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Circular 95-09


DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Indian Health Service
Rockville, Maryland 20857

Refer to: OHP

INDIAN HEALTH SERVICE CIRCULAR NO. 95-09

Effective Date:  05/23/1995

TUBERCULOSIS INFECTION CONTROL POLICY

  1. PURPOSE.  To establish responsibilities and procedures for reducing the risk of Mycobacterium (M.) tuberculosis (TB) transmission in Indian Health Service (IHS) operated health care facilities, and to health care workers (HCW), patients, volunteers, and other persons in these settings.

  2. SCOPE.  This policy applies to all Indian Health Service.  (IHS) employees, including Federal employees assigned to tribally operated programs under Public Law (P.L.) 93-638, the Indian Self-Determination and Education Assistant Act, as amended, and programs funded under Title V of Public Law (P.L.) 94-437, the American Indian Health Care Improvement Act, as amended.  Tribally-operated health care facilities are encouraged to adopt this or a similar policy.

  3. OBJECTIVES.

    1. To prevent the transmission of TB from infected patients or visitors to Health care workers (HCWs).

    2. To protect IHS patients and visitors to IHS health care facilities from being infected with TB.

    3. To comply with Occupational Safety Health Administration (OSHA) regulations Title 29 Part 1960.16 of the Code of Federal Regulations (CFR) and Executive Order 12196, Section 1-201.

  4. RESPONSIBILITIES.

    1. Headquarters Technical Consultant on TB Control.  The Associate Director, Office of Health Programs (OHP), or his/her designee, shall be the IHS technical consultant for the control of exposure to TB.

    2. Area Technical Consultant on TB control.  The Area Chief Medical Officer (CMO), or his/her designee, shall be the technical consultant for service units, Title V programs, and P.L. 93-638 contractors.  The CM0 shall act as consultant for the implementation of exposure control plans and other aspects of this policy.

    3. Service Unit Directors and P.L. 93-638 Program Directors.  The Directors of IHS-operated service units and P.L. 93-638 contracted/compacted programs shall assume responsibility for the implementation of the requirements of 29 CFR 1960.16 and Executive Order 12196, Section 1-201 at the local level.  Implicit in these responsibilities is preventing occupational exposure to TB.

  5. POLICY.  Managers of each health care facility shall designate an individual or group of persons as the TB control officer or the TB control committee.  This individual or group is responsible for implementation of the applicable TB exposure control measures contained in this document.  A high level of suspicion on the part of health care providers is a prerequisite for an effective tuberculosis control program.  It is the undiagnosed patient who poses the greatest risk.  Diagnosis brings about treatment, which usually reduces infectiousness rapidly.  An effective TB exposure control program requires early detection, isolation, and treatment of persons with active TB.

    1. The TB exposure control program shall be accomplished by the application of a hierarchy of control measures, including:

      1. Use of administrative measures to reduce the risk of exposure to persons with infectious TB;

      2. Use of effective engineering controls to prevent the spread and reduce the concentration of infectious droplet nuclei; and

      3. Use of personal respiratory protection equipment in areas where there is still a risk of exposure to TB such as isolation rooms.

    2. Specific TB control measures required include:

      1. A facility-wide or program specific TB risk assessment shall be conducted to identify factors likely to increase exposure, to identify employees at risk of exposure, and to identify control measures necessary to reduce TB exposure.

      2. Each facility or program shall use the information from the risk assessment to develop a TB exposure control plan tailored to that facility.  See Appendix C for an example of a model TB exposure control plan.

      3. Each inpatient facility shall have at least one isolation room that meets the Centers for Disease Control and Prevention (CDC) recommendations for Acid Fast Bacilli isolation.  Additional isolation rooms shall be provided based on the results of the risk assessment.

      4. Ambulatory care settings in which patients with TB frequently receive health care services shall have at least one negative pressure room where these patients can be seen.  The need for the negative pressure room shall be based on the risk assessment.

      5. Each facility that conducts high risk procedures (sputum induction, administration of aerosolized medication, etc.) shall have local exhaust ventilation devices (e.g., booths or special enclosures) or rooms under negative pressure with at least 12 air changes per hour, where these procedures will be performed.

      6. Each facility shall ensure that all engineering controls utilized to prevent the transmission of TB are properly installed and maintained.

      7. Each facility or program shall develop, implement, and maintain a respiratory protection program to protect employees against TB.  The respiratory protection program must comply with the requirements set forth in the OSHA "Enforcement Policy and Procedures for Occupational Exposure to Tuberculosis," and 29 CFR 1910.134.

      8. All HCWs shall receive education about TB that is appropriate to their job category.  Training shall be conducted before initial assignment and subsequently on a periodic basis.  Contract and agency HCWs shall receive appropriate training by the company/sponsoring agency before assignment at an IHS facility.

      9. All facilities shall have an employee TB skin testing program in place, as described in Appendix A, "Tuberculosis Skin Testing Program."  The program will apply to all permanent and temporary, full-time and part-time employees, tribal personnel, volunteers and trainees assigned to IHS facilities who are considered by the facility's employee health physician to be at risk for contracting TB by virtue of exposure in the course of their assigned duties.

        Screening and prophylactic treatment will be offered in accordance with guidelines published by the IHS, CDC, and the American Thoracic Society.  Contract and agency HCWs shall be tested and cleared by the company before assignment at an IHS facility.

      10. Individuals assigned to implement the health care facility TB control program and officials of health departments (tribal, State, local) shall coordinate their efforts to perform appropriate contact investigations on patients and HCWs with active TB.  A discharge plan coordinated with the patient or HCW, the health department, and the inpatient facility shall be implemented.

  6. REFERENCES.

    "The IHS Standards of Care for Tuberculosis:  INH preventive therapy."  The IHS Primary Care Provider.  1989; 14:54-58.

    "Treatment of Tuberculosis and Tuberculous Infection in Adults and Children."  Am J Respir Crit Care Med 149:1359-1374, 1994.

    "Screening for Tuberculosis and Tuberculous Infection in High-Risk Populations and The Use of Preventive Therapy for Tuberculous Infection in the U.S." MMWR 39: Supplement No. RR-8, May 18, 1990.

    "Diagnostic Standards and Classification of Tuberculosis." Amer Rev Respir Dis 142:725-735. 1990.

    "Prevention and Control of Tuberculosis in Facilities Providing Long Term Care to the Elderly." MMWR 39:  Supplement No. RR-l0, July 13, 1990.

    "Enforcement Policy and Procedures for Occupational Exposure to Tuberculosis."  U.S. Department of Labor (OSHA) Memorandum, October 8, 1993.

    "Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Facilities, 1994."  Centers for Disease Control and Prevention: MWWR 43: No. RR-13, October 28, 1994.

    "Control of Tuberculosis in the United States".  Amer Rev Respir DIS 146:1623-1633, 1992.

    Appendix B - Definitions of terms related to the control of Tuberculosis.

  7. SUPERSEDURE.  This circular supersedes IHS Circular 92-14, "Tuberculosis Testing Program, IHS Personnel - Policy", and the Interim Policy and Procedures for Occupational Exposure to Tuberculosis established by memorandum from the Acting Director, IHS, dated March 11, 1994.

  8. EFFECTIVE DATE:  This circular is effective upon the date of signature by the Director, IHS.

/Michael H. Trujillo, M.D./
Michael H. Trujillo, M.D., M.P.H.
Assistant Surgeon General
Director, Indian Health Service

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