Tuberculosis
Program and Facility Planning Guidance for
Tuberculosis Programs
Department of Veterans Affairs Veterans Health
Administration
August 18, 1995
OVERVIEW
Over the last several years, the issue of
tuberculosis (TB) has been prominent in both the
medical literature and the national press. This has
been emphasized in the last year coincident with an
increased public awareness of emerging and
re-emerging pathogens on the national and global
level. Finally, and after much work, the actual
number of new cases of active tuberculosis disease
is decreasing nationally with the most notable
decrease in the New York area. However, the TB
epidemic continues particularly along the coasts of
the United States. No section of the country has
been completely spared, however, as cases of
tuberculosis have been identified in all VHA
Regions.
To effectively plan and implement a tuberculosis
program, facilities must obtain information on
current and projected TB workload, evaluate and
define missions related to TB, and develop
integrated plans for patient care, employee health,
and enhance facility controls. This TB program
guidance will provide a consistent framework for
such VA TB program planning.
This planning document is organized in a format that
prioritizes overall guidance for a TB control plan
based on clinical and epidemiologic priorities. It
specifies infection control practices and regulatory
requirements, while incorporating work practice
controls, engineering controls, and personal
protective equipment into the overall guidance. This
is not designed to be a regulatory compliance
document, but rather to integrate the various
components of tuberculosis control strategies into
the medical facility culture.
CHARACTERISTICS OF A TB PROGRAM
I. Assign Responsibility.
While all programs within VA Medical Centers are the
ultimate responsibility of the Medical Center
Director, it is appropriate to assign the
responsibility for the tuberculosis program to a
specific qualified person or group of people within
the facility. Each facility is to have a coherent,
practical and implementable program. Then, the
program must be implemented, monitored, and
evaluated. The program will also ensure that a
mechanism will be established to identify
responsible parties for components of the program,
establish the program structure, and define the
hierarchy of responsibility from TB program
officials to the facility Director. Included in this
group should be representation from Infection
Control, Medical Staff (Infectious Diseases and
Pulmonary Medicine if available), Nursing,
Occupational Health, Safety/Industrial Hygiene, and
Engineering, thus assuring the availability of
expertise in all areas of TB control as well as
ownership of the program through a multidisciplinary
input process.
II. Risk Assessment, Tuberculosis Plan, and Periodic
Reassessment.
An initial facility risk assessment must be
undertaken. This includes gathering data regarding
the following: tuberculosis in the community,
tuberculosis within the facility, skin test
conversions within the facility, and other evidence,
if any, of person-to-person transmission of TB
within the local health care setting. A specific
level of risk can be assigned for purposes of
planning and monitoring or evaluating intervention
strategies to be incorporated into the written
facility tuberculosis plan. The plan should include
all components of the tuberculosis control
strategies for the facility in a format that is
concise yet comprehensive. It should be located in a
single document or group of documents that are
easily accessible by hospital employees.
Fragmentation of the tuberculosis control plan with
multiple non-centralized documents should be
avoided.
This risk assessment will need to be redefined at
intervals appropriate to the risk of transmission of
tuberculosis as defined by disease/infection
prevalence in the community and the facility.
Specifically, changes in case rates for the facility
or the community, clusters of skin test conversions,
or other evidence suspicious for facility TB
transmission will necessitate immediate reevaluation
of the facility risk. The repeat risk assessment
should also include evaluation of the effectiveness
of the extant, local methodologies for prevention of
TB transmission.
III. Identification, Evaluation, and Treatment of
Patients with Tuberculosis.
The most important factors in preventing
transmission of Mycobacterium tuberculosis are the
early identification of patients who may have
infectious TB, prompt implementation of TB
precautions for such patients, and prompt initiation
of effective treatment for those who are likely to
have TB.
For patients presenting to the health care facility
for care, screening for signs and symptoms of TB
should be done in the initial triage locale. The
detail and extent of this screening process should
be determined based on the facility risk category.
An example of a suitable screening methodology would
be questioning the patient regarding cough lasting
greater than three weeks, weight loss, night sweats
and malaise. A facility should individualize its
screening methodology in the most appropriate manner
for its own risk stratum based on perceived risk to
other patients and employees. As patients present
for care in high or moderate risk areas, the issue
of initial triage is extremely critical.
Consideration should be given to speed of triage,
traffic patterns as patients move about the
admissions area, clinic assignments, and risk to
employees performing administrative functions. Any
triage system must be designed to prevent patients
with suspected or known infectious tuberculosis (S/KI
TB) from moving about the facility in an unprotected
manner.
Tuberculin skin testing for high risk patients
(methodology to meet most current CDC Guidelines) is
designed to identify patients who are infected with
Mycobacterium tuberculosis before they develop
symptoms (cough, fever, sweats, weight loss) of
active disease and become infectious.
For long term care facilities, screening prior to
admission should include PPD testing (following most
recent CDC and VA guidance) and/or chest x-ray as
appropriate (routine screening chest x-rays should
only be implemented based on local risk assessment),
and include a focused physical examination. In high
or moderate risk areas this should be done prior to
admission to the long term care facility. In minimal
or low risk areas, this screening may be completed
within 72 hours of admission if adequate triage is
accomplished.
A. Patient Masks. When any patients are identified as
having S/KI TB, they should wear a surgical mask and
be placed in rooms meeting identified engineering
controls for S/KI TB patients as noted later in this
document.
B. Tuberculin Skin Test (TST) for High Risk
Patients. Screening for high risk individuals must
be a hospital-wide policy. This includes, but is not
limited to, timely ongoing screening of HIV-positive
patients, dialysis patients, the homeless, substance
abuse patients and patients in other high risk
special programs such as Hospital Based Home Care (HBHC)
and others as identified by the facility. All these
screening programs should use the most current
CDC-defined methodology for TST. If a patient has
signs or symptoms suggestive of tuberculosis
disease, a full evaluation must be conducted.
C. Laboratory Assessment. It is critical to expedite
the evaluation and treatment of patients with S/KI
TB. This includes access to current laboratory
technology for acid fast bacteria (AFB) smears,
cultures, and susceptibility testing.
1. AFB smears, the following is necessary.
a. Available five days per week and reported within
24 hours of specimen receipt.
b. Consideration should be given to seven days per
week for areas with a high incidence of TB.
c. One sputum per patient per day should be
sufficient.
2. Cultures for Mycobacterium tuberculosis, the
following is needed:
a. Available five days per week.
b. Rapid identification methodology.
Smears and culture results should be reported
immediately to designated person(s). This must
include the care provider and should be reported to
the infection control function.
3. Susceptibility testing for Mycobacterium
tuberculosis, the following is appropriate:
a. First isolate.
b. Additional isolates if:
(1) Failure to convert cultures within three months
of beginning therapy.
(2) Clinical evidence of failure to respond to
therapy.
(3) Other specific circumstances may dictate
additional susceptibility testing.
It is not required that all of these activities be
done on station. It is the facility's responsibility
to assure that rapid, current diagnostic laboratory
testing for Mycobacterium tuberculosis is readily
available to the clinicians. The guidance above
should be used as a basis for individual station
decision making regarding specific time
frames and location for each of the studies noted
above based on patient care needs. These decisions
should be documented in writing in the facility
tuberculosis control plan to ensure facility-wide
consensus by the process stakeholders on these
critical clinical testing issues.
D. Patient Management. If the patient has been
identified as having active tuberculosis disease,
initiation of therapy should be prompt using the
most current CDC guidelines. After a patient has
been identified as having S/KI TB, the patient
should be placed in a room meeting the engineering
control guidelines noted below in this document.
Enablers may be necessary to assure that the patient
remains in this controlled environment, since
patients cannot be allowed to wander about the
hospital in an unprotected manner. Enablers, such as
television sets, telephones, bathing facilities, and
recreational activities may be important to maintain
these precautionary measures. In order to maintain
proper directional air flow in the rooms, the doors
must remain closed. If the patient must be out of
the room for clinical purposes, the patient should
wear a surgical mask and administrative arrangements
made to expedite the return of the patient to the
negative pressure room. Discharge and follow-up
planning should be initiated as soon as possible in
order to assure seamless transition between the
hospital setting and outpatient care. This will
likely involve the VHA outpatient clinic system and
the governmental health department from which the
patient may receive follow-up. As part of this
process, immediate reporting of tuberculosis
patients to the health department consistent with VA
rules and regulations is necessary.
E. Visitors. Visitors to patients who have S/KI TB
should be given respirators to wear while in the
isolation room, and they should be given general
instructions on how to use their respirators (CDC
Guidelines, MMWR, October 28, 1994, Vol. 43, No.
RR-13, p. 28).
F. Discontinuation of AFB Precautions. The following
criteria must be used for discontinuing precautions
for patients in the Medical Center with S/KI TB:
1. The patient is found not to have tuberculosis;
or,
2. The patient is on appropriate therapy (It should
be noted that appropriate therapy needs to be
defined at the local level based on community
incidence of multi-drug resistant tuberculosis,
tuberculosis susceptibility testing of facility
isolates, and the specific known susceptibilities of
the patient's organism); and a positive clinical
response to therapy; and three consecutive negative
AFB smears collected on separate days.
IV. Engineering Controls.
A. General Guidelines. The CDC guidelines are the
minimum acceptable level, and should be increased
where required to satisfy other mandated criteria or
engineering requirements. Where current VA criteria
exceed the CDC guidance, the use of VA criteria is
recommended. However, if existing configuration or
cost do not allow compliance to more stringent VA
criteria, then the CDC guidance is the minimum
acceptable.
1. Six total air changes per hour are likely to
reduce the concentration of bacteria in the room.
For the purposes of reducing the concentration of
droplet nuclei, TB bedrooms and treatment rooms in
existing health care facilities should have an
airflow of greater than or equal to six air changes
per hour. Where feasible, this airflow rate should
be increased to greater than or equal to 12 air
changes per hour. New construction or renovation of
existing health care facilities should be designed
so that TB bedrooms achieve an air flow of greater
than or equal to 12 air changes per hour.
2. Air from TB bedrooms and treatment rooms for S/KI
TB patients should be exhausted to the outside. The
air should be exhausted in a manner and location so
that it is not pulled into intake louvers or windows
without significant dilution. At a minimum, the
exhaust shall be 25 feet from any air intake.
However, other factors, such as wind direction, wind
velocity, stack effect, system sizes, and height of
buildings must be evaluated and location of intake
and exhaust outlets adjusted as required. If, in
some instances, recirculation of air into the
general ventilation system from such rooms is
unavoidable, high-efficiency particulate air (HEPA)
filters should be installed in the exhaust leading
from the room to the general ventilation system. Air
from TB bedrooms and treatment rooms in new or
renovated facilities should not be recirculated into
the general ventilation system.
3. Exhaust air quantity must be 10% greater than the
supply air. It is further recommended that the
exhaust system should serve only the TB rooms and
not be part of the general exhaust system. If this
is not practical, then use of the general exhaust
system is acceptable provided appropriate
precautions are taken to assure that these systems
are adequately designed, installed, balanced, and
maintained. These requirements result in providing
additional outside air through the air handling
system which then impacts heating and cooling
capacities for both air side and primary equipment.
In all applications, thermal load calculations or
occupancy of the space may require a higher air
change rate.
4. Rooms should be under negative pressure with
respect to adjacent areas when occupied by a patient
with S/KI TB.
5. Anterooms are not necessary for S/KI TB patient
bedrooms.
6. The direction of the airflow for TB rooms shall
be monitored daily when an S/KI TB patient is
occupying the room. When not in use by SKI TB
patients, the directional airflow will be checked
monthly. The method of testing for directional
airflow in the S/KI TB rooms is at the discretion of
the facility, but must be of an acceptable standard.
This would include such methodologies as smoke tube
testing or an airflow gauge.
7. The number of air changes per hour in these rooms
should be checked yearly at a minimum. This may need
to be more frequent based on facility risk
assessment and recommendations of the Environmental
and Infection Control Committee. In addition, the
number of air changes per hour should be checked
after any maintenance to the airflow system.
8. In rooms where patient turnover is expected, use
CDC guidelines (MMWR, October 28, 1994, Vol.43, No.
RR-13) for air changes per hour to determine time
required for removal of airborne contaminants before
the next patient occupies the room vacated by a
patient with S/KI TB.
9. When in use by S/KI TB patients, doors in
negative pressure rooms must remain closed except
for entering or exiting the room. Proper airflow and
pressure differentials between areas are difficult
to control because of open doors, movement of
patients and staff, temperature, and the effect of
vertical openings. Air pressure differentials can
only be maintained in completely closed rooms. An
open door reduces or eliminates the desired effect
of negative pressure rooms. Whether windows are
needed in doors to S/KI TB patient bedrooms is a
local decision.
10. Medical Centers and outpatient clinics should
consider providing emergency power to exhaust
systems serving inpatient TB rooms and to some of
the ambulatory care rooms designated for management
of S/KI TB patients. The potential risks to patients
and staff, available emergency power system
capacity, and relative priority of other functions
covered by emergency power should be carefully
evaluated when considering costly emergency power
system expansion.
B. Medical Surgical and Neurological (MS&N) Nursing
Acute Care Units. To determine the number of TB
rooms, use the following formulae to determine
number of patient bedrooms for cases of S/KI TB:
1. Current Need: (Identify the maximum number of
patients requiring respiratory precautions for S/KI
TB at any one time within the past 12 months) x
(change in incidence of TB in community over the
past year).
2. Projected Need: Using the estimated change in the
population in the facility, Distributed Population
Planning Base (DPPB) for any future year, calculate
future needs based on current estimate as determined
above multiplied by this population change ratio.
EXAMPLE 1 - All specific numbers are for
illustrative purposes only.
15.0 - Maximum number of patients requiring AFB
precautions at one time (e.g., 15).
x 1.05 - Change in community incidence (this
represents a 5% increase in community
incidence).
15.75 - Need for TB beds based on changes in TB
incidence in community.
x 10.85 - Correct for future anticipated changes in
veteran population (this represents a
15% decrease in expected veteran population).
13.38 - Projected no. of AFB precaution beds needed
corrected for calculated changes
in veteran population and community incidence.
C. Nursing Unit Organization.
1. High Incidence Area or Referral Center. Medical
Centers with sufficient workload or those assigned
the mission of referral center may choose to
concentrate all TB bedrooms on an existing MS&N
nursing unit designated for TB inpatient care. Or,
they may designate bedrooms to be used for TB care
throughout their facility. In establishing groups of
TB bedrooms on an MS&N nursing unit, a Medical
Center should renovate a contiguous sub-set of the
bedrooms on the unit to meet HVAC and bathroom
requirements; not necessarily the entire ward. The
number of bedrooms included in the sub-set would be
based on anticipated workload determined for that
facility. The following facility requirements must
be met:
a. All one-bed rooms designated for TB must meet CDC
guidelines for S/KI TB.
b. Each one-bed room must have a private bathroom
and should have a shower where possible. Safe shower
facilities are to be available, however, if the
bedroom for S/KI TB patients does not offer these
facilities.
c. Anterooms are not required for the negative
pressure rooms designated for S/KI TB.
d. For S/KI TB patients, examination/treatment rooms
and any other special treatment rooms where sputum
induction, aerosol treatments and/or cough or
aerosol-generating procedures are performed should
meet CDC requirements for infectious TB with the
additional requirement of 12 or greater air changes
per hour. Ultraviolet germicidal irradiation (UVGI)
may be used as an enhancement to the recommended
engineering controls.
2. Low Incidence Areas. For those facilities
anticipating a low S/KI TB workload, little or no
change to existing nursing units may be required.
Existing VA space planning criteria for MS&N nursing
units (see Planning Criteria for VA Facilities,
H-08-9 Chapter 100.04) requires two isolation suites
per nursing unit. These rooms will be capable of
providing negative or positive pressure and have an
anteroom and attached private bathroom. Minimum air
changes are 8 per hour with 100% outside exhaust
through a HEPA filter. If these rooms are not
currently provided or if additional rooms are needed
for S/KI TB patients, then these additional rooms
must meet CDC guidance for S/KI TB and have a
private bathroom. An existing 2-bed room which has
appropriate ventilation, airflow and bathroom
facilities meeting, at a minimum, current CDC
guidance for S/KI TB, may be scheduled for use by a
single TB patient as a low cost alternative to
constructing or renovating an additional 1-bed room.
Sputum induction, aerosol treatments and/or cough or
aerosol-generating procedures should be performed
either in TB bedrooms or other rooms that meet CDC
guidance for S/KI TB.
D. MH&BS Nursing Units (Mental Health and Behavioral
Sciences). In general, no rooms should be required
for S/KI TB patients as they should be transferred
to an appropriate MS&N nursing unit for diagnosis
and treatment as needed until they are no longer
infectious.
E. Intensive Care Units (ICUs).
1. Existing ICUs should meet current VHA space
planning criteria (see Planning Criteria for VA
Facilities, H-08-9 Chapter 102.05) for the number of
isolation suites and at a minimum meet CDC criteria
for ventilation for S/KI TB.
2. All ICUs which utilize return air systems shall
have the return air HEPA filtered. Installation of
ultraviolet (UV) lamps may be considered in ICUs in
which there is a high risk for TB transmission. All
ICU rooms housing S/KI TB patients must, at a
minimum, meet the current CDC guidance for S/KI TB.
F. Post Anesthesia Recovery Units (PARUs). Medical
Centers should have at least one recovery room
within the PARU meeting at a minimum CDC ventilation
criteria for S/KI TB. As an option, especially in
low-incidence areas, Medical Centers may recover
surgical patients with S/KI TB in an ICU isolation
suite or room that meets CDC guidance for S/KI TB.
G. Surgical Suite (See MMWR, October 28, 1994, Vol.
43, No. RR-13, p. 50-51 for details).
1. Existing VHA facility criteria (see HVAC Design
Manual) and standards for surgery are appropriate
for surgical care of S/KI TB patients. Current VHA
criteria exceed the CDC guidelines. Typically, no
changes will be required unless return air is used
in the OR. VA criteria have not sanctioned the use
of return air in ORs for many years.
2. Traffic patterns should be designed to reduce
unnecessary movement throughout the surgical suite,
hallways and other associated areas when surgery on
a patient with S/KI TB is performed.
3. Appropriate scheduling and other controls are
necessary for surgery on S/KI TB patients since
positive pressure airflow is used in operating
rooms.
H. Long Term Care. In general, no rooms are required
for S/KI TB patients as they should be transferred
to an appropriate MS&N nursing unit for diagnosis
and treatment as needed until they are no longer
infectious.
I. Ambulatory Care.
1. Determining the Number of TB Rooms. Determining
the number of TB rooms in the Ambulatory Care
setting should be in alignment with the facility
risk assessment. Specifically, facilities in the
lowest risk assessment category may not need rooms
with specific tuberculosis engineering controls at
all, but rather a written plan for dealing with the
possible event of a S/KI TB patient reaching the
facility. For facilities above the minimal risk
category, the following is a suggested method for
determining the number of exam/treatment or special
treatment rooms designated for S/KI TB patients in
unscheduled ambulatory care areas (hospital-based,
satellite, and independent OPCs):
a. Obtain the estimated eligible veteran population
for the facility from the DPPB for any specified
future year and the current eligible veteran
population for the facility.
b. Each facility should generate the estimated
number of potential unscheduled S/KI TB patient
visits per year.
c. Calculate the projected number of potential
unscheduled S/KI TB Patient visits per year using
the following formula:
A = Estimated eligible veteran population for the
facility from the DPPB for any specified future
year.
B = Current eligible veteran population for the
facility from the DPPB.
C = Current number of potential unscheduled S/KI TB
patient visits.
D = Projected potential unscheduled S/KI TB patient
visits per year.
A x C = D
B
EXAMPLE 2 - All specific numbers are for
illustrative purposes only.
(A) 400,000 - Estimated veteran population for a
future year (e.g., 400,000 for the year 2000).
(B) 450,000 - Current veteran population (e.g.,
450,000).
0.88 - Result of A ¸ B
(C) 480 = Current number of unscheduled S/KI TB
patient visits per year, (e.g., 480 visits).
(D) 422.4 - Result of A ¸ B x C which is the
estimated number of unscheduled visits of S/KI
TB patients for future year (e.g., year 2000).
d. Provide the number of designated TB
exam/treatment or special procedure rooms as
determined below using the potential S/KI TB patient
visit estimate generated in I.1.c above.
CALCULATED POTENTIAL UNSCHEDULED S/KI TB PATIENT
VISITS (PER YEAR) DESIGNATED TB EXAM/TREATMENT ROOMS
500 or Less Use emergency area isolation room
501-1000 One additional TB room
Each additional 1000 One additional room
Designated TB rooms determined above may be located
in the walk-in clinic module and/or in other modules
to meet local operating procedures and needs.
2. Facility/air:
a. Meet at a minimum current CDC guidelines for
unscheduled areas and high risk clinics.
b. Meet at a minimum current CDC guidelines for
ventilation and airflow for S/KI TB:
(1) Emergency Area Isolation room(s) (anteroom not
required).
(2) ENT room(s).
(3) Aerosolized pentamidine room(s).
(4) Designated exam/treatment/procedure room(s).
3. All unscheduled ambulatory care areas and
associated waiting areas should have ventilation
designed and maintained to reduce the risk of
tuberculosis transmission. Germicidal UV lamps
and/or HEPA filters may provide additional benefit
when used to supplement ventilation, particularly in
facilities located in areas of high incidence for
TB.
4. Scheduled Areas (Clinics). All scheduled areas
serving patients who are at high risk for TB
transmission should be designed to reduce the risk
of TB transmission. Air from clinics serving
patients at high risk for TB should not be
recirculated unless it is first passed through an
effective high efficiency filtration system (HEPA
filters are currently the effective high efficiency
filtration system available).
5. Designated Exam/Treatment Rooms for S/KI TB. VHA
ambulatory care programs in Medical Centers and in
satellite/independent outpatient clinics must have
some facilities that are adequate to deal with S/KI
TB patients. These TB rooms can be exam/treatment
rooms and/or special procedure rooms that are
designated for use with S/KI TB patients. These
rooms should meet CDC guidance for S/KI TB with the
additional requirement that a minimum of 12 air
changes per hour must be exhausted (See IV.A.2).
These rooms would normally be located in or near the
walk-in clinic module.
J. High Risk Areas.
1. Potential Aerosol Producing Procedure Areas:
a. The pulmonary function laboratory (including
spirometry and exercise rooms), bronchoscopy
area(s), pulmonary function treatment rooms, and
sputum induction areas and any other special
procedure room (e.g., ENT) in which cough inducing
procedures are done on patients who may have
infectious TB must meet CDC guidelines for S/KI TB
with the additional requirement that a minimum of 12
air changes per hour must be exhausted.
Additionally, airflow rates should be calculated on
expected patient turnover in these treatment areas
based on the most recent CDC guidance.
b. Any room (e.g., examination/treatment room,
procedure room) in the health care facility in which
aerosolized pentamidine (AP) procedures are
performed on patients who may have infectious TB
must meet CDC guidelines for infectious TB with the
additional requirement that a minimum of 12 air
changes per hour must be exhausted (See IV. A.2).
Additionally, airflow rates should be calculated on
expected patient turnover in these treatment areas
based on the most recent CDC guidance. If a booth or
other containment entity is used for any potential
aerosol producing procedure, booth airflow and
exhaust should meet CDC guidelines.
K. Radiology. At least one radiology room with chest
x-ray capabilities should meet CDC guidance for S/KI
TB. Both ambulatory care and in-patient programs can
share this negative pressure radiology room if
feasible. This specialized room with these
engineering controls may not be necessary in
facilities in the minimal risk category.
L. Anatomic Pathology. The morgue must meet at a
minimum CDC guidance for infectious TB and follow
current VA criteria with a minimum of 12 air changes
per hour with 100% exhaust to the outside through a
HEPA filter.
M. Dental. At referral centers and at facilities in
which emergency dental care is provided, at least
one dental operatory should meet CDC guidance for
S/KI TB. Other health care facilities may send S/KI
TB patients for dental care to referral centers
based on workload and travel distance.
N. HIV Related Issues. No specific heating,
ventilation and air conditioning (HVAC)
considerations are necessary for patients with HIV
infection.
0. Dialysis Program. A room which meets at a minimum
current CDC ventilation and airflow guidelines for
S/KI TB must be available for dialysis of S/KI TB
patients. The location of this area is at the
discretion of the facility. Based on local need,
this area may be in the dialysis unit or ICU, or
other area in the Medical Center based on patient
need and efficient use of resources.
V. Respiratory Protection.
A. General Criteria. Performance criteria for
respiratory protective devices as outlined in the
most recent CDC guidance are to be met. This
requires a respiratory protection program that
follows the regulatory requirements of the
Occupational Safety and Health Administration (OSHA)
as well as American National Standards Institute
(ANSI) Standards.
B. Respiratory Protective Devices. Respiratory
protection is required for persons entering rooms in
which patients with S/KI TB are being housed, for
persons present during cough-inducing,
aerosol-generating procedures performed on such
patients, and for persons in other settings where
administrative and engineering controls are not
likely to protect them from inhaling infectious
airborne droplet nuclei. These other settings
include transporting patients who may have S/KI TB
in emergency transport vehicles, and providing
urgent surgical or dental care to patients who have
S/KI TB before determination has been made that the
patient is noninfectious. These settings may also
include home based health care programs, where
patients with S/KI TB are being seen in the home
setting.
In the Mycobacteriology Laboratory, routine use of
respiratory protective devices should not be
necessary. However, if the laboratorian is working
with significantly amplified Mycobacterium
tuberculosis cultures in liquid media, or performing
specific procedures where aerosolization is
expected, the use of respiratory protective
equipment, gloves and gowns may be appropriate. The
most recent standards for laboratory practices
should be followed.
VI. Healthcare Worker Training.
All health care workers are to receive periodic TB
education appropriate for their work
responsibilities and duties and should include
epidemiology of TB in the facility, mode of
transmission, pathogenesis, diagnosis, and
occupational risk for tuberculosis. The training
should also describe work practices that reduce the
likelihood of transmitting Mycobacterium
tuberculosis in the health care setting. The
training must be given to all those who work at the
VA Medical Center who are at risk for the
transmission of tuberculosis. All training is to
follow the latest written regulatory requirements of
valid oversight bodies such as OSHA.
VII. Healthcare Worker Counseling And Screening.
All health care workers should be counseled
regarding tuberculosis disease and tuberculosis
infection. This should include information about the
increased risk to immunocompromised persons for
developing active tuberculosis disease.
VIII. Personnel Health.
A. TB Screening using most current CDC methodology.
1. Prior to employment, TST results are required for
covered employees who work in the VHA. For any TST
done outside the Personnel Health Unit on station,
appropriate written documentation must be provided
as determined by the Personnel Health Physician.
2. Interval TST screening as determined by risk
assessment as outlined in the most recent CDC
guidance should be conducted.
3. TST is recommended at the time of separation for
all employees.
4. Follow all pertinent VA Headquarters’ Directives
and Manual references related to TB Screening.
B. Record keeping.
1. Record keeping is critical for the long term
needs of the employee, station, and regulatory
compliance.
2. Record keeping to comply with VHA directives,
manuals, and valid regulatory agency requirements.
C. Return to work clearance for health care workers
with S/KI TB.
1. At a minimum, return to work clearance should
follow current CDC guidelines.
2. Employees must be monitored for lack of
infectiousness.
D. Healthcare Worker TST Conversions. The facility
must track and evaluate TST conversions in order to
document possible episodes of transmission of
tuberculosis in the healthcare setting, to define
the facility risk assessment category and to
identify facility TST conversion rates.
IX. Coordination with Health Department.
It is critical that VA facilities coordinate all
phases of tuberculosis control with appropriate
health department authorities. Prompt reporting to
public health authorities is a critical component of
TB control. It is most critical that the discharge
planning for individual patients be done in close
alignment with community health officials.
X. Child Day Care.
For facilities with child day care facilities, state
and local guidelines regarding tuberculosis
screening and/or tuberculosis control programs
should be followed.
XI. References.
1. VHA Directive 10-93-094, Supplement No. 1. TB
(Tuberculosis) Control Responsibilities of VA
(Department of Veterans Affairs) Facilities. July
25, 1994.
2. VHA Directive 10-94-104. Administration of
Aerosolized Pentamidine to Human Immunodeficiency
HIV Positive Patients. October 17, 1994.
3. MP-5, Part I, Chapter 792, Change 7, Health
Services. June 30, 1990.
4. M-1, Part III, Chapter 4. Services and Benefits
Available to Volunteers. October 24, 1984.
5. M-2, Part I, Chapter 23, Change 1, Informed
Consent. February 21, 1991.
6. M- 1, Part I, Chapter 9, Release of Medical
Information. November 30, 1990.
7. 5 United States Code, Section 552A, Privacy Act.
8. Title 38, United States Code, Committees on
Veterans Affairs - Patient Rights. January 31, 1992.
9. Title 38, United States Code, Committees on
Veterans Affairs - Records. January 31, 1992.
10. VA Regulations, Title 38 Code of Federal
Regulations, Part 1, General Trans. Sheet 177,
Safeguarding Personal Information in VA Records. May
9, 1986.
11. H-08-9 Planning Criteria for VA Facilities:
Chapter 1, 100, 102, 212, 240, 262, 276, and 316.
12. H-088C2-15100 HVAC Design Manual for Hospital
Projects. November 1992.
13. M-5, Part IV. Geriatrics & Extended Care,
Domicilliary Care. December 6, 1990.
14. CDC. Core Curriculum on Tuberculosis. Third
Edition, 1994.
15. CDC. Typhoid immunization recommendations of the
immunization practices advisory committee (ACIP) and
prevention and control of tuberculosis in facilities
providing long-term care to the elderly.
Recommendations of the Advisory Committee for
Elimination of Tuberculosis. MMWR, May 18, 1990,
Vol. 39, No. RR-10.
16. Prevention and control of tuberculosis in U.S.
communities with at-risk minority populations and
prevention and control of tuberculosis among
homeless persons. Recommendations of the Advisory
Council for the Elimination of Tuberculosis. MMWR,
April 17, 1992, Vol. 41, No. RR-5.
17. CDC. Screening for tuberculosis and tuberculosis
infection in high risk populations and the use of
prevention therapy for tuberculosis infection in the
United States. Recommendations of the Advisory
Committee for Elimination of Tuberculosis. MMWR, May
18, 1990, Vol. 39, No. RR-8.
18. CDC. Guidelines for Preventing the Transmission
of Mycobacterium tuberculosis in Health-care
facilities. MMWR, October 28, 1994, Vol. 43, No.
RR-13.
19. M-2, Part IV, Chapter 6, Infectious Diseases.
April 29, 1994.
20. American Thoracic Society. Treatment of
Tuberculosis and Tuberculosis Infection in Adults
and Children. Am J Resp Crit Care Med
1994;149:1359-1374.
21. CDC/National Institutes of Health. Agent:
Mycobacterium tuberculosis, M bovis. In: Biosafety
in Microbiological and Biomedical Laboratories.
Atlanta: US Department of Health and Human Services,
Public Health Service, 1993:95, EDHHCS publication
no. (CDC) 93-8395.
22. Shinnick, TM and Good, RC. Tuberculosis
Commentary. CID, 1995;21:291-9.
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