Scope of TB Inspections
Inspections for occupational exposure to TB should be conducted only in response to employee complaints, related fatalities/catastrophes, or as part of industrial hygiene inspections in workplaces identified by the CDC as having a greater incidence of TB infection, according to the OSHA directive. The five high-risk workplaces are as follows:
- Health care facilities
- Correctional institutions
- Long-term care facilities
- Homeless shelters
- Drug-treatment centers
Health care facilities include hospitals where patients with confirmed or suspected TB are treated or to which they are transported, according to the directive. Coverage of nonhospital settings, such as physicians' offices and clinics, extends only to personnel present during the performance of high-hazard procedures on suspect or active TB patients. Dental health care workers are covered only if they treat suspect or active TB patients in a hospital or correctional facility.
All such inspections should include a review of the employer's plan for TB protection and may include the infection control, respiratory protection, and/or skin-testing programs. Employee interviews and site observations also may be included in the evaluation.
The directive also states the following:
- State-run occupational safety and health programs are required to adopt the federal policy or one that is equally effective
- Complaints from state and local government employees who are outside OSHA's jurisdiction in federal program states will be forwarded to the appropriate state agency
- Federal agencies may be cited for failing to protect workers from exposure to TB under authority of Executive Order 12196, Section 1-201(a), which requires agencies to provide places of employment that are free from recognized hazards likely to cause death or serious physical harm
 Inspection Procedures
When conducting a workplace inspection, OSHA inspectors generally must follow procedures described in the agency's Field Inspection Reference Manual (see OSHA Enforcement).
For TB-related inspections, however, there are some modifications to the usual procedures. According to the directive, these are as follows:
- Upon entry to the facility, the inspector should request the presence of the infection control director and employee health professional responsible for occupational hazard control. Individuals who may be asked to provide pertinent records include the training director, facilities engineer, director of nursing, and others.
- Before proceeding with the TB portion of an inspection, the inspector should establish whether the facility has had a suspect or confirmed case of TB within the previous six months. This may be determined through interviews or a review of infection control data.
- If the facility has had a suspect or confirmed TB case within the previous six months, the inspection should proceed and the inspector should verify implementation of the employer's TB control plan through employee interviews and direct observation. The inspector may use professional judgment to determine which areas of the facility to inspect during the walk-through (e.g., the emergency room, respiratory therapy areas, bronchoscopy suites, and the morgue).
- Inspectors who conduct smoke-trail visualization tests (i.e., to verify negative pressure isolation) should review the protocol for conducting such tests in Appendix B of the directive (see OSHA TB Compliance Directive) and should be prepared to provide the employer with a material safety data sheet for the smoke released by the test.
 General Duty Clause Citations
The Occupational Safety and Health Act's general duty clause (Section 5[a]) requires employers to provide a workplace free of hazards likely to cause death or serious physical harm. An employer may be cited for a violation of the general duty clause with respect to TB hazards in cases where employees have exposure as defined in the following ways:
- Exposure to the exhaled air of an individual with suspect or confirmed pulmonary TB disease. A "suspect" case is defined as one in which the facility has identified an individual as having symptoms consistent with TB. Such symptoms are productive cough, coughing up blood, weight loss, loss of appetite, lethargy/weakness, night sweats, or fever.
- Exposure to a "high-hazard procedure" performed on an individual with suspect or confirmed TB disease, which has the potential to generate potentially infectious airborne respiratory secretions. Examples of high-hazard procedures include aerosolized medication treatment, bronchoscopy, sputum induction, endotracheal intubation and suctioning procedures, emergency dental, endoscopic procedures, and autopsies.
 Abatement Methods
In cases where a TB hazard is found to exist in a facility, the directive describes five "feasible and useful abatement methods" that the employer is required to use to abate the hazard. Deficiencies found in any of these areas may result in the continued existence of a serious hazard and, therefore, may result in a general duty clause citation, according to the directive.
The five abatement methods are as follows:
- A protocol for the early identification of individuals with active TB.
- Medical surveillance of employees: (a) Initial exams with TB skin tests (see box, "Mantoux (PPD) Skin Tests") should be offered to all current, potentially exposed employees and to all new employees prior to exposure. Follow-up and treatment evaluations also should be offered at no cost to workers. (b) Periodic evaluations, with TB skin testing should be conducted every three months for workers in high-risk categories, every six months for workers in intermediate risk categories, and annually for low-risk personnel. (c) Reassessment should be provided following unprotected exposure to a TB suspect or confirmed infectious patient. An employee who develops symptoms of TB disease should be evaluated immediately and in accordance with CDC guidelines.
- Case management of infected workers including appropriate physical, laboratory, and radiographic evaluations for individuals who experience a skin-test conversion and work restrictions for infected employees.
- Education and training of all current employees and new workers, upon hire, to ensure knowledge of such issues as mode of TB transmission, its signs and symptoms, medical surveillance and therapy, and site-specific protocols, including purpose and use of controls. Training should be repeated as needed. Workers should be trained to recognize and report to a designated person any patients with symptoms suggestive of infectious TB and also should be instructed on post-exposure protocols to be followed after an exposure incident.
- Engineering controls. The use of each control measure should be based on its ability to abate the hazard. Controls include the following: (a) acid-fast bacilli (AFB) isolation-room placement of individuals with suspect or confirmed infectious TB disease and performance of high hazard procedures on such patients in AFB treatment or isolation rooms, booths, and/or hoods; (b) negative-pressure ventilation for isolation and treatment rooms in use by patients with suspect or confirmed TB disease; (c) air exhausted from AFB isolation or treatment rooms must be exhausted directly outside or, if recirculation is unavoidable, filtered through regularly monitored and maintained HEPA filters (the air handling system must be marked with a TB warning to maintenance personnel.); (d) all potentially contaminated air must be kept under negative pressure until safely discharged outside away from air intakes and occupied areas; (e) air from isolation and treatment rooms must be decontaminated by a recognized process, such as HEPA filtration, before recirculation back to the isolation/treatment room and ultraviolet radiation may not be the sole means of decontamination (except in waiting rooms, emergency rooms, etc., in accordance with CDC guidelines); (f) if high-hazard procedures are performed within AFB isolation or treatment rooms without source control or local exhaust ventilation (e.g., hood, booth, tent, etc.), and droplets are released into the environment, such as through coughing, then a purge time interval must be imposed during which personnel must use a respirator when entering the room; and (g) interim or supplemental ventilation units equipped with HEPA filters are acceptable.
 Required Use of Respirators
For health care workers who are required to wear respirators for protection against TB, the requirements of OSHA's respiratory protection standard for M. tuberculosis (29 CFR 1910.134 ) apply.
[Editor's note: In the final rule implementing its comprehensive respiratory protection standard, OSHA redesignated the original text found at 29 CFR 1910.134 as 29 CFR 1910.139, "Respiratory protection for M. tuberculosis." On December 31, 2003, OSHA withdrew the proposed TB standard, revoked 29 CFR 1910.139, and declared that all TB exposures fall under the 1998 revisions to 29 CFR 1910.134. For full text of the standard, see Occupational Safety and Health Standards: Subpart I - Personal Protective Equipment ]
OSHA's enforcement policy concerning required respirator use for TB is set out in the compliance directive, "Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis" (OSHA Instruction CPL 2.106). These enforcement procedures are based, in part, on the CDC's 1994 guidelines for preventing the transmission of M. tuberculosis in health care settings. Like the CDC recommendations, OSHA's directive clarifies that health care workers should use certified and appropriate respirators for protection against TB in the following situations:
- When employees enter rooms that house individuals with suspected or confirmed infectious TB
- When employees perform high-hazard procedures on individuals who have suspected or confirmed infectious TB (e.g., aerosolized medication treatment, bronchoscopy, sputum induction, endotracheal intubation and suctioning procedures, and autopsies)
- When emergency medical response personnel or others must transport, in enclosed vehicles, individuals with suspect or confirmed infectious TB
 Choice of Respirators
OSHA's respiratory protection standard requires that wherever respirators are required to protect the health of the employee, the employer must provide respirators that are applicable and suitable for the purpose intended.
Under its compliance directive, OSHA enforces the performance criteria recommended by the CDC for selecting a respirator suitable for use against TB. Such respirators must be
Under current NIOSH certification standards, the minimally acceptable level of protection to be used is the N-95 half-mask respirator, according to the directive. HEPA filter respirators that were certified under former NIOSH standards also remain acceptable.
 Respiratory Protection Programs
Wherever employees are required to use respirators for protection against TB, the employer is required to establish a written respiratory protection program. Employers that fail to comply may be cited for violation of the respiratory protection standard for M. tuberculosis, according to the OSHA directive.
The respiratory protection program should cover elements that include the following:
- Written standard operating procedures on selection and use of respirators
- Employee training in the use, limitations, proper fit, and maintenance of respirators
Reuse of disposable respirators is permitted by the same health care worker, as long as the respirator maintains its structural and functional integrity and the filter material is not physically damaged or soiled. The facility must address, in its respiratory protection program, the circumstances in which a disposable respirator will be considered contaminated and not available for reuse.
All issues relating to the use of respirators for protection against TB will be considered by OSHA, according to a September 6, 1995, memorandum to regional administrators (see OSHA Memorandum: Update on TB Respirators ). The requirements of OSHA's respiratory protection standard for M. tuberculosis should be followed, according to "Update: OSHA Enforcement Policy for Occupational Exposure to Tuberculosis," September 6, 1995.
For more information on respiratory protection standard requirements, seePersonal Protective Equipment-Resiratory Protection
 Warning Signs and Tags
Employers are required to post TB warning signs and biological hazard tags to identify hazards in accordance with the OSHA standard for accident signs and tags at 29 CFR 1910.145.
A warning sign is required outside the respiratory isolation or treatment room. The standard requires use of a signal word, such as "STOP" or "NO ADMITTANCE," or biological hazard sign along with a major message, such as "Special Respiratory Isolation" or "AFB Isolation," and a description of the necessary precautions to take before entering, such as donning a respirator.
Biological hazard tags should be used on air transport components, such as fans, ducts, or filters, to alert employees working on air systems of the presence of TB hazards.
 Injury and Illness Reporting
In health care and other high-risk settings, TB infections (as identified by a positive skin test) and TB disease should be recorded in the OSHA 300 Log by checking the "respiratory condition" column in accordance with OSHA requirements in the revised recordkeeping rule at 29 CFR 1904 (see OSHA Recordkeeping-General Requirements ).
Specifically, the directive states the following:
- A positive skin test for TB, even on initial or baseline testing (except preassignment or pre-employment screening), is recordable on the OSHA 300 Log because there is a presumption of work-relatedness in these settings, unless there is clear documentation that an outside exposure occurred
- If an employee's TB infection that has been entered on the OSHA 300 Log progresses to TB disease during the five-year maintenance period, the original entry for the infection should be updated to reflect the new information
- A positive TB skin test provided within two weeks of employment does not have to be recorded on the OSHA 300 Logs; however, the initial test must be performed prior to any potential workplace exposure
CDC Performance Criteria for Respirators
 Employee Medical and Exposure Records
Records concerning employee exposure to TB, including skin test results and medical evaluation and treatment, are covered by the requirements of OSHA's standard on medical and exposure records at OSHA Recordkeeping-General Requirements .
The standard generally requires employers to protect the confidentiality of such records, to preserve them for a period of 30 years, and to provide employees with access to them upon request.
Where known, a TB exposure record should contain a notation of the type of TB to which the employee was exposed (e.g., multidrug-resistant TB).
OSHA inspectors requesting access to employee medical records must comply with regulations at 29 CFR 1913.10. The rules contain confidentiality safeguards to protect employee privacy in cases where records contain personally identifiable medical information such as name, Social Security number, and payroll number, or information that could reasonably be used to identify an individual, such as age, height, weight, and job title. Records that contain only aggregate employee medical information or information on individual employees that is not personally identifiable are not covered by the requirements.
 Tuberculosis Requirements
In July 2004, OSHA required hospitals, under general industry respiratory standard 1910.134, to fit test employees annually for respirators to prevent potential exposure to tuberculosis (TB). In 2005, and again in 2006, the U.S. Congress enjoined OSHA from enforcing the annual fit-testing requirement (see the special issues box at the end of this section). The ban lasts through September 30, 2006, which is the end of the federal government's fiscal year, although lawmakers could renew the prohibition in the future.
OSHA encourages hospitals to review training for TB respiratory protection. Employers should make sure that affected workers understand the requirements. Following are five requirements under standard 1910.134 that now affect employees facing TB exposures:
- Fit-testing. Workers must fit test before using respirators if they use a different facepiece, when their facial features change enough to affect respirator use, and at least annually (see the special issues box at the end of this section).
- Respiratory protection program. OSHA provides more guidance about effective elements of a respiratory program. Examples include more information about respiratory hazards, the general types of respirators allowed, and cleaning and inspection of respirators.
- Medical evaluation. OSHA specifies minimum provisions for medical evaluation, including designating a physician or licensed healthcare professional to conduct the evaluations, obtaining information noted in mandatory appendix C of 1910.134, conducting the follow-up medical examinations in certain cases, providing the physician with information about the respirator to be used and activities involved, and obtaining a written recommendation about the employee's ability to use a respirator.
Also, at a minimum, hospitals must provide additional medical evaluations if their employees report symptoms related to the ability to use respirators, physicians or program administrators believe an employee needs reevaluation, observations made during fit-testing or a program review indicates a need for further employee medical evaluation, or changes may result in increased physiological burdens placed on employees.
- Training. Employers must provide their workers with training on the respiratory hazards they'll face on the job, as well as instruction on how to wear and use respirators. Training must occur before workers initially use respirators, at least annually thereafter, and more often if necessary.
- Records. Employers must obtain and keep records about medical evaluations, fit-testing (including the name of the employee and the type of test performed), and respirator programs.
OSHA Letter on TB Respirator Annual Fit Testing
NIOSH Respirator Certification