space shared with persons with TB disease.
Settings that serve communities with a high incidence of TB disease or that treat populations at high risk (e.g., those with human immunodeficiency virus
infection or other immunocompromising conditions) or that treat patients with drug-resistant TB disease might need to be classified as medium risk, even if
they meet the low-risk criteria.
A classification of potential ongoing transmission should be applied to a specific group of HCWs or to a specific area of the health-care setting in which
evidence of ongoing transmission is apparent, if such a group or area can be identified. Otherwise, a classification of potential ongoing transmission should
be applied to the entire setting. This classification should be temporary and warrants immediate investigation and corrective steps after a determination has
been made that ongoing transmission has ceased. The setting should be reclassified as medium risk, and the recommended timeframe for this medium risk
classification is at least 1 year.
All HCWs should have a baseline two-step tuberculin skin test (TST) or one blood assay for M. tuberculosis (BAMT) result at each new health-care setting,
even if the setting is determined to be low risk. In certain settings, a choice might be made to not perform baseline TB screening or serial TB screening for
HCWs who 1) will never be in contact with or have shared air space with patients who have TB disease (e.g., telephone operators who work in a separate
building from patients) or 2) will never be in contact with clinical specimens that might contain M. tuberculosis. Establishment of a reliable baseline result can
be beneficial if subsequent screening is needed after an unexpected exposure to M. tuberculosis.
** HCWs whose duties do not include contact with patients or TB specimens do not need to be included in the serial TB screening program.
The frequency of testing for infection with M. tuberculosis will be determined by the risk assessment for the setting.
During an investigation of potential ongoing transmission of M. tuberculosis, testing for M. tuberculosis infection should be performed every 810 weeks until
lapses in infection controls have been corrected and no further evidence of ongoing transmission is apparent.
Procedures for contact investigations should not be confused with two-step TST, which is used for newly hired HCWs.
52
Responsibility
Use the following worksheet to identify who is responsible for the various controls in the
TB ICP. In the first column, insert the appropriate name, position or committee responsible
for that control.
RESPONSIBILITY
Ensure full compliance with the provisions of this TB ICP
All Employees
Note: Delete the last row if your classification is low-risk, all patients with TB disease are
immediately transferred to another location, and you elect to not use respirators.
CLINICS
53
Administrative Controls
This TB ICP is based on a hierarchy of three levels of controls: administrative controls,
environmental controls, and respiratory protection. Administrative controls, the first level of
the hierarchy, are intended to reduce the risk or exposure to persons with infectious TB.
Administrative controls include:
Assigning responsibility for the TB ICP
Conducting a TB risk assessment of the setting
Implementing work practice controls
Training, educating, and counseling employees about TB
Screening employees for TB infection and disease
Developing and implementing TB control policies and procedures to ensure prompt
identification, isolation, evaluation, and treatment of persons likely to have TB
54
Early Identification
Efforts to identify suspected or confirmed infectious TB patients will begin as soon as the
patient enters the clinic. All clinic personnel are encouraged to identify patients who are
coughing. Registration personnel are encouraged to ask simple questions such as, How
long have you had that cough? or Do you have any symptoms other than your cough?
Patients with coughs lasting more than 3 weeks, or who have other signs and symptoms
of TB will be immediately referred to triage personnel.
Triage personnel can use a written questionnaire to assist in the early identification of
persons with suspected or known infectious TB. Rapid identification of these patients will
enable staff to mask or isolate them as necessary. See page 146 and page 155 for tools
that you can use for this identification process.
The TB ICP will document the risk level and/or practice at your facility. Choose one of the
following paragraphs for this documentation:
This clinic has been assessed as a low-risk facility for M. tuberculosis transmission.
Patients will not be screened for TB unless they have signs or symptoms of TB.
This clinic has been assessed as a medium-risk facility for M. tuberculosis transmission. Any patient with symptoms of TB or known HIV infection will be screened
for TB.
If the risk level of the clinic is ever determined to be potential ongoing transmission of
M. tuberculosis, all patients presenting to the clinic for service will be screened for TB
symptoms and risk factors. This is a temporary risk classification that requires immediate
investigation and corrective steps. After determination is made that ongoing transmission
has ceased, the clinic will be reclassified as medium-risk and maintain that classification
(medium-risk) for 1 year.
CLINICS
55
Fast Tracking
A person with suspected or known infectious TB in need of a medical test or procedure
will be accompanied to other departments and will not wait in occupied waiting rooms.
Communicating with the receiving department prior to the patients arrival will minimize
delays.
For example, a suspected infectious TB patient who needs a chest x-ray will be masked
and escorted to the radiology department. The escort is provided to ensure that the patient does not remove the mask or get lost. The receiving department will be notified prior
56
to patient arrival. Staff will be ready to perform the x-ray immediately to avoid possible
exposure of other patients and staff.
Whenever possible, tests such as electrocardiograms and specimen collection for laboratory analysis will be performed where the isolated or segregated patient is located, further
reducing the risk of transmission to other patients and staff.
Covering Coughs
Tissue dispensers are placed within reach of patients throughout the facility. Signs are
placed in all waiting areas to remind patients to Cover Your Cough (see Appendix L on
page 157 for sample signs).
Nursing and registration staff have been trained, and are encouraged, to provide tissues
and remind patients to cover coughs.
Whenever possible,
tests such as
electrocardiograms
and specimen
collection for
laboratory analysis
will be performed
where the isolated
or segregated
patient is located,
further reducing the
risk of transmission
to other patients
and staff.
While awaiting transfer, persons with suspected or known infectious TB will wear
surgical masks and will remain isolated in room _______ , which has been designated
for this purpose.
Employee Education
TB prevention training for employees is provided as mandated by OSHA and recommended by the CDC. Training is offered to employees upon employment during regular
work hours and annually thereafter.
The employee signs a training record sheet at the end of the session to acknowledge
understanding of information described in the learning objectives. See Appendix I TB
Infection Control Training Record on page 154 for a sample sign-off sheet.
The following topics are included in employee TB education:
Where to get a copy of the TB ICP if desired
Groups at risk for occupational TB, especially immunocompromised workers
Modes of M. tuberculosis transmission
Symptoms of TB
TB screening and treatment for LTBI
MDR TB
Procedure for isolating persons with suspected or known infectious TB
CLINICS
57
58
TB Symptom Screen
All employees, physicians, and volunteers will be screened at hire and at least annually for
TB symptoms such as:
Cough lasting more than 3 weeks
Fever
Night sweats
Fatigue
Unexplained weight loss
Hemoptysis (bloody sputum).
TB symptom screen will be repeated annually by all employees regardless of their TST
status.
Symptomatic Employees
Any employee, physician, or volunteer with a persistent cough, especially in the presence
of other signs or symptoms of TB, will be evaluated promptly for TB. The individual will not
return to work until the following criteria are met:
TB disease is ruled out based on physical exam, chest x-ray, and bacteriology (if
indicated); or
TB disease is diagnosed and treated, and the individual is determined to be noninfectious as defined below:
Had three negative AFB sputum smears obtained 8 -24 hours apart, with at least
one being an early morning specimen; and
Responded to antituberculosis treatment that will probably be effective, based
on susceptibility results; and
Had been determined to be noninfectious by a physician knowledgeable and
experienced in managing TB disease.
59
When using IGRAs in healthcare workers (HCWs) or other workers who need annual testing, only a single step test is needed at baseline, unlike the two-step testing used in skin
testing. If the test changes from a negative to a positive result within a 2-year period, the
person is considered a converter or newly infected. IGRAs are a new test and it is still
unclear how to use prior TST information when interpreting the new IGRA result and expert advice may be needed in some situations. In addition to a positive or a negative result, the test may be reported as indeterminate. An indeterminate result means that the
test cannot be used to determine infection because of a lack of appropriate responses to
the controls in the test. In these situations, the IGRA can be repeated or a TST can be
used to avoid getting another indeterminate result. As with the TST, QFT-G results and
their interpretation should be considered in conjunction with other epidemiological, historical, physical, and diagnostic findings.
More immunoassays are being developed that should be useful in the diagnosis of TB
infection. Future test methods using FDA-approved products, in combination with CDC
issued recommendations, may provide additional diagnostic options. CDC will periodically publish guidelines as alternate methods become available.
60
BCG Vaccination
A history of previous vaccination with Bacille Calmette-Guerin (BCG) is not a contraindication for having TSTs. Criteria for placing and interpreting TST results are unchanged.
TA B L E 4 .
5 mm or greater
is considered positive in:
10 mm or greater
is considered positive in:
15 mm or greater
is considered positive in:
TST Conversion
A TST conversion is defined as an increase of at least 10 mm in the size of induration from
less than 10 mm to 10 mm or greater within a 2-year period.
Note: the CDC states, For HCWs who are at low risk (e.g., those from low incidence
settings), a baseline result of >15mm of induration (instead of >10mm) might possibly be
the cut point.
CLINICS
61
62
dential health file. Records will be maintained for the duration of employment plus 30
years. Identify the person by position or title who will maintain an aggregate log of TSTs.
All employee TST conversions and confirmed TB cases will be recorded on the OSHA
300 Log unless substantiated as community-acquired.
_______________________________
100
Conversion Rate
Facility TST or IGRA conversion rates are not calculated because a small number of
employees receive TSTs or IGRAs. An epidemiological investigation will be conducted following any employee TST or IGRA conversion.
Determine and identify the appropriate committee or group (Infection Control Committee,
Administration, Safety Committee, TB control staff) who will interpret the TST or IGRA
conversion data. The committee will identify factors that could have contributed to transmission and infection, and recommend implementation of appropriate preventive measures.
Exposure Definition
An employee is considered exposed when the employee has contact for more than a few
hours in a confined space, without the benefit of all appropriate exposure control measures, with a patient who has a positive AFB smear result or positive culture result for M.
tuberculosis or is strongly suspicious for being contagious, and who has not met all three
criteria (listed on page 8) to indicate that the patient is noncontagious.
CLINICS
63
Suspected or
confirmed infectious
TB cases that
trigger contact
investigations must
be reported
promptly to the
local Public Health
Department.
Use of control measures that are functioning appropriately at the time of exposure
(e.g., employee wore a properly fitted N-95 respirator, TB patient was masked, and/
or sputum induction was conducted in a well-functioning LEV device)
Contact Investigation
Specify the name or position of the individual responsible for conducting a contact investigation. This person is responsible for the contact investigation, potentially in collaboration with the local Health Department, following any known occupational TB exposure.
The contact investigation will begin when employee exposure to a suspected infectious
TB case has been identified and results of sputum culture or NAAT for M. tuberculosis are
pending. The contact investigation will include interviews with the work area supervisor
and the patient with suspected infectious TB (index case), if possible. A thorough review
of the patients chart will determine if the patient was transported to the clinic, had laboratory work done, visited radiology, or was interviewed by screening or counseling personnel. A brief memo identifying the patient by initials and date and time of visit will be posted
in employee-only areas of all departments where an exposure could have occurred in
order to alert those who wish to self-identify. If the index case is an employee, the memo
will identify work areas and meetings that may have provided opportunities for exposure
without revealing the employees initials or identity. Suspected or confirmed infectious TB
cases that trigger contact investigations must be reported promptly to the local Public
Health Department.
64
INTERVENTION
Identifies employees occupationally exposed to TB by interviewing patient, area supervisor, and reviewing patients chart.
Writes notification letter and ensures all identified employees
are aware of exposure. Places notice on employee bulletin
board in all departments in which exposure may have occurred so that employees can self-identify.
Interviews identified employees to confirm exposure.
Places, reads, and interprets TST or IGRA results. Completes TST or IGRA form.
Evaluates TB symptom screening forms.
CLINICS
65
66
TA B L E 5 .
HIGH-RISK PROCEDURES
AIIR with 6*-12 air changes per hour (ACH) exhausted directly outdoors away from operable windows, doors, and air
intake vents (using HEPA filtration if possible, where human
traffic may exist)
Performed outdoors only (sputum collection only)
Bronchoscopy
Airway suctioning
Processing specimens for mycobacteriology
studies
CLINICS
67
TA B LE 6 .
AREA
RECOMMENDATION
COMMENTS
General
Ventilation
System
General Waiting
Rooms
Air should flow from clean areas toward less clean areas
General Exam
Rooms
Airborne
infection
Isolation/Exam
Room
Sputum
Induction
68
TA B L E 7 .
Environmental Controls for Medium Risk Clinics and Clinics with Potential Ongoing Transmission
AREA
RECOMMENDATION
COMMENTS
General
Ventilation
System
General Waiting
Rooms
Air should flow from clean areas toward less clean areas
Medium-Risk
Waiting Areas
such as those in
Radiology or
Pulmonary Clinics
Airborne
infection
Isolation/Exam
Room
Sputum
Induction
CLINICS
69
Supply and return air registers are cleaned every 6 months and as needed
by _____________________________________________________________________________________ .
The negative pressure of airborne infection isolation rooms (AIIRs) and sputum induction
rooms is checked daily (when in use) by _______________________________________________ .
UVGI bulbs are dusted monthly and changed according to manufacturers recommendations by _____________________________________________________________________________ .
UVGI warning signage stating, Caution, High Intensity Ultraviolet Energy, Protect Eyes
and Skin is posted by _________________________________________________________________ .
Engineering and infection control personnel work as a team in efforts to control TB.
Maintenance and monitoring results are promptly communicated to clinic management/
infection control staff by ________________________________________________________________ .
Results of air balance reports and negative pressure checks in AIIRs are copied to clinic
management/infection control staff by __________________________________________________ .
Shutdowns for maintenance of the ventilation system are coordinated with clinic
management/infection control staff by _________________________________________________ .
70
Respiratory Protection
The third level of the TB control hierarchy is the use of personal respiratory protection
equipment. Respirators are used by HCWs in certain situations in which the risk for exposure to M. tuberculosis may not be controlled by administrative or environmental measures alone.
If your clinic is a low-risk facility, include the following paragraph in the TB ICP:
This clinic has been designated as a low-risk ambulatory care setting. We have
opted to utilize administrative and environmental controls to prevent high-risk
exposure situations that require the use of respirators. For example, until they
can be transferred to a facility for appropriate evaluation and care, persons with
suspected or known infectious TB will be given surgical masks, educated on the
importance of keeping the mask in place and changing it when damp, and observed for compliance with this request. This risk designation will be reassessed
annually and after any occupational TB exposure.
This clinic has been designated as a medium-risk ambulatory care setting. Employees provide care to TB patients and may perform high-risk procedures such
as sputum induction. OSHA mandates respirator use for facilities unable to prevent certain high-risk situations via administrative or environmental controls. A
respiratory protection program utilizing N-95 respirators has been developed
and instituted to enhance staff safety.
Clinic employees are required to wear NIOSH-certified N-95 respirators, which
have been approved for protection against TB, when:
[All of the following are OSHA-mandated and should remain in your TB ICP]
We have selected the following [Insert brand(s) of respirators used here.
A selection of sizes must be offered] N-95 respirators for use in this
clinic: ___________________________________________________________________.
CLINICS
71
Any cluster of
employee TST or
IGRA conversions
will prompt an
immediate review
and assessment of
the TB infection
control program.
72
Sputum Induction
on
CHAPTER TITLE
73
SPUTUM INDUCTION
This section of the manual provides practice-based guidance on conducting sputum
induction safely. It addresses the following issues:
For a complete review and discussion of early identification of persons with suspected or known infectious TB in a variety of healthcare settings, refer to the Appendix for
TB triage tools and the Resources section for a list of additional materials and
suggested reading.
74
Effective TB control programs are based on a hierarchy of control measures. In the order
of priority, the three levels of the hierarchy are: administrative controls, environmental controls, and respiratory protection for employees.
Educating Staff
A system should be developed to inform staff of new or updated policies and procedures;
education should be provided as necessary. One simple way of documenting that staff
have read a new policy is to post it in a staff-only area and require that staff initial the
posted copy after reading it. After a 30-day posting, the document is placed in a binder
that remains available to staff. The information should also be included in departmentspecific orientations for new employees who will be assisting in sputum induction.
Product sales representatives will often train facility staff when equipment such as a local
exhaust hood or booth has been purchased from their company. After the initial training
session, a brief review of important safety issues can be presented periodically at staff
meetings.
SPUTUM INDUCTION
75
Early identification
of patients who
have TB is
especially important
prior to high-risk
procedures such as
sputum induction.
See Performing Sputum Induction on page 82 for highlights of a sputum induction procedure.
76
All patients having sputum induced for diagnostic purposes should first be screened for
TB. If the minimum criteria for a suspected infectious TB case are met, the sputum induction procedure is considered a high-risk procedure, and must be performed using LEV or
in a room that meets the ventilation requirements for TB isolation.
Two tools are included in the Appendix to assist in the early identification of persons with
suspected or known infectious TB. The first is the Respiratory Isolation of Pulmonary Tuberculosis (RIPT) protocol developed by Roger Lewis, MD, PhD, Department of Emergency Medicine at Harbor-UCLA Medical Center, in Appendix J on page 155. The second
tool, Early Detection of Tuberculosis Questionnaire, in Appendix D on page 146 is an
adaptation of a questionnaire developed by OSHA. See References and Resources at
the end of this document for additional articles and information on the early identification
of suspected TB patients.
SPUTUM INDUCTION
77
Complete Enclosure
A fully enclosed booth or tent is the preferred type of local exhaust device. These
devices physically separate the patient from others during sputum induction. Air
from booths and tents is usually HEPA-filtered and discharged back into the
room, but can also be exhausted outdoors. Some booths and tents can be easily assembled, dismantled, folded, and stored. Others are more difficult to assemble and disassemble, requiring greater installation time and effort.
Booths typically have rigid walls and are less portable than tents and partial enclosures. Some units require assembly in the room, while others come already
assembled and can be used immediately.
Tents have flexible walls with rigid frames. They require some minor assembly
prior to use and disassembly prior to storage.
F IG UR E 8 B .
Partial Enclosure
Patients must be instructed to sit as far as possible inside the hood opening
when coughing. The hood should maintain an air velocity of at least 200 feet per
minute (FPM) at the patients breathing zone to capture droplet nuclei. Air currents from open windows and doors or people moving about the room, can
adversely impact the effectiveness of these devices. Partial enclosures are commonly mounted on carts that can be moved to any room for sputum induction
procedures.
Since partial enclosures do not physically separate the patient from others, these
devices may not be as effective as fully enclosed units.
78
SPUTUM INDUCTION
79
Adequate time
must elapse
between patients
to allow for the
removal of >99%
of airborne
contaminants by
the exhaust system.
Air should be discharged away from other outdoor air intakes or openings into the building (such as operable windows and doors, and outdoor air intakes into building ventilation
systems).
Signage
It is essential to place a warning sign on the door of any room being used for sputum induction. Signage should:
Warn patients and family members not to enter the room
Remind clinic staff that a respirator is required for entrance when the room is, or has
recently been, occupied by a person with suspected or known infectious TB
Indicate when the room was last occupied by a person with suspected or known
infectious TB and at what time the room will be safe to enter without a respirator.
The signs message should be clear to non-English speaking individuals and children.
One suggestion is a sign that combines a stop sign symbol with the message, Do not
enter, N-95 respirator required. A second sign should state, Room will be safe to enter
without a respirator at ________. The sign should state the clearance time period needed
to attain 99% clearance of airborne particles in the room. This will make it easier for staff
to determine when it is safe to enter the room.
Signs can be developed in-house or purchased from a company that specializes in medical signs and labels. Professionally made signs tend to be more readily noticed, and
therefore are generally more effective. Sample signs are included in Appendix L starting
on page 157.
80
FI GUR E 9.
The CDC Guidelines recommend the confirmation of negative pressure through the use of manometer measurements, smoke tubes,
or other reliable indicators. Confirmation should be done daily
whenever a sputum induction room is used for high-risk procedures. Negative pressure in LEV devices, such as partial or complete enclosures, should also be verified daily. This testing can be
done with tissue paper or incense sticks if the other instruments are
not available.
To use smoke or incense, release the smoke parallel to the door
about 2 inches in front of the gap under the closed door outside the
room as shown in figure 9. The smoke should be observed moving
under the door into the AIIR, or into the enclosure.
To use tissue paper, hold a thin strip of tissue parallel to the door
outside the room, extending across the gap under the closed door.
The tissue should be drawn towards the room by the airflow under
the door. Tissue is not as sensitive to air movement as smoke or
incense.
SPUTUM INDUCTION
81
82
Equipment
Aerosol generator/nebulizer
Clear plastic zip-lock bag with biohazard label
Corrugated aerosol tubing (disposable preferred)
Cup of water
Disinfectant (household bleach 1:10 dilution or tuberculocidal quaternary ammonium
compound)
Gloves
Lab slip
Mouthpiece (disposable preferred)
Respirator (N-95 for HCW)
Sterile sputum collection container
Sterile water or sterile hypertonic saline
Surgical mask (for patient)
Tissues
SPUTUM INDUCTION
83
TA B LE 8 .
PROCEDURE
KEY POINTS
1.
Purpose of procedure
3.
4.
84
PROCEDURE
KEY POINTS
5.
7.
8.
9.
SPUTUM INDUCTION
85
TA B LE 9 .
TYPE OF CONTROL
Complete Enclosure
ADVANTAGES
Booth or Tent
Partial Enclosures
Partial hood is enclosed on all
sides except side where
patient sits
Sputum Induction
Rooms
Room meeting all
recommendations (see
Sputum Induction Rooms
on page 79) and/or
requirements for AIIRs
86
DISADVANTAGES
Airborne Infection
Isolation Rooms
CHAPTER TITLE
87
AIRBORNE INFECTION
ISOLATION ROOMS (AIIRS)
A properly designed and operating AIIR can be an effective infection control measure.
Infectious airborne particles are contained within the room, and the concentration of
these particles inside the room is reduced.
However, a badly designed and/or incorrectly operating AIIR can place HCWs and
other patients at risk for TB infection and disease. In this situation, infectious particles
may not be contained in the room, and/or their concentration inside the room may
not be effectively reduced. Staff members who rely on such an AIIR may have a false
sense of security.
The mechanical elements that make an AIIR effective will deteriorate over time, which
may make the controls ineffective. For example, fans can break and ducts can become clogged with dust and lint. People who have not been trained in environmental
controls may inadvertently adjust or alter the controls. An AIIR that was successfully
tested after construction may not be operating correctly a month later. Hence, periodic and ongoing assessment of AIIRs is important.
This manual provides basic information about assessing and improving the design
and operation of an AIIR. It also includes options to convert an existing patient room
into an AIIR and information on guidelines and regulations covering AIIR environmental controls.
TB control in high-risk settings is commonly organized in a hierarchy: administrative (or
work practice) controls are the most important, followed by environmental controls, and
then respiratory protection. Although this section only addresses environmental controls,
all three components should be in place for an effective TB control program.
Whenever an AIIR is used, written policies and procedures should be developed and implemented to address the administrative aspects of the AIIR. They should include:
criteria for initiating and discontinuing isolation
who has authority for initiating anddiscontinuing isolation
isolation practices
how often and by whom the policy and procedure is evaluated
developing and implementing a written respiratory protection program is also
required.
88
Planning Stage
During the planning stages of a new construction or a remodel project, users often meet
with architects to discuss various design elements. This enables the users to provide input to the design team. These discussions usually concentrate on the physical layout of
the space. The mechanical elements are often left to the mechanical engineers discretion.
Infection control coordinators and other appropriate managers should be included in this
process. The infection control aspects of the mechanical system should be addressed so
that the people relying on the controls understand this system.
Architects and mechanical engineers may not be aware of some infection control requirements. While engineers must comply with building codes to get approval for construction
and occupancy, they may not be aware of CDC recommendations, or of federal or local
OSHA requirements. However, architects and engineers should be familiar and comply with
the most current AIA Guidelines for Design and Construction of Hospital and Health Care
Facilities and ANSI/ASHRAE Standard for Ventilation for Acceptable Indoor Air Quality.
The mechanical design elements of a new hospital AIIR should, at a minimum, meet all
local code requirements, as well as OSHA requirements, CDC recommendations, AIA
Guidelines, and ANSI/ASHRAE Standards.
Architectural Considerations
Architecturally, an AIIR should meet all the detailed requirements for a single-patient room,
including a dedicated adjacent bathroom.
Architectural design elements should also meet local code requirements. For example,
California requirements include:
The mechanical
design elements of
a new hospital AIIR
should, at a
minimum, meet all
local code
requirements, as
well as OSHA
requirements, CDC
recommendations,
AIA Guidelines, and
ANSI/ASHRAE
Standards.
89
90
91
Labeling
Maintenance personnel and contractors often re-route ducts to accommodate new services. To help protect these workers from potentially contaminated AIIR exhaust, the exhaust ductwork should be permanently labeled. The label should read, Caution AIIR
Exhaust, or similar words to that effect. The labels should be attached, at most, 20 feet
apart, and at all floor and wall penetrations.
Maintenance workers may also shut down the exhaust fan without realizing this will cause
a loss of negative pressure. To avoid this possibility, a permanent warning sign should be
posted on the fan at the electrical disconnect and at appropriate electrical panel breakers.
The sign should read, AIIR Exhaust Fan Contact Infection Control Coordinator Before
Turning Off Fan, or have similar wording. The sign should also include the telephone
number of the infection control coordinator and the room number(s) of the AIIR(s) exhausted by the fan.
Exhaust Discharge
The exhaust fan discharge should be located and designed to minimize the possibility that
this air is inhaled by people who are outdoors or inside the building. Exhaust air should be
92
directed away from occupied areas (i.e., walkways) or openings into the building (i.e.,
windows or outside air intakes).
To promote dilution, the fan discharge should be directed vertically upward at a speed of
at least 2,000 FPM. The discharge location should be at least 25 feet away from public
areas or openings into a building.
If a suitable discharge location is unavailable, then the exhaust can be disinfected using a
HEPA filter (see page 42). In this case, a HEPA filter must be installed in the discharge duct
upstream of the exhaust fan. This is not a desirable option, however, because it will be
considerably more expensive to install, maintain, and operate than a simple exhaust fan
assembly.
93
sure is within programmed parameters. Unlike the audible alarm, the visual alarm will not
reset when the mute button is pressed. After negative pressure is restored, the lights will
either automatically reset or the reset button must be pressed, depending on the brand
of the monitor. In case no one was present, the latter option will indicate that negative
pressure was temporarily lost.
Remote Alarm
In addition to the alarm included on the wall panel, most room pressure monitors include
an extra identical signal that allows a safe or alarm signal to be sent from the wall
panel to a remote location. Common locations for this remote alarm are the nurses station, the engineering department, and the central switchboard.
It is usually possible to connect the alarm signals from a number of AIIR monitors to a
remote alarm panel. In California, for example, the hospital building codes require that
AIIRs be equipped with an alarm that annunciates at the room and at a nurses station or
other suitable location.
To validate the
continuous
pressure monitor,
negative pressure
should be verified
monthly with smoke
tube or similar
testing.
95
Providing an Anteroom
F IG UR E 1 0 .
An anteroom should be provided between the AIIR and the corridor. This will
help prevent infectious particles in the AIIR from escaping into the corridor.
When an AIIR door is open, negative pressure is immediately lost. If there is
an anteroom that is negative to the corridor, then the overall integrity of the
suite is maintained. The anteroom provides an air lock between the AIIR
and the rest of the facility.
-250 CFM
EXHAUST
ISOLATION
ROOM
-50 CFM
EXHAUST
(1000 ft 3 )
AIR FLOW
BATHROOM
WINDOW
(240 ft 3 )
200 CFM
SUPPLY
CLOSET
AIR FLOW
CONTROL
DAMPER
ANTEROOM
100 CFM
SUPPLY
TO DEDICATED
EXHAUST AIR
SYSTEM
SUPPLY AIR
SYSTEM
CORRIDOR
Local codes should be consulted regarding other design elements of anterooms for AIIRs.
For example, California requirements include:
Provision of a sink, cabinets, and work counter
Provision of a view window in the door to the AIIR
Alignment of door to corridor with door to AIIR, or provision of a second locked and
gasketed entry for gurney
Maximum of two AIIRs per anteroom.
Ventilation
To determine the ACH of a space, you will need to measure the airflow and calculate the
room volume. See Appendix K on page 156.
The airflow measurements and calculations should be performed by a certified testing
and balancing agency or by in-house engineering staff.
Airflow Measurement
The airflow of a room is usually measured at the individual registers and diffusers using
a balometer. This is a device that consists of a hood, a velocity sensor, and a microprocessor.
96
The hood is placed over a register or diffuser and should completely cover the air outlet.
The top of the hood should have a foam gasket that establishes a good seal between the
hood and the ceiling or wall around the outlet.
The hood directs all air entering or leaving the outlet past a velocity-sensing grid. The area
of the grid is fixed. Therefore, the microprocessor can calculate and display the quantity
of air being exhausted or supplied by the air outlet. Balometers usually provide an airflow
reading in cubic feet of air per minute (CFM).
The standard size of a balometer hood outlet is 24" X 24", although adapters are provided
to adjust the hood size. This size hood can be used to measure the airflow of any outlet
equal to or smaller than this (e.g., 12" X 24" or 18" X 18" diffuser). For other size outlets,
such as a 36" X 6" slot diffuser, the hood size on the balometer may need to be changed.
There may not be sufficient space in front of some outlets to place the balometer. In this
case, the airflow should be measured by a pitot traverse in the duct that serves the outlet.
Regularly
scheduled
assessment of
environmental
controls will identify
and may help
prevent failures.
A pitot traverse is a specialized measurement that requires access above the ceiling. Air
velocity is measured at a number of sample locations inside the duct. Airflow is calculated
based on these velocity readings and the area of the duct cross-section. However, pitot
traverses are not as accurate as balometers.
If a dedicated exhaust fan serves the AIIR suite, it may be possible to estimate the airflow
at the room by measuring the airflow at this fan. Because of duct leakage, this measurement will not be as accurate as one taken at or near the outlet. Inadequately sealed duct
joints can result in extra air being sucked into the duct between the AIIR exhaust grille and
the fan, which would result in an overestimate of airflow in the room. To compensate for
this, an allowance of at least 10% should be made. This allowance should be increased
in the case of a long duct run.
If room airflow is found to be inadequate, i.e., less than 12 ACH, it should be increased.
For information on modifying existing room airflow, see Upgrading or Converting an Existing Room on page 101.
97
98
Tissue Test
If smoke-generating devices are not available, or if the room is occupied by a
patient who may be vulnerable to the irritant properties of smoke, a thin strip
of tissue can be used to determine whether a room is at negative, neutral, or
positive pressure. A thin strip of tissue should be held parallel to the gap between the floor and bottom of the door. The direction of the tissues movement
will indicate the direction of air movement.
FI GUR E 11.
Manometer
Manometer
Relative room pressurization can also be verified using a handheld pressure
gauge or manometer, which is similar to a direct room pressure monitor,
except it is portable. A length of rubber tubing is attached to each of the two
ports on the manometer. The manometer displays " W.G., the pressure difference between the two spaces at the termination of the tubes. If one of the
tubes is threaded under the door into the AIIR and the other is in the hallway,
the manometer will indicate the pressure difference between the two spaces.
A negative symbol verifies that the room is at negative pressure.
1/2" gap
under door
99
Velometer
Air speed is measured by a velometer, usually in units of feet per minute (FPM). These
devices can be placed near the gap under the AIIR door to measure the speed of the
airstream. Velometers are available in a number of different configurations. Many only indicate air speed regardless of air direction. For instance, some velometers indicate how
fast the air is moving, but not whether the air is entering or leaving the room. However,
there are models available that can also be used to determine airflow direction.
Repeat Test
All of these tests to verify negative pressure should be conducted at least three times
until the results are consistent.
TABL E 10 .
100
PARAMETER
UNITS OF MEASUREMENT
MEASURING DEVICE
pressure difference
manometer
velometer
balometer
Upgrading or Converting an
Existing Room
This section covers methods of improving the ventilation characteristics of an existing
room to make it more effective for AII.
Previous sections have outlined recommendations for a new state-of-the-art AIIR and have
shown how to assess an existing room to see how it compares with these recommendations. This section describes how to correct deficiencies found during the assessment.
The methods outlined below could also be used to convert an existing patient room into
an AIIR.
Disconnect Recirculating Air System
The first step is to ensure that air from the room is not inadequately filtered and recirculated to other areas. The air removed from the room must either be exhausted
outdoors to a safe location or HEPA-filtered. If room exhaust is currently connected
to a recirculating air system that does not include a HEPA filter, it should be disconnected from this system.
Install HEPA Filter in Existing Return Air System
Theoretically, another safe option for correcting a recirculating system is to replace
the existing filter with a HEPA filter. However, CNTC does not recommend this. A
HEPA filter is a specialized piece of equipment that should only be used in a ventilation system specifically designed to accommodate it. HEPA filters are physically
larger than most filters and require larger fans to overcome increased resistance to
airflow.
Two Upgrade/Conversion Options
There are two basic approaches to upgrading or creating an AIIR. The preferred option is to adjust the building ventilation system to create a permanent AIIR. A temporary solution is to add a recirculating HEPA filter unit to supplement, or even replace, the building ventilation system.
Regardless of the upgrade option selected, steps must be taken to reduce unwanted air leakage from the room, i.e., the room must be sealed.
Negative Pressure
As explained previously, the negative pressure value will depend on two factors:
how much more air is exhausted than supplied (i.e., the offset); and how well the
room is sealed. In general, when converting or upgrading a room, the negative pressure value will not be as high as that attainable for new construction because there
is less control over the architectural elements.
CNTC recommends that the negative pressure value should be at least minus 0.006"
W.G. for upgraded or converted AIIRs.
This is more stringent than the CDC Guidelines, which recommend 0.01" of water
gauge as a minimum negative pressure value.
101
102
Adjust Dampers
Dampers are devices that control the flow of air in ducts, similar to the way valves control
the flow of fluids in pipes. Dampers, usually located above the ceiling, should only be
adjusted by a facility engineer or certified air balance contractor. To increase airflow, the
dampers in the ducts serving the room should be opened wider. It usually takes an air
balancer two or three adjustments to obtain the desired airflow.
The exhaust airflow rate should be at least 12 ACH. For existing rooms, this recommendation is more restrictive than the CDC Guidelines, which accept an air change rate of 6
ACH. However, 6 ACH will not satisfy some local regulatory agencies, including Cal/OSHA
and the Office of Statewide Health Planning and Development (OSHPD) in California.
Twelve (12) ACH, which meets all local requirements known to CNTC, is readily achievable using HEPA filter units.
The supply should be approximately 100 CFM less than exhaust. Depending on how well
the room is sealed, more air may need to be exhausted in order to achieve a larger pressure differential.
Most rooms do not have a dedicated ventilation system. They are connected to a fan
system that serves other rooms in the building. Before and after adjusting the AIIR airflow,
the air balancer should measure the airflow in some of these other spaces to make sure
that the AIIR adjustments do not have an adverse effect on ventilation elsewhere.
103
Theoretically, the technique described above could also be used to create negative pressure in a room that had no ventilation system. However, this is not recommended because the room would then have no outside air at all, only recirculated, HEPA-filtered air.
Building codes mandate that fresh outdoor air be supplied to all occupied spaces that do
not have an operable window.
Documentation
Records should be kept of all AIIR environmental control tests and measurements. Local
regulatory agencies may require that these records be kept for a number of years. For
example, Cal/OSHA requires that records be kept for a minimum of five years.
105
106
CASE STUDY
-250 CFM
EXHAUST
ISOLATION
ROOM
-50 CFM
EXHAUST
(1000 ft 3 )
AIR FLOW
BATHROOM
WINDOW
(240 ft 3 )
200 CFM
SUPPLY
CLOSET
AIR FLOW
CONTROL
DAMPER
ANTEROOM
100 CFM
SUPPLY
TO DEDICATED
EXHAUST AIR
SYSTEM
SUPPLY AIR
SYSTEM
CORRIDOR
Dedicated Bathroom
Background
The Options
The AIIR volume is approximately 1,000 cubic feet,
so the supply air change rate is 12 ACH.
The Reason
Each arrangement will result in both a 100 CFM offset across the AIIR door and an equal volume of air
moving through the AIIR. But only the preferred option provides more exhaust than supply in the AIIR
itself, resulting in negative pressure, and increases
airflow towards the head of the bed.
107
CASE STUDY
-150 CFM
EXHAUST
TB PATIENT ROOM
15'
WINDOW
130 CFM
SUPPLY
CORRIDOR
108
Assessment
The clinic manager, Janet, was concerned because the billing department shares a corridor with the
room used to isolate TB patients. M. tuberculosis transmission may have occurred due to failed environmental controls in the AIIR.
Janet tested pressurization of the AIIR with a piece of tissue. The room clearly had positive pressure
with respect to the corridor. She felt airflow from the supply grille. Even after wiping off the considerable amount of dust on the exhaust grille, there was no air movement. A tissue held against the grille
was not pulled toward the grille as would be expected.
The county facilities department sent out a maintenance engineer, Cynthia, to investigate further.
Cynthia remembered converting this room into an AIIR for TB patients about 2 years ago. She had
sealed the room and installed a small, dedicated rooftop exhaust fan. But now she found that dust and
lint had accumulated on the fan motor, causing the motor to overheat and burn out. She cleaned the
fan and ductwork and replaced the motor. Exhaust was now measured and found to be 150 CFM.
Room air supply was 130 CFM, which was 20 CFM less than exhaust. However, a series of smoke
tests showed that the room was now at neutral pressure rather than negative pressure. Room air
leakage exceeded the 20 CFM offset.
Room Volume
15 x 15 x 8.5
approx. 5 ACH
Therefore, even with the exhaust fan fixed, the room was unsuitable for isolation because it was at
neutral pressure with a low air change rate.
Clearly, something had to be done. See AIIR: Part 2 for conclusion.
109
CASE STUDY
60 minutes
400 CFM
- 150 CFM =
250 CFM
Additional airflow
safety factor
Based on this, the larger unit was selected and placed in the room. Cynthia replaced a windowpane
with a sheet metal panel. She connected a flexible duct from the HEPA unit discharge to a hole in the
sheet metal panel, set the unit to about 300 CFM, and diverted about a third of the discharge air to
the outdoors.
110
Effective supply
Effective exhaust
Effective supply
=
=
=
300 CFM
=
=
=
300 CFM
400 CFM
100 CFM
15'
AIR FLOW
-150 CFM
EXHAUST
170 CFM
RECIRC.
TB PATIENT ROOM
15'
SHEET METAL
PANEL
HEPA FILTER UNIT
80 CFM
DISCHARGED
OUTDOORS
AIR FLOW
130 CFM
SUPPLY
-250 CFM
INTAKE
SUPPLY AIR
AIR FLOW
-100 CFM
NEGATIVE AT DOOR
CORRIDOR
How often should the negative pressure be verified for this AIIR?
111
112
Emergency
Departments
CHAPTER TITLE
113
Facility type
Patient population
The risk of transmission is greater in areas in which care is provided to patients with
TB disease before they are identified, properly isolated, and started on appropriate
therapy. This care is often provided in hospital EDs.
In summary, EDs present a unique intersection of risk factors. Given these factors, the
cornerstone of effective TB control programs in EDs is early identification of patients with
infectious TB. After identifying these patients, implementing appropriate isolation and diagnostic procedures are the most important and effective risk reduction activities. An index of suspicion for TB appropriate to the facility, the community, and the client population
is an essential component of these practices.
EMERGENCY DEPARTMENTS
115
116
Next Steps
Compare the information you developed about your facility with the general ED risk classification in the revised version of Appendix B in the CDC guidelines. Use these classifications in conjunction with community-specific information to determine your ED risk.
Next, determine whether the community-specific information warrants a shift in the general ED risk classification. For example, if your facility sees few of the TB cases in your
community, or has an ED population that is not representative of the community demographics for confirmed TB cases, you may want to revise your classification to a lower-risk
category. Conversely, if your patient population closely matches the demographics of the
TB cases in your community, or you serve a particularly high-risk population, you should
consider revising your classification to a medium-risk category.
TA B L E 11.
POTENTIAL ONGOING
TRANSMISSION
MEDIUM RISK
LOW RISK:
Note: These are general classifications and may be modified depending on the facility
situation. For example, a facility that would fall into the low- or medium-risk categories
may upgrade to a classification of potential ongoing transmission if the facility is seeing patients with multidrug-resistant (MDR) TB.
EMERGENCY DEPARTMENTS
117
CASE STUDY
What are some actions or methods the ED personnel could use to prevent this in the future?
118
CASE STUDY
TB Symptom Screening
During Triage
Ms. K, a 39-year old Mexican woman, was brought to the ED after falling from a ladder at her sisters
home. She complained of arm and back pain and headache. After staff had ascertained that her injuries were minor, they set her broken arm.
While preparing to discharge her, Ms. K asked if she could also have something for her very productive cough, which she had had for several months. Before discharging Ms. K, the doctor called radiology for a reading on the chest x-rays which had been taken 6 hours earlier. The x-rays were abnormal, and a further work-up revealed that Ms. K had both a positive smear and TB culture.
Although Ms. K was not admitted to the ED for a complaint related to TB symptoms, she did have
TB. If TB screening were a routine part of the triage procedure at this urban ED, Ms. K would have
been isolated for the entire 6 hours she was there. Instead, she exposed staff members and other
patients.
What are some of the questions triage personnel should ask patients to determine their
TB status?
EMERGENCY DEPARTMENTS
119
Efforts to identify
infectious patients
and prevent
transmission
should begin as
soon as the patient
enters the door
and approaches
the admission or
registration desk.
Efforts to identify infectious patients and prevent transmission should begin as soon as
the patient enters the door and approaches the admission or registration desk.
When suspect TB patients are identified early in the admitting process, these patients can
be placed on a fast-track for further triaging and possible isolation or masking precautions. EDs that do not have a specific triage tool for this purpose tend to over-look suspect TB patients and triage for acuity only.
120
TA B L E 12 .
DEFINITION
TB symptom and risk factor
screening of all patients
presenting to the ED,
regardless of the nature of the
chief complaint.
Develop facility-defined
identifying criteria for
determining when to suspect
TB in your ED patients.
ADVANTAGES
DISADVANTAGES
EMERGENCY DEPARTMENTS
121
122
CASE STUDY
AIIR Signage
The housekeeping manager called the ED nurse manager. A housekeeper who was regularly assigned to the ED had complained about going into an exam room in the ED for routine matters, such
as emptying the trash containers. After he came out of the room, he found that the nurses and doctors going into the room were wearing respirators. He was worried that he was going to get sick, and
angry because he felt important information was being withheld. The ED manager tried to explain
that the staff was very busy, and that they communicated informally to one another about the
isolation status of the patients. But she realized that this would have to change, in order to better
protect the safety of all the workers in the ED. She called the infection control nurse (ICN) and enlisted his help.
At the next staff meeting, the ED manager and the ICN presented a plan they had developed jointly.
They made a double-sided sign to hang on the doors of the rooms that were sometimes used as
AIIRs for suspect TB patients. The sign was a simple one which on one side read Exam Room No
Special Precautions Required, and on the other side read AIIR N-95 Respirators Required. Since
the signs would be on the doors, staff would just need to turn them to the isolation side when occupied by a suspect TB patient. The staff agreed to give the signs a try. This was a simple system of
notification which benefited all staff who worked in the ED, including housekeeping, lab, and
radiology.
Can you think of other ways, ED managers can inform staff about potential TB transmission
in their facility?
EMERGENCY DEPARTMENTS
123
CASE STUDY
What are two ways a healthcare worker can check a room for negative pressure?
124
Patients with
suspected or
confirmed infectious
TB should be
masked as soon as
they are identified
and then moved to
isolation or
segregation.
EMERGENCY DEPARTMENTS
125
Many facilities do not have such a dedicated AIIR available in the ED. Such facilities often
segregate suspect TB patients in any available closed exam room, regardless of the ventilation characteristics of the room.
The two most important environmental characteristics of an AIIR are a high ventilation rate
and negative pressure relative to the adjacent space. The direct exhaust requirement is
not as crucial because ED supply air filters should remove most TB particles from recirculated air. We recommend that a specific exam room with these two ventilation characteristics be identified to segregate such patients. You can assess the ventilation of a number
of rooms and use the one that is most satisfactory. Alternately, you can select the room
based on other concerns, and then improve the ventilation as required. A removable sign
should be placed on the room door to warn staff that a segregated patient is inside.
The room should have a high ventilation rate (minimum 12 ACH). The airflow rate in the
room should be measured. The hospital engineering department may have the equipment
to measure room airflow. Otherwise, your engineering department can contract with a
certified air balancing firm to perform these measurements. Once you know the amount
of air moving through the room, you can calculate the air change rate. If the room airflow
is inadequate, it should either be increased, or supplemented with a portable High Efficiency Particulate Air (HEPA) filter unit.
The room should also be under negative pressure. Check the rooms pressurization relative to the corridor using a telltale such as smoke tubes or incense sticks. (Your engineering department may have smoke tubes that you can use. Otherwise you may be able to
buy them from a local safety supply company.) Hold the smoke-generating device at
ground level just outside the door and observe the smoke trail. Repeat this or a similar test
daily to verify negative pressure of any room used for segregation or isolation.
Negative air pressure may be achieved in a room by increasing the amount of air exhausted by the existing ventilation system so that more air is exhausted than supplied. If
this cannot be accomplished, you may have to add a dedicated exhaust fan, or a standalone HEPA filter unit with a portion of the discharge diverted outside.
For information about AIIR criteria, see AIIRs on page 88. For more information about
HEPA filters see page 42.
126
Educating Patients
Placing signs that show a coughing individual using tissue or a surgical-type mask are
non-judgmental and lend support to ED staff TB control efforts.
Signs in appropriate languages for your facilitys clientele should be easily visible in your
ED registration and waiting areas to encourage coughing patients to cover their coughs.
The sign should have a picture of a person covering their cough and be easily understandable. Sample signs for you to copy and use are included in Appendix L , starting on
page 157.
A variety of patient literature on TB should also be available in the waiting area. Pamphlets
can be obtained from a number of sources including the CDC, your state TB Control
Program, and the American Lung Association.
EMERGENCY DEPARTMENTS
127
Masking Considerations
Patients who are suspected or known to have infectious TB must be masked until placement in appropriate airborne infection isolation. A regular surgical mask is sufficient to
block droplets from escaping into the room air. Masks must be changed if they become
damp or difficult to breathe through.
Respirators should not be used on patients. Respirators increase the work of breathing which can prompt the patient to remove the respirator.
Ventilation
Ventilation is the most effective environmental control. Ventilation can dilute and remove
infectious TB particles, as well as other airborne contaminants. The current California
Building Code mandates a minimum air change rate of 10 ACH for new or renovated
hospital ED waiting rooms. Many EDs were constructed before 1991 when this requirement was added to the building code. Such EDs may have ventilation rates less than 10
ACH. Facilities are not required to bring existing ED ventilation rates into compliance with
the current code unless they are renovating the ED.
The first step you should take is to have the hospital engineer calculate the air change rate
in the waiting room. You will need to have the actual airflow in your waiting room measured, probably using an airflow hood.
128
If the air change rate is less than 10 ACH, it should be increased. It may be possible to
achieve this by adjusting the amount of air supplied and exhausted by the building ventilation system. Otherwise, self-contained HEPA filter units can be used to increase the effective air change rate. For more information, see page 42.
Negative Pressure
The ventilation system for an ED waiting room should be balanced to achieve negative
pressure in the room with respect to adjacent spaces. The amount of air exhausted from
an ED waiting room should exceed the amount supplied.
General air movement will, consequently, be towards the waiting room from adjacent areas in the hospital. This will help contain any infectious particles generated in the waiting
room.
For effective negative pressurization of a room, all doors should be kept closed. However,
this is usually not practical for an ED waiting room. Nevertheless, the design of the mechanical systems for EDs should endeavor to keep air moving towards the waiting room.
Smoke-generating devices can be used to confirm this airflow.
If the exhaust airflow rate in your waiting room does not exceed supply, then exhaust
should be increased. It may be possible to increase the exhaust airflow by adjusting (also
called rebalancing) the existing mechanical exhaust air system. Alternately, a new exhaust system could be installed. This option will obviously be more expensive. You should
discuss these options with your facilitys engineering staff. For more information, see
page 26.
EMERGENCY DEPARTMENTS
129
130
Homeless Shelters
CHAPTER TITLE
131
HOMELESS SHELTERS
Homeless shelters present considerable variation in the types of services they provide, the people they serve, and the type of buildings in which they are housed.
Some shelters provide food and shelter, but no other services. Other facilities provide
a range of services on-site, including case management and chemical dependency
recovery services
Some shelters serve a different group of clients every night on a first-come, firstserved basis. Other shelters allow clients to stay for up to 6 months
Buildings used as shelters vary from a converted warehouse sleeping 600 people to a
self-contained trailer for 4 clients
Many shelters serve only adult male clients. A smaller number serve women, families,
or teenagers
Because of these factors, the likelihood that TB will spread varies considerably from
shelter to shelter.
This section describes the challenges faced by shelters and how to reduce the risk of
spreading TB in these settings.
132
The following barriers to more effective use of ventilation, filters, and UVGI were encountered:
Limited knowledge about TB and how TB is spread
Limited knowledge of the role of ventilation, filters, and UVGI in reducing TB transmission risk
High staff turnover rate and overworked staff
Limited maintenance staff and budgets
Dilapidated buildings and mechanical ventilation systems
Limited funds to improve TB control through use of ventilation, filters, and UVGI
Following each consultation, the facility received a report recommending ways of reducing the likelihood that TB would spread in the shelter. Recommendations varied from immediate no-cost steps, such as opening windows and doors, to suggested modifications
of the shelters ventilation equipment.
HOMELESS SHELTERS
133
134
HOMELESS SHELTERS
135
Your shelters current system should be evaluated for effectiveness and modifications
should be made, if needed. Read the following information to help you determine any
changes that may work in your situation:
Natural Ventilation
If rooms in your building are not served by a central ventilation system, read Natural Ventilation and Fans on page 16 to learn how to check and improve natural ventilation, how to
use exhaust and freestanding fans more effectively, and to learn about the advantages and
disadvantages of natural ventilation and fans as compared to other types of ventilation.
Methods that help improve natural ventilation in the shelter include:
Providing fresh outside air to all occupied rooms in homeless shelters
Keeping doors, windows, and skylights open as often as possible and check that
they are easy to open
Adding fans to increase air mixing and directional airflow. Place them so air movement can be felt in all occupied parts of the room, and keep them running as much
as possible
Providing extra blankets to clients who complain of drafts so that ventilation can be
used when the space is occupied
Increasing ventilation at times when the space is unoccupied if ventilation and fans
cannot be used when the space is occupied because they are too noisy or cause
unacceptable drafts. Many shelters are closed during part of the day, for example.
This provides an opportunity to open windows and doors while running fans at high
speed to air out dormitories.
Natural ventilation can be unpredictable and may not be practical in cold climates. If this
is the case, consider adding a central ventilation system.
To see how one homeless shelter director improved the natural ventilation in her building,
see Case Study: Natural Ventilation and Fans on page 22.
Central Ventilation
If rooms in your building have an existing central ventilation system, read Central Ventilation on page 24 to learn about the various parts of your central ventilation system, how
they help control the spread of TB, what to check and how to make improvements, and
the advantages and disadvantages of central ventilation.
If you are considering the design of a central ventilation system for a new or an existing
building, read Recommendations for the Design of New Central Ventilation Systems on
page 34.
Methods that help improve existing central ventilation systems in the shelter include:
Using pleated filters
Providing outside air intakes
Setting outside air intakes to the fully open position
Using thermostats that allow continuous fan operation
Running ventilation systems continuously whenever the building is occupied
Providing a pressure gauge for ventilation units that have more than one filter
Providing natural ventilation to occupied rooms not served by ventilation systems
136
and to all occupied spaces at times when ventilation systems are broken or otherwise not operating
Considering the use of in-duct UVGI as a supplement to filtration and outside air
dilution.
In addition to the above methods, perform regular checks of each ventilation unit and the
rooms that it serves and perform routine upkeep. See Checking a Ventilation System on
page 32 for a description of the checks to perform, and see Summary of Ventilation Units
Worksheet on page 152 for a sample checklist that you can use. To learn about central
ventilation upkeep, see Routine Upkeep of Existing Ventilation Systems on page 33.
To see how one homeless shelter director used these ideas and made immediate lowcost improvements to ventilation in his shelter, read Case Study: Central Ventilation on
page 36.
Air Filters
There are three types of filters that are used in central ventilation systems:
High-efficiency particulate air (HEPA) filter
Pleated ASHRAE 25% efficient filter (MERV 7 or 8)
Lint filter
See the graph in Figure 3 on page 27 for a comparison of filter efficiency.
A pleated filter is the most suitable type of filter for many recirculating air systems, such as
those in homeless shelters. Pleated filters are readily available from hardware stores in
sizes that fit most ventilation systems. They are slightly more expensive than lint filters and
cause more of an obstruction, which will reduce airflow slightly. To read more about filters,
see Components: Air Filters on page 26.
HEPA filter units allow you to improve the air quality in a room almost immediately. These
units are especially useful in homeless shelters that may have inadequate or no ventilation
and limited funds for upgrades.
The following describes ways to use HEPA filter units in your shelter:
Provide portable HEPA filter units for all unventilated rooms frequented by clients
unless the rooms have an operable window or door that is usually kept open
Place small units off the floor and next to staff so that the purified air they generate
is delivered close to the faces of the people that they are used to protect. An ideal
location is on a desk or on a file cabinet adjacent to a staff member. Consider the
HEPA filter unit primarily as a source of clean air and secondly as a removal device
for contaminated air
Place units evenly throughout crowded rooms so that air movement can be felt in all
parts of the room
Operate HEPA filter units continuously while rooms are occupied by clients and for
approximately 1 hour after they leave
To keep HEPA filter units operating efficiently, designate a staff person to be the in-house
monitor of the units and to perform routine maintenance. This person should know the
basic principles of HEPA filter unit operation and should create a written schedule for
changing the filters. To read more about HEPA filter units, how to select suitable units, and
their routine upkeep, see HEPA Filter Units on page 42.
HOMELESS SHELTERS
137
UVGI
Only an experienced professional, such as a UVGI lamp manufacturer should design and
install UVGI in your shelter. This type of installation (and the maintenance of such an installation) requires expertise and equipment that may be difficult and expensive to acquire.
In-duct UVGI is a useful option for a recirculating air system that serves areas at high risk
for TB transmission and areas without risk. The UVGI lamps are installed inside an air
duct. This type of UVGI is usually less expensive to operate than a 100% outside air system. To read more about this type of UVGI and advantages and disadvantages of in-duct
UVGI, see Components: In-Duct UVGI on page 29.
Upper-air UVGI is a specialized technology that is particularly appropriate for homeless
shelters but can only be used in certain rooms. UVGI lamps are mounted high on walls or
hung from the ceiling (at a height of 7 feet), resulting in irradiating and disinfecting the upper-room air. UVGI lamps should not be installed in rooms with ceilings less than 8 feet tall
to avoid having people look into the lamps or bump into them. In addition, bunk beds
should not be used in rooms that have an upper-room UVGI installation.
When using upper-air UVGI, it is essential that the lamps and radiation levels be checked
on a regular basis.
Have an expert use a radiometer to check the radiation levels in parts of the room
where people are likely to be exposed. Radiation levels should be below the NIOSH
REL
If radiation levels are too high in any location, turn off the lamp or lamps causing the
high radiation levels. It may be necessary to add non-reflective paint to the ceiling
and/or wall, and/or to relocate or replace the fixtures to correct the problem
Check that lamps are not burned out or broken. If lamps are working, they emit a
visible violet blue glow that can be seen from below
Turn off lamps and check that lamps and fixtures are free of dust and lint
Check that the radiation level at each fixture meets the lamp manufacturers recommendation. Protective clothing or special equipment may be required to take these
readings without overexposing the skin or eyes to the radiation. Replace the bulbs if
the radiation levels are below the manufacturers recommended minimum levels
To read more about upper-air UVGI, how to determine whether a room is suitable, about
installation planning, routine upkeep, and the advantages and disadvantages of upper-air
UVGI, see Upper-Air UVGI on page 38.
138
USEFUL DOCUMENTS
AND WORKSHEETS
Appendices
This section contains a set of worksheets, forms, and signs that are referenced throughout the manual. Use
these items to assist in the assessment of risk; track training, triage criteria and other data; and calculate
conversion rates and room clearance times. In addition, the appendices contain a description of air change,
and sample Cover Your Cough and Respirator/Room Clearance signs.
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
SAMPLE SIGNS
. . . . . . . . . 143
. . . . 145
. . . . . . . . . . . . . . . . . . . . . . . . . . . 150
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
CHAPTER TITLE
139
x 100
Total number of persons (except new hires) who had TSTs applied and
read/year or IGRAs completed/year
To help you judge the risk of TB transmission in your setting compared with the entire facility, you should perform the following two calculations:
1.
For each year, note the total number of persons with newly positive TST or IGRA results
in your facility (excluding staff in your setting, ex. ED, clinic, etc.). Divide by the number of
facility employees (excluding staff in your setting) who received a TST with documented
results or who completed an IGRA test.
For example, if seven employees had a positive TST result and you tested a total of 350
employees (in areas other than in your setting), the calculation would be 7/350, or .02, or
2% conversion rate.
2.
For each year, note the number of employees in your setting with newly positive TST or
IGRA results. Divide by the total number of employees in your setting who received a TST
with documented results or who completed an IGRA test.
For example, if 50 employees were tested and two employees had a positive TST result, the
calculation would be 2/50, or .04, or 4% conversion rate.
These above examples tell you that the conversion rate is higher for employees in your setting
than for employees who work elsewhere in your facility. You should compare the conversion
rate of the staff in your setting and the rest of the facility from one year to the next to identify
any changing trends.
Please see the sample worksheet on the next page which uses the Emergency Department
as an example.
Note: Since there is no national, standardized, comparable database against which to evaluate
the data for your facility, you must establish your own facility criteria for periodic comparison.
APPENDICES
141
a. ________
b. ________
c.
c. ________
AB=
d. C x 100 =
d. ______ %
2. ED Conversion Rate
a.
a. ________
b. ________
c.
c. ________
AB=
d. C x 100 =
d. ______ %
The overall conversion rate for staff not working in the ED is _________%. (1d)
142
143
SECTION 1
Patient Gender
Discharge Diagnosis in ED
SECTION 2
EVENT
TIME ELAPSED
SINCE ARRIVAL
NOT
DOCUMENTED
0 hours, 0 minutes
TIME
Time of arrival in ED
Time of triage check-in
Time of ED admission
SECTION 3
HISTORY OF
144
DOCUMENTED
AS YES
DOCUMENTED
AS NO
NOT
DOCUMENTED
Fever
Night sweats
TB disease
HIV infection
Homelessness
Recent TB exposure
Time delay
____________ seconds
________________________
TASK
SIGNED OFF
BY
APPENDICES
145
HISTORY/SYMPTOMS
No
Dont
Know
Segregated in room
Date: _____________ Time:___________
No action required
Date: _____________ Time:___________
146
Date _____________________
_______________________________________________________________
Last Name
First Name
Middle Initial
/
/
Date of Birth ___________
Department ____________________
Work Phone___________________
1. Please check the general category that best describes your current job title
[Develop facility-specific categories from the examples below]
Admitting Clerk
Physician
Housekeeper
RN
Maintenance Worker
Respiratory Therapist
2. Check one general category that best describes where you will spend most of the work day
[Develop facility-specific categories from the examples below]
Yes
No
19_____
20_____
Dont know
4. Have you traveled or lived outside the U.S.A. in the last 2 years?
Yes
No
Yes
No
Dont know
/
/
a. If yes, when was your latest test? ______________
b. What was the test result?
Positive
Negative
Dont know
Yes
No
Dont know
d. If the test result was positive, what medication(s) did you take?
Isoniazid
None
Other ____________
Dont know
APPENDICES
147
Yes
No
Dont know
/
/
a. If yes, when was your latest test? ______________
b. What was the test result?
Positive
Negative
Indeterminate
Dont know
Yes
No
Dont know
Yes
No
Dont know
a. If yes:
1. In what year did you start treatment?
19 ____
20____
Dont know
Yes
No
Dont know
Yes
No
Dont know
11. Do you work, volunteer, or live in another facility that provides medical or social services?
Yes
No
Date TST
Initials
Site
Product
Lot #
Expiration
Dose
Date Read
Initials
Induration
Applied
(RA/LA)
Name
Date
(TU)
(mm)
/ /
/ /
/ /
________
_________ _________ _________ _________ _________
_________ _________
_________ _________
/ /
/ /
/ /
________
_________ _________ _________ _________ _________
_________ _________
_________ _________
148
_______________________
_____________________________________
________________________________
_________________________________________________
_____________________________
7. Divide the answer to number 6 by the answer to number 1. Multiply the result by 100.
x 100 = %
This gives you an idea of the percentage of the TB cases in your county that were admitted to your
facility. Since your facility may draw significant numbers of patients from more than one county,
this may be a crude estimate.
8. How many of the confirmed TB cases admitted to your facility were seen in the ED? _____
APPENDICES
149
1c
1a. ____________ ft
1b. ____________ ft
1c. ____________ ft
1a
1d. 1a x 1b x 1c
= volume
1b
2b.
= 2a x 60 minutes
2c.
= 2b 1d
150
TA B L E 1 . F R O M T HE CD C GU ID EL INES
Air changes per hour (ACH) and time required for removal
efficiencies of 99% and 99.9% of airborne contaminants*
ACH
99%
99.9%
138
207
69
104
46
69
12
23
35
15
18
28
20
14
21
50
400
<1
* This table can be used to estimate the time necessary to clear the air of airborne Mycobacterium tuberculosis
after the source patient leaves the area or when aerosol-producing procedures are complete.
APPENDICES
151
UNIT
LOCATION
152
ROOMS SERVED
BY UNIT
THERMOSTAT
LOCATION
FILTERS
( NUMBER ) & SIZE
Samples:
UNIT
LOCATION
Womens and
mens dorm
THERMOSTAT
LOCATION
FILTERS
( NUMBER ) & SIZE
Large mens
dorm
(1) 15 x 27
x 2
Attic above
mens dorm
ROOMS SERVED
BY UNIT
Kitchen,
meeting room,
dining room,
womens
bathroom
Dining room
(1) 24 x 19
x 2
Janitors
closet in
kitchen
Roof above
directors
office
Offices,
womens dorm,
small mens
dorm, mens
bathroom
Womens
room
(1) 24 x 19
x 2
APPENDICES
153
Instructor ___________________________________
Employee
Initials
154
1. I know where the tuberculosis (TB) infection control plan (ICP) is kept and
how to obtain a copy.
5. I am aware that health-care workers (HCWs) are at risk for TB infection and
TB disease.
6. I know that diseases and drugs that affect the immune system increase the
risk of TB infection progressing to TB disease.
9. I know what to do if I see a coughing patient who has other signs and
symptoms of TB.
10. I know that treatment for TB infection can reduce the risk of progressing to
TB disease.
11. I know when employees must wear respirators for protection against TB
transmission.
13. I know where to find safety and protective equipment (respirators, gloves),
how to use these devices, and how to dispose of them after use.
15. I have had an opportunity to have my questions answered about the above
topics.
______________________________________________
Employee Name (Please PRINT)
__________________________________________
Employee Department
______________________________________________
Signature
__________________________________________
Date
Date ______________________
SYMPTOMS/COMPLAINTS:
__________________________________________
Add up points. Respiratory Isolation scale scores of 5 or more points indicate a need for immediate
mask and respiratory isolation. For patients meeting criteria, please order a posterior-anterior (PA) and
lateral chest x-ray and have an emergency medicine senior resident or emergency medicine attending
physician record their reading of the chest x-ray and their decision regarding the need for continued
isolation below. This form should be attached to the nursing notes for the patient and, when the chart
is broken down, returned to the envelope by the clerks desk. All patients with scores of 5 or more
must be entered in the RIPT logbook.
Name ______________________________________________________________________________________
LAST
FIRST
MI
Normal
APPENDICES
155
CFM x 60 minutes
______________________
cubic feet
A room may have two airflow values, one for supply and another for exhaust. (The airflow
difference between these two values is called the offset.) To calculate the air change rate,
use the greater of the two airflow values. For AIIRs, the exhaust should be greater than
the supply.
480 CFM x 60
__________________
=
200 ft 2 x 9ft
16 ACH
= 120 CFM
As you can see, this room exceeds the CDC minimum requirement. The offset of 120
CFM is made up by air from outside the room.
156
L. Sample Signs
COVER YOUR COUGH: ENGLISH ......................................................... 158
COVER YOUR COUGH: ENGLISH ......................................................... 159
COVER YOUR COUGH: CHINESE ......................................................... 160
COVER YOUR COUGH: TAGALOG ....................................................... 161
COVER YOUR COUGH: RUSSIAN ......................................................... 162
COVER YOUR COUGH: VIETNAMESE ................................................ 163
COVER YOUR COUGH: SPANISH ......................................................... 164
COVER YOUR COUGH: ENGLISH ......................................................... 165
RESPIRATORY PROTECTION REQUIRED ......................................... 166
ROOM CLEARANCE .................................................................................... 167
APPENDICES
157
Stop the spread of germs that make you and others sick!
Cover
your
Cough
Cover your mouth
and nose with a
tissue when you
cough or sneeze
or
cough or sneeze into
your upper sleeve,
not your hands.
Clean
your
Hands
Wash hands
with soap and
warm water
for 20 seconds or
clean with
alcohol-based
hand cleaner.
158
Minnesota
Antibiotic
Resistance
Collaborative
P L E A S E
159
160
APPENDICES
161
Kapag
umubo,
paki-takpan
ang inyong
bibig
162
APPENDICES
163
cbrase
la boca
cuando
tosa.
por favor
164
Please cover
your cough
APPENDICES
165
WEAR RESPIRATOR TO
PROTECT YOUR LUNGS
166
N-95 RESPIRATOR
MUST BE WORN
WHEN ENTERING
THIS ROOM UNTIL
APPENDICES
167
Glossary
The following terms are defined or used in this manual. Terms are listed in alphabetical
order, followed by their definition.
ACH: Air changes per hour. This is a measurement commonly used to express the ventilation rate of a space. ACH is the number of times an amount of air equal to the
volume of the space is exhausted or supplied every hour.
BAMT: Blood assay test for Mycobacterium tuberculosis. This is a general term which
refers to recently developed in vitro (iv) diagnostic tests that assess for the presence
of infection with M. tuberculosis, the term includes but is not limited to IGRAs.
QuantiFERON-TB Gold is the IGRA that was approved by the FDA in 2005 and is
approved by the CDC as a diagnostic test for TB infection.
Boosted Reaction: A positive reaction to a tuberculin skin test due to a boosted immune
response from a skin test given up to a year earlier. Occurs in people who were
infected a long time ago and whose ability to react to tuberculin has lessened.
CFM: Cubic feet per minute. This is a measurement commonly used to express an airflow
quantity. Airflow hoods usually provide readouts in CFM.
Diffuser: Mechanical device, installed on a ceiling, that supplies air to a room.
Droplet nuclei: Microscopic particles (1-5 microns in size) that can become airborne
when a person coughs, sneezes, shouts, sings, breathes, or talks. Droplet nuclei
produced by a person who has TB disease of the lungs or larynx in an infectious
state can remain airborne for a long time and can spread TB to others.
Exhaust air: Air that is removed from a building by a fan system, as opposed to air that
is removed from a space and then recirculated or returned.
Fit Check: Should be conducted each time a respirator is put on to determine if it is
properly sealed to the face.
Fit Test: Evaluation of how a respirator fits conducted by trained personnel. Includes the use
of scented solution and the determination of whether the employee can detect the
odor. Should be conducted prior to the use of a respirator and annually thereafter.
Grille: Mechanical device that usually removes exhaust or return air from a room. Grilles
are usually on the ceiling but can be on the wall or floor. If a grille is on a ceiling or
floor or low on a wall, it is usually for exhaust or return air. However, if a grille is high
on a wall, it can be exhaust, return, or supply.
HEPA filter: High-Efficiency Particulate Air filter. This is a filter that is capable of removing
99.97% of particles 0.3 micron in diameter or greater. HEPA filters remove all particles in the size range of TB droplet nuclei.
HEPA filter unit: Self-contained device consisting mainly of a HEPA filter, a prefilter, and
a fan. These units can be used to provide clean air to supplement a building ventilation system.
HIV: Human Immunodeficiency Virus. This is the virus that causes AIDS.
IGRA: Interferon gamma release assay. This is a type of blood test that detects cell-mediated immune response to this cytokine. In the U.S., QuantiFERON-TB Gold is a
currently available IGRA.
168
Index Patient: The first case who comes to attention as an indicator of a potential public
health problem.
In-duct UVGI: The installation of ultraviolet germicidal irradiation (UVGI) lamps in a return
or exhaust air duct to kill any M. tuberculosis that may be in the air stream.
MDR TB: Multidrug-resistant TB. TB that is resistant to Isoniazid and Rifampin. More difficult to treat than drug-susceptible TB.
Mycobacterium tuberculosis (M. tuberculosis): The germ that causes TB.
Nosocomial: Infections which are a result of treatment in a hospital or hospital-like setting, but secondary to the patients original condition.
OSHA 300 log: Used by employers to record all work-related injuries and illnesses.
PPD: Purified Protein Derivative. It is the substance used in the Mantoux TB skin test,
which is the accepted standard method of TB skin testing. Commonly, TB skin
tests are referred to as TSTs.
Recirculation: Ventilation system in which supply air includes air that has been previously removed from an interior space.
Return air: Air that is removed from a space by a mechanical system, but not all of it is
discharged directly outdoors. This air is usually returned to the mechanical system,
where a portion of it is exhausted. The remainder is diluted with some outdoor air,
filtered, conditioned (or heated), and then distributed.
Short-circuiting: Occurs when clean air is removed before it has mixed well with room
air, such as when the exhaust is located right next to the supply of incoming air.
Stagnation: Occurs when part of the room does not benefit from the fresh supply air or
in a room that does not have any ventilation.
Supply air: Air that is introduced into a space by a mechanical system.
TB control measures: Steps taken to reduce the risk of TB transmission. TB control
measures are divided into a hierarchy: (1) administrative (work practice) controls, (2)
environmental controls, and (3) respiratory protection controls.
TST: Tuberculin Skin Test. Refers to administration of the Mantoux TB skin test and replaces the term PPD.
Upper-air UVGI: Refers to the use of UV lamps directly in the upper part of a room.
UVGI: Ultraviolet Germicidal Irradiation. The use of ultraviolet radiation to kill or inactivate
microorganisms.
UVGI lamps: Lamps that kill or inactivate microorganisms by emitting ultraviolet germicidal irradiation, predominantly at a wavelength of 254 nanometers. UVGI lamps
are used in ceiling or wall fixtures for upper-air UVGI and inside air ducts or air
cleaners for in-duct UVGI.
Ventilation: Movement of air in a building and replacement of air with air from outside.
Ventilation rate: Quantity of air that is removed from or supplied to a room. It is usually
expressed in air changes per hour (ACH).
XDR TB: Extensively Drug-resistant TB. MDR TB that is also resistant to fluoroquinolones and
at least one of three injectable drugs (i.e., amikacin, kanamycin, or capreomycin).
GLOSSARY
169
Resources
This section contains a list of resources that provide more information about the topics
covered in this manual.
Web Sites
American Society for Healthcare Engineering of the American Hospital Association:
http://www.ashe.org
California Tuberculosis Controllers Association: http://www.ctca.org
Centers for Disease Control and Prevention (CDC): http://www.cdc.gov/tb
CDC Slide SetGuidelines for Preventing the Transmission of M. tuberculosis in
Health-Care Settings, 2005:
http://www.cdc.gov/tb/pubs/slidesets/InfectionGuidelines/default.htm
CDC Revised Version of Appendix B: Tuberculosis (TB) risk assessment worksheet:
http://www.cdc.gov/tb/pubs/mmwr/Maj_guide/AppendixB_092706.pdf
Francis J. Curry National Tuberculosis Center: http://www.nationaltbcenter.edu
Heartland National Tuberculosis Center: http://www.heartlandntbc.org
National Institute for Occupational Safety and Health (NIOSH):
http://www.cdc.gov/niosh/
National Tuberculosis Controllers Association: http://www.ntca-tb.org
New Jersey Medical School Global Tuberculosis Institute:
http://www.umdnj.edu/globaltb/home.htm
Occupational Health and Safety Administration: http://www.osha.gov
Southeastern National Tuberculosis Center: http://sntc.medicine.ufl.edu
World Health OrganizationWHO Tuberculosis Site: http://www.who.int/tb/en
170
References
2001 Triennial Edition of the California Code of Regulations, Title 24: California Mechanical Code. Apr
2004;Title 24, Part 4.
American Association for Respiratory Care. Clinical Practice Guideline. Respiratory Care. 1996;41(7):647653.
The American Institute of Architects and the Facilities Guidelines Institute. Guidelines for Design and
Construction of Hospital and Healthcare Facilities, 2001. Washington, DC: American Institute of Architects Press, 2001.
American National Standards Institute and American Society of Heating, Refrigerating, and Air-conditioning Engineers, Inc. Standard 62-2004, Ventilation for Acceptable Indoor Air Quality. 2004.
American Society of Heating, Refrigerating, and Air Conditioning Engineers, Inc. Handbook 2004: HVAC
Systems and Equipment. Chapter 24: Air Cleaners for Particulate Contaminants. 2004:25.
American Society of Heating, Refrigerating, and Air Conditioning Engineers, Inc. Handbook 2003: HVAC
Applications. Chapter 7: Healthcare Facilities. 2003:8.
Asimos AW, Kaufman JS, Lee CH, et al. Tuberculosis exposure risk in emergency medicine residents.
Acad Emerg Med. Oct 1999;6(10):1044-1049.
Association for Professionals in Infection Control and Epidemiology, Inc. (APIC). St. Louis, Missouri:
Mosby Year Book, Inc;1996.
Bock NN, McGowan JE Jr., Ahn J, et al. Clinical predictors of tuberculosis as a guide for a respiratory
isolation policy. Am J Respir Crit Care Med. Nov 1996;154(5):1468-1472.
Cal/OSHA. California Division of Occupational Safety and Health Policy and Procedures Manual: Bloodborne Pathogens Standards. California Code of Regulations, Title 8, Section 5193. Dec 1991.
Cal/OSHA. California Division of Occupational Safety and Health Policy and Procedures Manual: Interim
Tuberculosis Control Enforcement Guidelines. Issued Dec 1992, revised April 1997:P&P C-47.
Campos Communications. Community Clinic Fact Book, 1992 Edition. San Francisco, CA, Mar 1994.
Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR2005; 54 (No.RR-17),
URL: http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf
Errata URL : http://www.cdc.gov/tb/pubs/mmwr/Errata09-25-06.pdf
Cohen R, Muzaffar S, Capellan J, et al. The validity of classic symptoms and chest radiographic configuration in predicting pulmonary tuberculosis. Chest. 1996;109:420-423.
Francis J. Curry National Tuberculosis Center. Tuberculosis Infection Control Plan Template for Jails.
2002. http://www.nationaltbcenter.edu/products/product_details.cfm?productID=WPT-09
Griffith DE, Hardeman JL, Zhang Y, et al. Tuberculosis outbreak among healthcare workers in a community hospital. Am J Respir Crit Care Med. Aug 1995;152(2):808-811.
Haley CE, McDonald RC, Rossi L, et al. Tuberculosis epidemic among hospital personnel. Infect Control
Hosp Epidemiol. May 1989;10(5):204-210.
El-Solh A, Mylotte J, Sherif S, et al. Validity of a decision tree for predicting active pulmonary tuberculosis. Am J Respir Crit Care Med. 1997; 155(5):1711-1716.
Mathur P, Sacks L, Auten G, et al. Delayed diagnosis of pulmonary tuberculosis in city hospitals. Arch
Intern Med. 1994;154(3):306-310.
Moran GJ, Fuchs MA, Jarvis WR, et al. Tuberculosis infection control practices in United States emergency departments. Ann Emerg Med. Sept 1995; 26(3):283-289.
Moran GJ, McCabe F, Morgan MT, et al. Delayed recognition and infection control for tuberculosis patients in the emergency department. Ann Emerg Med. Sept 1995; 26(3):290-295.
OSHA. Health Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis.
CPL 2.106, Feb 1996.
Sokolove PE, Lee BS, Krawczyk JA, et al. Implementation of an emergency department triage procedure for the detection and isolation of patients with active pulmonary tuberculosis. Ann Emerg Med. Apr
2000; 35(4):327-336.
Sokolove PE, Mackey D, Wiles J, et al. Exposure of emergency department personnel to tuberculosis:
PPD testing during an epidemic in the community. Ann Emerg Med. Sept 1994; 24(3):418-421.
RESOURCES
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