Administrative Controls

Administrative controls are the key for minimizing the occupational acquisition of TB in an AOD program. Administrative controls are intended to result in the early detection of active TB among both patients and employees. Administrative controls will include screening mechanisms, such as patient and new employee questionnaires designed to elicit complete medical histories and to identify risk factors. (See chapter 5 for a discussion of questionnaires.) Administrative controls will also include tuberculin skin testing for new employees and written policies for the referral for evaluation and treatment of those who have positive PPD results.

Administrative controls will emphasize the importance to both patients and staff of identifying, isolating, and treating active disease at the earliest possible instance. Administrative controls will provide for periodic PPD testing and assessment of symptoms or chest x-rays for both patients and staff. In devising administrative controls, programs must proceed from this clear conviction with respect to TB: The best thing any program can do for its patients and staff is to put in place a policy that will result in the prompt identification, isolation, evaluation, and treatment of persons who pose a threat of transmitting the disease to others.

Engineering Controls

Because of the costs involved, and the expertise required to install and maintain them, the full gamut of engineering controls may not be possible or realistic for many AOD programs. Engineering controls involve developing specifically designated areas that meet the engineering standards for respiratory isolation. Such engineering standards are rigidly defined and are not commonly found, even in most hospitals. They include the use of adequate ventilation systems, high-efficiency particulate air filters, and special ultraviolet lighting in high-risk areas. Those controls are intended to reduce the concentration of infectious droplet nuclei in the air, prevent the transmission of such nuclei throughout the facility, or render the nuclei noninfectious by killing the tubercle bacilli they contain.

Assuming the space and resources, AOD programs in areas where TB and substance abuse are linked should try to develop an area or room with such controls. Such a project should be undertaken only in consultation with environmental engineers from the local or State public health departments or from other appropriate agencies or organizations. Once the appropriate engineering controls are in place, the designated area or room can be used as an isolation or holding area for any patient or applicant who is suspected of having infectious TB. The patient or applicant will remain in this area until he or she can be transferred to a medical facility.

When Are Masks (or Respirators) Necessary?

Assuming that effective administrative controls are in place, masks are the least important of the three components of the recommended hierarchy of controls. This is at least true for the typical AOD program, since, generally, masks protect only the wearer. Masks are required only when interacting with someone who is or may be infectious, for example, when one is in the same room with such a person or when one is transporting such a person in an enclosed vehicle. Employees who may need to resort to masks to protect themselves must be instructed in their proper use. Masks should also be available for persons who are potentially infectious. Such persons should be isolated and instructed to wear masks and observe other precautions both while awaiting and during transfer to a medical facility. Unless a program functions as a full-service health care facility, employees should not attempt to counsel potentially infectious persons until infectiousness has been ruled out. Programs should contact local occupational safety experts for guidance as to the selection, use, and maintenance of masks, and the development of a respiratory protection program.

New Employees Should Be Screened for TB

New employees should be screened via an appropriately detailed questionnaire and a two-step PPD procedure (see chapter 5). Those with positive PPDs should be evaluated for symptoms and sent for chest x-rays to rule out infectious TB. If a new employee presents with suspected or confirmed infectious TB, he or she should be referred for appropriate evaluation and medical treatment; this employee should not be permitted to begin or return to work until infectious disease is ruled out. Employees should be counseled about the importance of participating in TB screening. Programs should bear the costs of screening procedures or arrange to have screening done by a public health agency.¹

Employees Should Be Counseled About the Risk of Acquiring TB on the Job

Employees should be counseled regarding the specific situations that might put them at increased risk for TB. Counseling should occur at the earliest possible point in the hiring process and periodically thereafter. Special attention should be paid to the risks of acquiring TB on the job for those who are immunosuppressed, namely, those with HIV or other immunosuppressing conditions or those on immunosuppressive therapies. Employees (new or continuing) who are at increased risk for TB should be given the option of working in areas where the risk of acquiring TB on the job is minimized. Working in a high-risk situation should be voluntary on the part of the employee. Unless it would cause undue hardship for them, employers must find alternative work for employees if they request transfer to a lower risk work situation. AOD programs must be particularly sensitive to those sorts of accommodations.

Employees Should Receive Annual PPDs

Employees should be given PPDs annually. Careful records should be kept to identify

on-the-job converters. Employee records should also reflect whether a given employee does or does not have contact with other employees. Such records can help programs to identify inadequacies in their controls. Finally, as with initial screenings, the employee should not have to bear the costs of an annual PPD.

PPD Conversions Must be Analyzed

Programs must analyze PPD conversions to determine whether conversions are a result of patient contact. If so, this is evidence that a program's administrative and other controls are inadequate, and that the program is seeing patients with unrecognized TB. A program that encounters such problems should review its risk assessment.

Contact Investigation Policy

Programs should have a contact investigation policy to determine the source of on-the-job exposures to TB. An appropriate policy will provide for:

1. The identification of those exposed to TB on the job
2. PPD testing at baseline and after 12 weeks to identify those who convert as a result of the exposure
3. Evaluation for active disease
4. Referral for treatment or preventive therapy (or provision of same).

Employee Training on Workplace Safety

Employees should receive annual training on TB and workplace safety. Attendance at such training should be mandatory and should be recorded. The training must be conducted by someone who is versed in both TB and the workplace safety features outlined above. This training should be supplemented by a TB library for both patients and staff. Programs should not rely on videotaped training unless the tapes are presented by someone who can answer employee questions about TB and workplace safety.

Review of Workplace Safety Practices

Programs should periodically review not only their risk assessments and on-the-job conversion rates, but also their employee infection control practices.