Evaluation of Exposure 

to Tuberculosis Among

Immigration Employees

Marie A. de Perio, MD

R. Todd Niemeier, MS, CIH

Health Hazard Evaluation Report

HETA 2009-0074 and HETA 2009-0193-3114

U.S. Immigration and Customs Enforcement

Detention and Removal Operations

Chicago, Illinois

Broadview, Illinois

September 2010

Department of Health and Human Services

Centers for Disease Control and Prevention

Workplace

Safety and Health

 National Institute for Occupational 

Safety and Health

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific 

facility evaluated and may not be universally applicable. Any recommendations made are not to be 

considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE 

reports are available at http://www.cdc.gov/niosh/hhe/
The employer shall post a copy of this report 

for a period of 30 calendar days at or near 

the workplace(s) of affected employees. The 

employer shall take steps to insure that the 

posted determinations are not altered, defaced, 

or covered by other material during such 

period. [37 FR 23640, November 7, 1972, as 

amended at 45 FR 2653, January 14, 1980].
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page i

Appendix A

Report Abbreviations.......................................................................ii

Highlights of the NIOSH Health Hazard Evaluation............ iii

Summary .............................................................................v

Introduction..........................................................................1

Assessment.........................................................................3

Results.................................................................................6

Discussion .........................................................................16

Conclusions.......................................................................20

Recommendations.............................................................20

References ........................................................................25

Contents

Good Practice Guidelines for Maintaining Acceptable Indoor 

Environmental Quality During Construction and Renovation 

Projects..............................................................................39

Health Effects ....................................................................28

Tables ................................................................................36

Acknowledgments

Appendix B

Appendix C

Acknowledgments and Availability of Report.....................45
Page ii Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

ACGIH® American Conference of Governmental Industrial Hygienists

ACH Air changes per hour

AHU Air handling unit

ANSI American National Standards Institute

ASHRAE American Society of Heating, Refrigerating, and Air-Conditioning Engineers

BCG Bacillus Calmette-Guerin

BSSA Broadview Service and Staging Area

CDC Centers for Disease Control and Prevention

CDO Chicago District Office

cfm Cubic feet per minute

cfm/person Cubic feet per minute per person

CFR Code of Federal Regulations

CO2 Carbon dioxide

DRO Detention and Removal Operations

EPA Environmental Protection Agency

FDA Food and Drug Administration

FOH Federal Occupational Health

HEPA High-efficiency particulate air

HHE Health hazard evaluation

HVAC Heating, ventilating, and air-conditioning

IEQ Indoor environmental quality

ICE Immigration and Customs Enforcement

IGRA Interferon-gamma release assay

Ls-1/person Liters per second per person

MERV Minimum efficiency reporting value

mL Milliliter

mm Millimeter

NIOSH National Institute for Occupational Safety and Health

OSHA Occupational Safety and Health Administration

PPD Purified protein derivative

PPE Personal protective equipment

ppm Parts per million

QFT-GIT QuantiFERON®-TB Gold in-tube test

RH Relative humidity

TB Tuberculosis

TST Tuberculin skin test

VAV Variable air volume

Abbreviations
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page iii

Highlights of the

NIOSH Health

Hazard Evaluation

The National Institute for 

Occupational Safety and 

Health (NIOSH) received 

requests from the 

American Federation of 

Government Employees, 

Local 2718 for a health 

hazard evaluation (HHE) at 

the U.S. Immigration and 

Customs Enforcement 

(ICE) Broadview Service 

and Staging Area (BSSA) 

facility in Broadview, 

Illinois, and at the Chicago 

District Office (CDO) in 

Chicago, Illinois. The 

union submitted the 

HHE requests because 

of concerns about the 

potential for transmission 

of tuberculosis (TB).

What NIOSH Did

● We made a site visit to BSSA in April 2009. We made site 

visits to BSSA and CDO in August 2009.

● We toured both facilities and saw work processes, practices, 

and conditions. We also talked with employees and collected 

ventilation flow measurements and temperature, humidity, 

and carbon dioxide readings.

● We screened employees at both facilities for latent TB 

infection. We used both the tuberculin skin test (TST) and 

an interferon-gamma release assay (IGRA) blood test.

What NIOSH Found

● Most employees have direct contact with detainees every day 

and participate in job activities that place them at risk of 

acquiring TB infection.

● The ventilation system at BSSA recirculates air throughout 

the building. This allows for air to be shared between 

detainees and employees.

● The ventilation system in the detainee areas at CDO 

exhausts air directly out of the building, an effective design. 

However, it does not provide enough air changes per hour in 

the detainee areas. We also found that air flows both in and 

out of many detainee areas, which allows for air to be shared 

between detainees and employees.

● Many employees were not aware that they should undergo 

periodic TB screening.

● Fewer ICE employees completed the TST test than the IGRA 

test during our HHE.

What Managers Can Do

● Use the existing ICE tuberculosis exposure control plan to 

develop plans specific for BSSA and CDO.

● Change the ventilation system in detainee areas at BSSA to 

either a single pass or a high efficiency particulate air filtered 

system.

● Rebalance the ventilation system at CDO to increase the 

amount and direction of air flow in detainee areas.

● Provide annual TB training to all employees. This training 

should be offered during normal working hours.
Page iv Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Highlights of the

NIOSH Health

Hazard Evaluation

(continued)

● Provide on-site TB screening on designated dates and hours. 

ICE should consider using IGRA testing instead of TST 

testing.

● Implement a respiratory protection program for all employees 

who may be exposed to TB.

What Employees Can Do

● Get tested for TB annually.

● Wear a NIOSH-certified N95 filtering facepiece respirator 

when in close contact with a detainee with a known or 

suspected active case of TB. A respirator should also be worn 

when entering an isolation room that is occupied by a person 

with a known or suspected case of TB.
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page v

Summary

NIOSH investigators 

investigated the potential 

for TB transmission at 

two immigrant detention 

facilities in Illinois. 

We found lapses in 

the environmental, 

administrative, and PPE 

controls concerning TB 

exposure prevention at 

both facilities.

In January 2009, NIOSH received an HHE request from the 

American Federation of Government Employees, Local 2718. The 

request concerned the potential for transmission of TB at the U.S. 

ICE BSSA facility in Broadview, Illinois. While no known cases of 

active TB had occurred among employees, the incidence of latent 

TB infection among employees was unknown.

NIOSH investigators made an initial site visit to BSSA on April 

8–9, 2009. We walked through the facility and observed work 

processes, practices, and conditions. We spoke with employees 

about health and workplace concerns about TB and collected 

environmental and ventilation measurements. We also held 

confidential interviews with all 29 employees present at the facility.

Most employees reported having daily direct contact with 

detainees, and none of the employees reported receiving general 

TB training, respirator fit testing, or respirator training during 

their employment at BSSA. Many employees were unaware of the 

ICE recommendation that they undergo periodic TB screening. 

We also learned that the return air from the detainee areas, 

including the isolation room, was recirculated throughout BSSA. 

In addition, all of the detainee areas, including the isolation 

room, were positively pressurized relative to the adjacent hallway 

and employee areas. Both situations result in air that was shared 

between employees and detainees, which could lead to an 

increased risk of exposure if airborne infectious agents (including 

Mycobacterium tuberculosis) are present.

On July 10, 2009, NIOSH received a second HHE request from 

the American Federation of Government Employees, Local 2718 

concerning the potential for transmission of TB at the ICE CDO 

in Chicago, Illinois.

We made a second site visit to BSSA and an initial site visit to 

the CDO on August 10–12, 2009. During that visit, we walked 

through both facilities and observed work processes, practices, and 

conditions. We spoke with employees about TB-related health and 

workplace concerns and collected environmental and ventilation 

measurements. We also screened employees at both facilities for TB 

with both the TST skin test and QFT GIT blood test methods.

At the CDO, the HVAC system in the detainee area is a constant 

air volume system that exhausts air directly out of the building 

without recirculation, which is an optimal design. However, 
Page vi Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Summary (continued)

the calculated ACH in the holding cells, processing area, and 

courtrooms were below those recommended by CDC. We also 

noted that the air flow movement between many of the holding 

cells and the processing area and between Courtroom B and a 

secure hallway was bidirectional. These deficiencies can increase 

the risk of exposure if airborne infectious agents (including 

Mycobacterium tuberculosis) are present.

Most ICE employees participate in job activities that place them 

at risk of acquiring TB infection, including transporting and 

interviewing detainees and supervising court visits. Despite this, 

few participants reported having annual TB screening. Even when 

we offered TB screening on-site, the number of employees who 

returned for the TST reading and second step placement was low. 

All employees who underwent blood collection for the QFT-GIT 

completed screening. Our evaluation demonstrates the feasibility 

and practicality of the QFT-GIT as the preferred TB screening 

method among ICE employees who often have unpredictable 

schedules.

We recommend that the Field Office Director and other local ICE 

supervisors familiarize themselves with ICE’s existing tuberculosis 

exposure control plan and then develop plans specific for both 

BSSA and the CDO.

A separate constant air volume HVAC system should be designed 

for BSSA to provide single-pass exhaust ventilation in the detainee 

holding cells, isolation room, and processing area. Negative 

pressure should be maintained in these areas relative to all 

adjacent administrative areas at BSSA. The HVAC system in the 

detainee areas at the CDO should be rebalanced to provide the 

appropriate ACH and air flow patterns to minimize the potential 

for transmission of TB.

General training on TB should be provided annually to all 

employees. All employees should be made aware that annual TB 

screening is recommended and that it is offered at no cost through 

FOH. FOH should consider conducting on-site TB screening on 

predetermined dates and hours at BSSA and CDO and using 

IGRA testing instead of TST testing to improve participation rates.
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page vii

Summary (continued)

A respiratory protection program should be implemented for all 

employees to minimize the potential for transmission of TB. All 

employees should receive training and medical clearance, and 

undergo fit testing as defined in the OSHA Respiratory Protection 

Standard (29 CFR 1910.134).

Keywords: NAICS 928120 (International Affairs), tuberculosis, TB, 

immigration facility, ventilation, indoor environmental quality, IEQ
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Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 1

Introduction

NIOSH received an HHE request from the American Federation 

of Government Employees, Local 2718 on January 20, 2009. The 

request concerned the potential for transmission of TB at the U.S. 

ICE BSSA facility in Broadview, Illinois. While no known cases of 

active TB had occurred among employees, the incidence of latent 

TB infection among employees was unknown.

We made an initial site visit to BSSA on April 8–9, 2009. During 

that visit, we met with local ICE management and the local 

union president to discuss the HHE request; walked through the 

facility; observed work processes, practices, and conditions; spoke 

with employees; and collected environmental and ventilation 

measurements. We held confidential interviews with all 29 

employees present at the facility.

NIOSH received a second HHE request from the American 

Federation of Government Employees, Local 2718 on July 10, 

2009, concerning the potential for transmission of TB at the ICE 

CDO in Chicago, Illinois.

We made a second site visit to BSSA and an initial site visit to the 

CDO on August 10–12, 2009. At CDO, we met with local ICE 

management and the local union president to discuss the HHE 

request; walked through the facility; observed work processes, 

practices, and conditions; spoke with employees; and collected 

environmental and ventilation measurements. We used two testing 

methods to screen employees for TB at both facilities.

U.S. Immigration and Customs 

Enforcement 

ICE, a federal agency under the Department of Homeland 

Security, is charged with protecting national security by enforcing 

the nation’s customs and immigration laws. ICE employs 

approximately 19,000 persons. DRO, a division of ICE, is the 

primary enforcement arm within ICE for the identification, 

apprehension, and removal of illegal, fugitive, and criminal 

immigrants from the United States. DRO operates eight secure 

detention facilities called Service Processing Centers and has 

seven contract detention facilities across the country. ICE DRO 

employees also work out of Field Offices and Service and Staging 

Area facilities. ICE removed 356,739 illegal immigrants from the 

United States in 2008, including more than 100,000 who returned 

to their home country voluntarily [ICE 2009].
Page 2 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Introduction 

(continued) ICE operates BSSA, a federal facility that serves as the processing 

center for adult immigrant detainees entering ICE custody in 

the midwestern United States. Approximately 300 immigrant 

detainees are processed at this facility every week. BSSA receives 

transfer detainees from many sources including local jails, the 

U.S. Marshals Service, and ICE detention facilities from across 

the United States. Detainees are maintained at BSSA for up to 10 

hours and are subsequently transferred to an ICE detention center 

where they are housed pending the outcome of their immigration 

case. BSSA also serves as the last stop for illegal immigrants in the 

Midwest before they are shuttled to airports and deported. BSSA 

employs approximately 50 immigration enforcement agents and 

detention and deportation officers.

The CDO is in a 10-story federal government building in 

downtown Chicago that also serves as a processing center for 

adult immigrant detainees entering ICE custody. Approximately 

100 immigrant detainees are processed at this facility every week; 

they are maintained in holding cells for up to 10 hours before 

subsequent transfer. The CDO also houses an immigration court. 

The CDO employs approximately 70 immigration enforcement 

agents and detention and deportation officers.

Occupational medical clinical services, including immunizations, 

TB screening, and medical clearance for respirator use are provided 

to ICE employees in partnership with the U.S. Public Health 

Service/FOH. ICE employees working out of BSSA and CDO can 

obtain services at the FOH Occupational Health Center on 230 

South Dearborn Street in downtown Chicago, Illinois.

Tuberculosis 

TB, a disease caused by the bacteria Mycobacterium tuberculosis, is 

spread from person to person through the air. TB usually infects 

the lungs, but it can also infect other body parts such as the brain, 

kidneys, or spine. The symptoms of active TB disease in any body 

part include feeling sick or weak, weight loss, fever, and night 

sweats. The symptoms of TB disease of the lungs also include 

coughing, chest pain, and coughing up blood.

TB bacteria are released into the air when a person with TB disease 

of the lungs or throat coughs, sneezes, speaks, or sings. These 

bacteria can stay in the air for several hours, depending on the 
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 3

Introduction (continued)

Assessment

environment. Persons who breathe in the air containing these TB 

bacteria can become infected; this is called latent TB infection.

Persons with latent TB infection have TB bacteria in their bodies, 

but they are not ill because the bacteria are not active. These 

persons do not have symptoms of TB disease, and they cannot 

spread the germs to others. They may develop TB disease in 

the future but can be treated to prevent this from happening. 

Persons with TB disease are sick from active TB bacteria that 

are multiplying and destroying tissue in their body. They usually 

have symptoms of TB disease and are capable of spreading TB 

bacteria to others. Additional information on TB can be found in 

Appendix A.

Prior to our first site visit, we reviewed the tuberculosis 

exposure control plan prepared for the Office of Environmental 

Occupational Safety and Health at ICE by the U.S. Public Health 

Service/FOH. Because medical clinical services are provided to 

ICE employees in partnership with the U.S. Public Health Service/

FOH, we asked to see the TB screening records from 2003 to 

February 2009 for ICE employees at BSSA. We also asked to see 

the OSHA 300 Log of Work-Related Illnesses and Injuries from 

2003 to April 2009, as well as the site-specific TB exposure plan 

for BSSA. In addition, we asked to view the general TB training 

records, respirator medical clearance records, and respirator fit 

testing and training records for employees at BSSA.

Medical Assessment 

First Site Visit 

During the initial site visit at BSSA from April 8–9, 2009, we 

held confidential interviews with employees to discuss health 

and workplace concerns regarding TB and their knowledge about 

TB and the exposure control plan at the facility. All 29 available 

employees working at the facility during our visit participated 

in the interviews. During these interviews, we also educated the 

employees about the signs and symptoms of TB and the difference 

between latent TB infection and active TB disease.
Page 4 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Assessment (continued) Second Site Visit 

During the second site visit at BSSA and first visit at the CDO 

from August 11–12, 2009, we screened employees for TB with two 

types of tests: the TST skin test and the QFT-GIT blood test. All 

ICE employees at BSSA and the CDO were invited to participate 

in the evaluation. Participating ICE employees were asked to 

fill out a short questionnaire regarding personal characteristics, 

work history, pertinent medical history, and risk factors for TB. 

Participants who did not report a history of a positive TST, latent 

TB infection, or active TB disease were asked to provide a blood 

sample for the QFT-GIT assay, and to undergo a TST. Employees 

who reported a history of a positive TST or latent TB infection 

were encouraged to see their primary care physician for annual 

screening for TB symptoms.

A NIOSH phlebotomist collected whole blood totaling 3 mL 

into three tubes prefilled with antigen (a negative control tube, a 

Mycobacterium tuberculosis-antigen tube, and a mitogen tube) from 

each participant. The samples were then transported by courier 

to the University of Illinois at Chicago reference laboratory where 

they were analyzed using the QFT-GIT assay and interpreted in 

accordance with manufacturer guidelines. QFT-GIT results were 

considered positive if the interferon-γ level was greater than or 

equal to 0.35 International Units per mL.

An FOH nurse placed the TST on each participant according 

to standard protocols. Using the Mantoux method, 0.1 mL of 

Tuberculin PPD (Tubersol®) was injected intradermally with a 

syringe and needle. Induration (hard, dense, raised formation on 

the skin) was measured in millimeters by FOH nurses after 48–72 

hours via standard protocols. If more than 1 year had elapsed since 

an employee’s last test and if he or she was found to be nonreactive 

(negative), a repeat TST was placed by the FOH nurse. This is 

known as two-step testing. The second TST was placed and read 

during the week of August 24, 2009. FOH nurses visited both 

facilities on the assigned dates to perform the TST reading on 

employees. FOH nurses were blinded to the results of the QFTGIT. Induration measuring greater than 10 mm was considered 

reactive (positive).

We calculated the prevalence of latent TB infection using both 

screening methods. We also calculated and compared completion 

rates for each testing method and determined predictors for 
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 5

Assessment (continued) completion of TST screening through bivariate analyses with SAS 

9.2 (SAS Institute, Cary, North Carolina). All statistical tests were 

2-tailed, with a P value of less than 0.05 considered statistically 

significant.

Industrial Hygiene Assessment

We evaluated the HVAC systems at each facility, reviewed 

ventilation mechanical plans, and held discussions with persons 

responsible for maintenance of the HVAC systems. Evaluations 

included an HVAC system inspection and collection of airflow 

measurements at the supply diffusers and ducted returns in 

areas where detainees were located to assess the potential for 

dissemination of airborne Mycobacterium tuberculosis. Airflow 

measurements were collected with a TSI Accubalance® Plus 

air capture hood (TSI, Inc., Shoreview, Minnesota). The 

direction of airflow between the detainee areas and adjacent 

areas was evaluated with smoke tubes, and the number of ACH 

was calculated in most CDO areas. General IEQ data (CO2

concentrations, temperature, and RH levels) were collected 

in multiple areas of both facilities with TSI Q-TrakTM Plus 

Model 8554 instruments (TSI, Inc., Shoreview, Minnesota) to 

evaluate general ventilation and occupant comfort indicators. 

Measurements were collected for an approximate 1-day period 

in areas outside of the holding cells. Spot measurements were 

collected in the holding cells. Additional information on IEQ is 

provided in Appendix A.

We visually inspected the design of the subfloor supply air plenum 

on the fourth floor of the CDO building. We also reviewed 

an FOH industrial hygiene report from 2007 in which area air 

samples for total and respirable particulate and bulk dust were 

collected on the second floor of the CDO building in response 

to employee complaints about IEQ in the building. Specifically, 

office employees on multiple floors of the building had reported 

excessive dustiness that caused eye and throat irritation. These 

issues started after the installation of a subfloor open plenum 

supply air ventilation system and occurred from approximately 

2002–2007.
Page 6 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

During our first site visit, we learned that BSSA had no sitespecific TB exposure control plan. In addition, we learned that 

programs for TB training, respirator medical clearance, and 

respirator training and fit-testing records did not exist. We also 

learned that FOH did not keep TB screening records specific for 

BSSA employees. We were not able to obtain the TB prevalence 

rate for detainees passing through BSSA or the CDO through ICE 

management.

Medical Assessment 

First Site Visit 

OSHA 300 Logs were only available for 2008 and 2009 and 

contained 22 reports from both BSSA and CDO employees. Most 

of the reports described musculoskeletal injuries, and one entry 

reported exposure to TB. The logs did not contain reports of 

positive TST results.

During our confidential medical interviews with all 29 BSSA 

employees, we learned that most employees (93%) reported having 

daily direct contact with detainees, and many (59%) reported 

responsibilities that included transporting detainees in enclosed 

vehicles. None of the employees reported receiving general TB 

training, respirator fit testing, or respirator training during their 

employment at BSSA. Some employees were unaware that they had 

access to surgical face masks or N95 filtering facepiece respirators. 

Additionally, some employees were unaware that they should use 

N95 or higher respirators for their own respiratory protection 

nor that they should provide surgical face masks to sick detainees 

under certain circumstances. Many employees were unaware of the 

ICE recommendation for periodic TB screening, and none of the 

employees reported obtaining annual TB testing through FOH.

Second Site Visit 

Seventy-two (60%) of 120 employees working during the site visit 

participated in the TB screening: 42 at CDO and 30 at BSSA. The 

flow diagram in Figure 1 illustrates the HHE participants and the 

TB screening tests.

Seven employees reported a previous history of a positive TST and 

did not undergo further testing. None of the employees reported 

Results
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 7

Results (continued)

a history of active TB. One employee reported having undergone 

both the blood test and the TST in the previous week by his 

personal physician and did not undergo further testing. Fifty-four 

(75%) employees underwent blood collection for the QFT-GIT and 

TST placement. Five employees underwent TST placement but not 

blood collection, and five employees underwent blood collection 

for the QFT-GIT but not TST placement. Reasons employees did 

not undergo TST placement included an inability to return for 

reading on the assigned date and medical preference. Reasons 

employees did not undergo blood collection for QFT-GIT included 

not wanting to have their blood drawn and fear of needles.

The median age for participants was 35 years (range: 22 to 

61 years), and the majority (71%) were male. Sixty-two (86%) 

participants were born in the United States, though 24 (33%) 

reported having lived outside of the United States. Ten (14%) 

participants reported having received the BCG vaccine for TB. 

Figure 1. Number of participants and test results by type of test for ICE employees participating in latent 

tuberculosis screening using tuberculin skin testing and QuantiFERON®-TB Gold in-tube testing.
Page 8 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Results (continued) This vaccine can produce a false positive reaction, reducing the 

specificity of the TST. Sixty-eight (94%) participants reported 

no history of an underlying medical condition associated with a 

higher risk of progression to active TB if infected. These medical 

conditions included diabetes mellitus, silicosis, kidney failure, 

gastrectomy, cancer, or any immunosuppressive condition. Work 

history characteristics of the 72 participants are shown in Table 1.

In total, 67 (93%) participants reported having face-to-face contact 

with detainees in their current job. Reported job activities included 

transporting detainees in enclosed vehicles (68%), interviewing 

detainees (81%), and supervising court visits (31%). A photograph 

of the interior of a transport vehicle can be seen in Figure 2, and a 

photograph of the processing area where interviews are conducted 

can be seen in Figure 3. Twenty-five (35%) participants reported 

ever having face-to-face contact with a detainee known to have 

active TB, while none of the participants reported ever having faceto-face contact with a household member, family member, friend, 

or other community member known to have active TB.

Table 1. Work history characteristics of health hazard evaluation participants

Demographic Characteristic No. Participants (%)

n = 72

Job title

 Supervisor 5 (7)

 Immigration and enforcement agent 44 (61)

 Detention and deportation officer 13 (18)

 Detention and removal assistant 7 (10)

 Other job title 3 (4)

Mean years worked at ICE 

Mean years worked at BSSA 

6.5 

3.5 

Mean years worked at CDO 4.0 

Previous employment or volunteer work 

 Another ICE facility 22 (31)

 Correctional facility 26 (36)

 Hospital 17 (24)

 Nursing home 5 (7)

 Homeless shelter 4 (6)
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 9

Results (continued)

Sixty-seven (93%) participants reported ever having a TST 

while only four (6%) reported having an annual TST. The four 

participants who reported having an annual TST worked for ICE 

for less than 2 years and had their previous annual TST through 

their previous employment or military service. Reasons cited by the 

64 participants not reporting annual TSTs are shown in Table 2. 

Participants could cite more than one reason.

Figure 2. Photograph of the interior of a detainee transport vehicle.

Figure 3. Photograph of a processing area at BSSA where detainees 

sit facing ICE employees.
Page 10 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Results (continued)

Fifty-five (76%) participants reported having had training on the 

proper way of wearing, taking off, and disposing of a respirator 

since starting work at their current workplace. Fifty-eight (81%) 

participants reported having had respirator fit testing since starting 

work at their current workplace. Participants reported having this 

training and fit testing during a period from May to July 2009, 

which was the period between our two site visits.

The flow diagram in Figure 1 also illustrates that all 59 

participants who underwent blood collection for the QFT-GIT 

had interpretable results, which were all negative. Of the 59 

participants who had a first TST placed, 16 (27%) did not return 

for their first TST reading by the FOH nurse. Of the 43 first TSTs 

that were read, three (7%) had positive results or indurations 

>10 mm. Fifty-two (93%) participants required two-step testing, 

but only 27 (52%) underwent a second TST, and 6 (22%) did 

not return for the second TST reading by the FOH nurse. The 

completion rate for the QFT-GIT was higher than the TST (100% 

vs. 39%, P < 0.001). Among the 41 participants who completed 

both the QFT-GIT and the first TST, overall agreement between 

the TST and QFT-GIT results was 93%. All three participants 

who had positive TST results had negative QFT-GIT results. 

No participants had positive QFT-GIT results and negative TST 

results.

Table 2. Reasons cited by participants for not receiving annual tuberculin skin tests

Reason Cited* No. Participants (%)

n = 64

I have not been told that I need to get tested 27 (42)

I have not felt sick 21 (33)

I do not think I need an annual test 17 (27)

I do not know where to get tested 14 (22)

It is inconvenient for me to get tested 11 (17)

I have previously tested positive 5 (8)

No reason 3 (5)

*Participants could cite more than one reason
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 11

Results (continued) Two of the three participants with positive TST but negative 

QFT-GIT results were foreign-born and had received the 

BCG vaccination as children. Though all three participants 

initially denied having a history of a positive TST, upon further 

questioning, two did recall having had a positive TST in the past, 

and one reported a history of taking medication for this for 3 

months. The other participant was uncertain if he had ever had a 

positive TST. All three participants were advised to follow up with 

their primary care physician.

No differences were present between groups who completed and 

did not complete TST screening with respect to sex, country 

of birth, BCG vaccination, and history of underlying medical 

condition. Employees who completed TST screening were more 

likely to be older (41 years vs. 34 years, P < 0.01), ever lived outside 

of the United States (57% vs. 19%, P < 0.01), or employed as a 

detention removal assistant (22% vs. 3%, P = 0.03) than those 

employees not completing TST screening. Employees were less 

likely to have completed TST screening if they were employed as 

an immigration enforcement agent (48% vs. > 78%, P < 0.01) or 

previously worked at another ICE facility (9% vs. 36%, P = 0.01).

Industrial Hygiene Assessment 

Broadview Service and Staging Area Facility 

The BSSA facility was solely occupied by ICE DRO. The facility 

consisted of offices and holding cells on the first floor of the 

building. The detainee area included four large holding cells that 

could house up to approximately 40 detainees each. Additional 

detainee areas included a small isolation cell, a receiving and 

discharge area, a processing area, visitor areas, and a sally port (a 

secure entryway where detainees are brought into the facility). Most 

office staff worked in either a large squad room on the first floor 

or in offices adjacent to the squad room. Some staff stationed 

near detainee cells worked in the receiving and discharging area, 

processing areas, or in a computer room adjacent to the receiving 

and discharge area. The building also had a partially finished 

second floor that included a small workout facility, kitchen, and 

restrooms.

The HVAC system was a multizone VAV design, meaning the 

amount of air delivered to the space varies depending on the 

temperature setpoints and thermostat readings. In the evaluated 
Page 12 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Results (continued) areas, minimal airflow was detected if the thermostat was satisfied, 

so we lowered the temperature setpoints to collect airflow 

measurements. The system consisted of a single AHU providing 

conditioned air to the office and detainee areas of the building. 

The AHU was fitted with two different types of pleated filters, a 

GlasFloss® ZL (MERV 8) and an Air Handler® (MERV 7). No 

filter changeout schedule was in place. During our evaluation 

a BSSA maintenance employee reported to us that the AHU 

dampers introduced approximately 50% outdoor air into the 

HVAC system. We did not verify this figure.

The detainee holding cells, small isolation cell, receiving and 

discharge area, processing area, and the visitor area had supply 

diffusers and ducted returns. The HVAC system recirculated return 

air from the detainee areas to all areas of the facility. Additionally, 

all of the detainee areas were positively pressurized relative to 

adjacent hallway and employee areas. Table B1 (Appendix B) 

provided the supply and return airflow measurements and 

the direction of airflow between different areas. As a trial, we 

temporarily adjusted the air dampers on the AHU to bring in 

100% outdoor air into the facility. This action resulted in no 

recirculated air, but the detainee areas became even more positively 

pressurized relative to adjacent hallways and employee areas.

The results of the general IEQ measurements are provided in 

Table B2 (Appendix B). All temperature and RH average readings, 

as well as almost all CO2 concentrations, were within the ANSI/

ASHRAE guidelines [ANSI/ASHRAE 2004, 2007]. Exceptions 

included a 5-minute period in the detention hallway across from 

Holding Cell 140 where CO2 concentrations were slightly elevated 

and in Holding Cells 139 and 141 where spot measurements were 

elevated when measurements were taken with 35–40 detainees in 

each room.

Chicago District Office 

Detainee Area and Immigration Courtrooms 

Detainees were housed in the facility basement in four large cell 

blocks and one small cell block. Some immigration enforcement 

agents and detention and deportation officers worked in the 

processing area adjacent to the cells. Two immigration courtrooms 

are adjacent to the detainee areas.
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 13

Results (continued) The HVAC system in the detainee and courtroom areas of the 

basement was a constant air volume system, meaning that the 

airflow rate in the area remains steady throughout the day but 

the temperature of the air varies depending on the thermostat 

setpoints. This system was specifically designed for this area 

and was separate from the other HVAC systems in the CDO. 

All of these areas, including holding cells, processing area, and 

courtrooms, had supply diffusers and ducted returns. Return 

air from these areas was directly exhausted out of the building. 

In most of the holding cells, more air was exhausted from the 

ducted return than was supplied. In one of the cells (B03), the 

solitary exhaust grille was almost fully blocked with wads of toilet 

paper, preventing the air from properly exhausting the cell. In the 

processing area, slightly more air was supplied than exhausted. In 

Courtroom 1, there was no measurable air return, but we could 

not determine the reason for this. In Courtroom 2, there was 

slightly more air supplied than exhausted. The exhaust vent on the 

exterior of the building was not near any outdoor air intakes.

When we used smoke tubes to test the direction of airflow through 

the doorways separating the holding cells and the processing area, 

it appeared that airflow was bidirectional through some of the 

doorways (Cells B03, B04, B05 and B06) (Appendix B, Table B3). 

Specifically, the air was observed to be moving from the processing 

area into the cell areas at the top of the doorway, and from the cell 

areas into the processing area at the bottom of the doorways. We 

also noted the same effect in the doorway between Courtroom 2 

and the detainee hallway.

We calculated the number of ACH in the holding cells, processing 

area, and courtrooms in the CDO basement. In the holding 

cells, the calculated air change rate ranged from 1.5 to 11.6 ACH. 

We calculated 4.9 ACH in the processing area. In Courtroom 1, 

because no return air entered into the ducted exhaust, we could 

not calculate air change rate, while in Courtroom 2, we calculated 

3.4 ACH.

The results of the general IEQ evaluation are provided in Table 

B2 (Appendix B). The CO2, temperature, and RH average ranges 

in the detainee processing area and Courtroom 1, collected for 

approximately 24 hours, were within the guidelines recommended 

by ANSI/ASHRAE [ANSI/ASHRAE 2004, 2007]. Spot CO2 and 

temperature measurements collected in the holding cells were also 

within the ANSI/ASHRAE guidelines [ANSI/ASHRAE 2004, 
Page 14 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Results (continued) 2007]. However, some spot RH levels (Cells B05, B06, and B07) 

exceeded the ANSI/ASHRAE guideline [ANSI/ASHRAE 2007]. 

Additionally, the RH levels in the detainee processing area (North 

and South) and Courtroom 1 exceeded the ANSI/ASHRAE 

guideline from approximately 6 p.m. until 5 a.m. Figure 4 shows 

an example of this data, as well as temperature readings and CO2

concentrations collected in the Detainee Processing Area (North).

Figure 4. CO2, temperature, and RH levels in the North Detainee Processing Area.

Office and Visitor Areas 

Some ICE employees worked in a squad room adjacent to the 

detainee area in the basement. The basement also had a visitor area 

adjacent to the immigration courtrooms. A sally port was on the 

ground floor of the building. Most ICE staff worked in office space 

on the fourth floor of the building. ICE also leased space on the 

third floor of the building. The fourth floor of the building also 

had a family waiting room and family interview rooms adjacent to 

the staff office space. All of these areas (other than the basement) 

were served by a subfloor open plenum design VAV HVAC system. 
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 15

Results (continued) The open plenum was the approximately 1-foot space between the 

floor and subfloor. The basement had supply diffusers and ducted 

returns in the ceiling space.

The results of the general IEQ evaluation in the office and 

visitor areas are provided in Table B3 (Appendix B). All CO2, 

temperature, and RH average readings in the fourth floor office 

and visitor areas and squad room in the basement were within 

the ANSI/ASHRAE guidelines [ANSI/ASHRAE 2004, 2007]. 

These measurements were collected for approximately 24 hours. 

RH measurements in these areas approached but did not exceed 

the ANSI/ASHRAE guideline [ANSI/ASHRAE 2004]. CO2

concentrations exceeded the ANSI/ASHRAE guideline in the 

family waiting area on the fourth floor for approximately 30 

minutes on August 11, 2009 [ANSI/ASHRAE 2007].

A visual inspection of the subfloor plenum on the fourth floor 

revealed dust as did the FOH industrial hygiene report from 

2007. The space between the subfloor and flooring served as 

a supply air plenum where filtered air was distributed via floor 

registers throughout the fourth floor. AHUs filtered the air prior 

to entering the supply air plenum; however, no additional air 

filtration was provided before the air entered the occupant space. 

CDO employees informed us that piles of construction debris had 

been left in some subfloor areas following renovation, though we 

did not verify this.
Page 16 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Our results show that most (93%) ICE employees at BSSA and 

CDO reported having face-to-face contact with detainees. Though 

prevalence of latent TB infection among tested employees was low 

(0% by QFT-GIT and 7% by TST), many employees participated in 

job activities that placed them at risk of exposure to TB, including 

transporting and interviewing detainees and supervising court 

visits. While we were unable to determine the TB case rates among 

people in ICE custody at BSSA and CDO, Schneider and Lobato 

estimated that the TB case rate among people in ICE custody 

nationwide was 12.5 per 100,000 persons in 2005 [Schneider and 

Lobato 2007]. Our results do demonstrate that 35% of participants 

reported having face-to-face contact with a detainee known to have 

active TB.

We observed ventilation deficiencies at both BSSA and CDO that 

could increase the potential for transmission of TB, if present. 

The HVAC system at BSSA mixed return air from the detainee 

areas with outdoor air, then redistributed this air throughout 

the building. Although the VAV system used both MERV 7 and 

MERV 8 rated air filters, CDC recommends that air from areas 

likely to contain infectious aerosols, such as isolation cells, be 

directly exhausted from the building or filtered using HEPA 

filters before redistribution into the general HVAC system [CDC 

2006]. For general population areas in which the potential for 

transmission of TB exists, such as holding cells and the processing 

area, the optimal design would be to exhaust air directly from the 

building. However, this is not always feasible because of energy 

and equipment costs, so CDC recommends filtering air through a 

minimum of a MERV 8 rated filter before it is recirculated [CDC 

2006]. At BSSA, air from almost all of the holding cells and the 

isolation room flowed from the cells to the adjacent hallways. 

Additionally, air flowed from the receiving and discharge area to 

the squad room. CDC recommends that air flow into isolation 

rooms, holding cells, and processing areas to contain potentially 

contaminated air and reduce employees’ potential exposure to 

Mycobacterium tuberculosis [CDC 2006]. The VAV system at BSSA 

could cycle on and off throughout the work day depending on 

the temperature settings, leaving detainee areas without sufficient 

outdoor air to dilute contaminants.

The CDO HVAC system in the detainee area was a constant air 

volume system that exhausted air directly out of the building 

without recirculation, an optimal design. However, the calculated 

ACH in the holding cells, processing area, and courtrooms 

Discussion
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 17

Discussion (continued) were below those recommended by CDC [CDC 2006]. CDC 

recommends a minimum of 12 ACH for intake, holding, and 

processing areas, and a minimum of 6 ACH in courtrooms [CDC 

2006]. We also noted that the airflow between several holding cells 

and the processing area was bidirectional. Bidirectional airflow was 

also noted between Courtroom B and the secure hallway where 

detainees were led into the courtrooms. CDC recommends that 

air should move from clean to less clean areas (e.g., into holding or 

isolation cells) to reduce the potential transmission of TB [CDC 

2006].

The CDC-recommended outdoor air supply rates in correctional 

facilities are different for different areas in the facility [CDC 2006]. 

In areas that are not intended to contain persons with infectious 

TB, the percentage of outdoor air supply should meet or exceed 

the amount recommended in ANSI/AHSRAE Standard 62.1-2007 

[ANSI/ASHRAE 2007]. For areas with enhanced potential for 

undiagnosed cases of infectious TB, facility designers and owners 

may consider using higher supply rates of outdoor air (e.g., those 

recommended for healthcare facilities anticipated to contain 

infectious patients) [CDC 2006]. Areas such as intake, holding, 

and processing areas may be analogous to the emergency waiting 

room area in a healthcare facility. In that case, the recommended 

outdoor air supply would be at least 2 ACH [CDC 2006].

Despite the risk of exposure, only 6% of participants reported 

having an annual TST. Those participants all worked for ICE less 

than 2 years and received annual TSTs through their previous 

employment. The most common reasons cited for not receiving 

an annual TST included not being told they had to get tested 

(42%), not feeling sick (33%), and not thinking an annual TST 

was needed (27%). These results demonstrate that more than half 

of ICE employees at these two facilities were not aware of the ICE 

recommendation that they undergo at least annual TB screening.

Our results also show that ICE employees had high no-show rates 

for return reading of TST results, 26% for the first TST and 22% 

for the second TST. Although the FOH nurses visited both sites 

for several hours on the assigned reading days, some employees 

still did not have their TST read. Predictors for completing TST 

screening included older age, ever having lived outside of the 

United States, and being a detention removal assistant. Detention 

removal assistants do not typically have job duties requiring them 

to be out of the office, making it easier for them to be present for 
Page 18 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Discussion (continued) all steps of the TST screening process. In contrast, predictors for 

not completing TST screening included being an immigration 

enforcement agent. These employees spent a significant portion of 

their work week away from the facility through their involvement 

in the transportation of illegal immigrants, which made it more 

difficult for them to be present for all steps of the TST screening 

process. In addition, employees were less likely to complete the 

TST screening process if they had previously worked at another 

ICE facility. This suggests TB screening at other ICE facilities may 

also be suboptimal.

All 59 participants who underwent blood collection for QFTGIT had interpretable results and completed TB screening 

through that method because only one site visit was required. In 

contrast, only 23 (39%) of participants completed all appropriate 

steps of TB screening through the TST method. Our evaluation 

demonstrates the feasibility and practicality of performing the 

QFT-GIT as the TB screening method in this population of ICE 

employees who often have unpredictable schedules. In 2010, 

CDC guidelines indicated that TSTs and IGRAs may be used as 

aids in diagnosing infection with Mycobacterium tuberculosis [CDC 

2010]. A major advantage of the QFT-GIT over the TST is that 

only one employee visit is needed, unlike the TST, which requires 

two or four employee visits. Although the QFT-GIT has a higher 

direct cost per test than the TST, it has been demonstrated to be 

a less costly screening strategy overall for healthcare workers when 

factoring in costs associated with missed work time [de Perio et al. 

2009]. Additionally, IGRAs have been found to be cost-effective 

TB screening strategies in other populations such as contacts of 

persons with active TB [Diel et al. 2007; Kowada et al. 2008].

Overall agreement between the TST and QFT-GIT results was 

high at 93%. This is consistent with previous studies that screened 

Navy recruits (87.7%) and healthcare workers (96%) for latent TB 

infection in the United States [Mazurek et al. 2007; Cummings et 

al. 2009]. Three employees were found to have discordant results: 

positive TST but negative QFT-GIT. Upon further questioning, 

two recalled a previous history of a positive TST and had received 

the BCG vaccination, and one was uncertain about a history of 

a positive TST. Given the TST has lower specificity in previously 

BCG-vaccinated individuals, it is possible these first two employees 

had false positive results. It has been demonstrated that IGRAs 

have a higher specificity in BCG-vaccinated subjects compared to 

the TST [Mori et al. 2004; Menzies et al. 2007; Pai et al. 2008]. 
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 19

Discussion (continued) The proteins present in the QFT-GIT test are absent from all BCG 

vaccine strains. This may be one reason these employees were 

found to have negative QFT-GIT results.

The TB screening evaluation was subject to some limitations. 

Because most of the TST participants also underwent blood 

collection for the QFT-GIT test, participants may have chosen 

not to have their TST read knowing that they had had another 

adequate TB screening test. While return rates for TST reading 

among immigration employees have not been described in previous 

studies, our no-show rates for return reading, 26% for the first TST 

and 22% for the second TST, were higher than those of healthcare 

workers (4-12%) [Rattner et al. 1996; Ball and Van Wey 1997; 

Hallak et al. 1999]. In addition, participants did not know their 

QFT-GIT results until both steps were complete, and FOH nurses 

visited each facility to perform the readings. Also, whether our 

TB screening results can be generalized to other ICE employees is 

unclear.

The IEQ measurements collected at BSSA and CDO, including 

temperature, RH, and CO2, were generally within ANSI/ASHRAE 

guidelines. Spot measurements collected in some of the occupied 

holding cells at the BSSA exceeded the ANSI/ASHRAE guideline 

for CO2. ANSI/ASHRAE recommends that the indoor CO2

concentration be within 700 ppm of the outdoor concentration for 

comfort (odor) reasons [ANSI/ASHRAE 2007]. A few temperature 

readings in the detention hallway across from Holding Cell 140 

and in the Processing area were slightly below the ANSI/ASHRAE 

guidelines for a few minutes. At the CDO building, RH levels fell 

outside the ANSI/ASHRAE guidelines during overnight hours 

when the ventilation system was shut down to save energy. ANSI/

ASHRAE recommends keeping RH levels at or below 65% in 

indoor environments to prevent excessive microorganism or dust 

mite growth [ANSI/ASHRAE 2007].

Employees at the CDO facility who worked on the third and fourth 

floors reported odor and dust issues related to the subfloor air 

plenum design in the building. It is plausible that the dust in the 

subfloor space may be causing employee eye and throat irritation. 

We agree with the recommendations issued in the consultant’s 

report completed prior to our site visit that this subfloor space 

be cleaned (to the extent possible) and any construction debris 

removed.
Page 20 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Most ICE employees at BSSA and CDO had face-to-face contact 

with detainees, and this placed them at risk for potential exposure 

to TB. Despite this, few participants reported having annual TB 

screening as recommended by ICE. Even when TB screening was 

carried out on-site, ICE employees had low return rates for TST 

reading and second step placement, while all employees who 

underwent blood collection completed screening.

Ventilation deficiencies were identified that could contribute to TB 

transmission if detainees with active TB were present. At the CDO, 

the subfloor air supply plenum on the upper floors may also have 

been a source of dust contamination causing the eye and throat 

irritation reported by employees.

On the basis of our findings, we recommend the actions listed 

below to create a more healthful workplace. We encourage ICE to 

use a labor-management health and safety committee or working 

group to discuss the recommendations in this report and develop 

an action plan. Those involved in the work can best set priorities 

and assess the feasibility of our recommendations for the specific 

situation at ICE. Our recommendations are based on the hierarchy 

of controls approach (refer to Appendix A: Health Effects). This 

approach groups actions by their likely effectiveness in reducing 

or removing hazards. In most cases, the preferred approach is to 

install engineering controls to reduce exposure or shield employees. 

Until such controls are in place, or if they are not effective or 

feasible, administrative measures and/or personal protective 

equipment may be needed.

Engineering Controls 

Engineering controls reduce exposures to employees by removing 

the hazard from the process or placing a barrier between the 

hazard and the employee. Engineering controls are very effective 

at protecting employees without placing primary responsibility for 

implementation on the employee.

1. Provide a separate HVAC system in the detainee holding 

cells, isolation cell, and processing area at BSSA. Ideally 

this should consist of a constant volume, single pass system 

with air directly exhausted to the outside. If return air is 

Conclusions

Recommendations
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 21

Conclusions

(continued) recirculated throughout the building, it should be passed 

through a HEPA filter before being returned through any 

areas within the building. The air change rate in each of 

these areas should be maintained at 12 ACH, and negative 

pressure should be maintained in all of these areas relative 

to all adjacent administrative areas in BSSA.

2. Rebalance the HVAC system in the detainee areas at the 

CDO to provide the appropriate ACH and airflow patterns 

to help minimize the potential for TB transmission from 

detainees with unrecognized active TB.

3. Maintain temperature, RH, and CO2 at comfort levels 

recommended by ANSI/ASHRAE [ANSI/ASHRAE 2004, 

2007].

4. Transport patients with suspected or confirmed infectious 

TB in an ambulance whenever possible. Additional 

information on ongoing maintenance programs can be 

found in the CDC document “Prevention and Control 

of Tuberculosis in Correctional and Detention Facilities: 

Recommendations from CDC” [CDC 2006].

Administrative Controls

Administrative controls are management-dictated work practices 

and policies to reduce or prevent exposures to workplace hazards. 

The effectiveness of administrative changes in work practices 

for controlling workplace hazards is dependent on management 

commitment and employee acceptance. Regular monitoring and 

reinforcement are necessary to ensure that control policies and 

procedures are not circumvented in the name of convenience or 

production.

1. Develop plans specific for BSSA and the CDO based on 

the ICE tuberculosis exposure control plan. In particular, 

complete Appendix A, “ICE TB Site-Specific Information.” 

The Field Office Director and the local ICE supervisors 

should review this site-specific plan annually, and revise 

when necessary. Make copies of this plan available to all 

employees at both facilities. Commit to the tuberculosis 

exposure control plan and ensure that every aspect of the 

plan is carried out.
Page 22 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Recommendations

(continued) 2. Assess the level of TB risk at least annually at each 

facility using the risk assessment methods outlined in the 

tuberculosis exposure control plan. This TB risk assessment 

should then be used to make site-specific adjustments to the 

appropriate areas of the TB exposure control plan. The TB 

risk assessment can be conducted by examining the burden 

of disease (i.e., the number of active TB disease cases in 

the facility during the preceding year and the number and 

percentage of detainees and staff with latent TB infection) 

and facility transmission (i.e., the number and percentage 

of employees whose tests for TB infection converted and the 

number of TB exposure incidents).

3. Add an ongoing maintenance program to the tuberculosis 

exposure control plan for each facility to ensure that the 

HVAC systems are appropriately maintained to minimize 

the potential for TB transmission. The plan should include 

the responsibility and authority for maintenance and staff 

training needs. Additionally, the program should include 

a preventive maintenance schedule for all components of 

the HVAC systems. Performance monitoring should be 

conducted regularly to ensure that HVAC controls are 

operating as designed. Additional information on ongoing 

maintenance programs can be found in the CDC document 

“Prevention and Control of Tuberculosis in Correctional 

and Detention Facilities: Recommendations from CDC” 

[CDC 2006].

4. Provide general TB training annually during normal 

working hours to all employees, as outlined in the 

tuberculosis exposure control plan. Training should ensure 

that employees understand TB transmission modes, signs, 

symptoms, diagnosis, and prevention. Training should 

also include information regarding the importance of 

following up on detainees or employees demonstrating 

signs or symptoms of TB disease and a discussion of basic 

principles of treatment for TB disease and latent TB 

infection. Additional training and education material can be 

found at the CDC TB website at http://www.cdc.gov/tb/

publications/default.htm.

5. Inform all employees of the protocol for reporting contact 

with a detainee suspected or known to have active TB. The 

TB post-exposure reporting form found in Appendix B of 

the tuberculosis exposure control plan should be completed 

and faxed to the appropriate FOH point of contact.
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 23

Recommendations

(continued) 6. Inform all employees that routine TB screening is 

recommended in the tuberculosis exposure control plan and 

that this screening should occur at least annually. Employees 

should also be made aware that FOH offers TB screening at 

no cost to the employee.

7. Consider conducting TB screening on designated dates 

and hours at BSSA and CDO through FOH or other 

contractors. Because employees’ schedules, especially those 

of immigration enforcement agents and detention and 

deportation officers, can be unpredictable, conducting onsite testing may increase participation and compliance.

8. Consider implementing IGRA testing instead of TST testing 

through FOH or other contractors. IGRAs have several 

advantages over the TST including that they necessitate 

only a single patient visit, results are available in as quickly 

as 24 hours, the findings are not subject to reader bias, and 

they have a higher specificity. IGRAs should be performed 

and interpreted according to established protocols using 

FDA-approved test formats. Additionally, both the standard 

qualitative test interpretation and the quantitative assay 

measurements should be reported together with the criteria 

used for the test interpretation [CDC 2010]. The TST can 

be continued to be offered as an option for employees who 

prefer not to have blood testing.

9. Refer employees with positive TST or IGRA results for a 

medical and diagnostic evaluation.

10. Track conversion rates for employees by annual testing over 

time to monitor for unsuspected transmission in the facility. 

TB conversions should be documented in the OSHA Logs 

for each facility. ICE management, in conjunction with 

FOH, should analyze contributing factors to TB exposure 

and transmission and plan for appropriate corrective 

intervention.

11. Clean the subfloor supply air plenum at the CDO. 

Minimize office employees’ exposure to dust during this 

cleaning. Appendix C provides information on maintaining 

good IEQ during construction projects.
Page 24 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Recommendations

(continued) Personal Protective Equipment 

PPE is the least effective means for controlling employee exposures. 

Proper use of PPE requires a comprehensive program, and calls 

for a high level of employee involvement and commitment to be 

effective. The use of PPE requires the choice of the appropriate 

equipment to reduce the hazard and the development of 

supporting programs such as training, change-out schedules, and 

medical assessment if needed. PPE should not be relied upon as 

the sole method for limiting employee exposures. Rather, PPE 

should be used until engineering and administrative controls can 

be demonstrated to be effective in limiting exposures to acceptable 

levels.

1. Develop, implement, and maintain a respiratory protection 

program for all employees to protect against TB. All 

employees should participate in training, receive medical 

clearance, and undergo fit testing as defined in the OSHA 

Respiratory Protection Standard [29 CFR 1910.134].

2. Provide (at a minimum) NIOSH-certified N95 filtering 

facepiece respirators whenever respiratory protection for 

TB is necessary. The tuberculosis exposure control plan 

indicates that employees should wear respirators in high 

hazard settings when administrative and engineering 

controls are not likely to provide adequate protection. The 

plan defines high hazard settings as those that “include close 

contact with a suspected active case of TB and entering a TB 

isolation room when it is occupied by an individual with a 

known or suspected case of TB.”

3. Instruct drivers or other employees involved in transporting 

detainees with suspected or confirmed infectious TB disease 

in an enclosed vehicle to wear at least an N95 filtering 

facepiece respirator. If the detainee has signs or symptoms 

of infectious TB disease, consider also having the detainee 

wear a surgical mask, if possible, during transport and in 

waiting areas. CDC also provides guidance on the types of 

transport vehicles that should be used to transport detainees 

with known or suspected TB [CDC 2006].

4. Develop a visitors’ policy regarding the potential use of 

respirators for regular visitors (e.g., law enforcement officials, 

social workers, clergy, and attorneys) who may be present in 

the facilities in an occupational capacity. Minimize visitors’ 

direct contact with detainees with active TB when possible 
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 25

Recommendations

(continued)

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Tsuyuguchi K, Sasaki Y, Mazurek GH, Tsuyuguchi I [2004]. Specific 

detection of tuberculosis infection: an interferon-gamma–based 

assay using new antigens. Am J Respir Crit Care Med 170(1):

59–64.

Pai M, Zwerling A, Menzies D [2008]. Systematic review: T-cellbased assays for the diagnosis of latent tuberculosis infection: an 

update. Ann Intern Med 149(3):177–184.

Rattner SL, Fleischer JA, Davidson BL [1996]. Tuberculin positivity 

and patient contact in healthcare workers in the urban United 

States. Infect Control Hosp Epidemiol 17(6):369–371.
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 27

References (continued) Schneider DL, Lobato MN [2007]. Tuberculosis control among 

people in U.S. Immigration and Customs Enforcement custody. 

Am J Prev Med 3(1):9–14.
Page 28 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Tuberculosis 

It is estimated that one third of the world’s population has latent TB infection, and approximately 5%–

10% of those infected will develop active TB disease within their lifetimes [Styblo 1980; Dye et al. 1999; 

Jasmer et al. 2002; Stewart et al. 2003]. More than 37 million foreign-born persons are currently living in 

the United States [DHS 2008]. Many of the undocumented immigrants processed by ICE annually come 

from countries with a high prevalence of TB.

In 2009, foreign-born persons accounted for 60% of all TB cases in the United States [CDC 2010a]. The 

TB case rate for foreign-born persons is more than 10 times as high as the case rate for U.S.-born persons 

(18.6 vs. 1.7 cases per 100,000 persons) [CDC 2010a]. In 2009, four countries accounted for more than 

half of the TB cases in foreign-born persons: Mexico, the Philippines, India, and Vietnam [CDC 2010a]. 

Among all foreign-born populations, TB rates are highest in the first 2 years after U.S. entry (75 vs. 16 

cases per 100,000 persons) [Cain et al. 2008]. Achkar and colleagues showed that undocumented foreignborn persons had a longer duration of symptoms before medical evaluation for TB when compared to 

U.S.-born persons and documented foreign-born persons [Achkar et al. 2008]. Schneider and Lobato 

found the TB case rate among people in ICE custody to be 12.5 per 100,000 persons in 2005, with 

patients from Mexico, Honduras, Guatemala, and El Salvador accounting for 84.4% of the cases 

[Schneider and Lobato 2007].

It has been shown that 20%–30% of TB patient case contacts will be found to have latent TB infection 

and that approximately 5% of individuals with recently acquired latent TB infection will develop active 

TB disease within 2 years [Iseman 2000; CDC 2005a]. These data, in conjunction with the higher rates 

demonstrated among foreign-born persons, suggest that individuals who come into contact with these 

recent entrants, including immigration officers and agents, are at risk for acquiring TB.

In 1996, OSHA issued revised enforcement guidelines concerning occupational TB exposure [OSHA 

1996]. The workplaces covered in those guidelines are those where the CDC has identified workers as 

having an elevated incidence of TB infection. These include healthcare settings, correctional institutions, 

homeless shelters, drug treatment centers, and long-term care facilities for the elderly. At these facilities, 

the OSHA guidelines require (1) a protocol for the early identification of individuals with active TB; (2) 

skin test surveillance for employees; (3) medical evaluation and management of employees with positive 

skin tests or symptoms of active TB; (4) placement of individuals with confirmed or suspected TB in 

isolation rooms; (5) performing high risk procedures in areas with negative pressure and appropriate 

exhausts; and (6) training and information for employees about TB transmission, signs and symptoms of 

disease, medical surveillance and follow-up therapy, and proper use of controls.

The OSHA guidelines are based on the 1994 CDC guidelines for preventing TB transmission in 

healthcare facilities, which were subsequently updated in 2005 [CDC 2005b]. This document discusses, in 

detail, the importance of administrative and engineering controls, PPE, early identification and screening, 

risk assessment, a written TB control program, skin testing programs, and employee education. The 2006 

CDC guidelines for preventing TB transmission in correctional and detention facilities also recommend a 

Appendix A: Health Effects
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 29

Appendix A: Health Effects (continued)

comprehensive program consisting of administrative, environmental, and personal respiratory protection 

controls [CDC 2006].

Environmental controls should be implemented when the risk for TB transmission persists despite efforts 

to screen and treat inmates. Environmental controls are used to remove or inactivate Mycobacterium 

tuberculosis in areas in which the organism could be transmitted. Additional information on the types of 

environmental controls used in correctional and detention facilities can be found in the CDC document, 

Prevention and Control of Tuberculosis in Correctional and Detention Facilities: Recommendations from CDC [CDC 

2006]. This document provides ventilation design considerations and air exhaust/cleaning methods for 

airborne infection isolation rooms and local and general exhaust ventilation systems in areas intended to 

contain persons with diagnosed or undiagnosed infectious TB.

One important administrative component of TB control in correctional and detention facilities involves 

routinely screening employees and inmates for latent TB infection, using the TST or an IGRA, and 

administering isoniazid treatment to those individuals testing positive. Two-step TST testing is necessary 

for those employees who have not undergone a TST in more than a year to account for the boosting 

effect [ATS and CDC 2000, ATS et al. 2000]. The ICE tuberculosis exposure control plan states that TST 

testing should be conducted at least annually on employees. Upon admission to ICE custody, detainees are 

expected to be screened for TB disease in accordance with ICE detention standards. Suspected TB patients 

are further evaluated and started or continued on treatment for TB disease if medically indicated.

The TST, also known as the intradermal Mantoux test or the PPD, was introduced in 1890. It has been 

in routine use for diagnosis of latent TB infection since 1910 and is thought to be the oldest diagnostic 

medical test still routinely used [Mandell et al. 2005].

Although the TST has been very useful in the control of TB, its limitations are well recognized. First, the 

antigens included in the PPD are shared by other nontuberculous mycobacteria. Thus, a positive reaction 

can be produced by nontuberculous mycobacteria infections or by vaccination with BCG, reducing 

the specificity. Second, the sensitivity of the TST depends on host immunity, and false-negative results 

can be seen in cases of immunosuppression or active TB disease. Third, the results of the TST can be 

influenced by the booster effect, which is the conversion of an initial negative TST when a second test 

is administered, as a consequence of a recall of immunity. Finally, the TST requires two patient visits for 

placement and reading.

In 2005, the FDA approved the QuantiFERON-TB Gold test (Cellestis Limited, Victoria, Australia), a 

whole blood IGRA used to diagnose active TB and latent TB infection [CDC 2005c]. The QuantiFERONTB Gold test is an enzyme-linked immunosorbent assay test that measures the release of interferon 

gamma in blood from sensitized persons. The antigens consist of synthetic peptides representing two 

Mycobacterium tuberculosis proteins, early secretory antigenic target 6 and culture filtrate protein 10. Blood 

is incubated with the antigens, and interferon gamma released by sensitized leukocytes is measured [Pai et 

al. 2004]. The CDC guidelines published in 2005 indicate that the QuantiFERON-TB Gold test can be 

used in any instance in which the TST is used [CDC 2005b].
Page 30 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Appendix A: Health Effects (continued)

In 2007, the FDA approved the next generation IGRA, the QuantiFERON-TB Gold in Tube test. This 

test contains an extra antigen, TB7.7, which theoretically improves sensitivity and circumvents the timeconsuming step of manually stimulating lymphocytes, as the tubes already contain the antigens. In 2008, 

the FDA approved another IGRA, the TSPOT® TB (Oxford Immunotec, Marlborough, Massachusetts) 

test. In 2010, CDC guidelines indicated that TSTs and IGRAs (QuantiFERON-TB Gold, QFT-GIT, 

TSPOT® TB) may be used as aids in diagnosing infection with Mycobacterium tuberculosis [CDC 2010b].

Advantages of these IGRAs over the TST include that they necessitate only a single patient visit, results are 

available in 24 hours, and the findings are not subject to reader bias. The early secretory antigenic target 

6, culture filtrate protein 10, and TB7.7 proteins are absent from all BCG vaccine strains and from many 

nontuberculous mycobacteria [Anderson et al. 2000]. Therefore, among previously BCG-vaccinated and 

non-BCG-vaccinated subjects, the IGRAs have high specificity [Mori et al. 2004]. Major disadvantages of 

the IGRAs include their high relative cost and the need for an equipped laboratory [Menzies et al. 2007]. 

Although the cost-effectiveness analyses of IGRA testing in immigration employee populations have not 

been conducted, one analysis of U.S. healthcare workers did demonstrate that IGRAs can lead to cost 

savings [de Perio et al. 2009]. Additionally, IGRAs have been found to be cost-effective TB screening 

strategies in other populations such as contacts of persons with active TB [Diel et al. 2007; Kowada et al. 

2008].

Indoor Environmental Quality

More than 70 million American employees spend their workday in indoor environments, and a number 

of published studies have reported symptoms among occupants of office buildings, schools, healthcare 

facilities, and other indoor work locales [Gammage and Kaye 1985; Burge et al. 1987; Kreiss 1989; 

Norbäck et al. 1990; Mendell 1993; Malkin et al. 1996; Rosenstock 1996]. Although NIOSH investigators 

have often found multiple environmental deficiencies in buildings with IEQ complaints, the relationship 

of these environmental deficiencies and symptoms reported by building occupants is often unclear.

No standards specific to the nonindustrial indoor environment exist. Measurement of indoor 

environmental contaminants has seldom proved helpful in determining the cause of symptoms except 

where there are unusual sources, or a proven relationship between specific exposures and disease. With few 

exceptions, concentrations of frequently measured chemical substances in the indoor work environment 

fall well below the published occupational standards or recommended exposure limits set by NIOSH, 

OSHA, and ACGIH [NIOSH 1988; 29 CFR 1910.1000; ACGIH 2009]. ANSI/ASHRAE has published 

recommended building ventilation and thermal comfort guidelines [ANSI/ASHRAE 2004, 2007]. 

ACGIH has also developed a manual of guidelines for approaching investigations of building-related 

symptoms that might be caused by airborne living organisms or their effluents [ACGIH 1999].Other 

resources that provide guidance for establishing acceptable IEQ are available through the EPA at http://

www.epa.gov/iaq, especially the joint EPA/NIOSH document, Building Air Quality, A Guide for Building 

Owners and Facility Managers at http://www.epa.gov/iaq/largebldgs/baqtoc.html. NIOSH also provides 

additional information on IEQ at http://www.cdc.gov/niosh/topics/indoorenv/.
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 31

Appendix A: Health Effects (continued)

Heating, Ventilating, and Air-Conditioning 

One of the most common deficiencies in the indoor environment is the improper operation and 

maintenance of ventilation systems and other building components [Rosenstock 1996]. NIOSH 

investigators have found that correcting HVAC problems often reduces reported symptoms. Most studies 

of ventilation rates and building occupant symptoms have shown that rates below 10 Ls-1/person (which 

equates to 20 cfm/person) are associated with one or more health symptoms [Seppanen et al. 1999].

Moreover, higher ventilation rates, from 10 Ls-1/person up to 20 Ls-1/person, have been associated with 

further significant decreases in the prevalence of symptoms [Seppanen et al. 1999]. Thus, improved HVAC 

operation and maintenance, higher ventilation rates, and comfortable temperature and RH may improve 

symptoms even when no specific cause-effect relationships are identified. When conducting an IEQ survey, 

NIOSH investigators often measure ventilation and comfort indicators such as CO2, temperature, and RH 

to provide information relative to the functioning and control of HVAC systems.

Carbon Dioxide 

CO2 is a normal constituent of exhaled breath and is not considered a building air pollutant. It is an 

indicator of whether sufficient quantities of outdoor air are being introduced into an occupied space. 

However, CO2 is not an effective indicator of ventilation adequacy if the ventilated area is not occupied 

at its usual level at the time the CO2 is measured. ANSI/ASHRAE recommends that the indoor CO2

concentration be within 700 ppm of the outdoor concentration for comfort (odor) reasons [ANSI/

ASHRAE 2007]. Elevated CO2 concentrations suggest that other indoor contaminants may also be 

increased. If CO2 concentrations are elevated, the amount of outdoor air introduced into the ventilated 

space needs to be increased. ANSI/ASHRAE’s ventilation standard, ANSI/ASHRAE 62.1-2007: Ventilation 

for Acceptable Indoor Air Quality, recommends outdoor air supply rates of 17 cfm/person for office spaces, 

10 cfm/person for correctional facility cells, 7 cfm/person for correctional facility dayrooms, and 9 cfm/

person for correctional facility guard stations and booking/waiting areas.[ANSI/ASHRAE 2007].

Temperature and Relative Humidity

Temperature and RH measurements are often collected as part of an IEQ investigation because these 

parameters affect the perception of comfort in an indoor environment. The perception of thermal comfort 

is related to one’s metabolic heat production, the transfer of heat to the environment, physiological 

adjustments, and body temperature [NIOSH 1986]. Heat transfer from the body to the environment is 

influenced by factors such as temperature, humidity, air movement, personal activities, and clothing. 

The ANSI/ASHRAE Standard 55-2004: Thermal Environmental Conditions for Human Occupancy, specifies 

conditions in which 80% or more of the occupants would be expected to find the environment thermally 

acceptable [ANSI/ASHRAE 2004] Assuming slow air movement and 50% RH, the operative temperatures 

recommended by ANSI/ASHRAE range from 68.5°F to 76°F in the winter, and from 75°F to 80.5°F in 

the summer. The difference between the two is largely due to seasonal clothing selection. ANSI/ASHRAE 
Page 32 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Appendix A: Health Effects (continued)

also recommends maintaining RH at or below 65% [ANSI/ASHRAE 2007]. Excessive humidity can 

promote the excessive growth of microorganisms and dust mites.

References 

ACGIH [1999]. Bioaerosols: assessment and control. Cincinnati, OH: American Conference of 

Governmental Industrial Hygienists.

ACGIH [2009]. Threshold limit values for chemical substances and physical agents, and biological 

exposure indices, for 2009. Cincinnati, OH: American Conference of Governmental Industrial Hygienists.

Achkar JM, Sherpa T, Cohen HW, Holzman RS [2008]. Differences in clinical presentation among 

persons with pulmonary tuberculosis: a comparison of documented and undocumented foreign-born 

versus U.S.-born persons. Clin Infect Dis 47(10):1277–83.

ATS (American Thoracic Society), CDC [2000]. Targeted tuberculin testing and treatment of latent 

tuberculosis infection. Am J Respir Crit Care Med 161(4):S221–47.

ATS (American Thoracic Society), CDC, IDSA (Infectious Diseases Society of America) [2000]. 

Diagnostic standards and classification of tuberculosis in adults and children. Am J Respir Crit Care Med 

161(4):1376–1395.

Andersen P, Munk ME, Pollock JM, Doherty TM [2000]. Specific immune-based diagnosis of tuberculosis. 

Lancet 356(9235):1099–1104.

ANSI/ASHRAE [2004]. Thermal environmental conditions for human occupancy. American 

National Standards Institute/ASHRAE standard 55-2004. Atlanta, GA: American Society for Heating, 

Refrigerating, and Air-Conditioning Engineers, Inc.

ANSI/ASHRAE [2007]. Ventilation for acceptable indoor air quality. American National Standards 

Institute/ASHRAE standard 62.1-2007. Atlanta, GA: American Society of Heating, Refrigerating, and AirConditioning Engineers, Inc.

Burge S, Hedge A, Wilson S, Bass JH, Robertson A [1987]. Sick building syndrome: a study of 4373 office 

workers. Ann Occup Hyg 31(4a):493–504.

Cain KP, Benoit SR, Winston CA, MacKenzie WR [2008]. Tuberculosis among foreign-born persons in 

the United States. JAMA 300(4):405–412.

CDC [2005a]. Guidelines for the investigation of contacts of persons with infectious tuberculosis: 

recommendations from the National Tuberculosis Controllers Association and CDC. MMWR 54(RR15):1–47.
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 33

Appendix A: Health Effects (continued)

CDC [2005b]. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care 

settings. MMWR 54(RR–17).

CDC [2005c]. Guidelines for using the QuantiFERON-TB Gold test for detecting Mycobacterium 

tuberculosis infection, United States. MMWR 54(RR-15):49–55.

CDC [2006]. Prevention and control of tuberculosis in correctional and detention facilities: 

recommendations from CDC. MMWR 55(RR-9):1–48.

CDC [2010a]. Decrease in reported tuberculosis cases – United States, 2009. MMWR 59(RR-10):289–294.

CDC [2010b]. Updated guidelines for using interferon gamma release assays to detect Mycobacterium 

tuberculosis infection–United States, 2010. MMWR 59(RR-5):10.

CFR. Code of Federal Regulations. Washington, DC: U.S. Government Printing Office, Federal Register. 

de Perio MA, Tsevat J, Roselle GA, Kralovic SM, Eckman MH [2009]. Cost-effectiveness of interferon 

gamma release assays vs. tuberculin skin tests in health care workers. Arch Intern Med 169(2):179–187.

DHS [2008]. Yearbook of immigration statistics: 2007. Washington, DC: U.S. Department of Homeland 

Security, Office of Immigration Statistics.

Diel R, Wrighton-Smith P, Zellweger JP [2007]. Cost-effectiveness of interferon-gamma release assay testing 

for the treatment of latent tuberculosis. Eur Respir J 30(2):321–32.

Dye C, Scheele S, Dolin P, Pathania V, Raviglione MC [1999]. Consensus statement. Global burden of 

tuberculosis: estimated incidence, prevalence, and mortality by country. WHO global surveillance and 

monitoring project. JAMA 282(7):677–686.

Gammage RR, Kaye SV, eds [1985]. Indoor air and human health: Proceedings of the Seventh Life 

Sciences Symposium. Chelsea, MI: Lewis Publishers, Inc.

Iseman MD [2000]. A clinician’s guide to tuberculosis. Baltimore, MD: Lippincott, Williams & Wilkins.

Jasmer RM, Nahid P, Hopwell PC [2002]. Clinical practice. Latent tuberculosis infection. N Engl J Med 

347(23):1860–1866.

Kowada A, Takahashi O, Shimbo T, Ohde S, Tokuda Y, Fukui T [2008]. Cost effectiveness of interferongamma release assay for tuberculosis contact screening in Japan. Mol Diagn Ther 12(4):235–251. 

Kreiss K [1989]. The epidemiology of building-related complaints and illness. Occupational Medicine: 

State of the Art Reviews 4(4):575–592.
Page 34 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Appendix A: Health Effects (continued)

Malkin R, Wilcox T, Sieber WK [1996]. The National Institute for Occupational Safety and Health indoor 

environmental evaluation experience. Part two: symptom prevalence. Appl Occup Environ Hyg. 11(6):540–

545.

Mandell GL, Bennett JE, Dolin R (ed.) [2005]. Mandell, Douglas, and Bennett’s principles and practice of 

infectious diseases, 6th ed. Philadelphia, PA: Elsevier.

Mendell MJ [1993]. Non-specific symptoms in office workers: a review and summary of the epidemiologic 

literature. Indoor Air 3(4):227–236.

Menzies D, Pai M, Comstock G [2007]. Meta-analysis: new tests for the diagnosis of latent tuberculosis 

infection: areas of uncertainty and recommendations for research. Ann Intern Med 146(5):340–344.

Mori T, Sakatani M, Yamagishi F, Takashima T, Kawabe Y, Nagao K, Shigeto E, Harada N, Mitarai 

S, Okada M, Suzuki K, Inoue Y, Tsuyuguchi K, Sasaki Y, Mazurek GH, Tsuyuguchi I [2004]. Specific 

detection of tuberculosis infection: an interferon-gamma–based assay using new antigens. Am J Respir Crit 

Care Med 170(1):59–64.

NIOSH [1986]. Criteria for a recommended standard: occupational exposure to hot environments, revised 

criteria. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control, 

National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 86–13.

NIOSH [1988]. NIOSH recommendations for occupational safety and health – Compendium of policy 

documents and statements. 1992. Cincinnati, OH: U.S. Department of Health and Human Services, 

Centers for Disease Control, National Institute for Occupational Safety and Health. DHHS (NIOSH) 

Publication No. 92–100.

Norbäck D, Michel I, Widstrom J [1990]. Indoor air quality and personal factors related to the sick 

building syndrome. Scan J Work Environ Health 16(2):121–128.

OSHA [1996]. Enforcement procedures and scheduling for occupational exposure to tuberculosis. 

Directive number CPL 02-00-106. Occupational Safety and Health Administration. Information date: 

02/09/1996.

Pai M, Riley LW, Colford JM Jr [2004]. Interferon-gamma assays in the immunodiagnosis of tuberculosis: a 

systematic review. Lancet Infect Dis 4(12):761–767.

Rosenstock L [1996]. NIOSH Testimony to the U.S. Department of Labor on indoor air quality. Appl 

Occup Environ Hyg 11(12):1365–1370.

Schneider DL, Lobato MN [2007]. Tuberculosis control among people in U.S. Immigration and Customs 

Enforcement custody. Am J Prev Med 3(1):9–14.
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 35

Appendix A: Health Effects (continued)

Seppanen OA, Fisk WJ, Mendell MJ [1999]. Association of ventilation rates and CO2 concentrations with 

health and other responses in commercial and institutional buildings. Indoor Air 9:226–252.

Stewart GR, Robertson BD, Young DB [2003]. Tuberculosis: a problem with persistence. Nat Rev 

Microbiol 1:97–105.

Styblo K [1980]. Recent advances in epidemiological research in tuberculosis. Adv Tuberc Res 20:1–63.
Page 36 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Appendix B: Tables

Table B1. Ventilation air flow measurements collected at the BSSA facility on April 8 and April 9, 2009

Area

Measured supply 

airflow (cfm)

Measured return 

airflow (cfm)

Air pressure relationship 

to adjacent area

Holding Cell 129 233 75 Positive

Processing Area (Room 130) 556 339 Negative

Holding Cell 139 569 268 Positive

Holding Cell 140 389 259 Positive

Holding Cell 141 379 110 Positive

Isolation Cell 143 99 45 Positive

Interview Area (Room 144) 103 48 Positive

Detainee Side of Visitor’s Area 95 0 Positive

Property Room 99 No return vent Positive
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 37

Appendix B: Tables (continued)

Table B2. CO2, temperature, and relative humidity data collected at the BSSA and CDO facilities

Area CO2

 concentration 

(ppm) Temp (°F) RH (%)

BSSA (4/8/2009–4/9/2009)

Detention Hallway (across from Cell 140) 365–1245 68–73 13–25

Processing 397–651 68–71 16–19

Receiving and Discharge 408–846 74–78 10–18

Second Floor Kitchen 396–773 23–24 13–17

Squad Room 445–873 74–78 11–19

Outdoors 393–440 47–66 15–33

Holding Cell 139* 1540 74 22

Holding Cell 140† 675 74 17

Holding Cell 141‡ 1305 73 25

CDO (8/10/2009–8/11/2009)

Courtroom 1 (basement) 377–964 72–77 51–67

Detainee Processing Area South (basement) 351–1065 76–78 49–69

Detainee Processing Area North (basement) 284–934 72–77 53–76

Employee Cubicle Area (basement) 317–707 75–81 44–59

Family Waiting Room (fourth floor) 366–1213 72–76 45–62

Cubicle 4809 (fourth floor) 383–764 73–75 46–64

Interview Room 4002 (fourth Floor) 349–803 68–73 50–62

Holding Cell B04§ 550 71 64

Holding Cell B05¶ 575 71 65

Holding Cell B06** 590 71 67

Holding Cell B08¶ 518 70 71

Outdoors 394 75 76

* 40 detainees in cell † 4 detainees in cell ‡ 35 detainees in cell

§ 5 detainees in cell ¶ 0 detainees in cell ** 6 detainees in cell
Page 38 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Appendix B: Tables (continued)

Table B3. Ventilation air flow measurements collected at the CDO facility on August 10–11, 2009, 

and calculated ACH 

Area

Measured 

supply airflow 

(cfm)

Measured 

return airflow 

(cfm)

Calculated ACH Air pressure relationship to 

adjacent area

Processing Area 330 315 4.9

Negative (to adjacent 

non-detainee areas) 

Bidirectional* to some 

detainee cells

Holding Cell B03 376 76 1.5 Bidirectional*

Holding Cell B04 367 415 8.3 Bidirectional*

Holding Cell B05 374 251 5.1 Bidirectional*

Holding Cell B06 363 548 11.6 Bidirectional*

Holding Cell B07 336 518 10.8 Negative

Holding Cell B08 427 622 9.7 Negative

Holding Cell B16 52 111 10.6 Negative

Courtroom 1 231 0 0.0 Not measured

Courtroom 2 261 221 3.4

Bidirectional* measured at 

doorway to adjacent secure 

hallway

Courtroom 

Administration Area 108 233 Not calculated Not measured

Judge Office 1 101 107 Not calculated Not measured

Judge Office 2 139 0 Not calculated Not measured

* Air moved in different directions at the top and bottom of the doorway.
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 39

Introduction 

The following good practice guidelines for maintaining acceptable IEQ during construction and 

renovation projects were prepared to serve as objective criteria for the evaluation of building construction 

and renovation practices by NIOSH. They are also intended to be educational and informative. These 

guidelines were prepared from information contained in two reference documents along with our own 

collective experience. These two reference documents are “IAQ Guidelines for Occupied Buildings Under 

Construction,” prepared and published by the Sheet Metal and Air-Conditioning Contractors’ National 

Association, Inc. [SMACNA 2007] and “Construction/ Renovation Influence on Indoor Air Quality” 

by Dr. Thomas Kuehn, an article published in the October 1996 issue of the ASHRAE Journal [Kuehn 

1996].

Background

Construction and renovation projects can adversely affect building occupants by the release of 

airborne dusts, gases, organic vapors, and odors during construction, renovation, demolition, repair, or 

reconfiguration activities. Microbiological contaminants can also be released during construction and 

renovation activities. Two sources of contaminants, those generated from inside the building and those 

generated from outside the building, need to be considered. There are several important distinctions 

regarding exposures of construction workers versus exposures of nonconstruction workers (building 

occupants). These differences are critically important in the development of management strategies to (1) 

ensure awareness on the part of the construction contractors of the potential impact of construction and 

renovation activities on building occupants, (2) anticipate construction and renovation activities that may 

generate contaminants, and (3) implement controls to minimize or prevent exposures of both construction 

and renovation workers and building occupants. Foresight and planning are necessary prerequisites to 

prevent IEQ-related complaints during building construction and renovation activities. Even nuisance 

odors and dusts from construction and renovation activities can be triggering factors, resulting in 

complaints from building occupants. These complaints can be due to actual symptoms resulting from 

exposures or to a perceived risk of exposures to unknown materials, which may or may not be an actual 

health hazard.

Effective maintenance of acceptable IEQ during construction and renovation activities requires a collective 

effort and input from building managers, the general contractor, subcontractors, engineers, and building 

occupants. Input from HVAC professionals and architects is important to assess ventilation system 

performance when making design changes or implementing control measures. The ability and desire for 

effective communication between all parties is essential, especially during rapidly changing circumstances, 

which are often a hallmark of construction- and renovation-related activities.

Appendix C: Good Practice Guidelines for Maintaining Acceptable

Indoor Environmental Quality During Construction

and Renovation Projects
Page 40 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Appendix C: Good Practice Guidelines for Maintaining Acceptable Indoor Environmental Quality During Construction and Renovation Projects 

(continued) 

Guidelines for Initial Planning 

The initial stage of any construction or renovation activity is the appropriate time to develop a site- and 

activity-specific plan to control contaminants that may affect construction or renovation workers and 

building occupants.

● Identify all key personnel (representatives from the building and general contractor) responsible for 

addressing construction- or renovation-related activities and airborne contaminant control. Other 

personnel such as building staff, engineers, and subcontractors, should be involved as necessary.

● Develop a construction or renovation impact assessment describing anticipated work activities, along 

with their associated source contaminants, generation points, and areas potentially affected by the 

release of air contaminants.

● Develop a detailed budget for the contaminant control methods to be utilized.

Guidelines for Bid Specifications 

Bid document specifications should be developed. In addition to general control measures, the bid 

document should include the particular control measures appropriate for the specific construction or 

renovation project being proposed. These bid specifications should be clearly written to reduce the 

likelihood of misinterpretation.

● Identify the specific controls needed for the construction or renovation project along with the 

appropriate performance metrics, and write specifications into the bid document accordingly.

● Require the general contractor to designate a representative to handle IEQ issues and establish 

appropriate channels of communication with subcontractors.

● Specify construction or renovation conditions that would require an emergency response (such as a 

contaminant release into an occupied area).

Guidelines for Control Options 

Because a variety of methods are available for the control of both indoor- and outdoor-generated 

contaminants, the most effective and cost efficient strategies should be considered for implementation.

● Schedule construction or renovation work during periods of low building occupancy or low 

occupancy adjacent to the work areas, if possible.
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 41

Appendix C: Good Practice Guidelines for Maintaining Acceptable Indoor Environmental Quality During Construction and Renovation Projects 

(continued)

● Isolate work areas from occupied areas using critical barriers, negative and positive pressurization, 

HEPA filtration, as necessary, and minimize the number of building penetrations required for the 

construction or renovation activities.

● Negatively pressurize work areas and/or positively pressurize occupied areas to prevent migration of 

air contaminants from work areas to occupied areas.

● Modify HVAC operations as necessary during times of construction or renovation to ensure 

isolation of work areas from occupied areas. This could include increasing the HVAC outdoor air 

intake filtration efficiency and temporarily relocating the HVAC outdoor air intakes serving the 

occupied areas.

● Maintain an adequate unoccupied buffer zone around the work areas to allow for construction or 

renovation traffic and to ensure acceptable IEQ. This could require temporarily relocating building 

occupants in the immediate vicinity of the work areas.

● Increase housekeeping activities in adjacent occupied areas during construction or renovation 

projects.

● Specify low-emitting materials for use in construction or renovation projects to reduce the likelihood 

of contaminant generation.

Guidelines to Protect HVAC Systems 

Protect the HVAC system(s) serving the construction or renovation areas from damage or contamination.

● Disable, if possible, the HVAC system(s) serving the construction or renovation areas.

● Isolate portions of the HVAC system where appropriate to prevent damage or contamination.

● Block or seal return air grilles in construction or renovation areas.

● Upgrade filtration efficiency in the HVAC systems continuing in use during construction or 

renovation.

● Do not store construction materials or equipment in HVAC mechanical rooms.

Guidelines for Good Work Practices 

Good work and housekeeping practices that minimize contaminant release and ensure acceptable IEQ are 

essential to the success of any construction or renovation project.

● Use local exhaust ventilation with HEPA filtration where dust generation is anticipated. If local 

exhaust is not feasible, portable air cleaning devices could be used as appropriate.
Page 42 Health Hazard Evaluation Report 2009-0047 and 2009-0193--3114

Appendix C: Good Practice Guidelines for Maintaining Acceptable Indoor Environmental Quality During Construction and Renovation Projects 

(continued) 

● Use work practices and materials that result in little or no generation of airborne contaminants 

during construction or renovation activities, such as wet methods to suppress dust generation.

● Identify routes for construction or renovation traffic through unoccupied areas and away from 

building openings to occupied areas.

● Use HEPA vacuums and damp mop regularly to clean floors and ledges during construction or 

renovation activities.

● Bag and promptly remove off site all construction or renovation debris through demolition chutes 

on the exterior of building and/or through other dedicated perimeter wall penetrations.

● Locate dumpsters and salvage bins away from operating HVAC outdoor air intakes and exterior 

doors to occupied areas.

Guidelines to Implement Project Specifications 

Effective implementation and management of the construction or renovation project is essential to 

maintain acceptable IEQ for the building occupants.

● Ensure that the general contractor’s IEQ designee is adequately trained and has the authority to 

immediately correct problems affecting IEQ as they arise.

● Hold regularly scheduled meetings between building representatives, the general contractor, 

subcontractors, and other personnel as appropriate to ensure the acceptability of IEQ.

● Monitor construction or renovation activities carefully so that all work conforms to the bid 

document specifications.

● Monitor the pressurization of both construction or renovation and occupied areas to ensure that the 

complete isolation of the work area is maintained.

● Monitor for airborne contaminants in the occupied areas as appropriate to ensure acceptable IEQ.

Guidelines to Maintain Effective Communication 

Ensure that effective communication exists between building occupants, the project manager, the general 

contractor, subcontractors, and other personnel as appropriate.

● Prior to the start of construction or renovation activities, communicate the scope of work and the 

precautions that will be used to control the release of contaminants.
Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 43

Appendix C: Good Practice Guidelines for Maintaining Acceptable Indoor Environmental Quality During Construction and Renovation Projects 

(continued)

● During the construction or renovation project, update building occupants regarding the project’s 

progress and other pertinent information.

● Promptly respond to complaints from building occupants regarding construction- or renovationrelated IEQ issues and specify any situations requiring an emergency response.

Guidelines to Commission Work Area 

● Use 100% outdoor air to ventilate the work areas before and during initial occupancy.

● Ensure the HVAC system(s) in the work areas are tested and balanced, preferably before occupancy.

● Monitor for airborne contaminants in the work areas (as necessary) to ensure acceptable IEQ during 

initial occupancy.

References 

SMACNA [2007]. IAQ guidelines for occupied buildings under construction. 2nd edition. Chantilly, VA: 

Sheet Metal and Air Conditioning Contractors’ National Association, Inc. ANSI/SMACNA 008–2008.

Kuehn T [1996]. Construction/renovation influence on indoor air quality. ASHRAE Journal 38(10):

22–29.
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Health Hazard Evaluation Report 2009-0074 and 2009-0193-3114 Page 45

Acknowledgments and

Availability of Report

The Hazard Evaluations and Technical Assistance Branch 

(HETAB) of the National Institute for Occupational Safety and 

Health (NIOSH) conducts field investigations of possible health 

hazards in the workplace. These investigations are conducted 

under the authority of Section 20(a)(6) of the Occupational Safety 

and Health (OSHA) Act of 1970, 29 U.S.C. 669(a)(6) which 

authorizes the Secretary of Health and Human Services, following 

a written request from any employer or authorized representative 

of employees, to determine whether any substance normally found 

in the place of employment has potentially toxic effects in such 

concentrations as used or found. HETAB also provides, upon 

request, technical and consultative assistance to federal, state, and 

local agencies; labor; industry; and other groups or individuals to 

control occupational health hazards and to prevent related trauma 

and disease.

The findings and conclusions in this report are those of the 

authors and do not necessarily represent the views of NIOSH. 

Mention of any company or product does not constitute 

endorsement by NIOSH. In addition, citations to websites 

external to NIOSH do not constitute NIOSH endorsement of 

the sponsoring organizations or their programs or products. 

Furthermore, NIOSH is not responsible for the content of these 

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accessible as of the publication date.

This report was prepared by Marie A. de Perio and R. Todd 

Niemeier of HETAB, Division of Surveillance, Hazard Evaluations 

and Field Studies. Industrial hygiene field assistance was provided 

Gregory Burr. Medical field assistance was provided by Michael 

Knipp, Barbara Mackenzie, Deborah Sammons, Mary Staresinich, 

Saify Talib, and Linda Boyer. Analytical support was provided 

by the University of Illinois at Chicago reference laboratory. 

Statistical support was provided by Matthew Groenewold. Health 

communication assistance was provided by Stefanie Evans. 

Editorial assistance was provided by Ellen Galloway. Desktop 

publishing was performed by Robin Smith.

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Below is a recommended citation for this report:

NIOSH [2010]. Health hazard evaluation report: evaluation of exposure to 

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Perio MA, Niemeier RT. Cincinnati, OH: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, National Institute for 

Occupational Safety and Health, NIOSH HETA No. 2009-0074; 2009-0193-3114.

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