Text For Citation: 01 Item/Group: 003 Hazard: TB

Nevada Revised Statute 618.375(1): Duties of employers. Every employer shall fur nish employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his o r her employees: Prior to this inspection, Summerlin Hospital Medical Center did not have procedures in place to ensure that employees who have been directly exposed to patients wit h tuberculosis (TB) disease are screened for the infection as soon as possible a fter exposure to Mycobacterium tuberculosis, or are provided follow up screening s if needed. In 2013, at least two patients with unrecognized tuberculosis disea se were admitted into the hospital and cared for by staff, exposing employees to Mycobacterium tuberculosis and subsequently causing 20 employees to contract tu berculosis and exhibit either active or latent forms of the infection. At least one hospital employee who had direct contact with at least one of the infected p atients was not given an initial TB screening until 8 weeks after the exposure. A feasible and accepted abatement method for reducing this hazard, as recommende d by the Center for Disease Control and Prevention (CDC), is to follow their 200 5 "Guidelines for the Transmission of Mycobacterium tuberculosis in Health Care Facilities" and institute proper procedures according to the Guideline's Problem Evaluation and Contact Investigation sections. The facility's TB Exposure Contr ol Plan should be revised to reflect the implementation of this. References: 1) Nevada Administrative Code 441A.200: Infectious Diseases. List of adopted recomm endations, guidelines and publications; review of revision or amendment of adopt ed recommendation, guideline or publication: The following recommendations, guid elines and publications are adopted by reference: (h) The recommendations of the Centers for Disease Control and Prevention for preventing the transmission of t uberculosis in facilities providing health care set forth in "Guidelines for Pre venting the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005," Morbidity and Mortality Weekly Report[54(RR17):1-141, December 30, 2005]. 2) "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health Care Facilities," 2005. Centers for Disease Control and Prevention (CDC), MMWR December 30, 2005/Vol. 54/No. RR-17. Investigating Conversions in Test Res ults for M. tuberculosis Infection in HCWs: Known Source in the Health-Care Sett ing An investigation of a test conversion should be performed in collaboration w ith the local or state health department. If a conversion in an HCW is detected and the HCW's history does not document exposure outside the health-care setting but does identify a probable source in the setting, the following steps should be taken: 1) identify and evaluate close contacts of the suspected source case, including other patients and visitors; 2) determine possible reasons for the exp osure; 3) implement interventions to correct the lapse(s) ininfection control; and 4) immediately screen HCWs and patients if the y were close contacts to the source case. For exposed HCWs and patients in a set ting that has chosen to screen for infection with M. tuberculosis by using the T ST, the following steps should be taken: - administer a symptom screen; - admini ster a TST to those who had previously negative TST results; baseline two-step T ST should not be performed in contact investigations; - repeat the TST and sympt om screen 8-10 weeks after the end of exposure, if the initial TST result is neg ative (33); - administer a symptom screen, if the baseline TST result is positiv e; - promptly evaluate (including a chest radiograph) the exposed person for TB disease, if the symptom screen or the initial or 8-10-week follow-up TST result is positive; and - conduct additional medical and diagnostic evaluation (which i ncludes a judgment about the extent of exposure) for LTBI, if TB disease is excl uded. If no additional conversions in the test results for M. tuberculosis infection a re detected in the follow-up testing, terminate the investigation. If additional conversions in the tests for M. tuberculosis infection are detected in the foll ow-up testing, transmission might still be occurring, and additional actions are needed: 1) implement a classification of potential ongoing transmission for the specific setting or group of HCWs; 2) the initial cluster of test conversions s hould be reported promptly to the local or state health department; 3) possible reasons for exposure and transmission should be reassessed and 4) the degree of adherence to the interventions implemented should be evaluated. Testing for M. t uberculosis infection should be repeated 8-10 weeks after the end of exposure fo r HCW contacts who previously had negative test results, and the circle of conta cts should be expanded to include other persons who might have been exposed. If no additional TST conversions are detected on the second round of follow-up test ing, terminate the investigation. If additional TST conversions are detected on the second round of follow-up testing, maintain a classification of potential on going transmission and consult the local or state health department or other per sons with expertise in TB infection control for assistance. The classification o f potential ongoing transmission should be used as a temporary classification on ly. This classification warrants immediate investigation and corrective steps. A fter determination has been made that ongoing transmission has ceased, the setti ng should be reclassified as medium risk. Maintaining the classification of medi um risk for at least 1 year is recommended. Contact Investigations The primary g oal of contact investigations is to identify secondary cases of TB disease and LTBI among contacts so that therapy can be initiated as needed (2 63-265). Contact investigations should be collaboratively conducted by both infe ction control personnel and local TB control program personnel. Initiating a Con tact Investigation A contact investigation should be initiated when 1) a person with TB disease has been examined at a health-care setting, and TB disease was n ot diagnosed and reported quickly, resulting in failure to apply recommended TB infection controls; 2) environmental controls or other infection control measure s have malfunctioned while a person with TB disease was in the setting; or 3) an HCW develops TB disease and exposes other persons in the setting. As soon as TB disease is diagnosed or a problem is recognized, standard public health practic e should be implemented to prioritize the identification of other patients, HCWs, and visitors who might have been exposed to the index case before TB infec tion control measures were correctly applied (52). Visitors of these patients mi ght also be contacts or the source case. The following activities should be impl emented in collaboration with or by the local or state health department (34,266 ): 1) interview the index case and all persons who might have been exposed; 2) r eview the medical records of the index case; 3) determine the exposure sites (i. e., where the index case lived, worked, visited, or was hospitalized before bein g placed under airborne precautions); and 4) determine the infectious period of the index case, which is the period during which a person with TB disease is con sidered contagious and most capable of transmitting M. tuberculosis to others. F or programmatic purposes, for patients with positive AFB sputum smear results, the infectious period can be considered to begin 3 months before the collection date of the first positive AFB sputum smear result or the symptom onset date (wh ichever is earlier). The end of the infectious period is the date the patient is placed under airborne precautions or the date of collection of the first of con sistently negative AFB sputum smear results (whichever is earlier). For patients with negative AFB sputum smear results, the infectious period can begin 1 month before the symptom onset date and end when the patient is placed under airborne precautions. The exposure period, the time during which a person shared the sam e air space with a person with TB disease for each contact, should be determined as well as whether transmission occurred from the index patient to persons with whom the index patient had intense contact. In addition, the following should b e determined: 1) intensity of the exposure based on proximity, 2) overlap with the infectious period of the index case, 3) duration of exposure, 4) presence or absence of infection control measu res, 5) infectiousness of the index case, 6) performance of procedures that coul d increase the risk for transmission during contact (e.g., sputum induction, bro nchoscopy, and airway suction), and 7) the exposed cohort of contacts for TB scr eening. The most intensely exposed HCWs and patients should be screened as soon as possible after exposure to M. tuberculosis has occurred and 8-10 weeks after the end of exposure if the initial TST result is negative. Close contacts should be the highest priority for screening. For HCWs and patients who are presumed t o have been exposed in a setting that screens for infection with M. tuberculosis using the TST, the following activities should be implemented: - performing a s ymptom screen; - administering a TST to those who previously had negative TST re sults; - repeating the TST and symptom screen 8-10 weeks after the end of exposure, if the initial TST result is negative; - promptly evaluating the HCW for TB disease , including performing a chest radiograph, if the symptom screen or the initial or 8-10-week follow-up TST result is positive; and - providing additional medica l and diagnostic evaluation for LTBI, including determining the extent of exposu re, if TB disease is excluded. For HCWs and patients who are presumed to have be en exposed in a setting that screens for infection with M. tuberculosis using th e BAMT (A general term to refer to recently developed in vitro diagnostic tests that assess for the tuberculosis (BAMT) presence of infection with M. tuberculos is. In the United States, the currently available test is QuantiFERON.-TB Gold t est (QFT-G).), the following activities should be implemented (see Supplement, S urveillance and Detection of M. tuberculosis Infections in Health Care Settings). If the most intensely exposed persons have test conversions or positi ve test results for M. tuberculosis infection in the absence of a previous histo ry of a positive test result or TB disease, expand the investigation to evaluate persons with whom the index patient had less contact. If the evaluation of the most intensely exposed contacts yields no evidence of transmission, expanding te sting to others is not necessary. Exposed persons with documented previously pos itive test results for M. tuberculosis infection do not require either repeat te sting for M. tuberculosis infection or a chest radio-graph (unless they are immu nocompromised or otherwise at high risk for TB disease), but they should receive a symptom screen. If the person has symptoms of TB disease, 1) record the sympt oms in the HCW's medical chart or employee health record, 2) perform a chest rad iograph, 3) perform a full medical evaluation, and 4) obtain sputum samples for smear and culture, if indicated. The setting should determine the reason(s) that a TB diagnosis or initiation of airborne precautions was delayed or procedures failed, which led to transmission of M. tuberculosis in the setting. Reasons and corrective actions taken should be recorded, including changes in policies, procedures, and TB training and educ ation practices.