# Presentation: 678443

## Overview of Enforcement for Occupational Exposure to Tuberculosis (TB)

**Notes:**
This presentation provides a brief overview of OSHA’s enforcement policy for occupational exposure to tuberculosis. OSHA’s tuberculosis policy is found in CPL 02-00-106 – CPL 2.106 – Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis.

## Tuberculosis

- Infectious disease cause by the bacterium, *Mycobacterium tuberculosis.*
- Spread by airborne droplets, “droplet nuclei,” which may be generated when a person with TB disease coughs, sneezes, speaks or sings.

**Notes:**
TB infection occurs when a susceptible person inhales droplet nuclei containing the bacteria and becomes established in the body.
There are various symptoms that may indicate exposure to TB. These  include: lethargy, weakness, fatigue, fever, weight loss, persistent productive cough, coughing up blood, loss of appetite, and night sweats.
The Mantoux tuberculin skin test is used to detect TB infection. Positive result indicate TB infection. Other  tests are needed to confirm TB disease. 
TB is largely a preventable disease. Several drugs are used to treat TB. The most common drugs are isoniazid (INH) and rifampin.

## Occurrence

- Nearly one-third of the world’s population is infected with TB, which kills almost 3 million people per year.

**Notes:**
In the mid-1980s, a resurgence of outbreaks in the U.S. brought renewed attention to TB. Since 1985, the incidence of TB in the general population has increased 14% reversing a 30 year downward trend. In 1993, over 25,000 new cases of TB were reported in the U.S. During 1994 and 1995, however, there was a decrease in TB cases in the U.S. likely due to increased awareness and efforts in prevention and control of TB.

## Why Is TB Increasing?

- Multiple contributing factors:
- Homelessness
- Intravenous drug use
- Overcrowding in institutional settings
- HIV infection
- Drug-resistant strains of TB
- Reduced TB control and treatment resources
- Immigration from high TB prevalence areas

**Notes:**
These factors contribute to the growing increase in TB cases.

## Where Is TB Found in the Workplace? 

- Healthcare Facilities
- Correctional Institutions
- Homeless Shelters
- Long-term Care Facilities for the Elderly
- Drug Treatment Centers

**Notes:**
The Centers for Disease Control and Prevention (CDC) has identified these workplaces as having high incidences of TB. 
Health care facilities include hospitals where patients with confirmed or suspect TB are treated or to which they are transported. 
Coverage of non-health care settings (doctors’ offices, clinics, etc.) include only personnel present during performance of high hazard procedures on suspect or active TB patients. Dental health care personnel are covered only if they treat suspect or active patients in a hospital, correctional facility, or as part of their practice.

## OSHA’s TB Policy

- Employers must comply with the provisions of the following requirements whenever an employee may be occupationally exposed to TB:
- Section 5 (a)(1) - General Duty Clause and Executive Order 12196, Section 1-201(a) for federal facilities;
- 29 CFR 1910.134 - Respiratory Protection;

## OSHA TB Policy (Continued)

- 29 CFR 1910.145 - Accident Prevention Signs and Tags;
- 29 CFR 1910.1020 - Access to Employee Exposure and Medical Records; and
- 29 CFR 1904 - Recording and Reporting Occupational Injuries and Illnesses.

## General Duty Clause

- Section 5 (a)(1) of the OSH Act states:
- “Each employer shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees.”

**Notes:**
Section 5 (a)(1) citations must meet the requirements outlined in OSHA’s Field Inspection Reference Manual( FIRM), and shall be issued only when there is no standard that applies to the particular hazard.
The hazard, not the absence of a particular means of abatement, is the basis for a general duty clause citation.
Four required elements are necessary for issuing general duty clause violations include: These include: the employer failed to keep the workplace free of a hazard to which employees of that employer were exposed; the hazard was recognized; the hazard was causing or was likely to cause death or serious physical harm; and there was a feasible and useful method to correct the hazard.

## General Duty Clause (Continued)

- Citations shall be issued to employers with employees working in one of the workplaces where the CDC has identified workers as having a higher incident of TB infection than the general population, when the employees are not provided appropriate protection and who have TB exposure.

**Notes:**
Employee exposure to TB is defined as exposure to the exhaled air of an individual with suspected or confirmed pulmonary TB disease, or employee exposure without appropriate protection to a high hazard procedure performed on an individual with suspected or confirmed infectious TB disease and which has the potential to generate infectious airborne droplet nuclei.

## Feasible and Useful TB Abatement Methods

- Protocol for the early identification of individuals with active tuberculosis
- Medical surveillance
- Case management of infected employees
- Worker training and education
- Engineering controls

**Notes:**
These are examples of feasible and useful TB abatement methods recommended by the CDC. These methods are explained in detail in Appendix A of the compliance directive.

## TB and Respiratory Protection

- The primary means to control occupational diseases caused by breathing contaminated air is through the use of feasible engineering controls such as enclosures, confinement of operations, ventilation or substitution of less toxic materials.
- When these controls are not feasible, or while they are being instituted, appropriate respirators shall be used.

**Notes:**
Respirators shall be provided by the employer when such: equipment is necessary to protect the health of the employee and equipment is applicable and suitable for the purpose intended.

## TB and Respiratory Protection (Continued)

- Covered establishments must comply with 29 CFR 1910.134 when using respirators for protection from TB.

**Notes:**
Respiratory protection for TB was formerly covered under 29 CFR 1910.139. This standard was withdrawn on 12/31/03. At that time, establishments whose respiratory protection programs for TB were formerly covered under 29 CFR 1910.139 were required to adapt their programs to comply with the requirements of 29 CFR 1910.134. Since the withdrawal made compliance with 1910.134 effective immediately, OSHA decided to delay enforcement of several portions of 29 CFR 1910.134 until July 2, 2004 for covered establishments to allow employers time to come into compliance.
The delay in enforcement applied only to respiratory protection used for protection used for protection from TB and did not apply to respirators used for protection from other bioaerosols which may be found in patient setting such as Severe Acute Respiratory Syndrome (SARS). Health care facilities that had employees exposed to any other airborne contaminants requiring respirator protection were already required to have a respiratory protection program that was in compliance with 1910.134.
Effective July 2, 2004, covered establishments must comply with 1910.134 when using respirators for protection from TB.

## TB and Respiratory Protection (Continued)

- Respirator Program Elements
- Selection
- Medical evaluation
- Fit testing
- Use
- Maintenance and care
- Breathing air quality and use
- Training
- Program evaluation

**Notes:**
The establishment and maintenance of the respiratory protection program shall be the responsibility of the employer and include the requirements outlined in 29 CFR 1910.134 (c). The respiratory program must be written and include the elements described above.

## TB and Respiratory Protection (Continued)

- NIOSH certifies three categories of non-powered air purifying respirators based on filtering efficiency. All three categories are acceptable for use against TB:
- Type 100 (99.97% efficient)
- Type 99 (99% efficient)
- Type 95 (95% efficient)

**Notes:**
The minimal acceptable level of respiratory protection for TB is the Type 95 respirator. NIOSH respirator certification requirements are contained in 42 CFR Part 84.

## TB and Respiratory Protection (Continued)

- The 1994 CDC Guidelines specify the following criteria for respirators for exposure to TB:
- Ability to filter 1 micron in size in the unloaded state with a filter efficiency greater than 95%.
- Ability to be qualitatively or quantitatively fit tested in a reliable way to obtain face-seal leakage of less than 10%.

## TB and Respiratory Protection (Continued)

- CDC Guidelines (continued):
- The ability to fit the different facial sizes and characteristics of health care workers which can usually be met by making the respirators available in at least three sizes.
- The ability to check for face piece fit in accordance with OSHA standards and good industrial hygiene practice, by health care workers each time they put on their respirator.

**Notes:**
Employees using tight-fitting respirators must be fit tested before use and whenever a change in respirator design or facial changes occur that could affect the proper fit of the respirator.  
Examples of conditions which would require additional fit testing of an employee include (but are not limited to) the use of a different size or make of respirator, weight loss, cosmetic surgery, facial scarring, and the installation of dentures or absence of dentures that are normally worn by the individual.  
Employers must follow one of the fit testing methods detailed in Appendix A to the standard and maintain records of each fit test performed.

## TB and Respiratory Protection (Continued)

- Employees must wear NIOSH certified respirators in the following circumstances:
- When workers enter rooms housing individuals with suspected or confirmed TB disease;
- When workers perform high hazard procedures on persons who have suspected or confirmed TB disease; and
- When emergency response employees or others must transport in a closed vehicle, an individual with suspected or confirmed TB disease.

**Notes:**
High hazard procedures: characterized by potential to generate airborne secretions; aerosolized medication treatment; bronchoscopy; sputum induction; endotracheal intubation and suctioning; and autopsies conducted in hospitals.

## Access to Employee Medical and Exposure Records

- A record concerning employee exposure to TB is an employee exposure within the meaning of 29 CFR 1910.1020.
- A record of TB skin test results and medical evaluations and treatments are employee medical records within the meaning of 29 CFR 1910.1020.
- These records shall be handled according to 29 CFR 1913.10 in order for the CSHO to determine compliance with 29 CFR 1910.1020.

**Notes:**
The employer is required to keep all medical evaluation records and a copy of the current fit-test record for each respirator user.

## Accident Prevention Signs and Tags

- In accordance with 1910.145 (f)(8), a warning shall be posted outside the respiratory isolation or treatment room or a message referring one to the nursing station for instruction may be posted.
- 1910.145 (f)(4) requires that a signal word or biological hazard symbol may be presented as well as a major message.

**Notes:**
Warning signs must be posted on respiratory isolation or treatment rooms stating “pulmonary isolation,” “respiratory isolation,” or “AFB isolation.” the sign must state specifically the precautions required to interact with patients.

## Accident Prevention Signs and Tags (Continued)

- Employers are also required to use biological hazard tags on air transport components which identify TB hazards to employees associated with working on air systems that transport contaminated air.

## OSHA 300 Log

- For OSHA 300 recordkeeping purposes, both TB infections (positive TB skin tests) and TB disease are recordable in the workplace.
- If the employee’s TB infection which was entered on the OSHA 300 log progresses to TB disease during the 5 year maintenance period, the original entry for the infection must be updated to reflect new information.
- A positive TB skin test provided within two weeks of employment does not have to be recorded on the OSHA 300 form.

**Notes:**
According to 29 CFR 1904.11, Recording Criteria for Work-Related Tuberculosis Cases, employers who have employees who have been occupationally exposed to anyone with a known case of active TB, and subsequently develops a tuberculosis infection must record the case. The case must be recorded on the OSHA 300 log by checking the “respiratory condition column.”

## Additional TB Information