SAFETY EDUCATION MODULE VII TUBERCULOSIS (TB)

I. After completing this module you will

A. Have a basic understanding about TB (M. tuberculosis), including its epidemiology, transmission, pathogenesis, and particular risks for health care personnel.

B. Know how TB is transmitted and who is most vulnerable for infection, particularly immuno compromised persons.

C. Know the medical risk factors and signs and symptoms of TB.

D. Understand the TB skin test, including who should be tested, how the test is carried out, and interpretation of the test results.

A. Employees who will have a basic understanding of TB and the processes for TB transmission and infection.

B. Employees who will know the basic principals for protecting themselves and their patients from infection by TB.

C. Employees who will know how the TB skin test is carried out, and its purpose and limitations.

A. Read the module

B. Take the post-test

C. Return the post-test to your director/manager/supervisor to receive credit for this module.

A. Module

B. Pen/pencil

C. Post-test

A. In 2000, the incidence of TB in the general US population decreased by 6.6 percent from 1999 and 81 percent from 1953, the first year of recorded statistics. Some 16,400 cases were reported in the United States in 2000.

B. Transmission of M. tuberculosis is a recognized risk to patients and HCW in healthcare facilities. Transmission is most likely to occur from patients who have unrecognized pulmonary or laryngeal TB and are not on effective anti-TB therapy.

C. Patients who have multi-drug resistant TB can remain infectious for prolonged periods, which increase the risk for occupational transmission of M. tuberculosis. Increases in the incidence of TB have been observed in some geographic areas. These increases are related partially to the high risk for TB among immuno-suppressed persons, particularly those infected with human immunodeficiency virus (HIV Transmission of M. tuberculosis to HIV-infected persons is of particular concern because these persons are at high risk for developing active TB if they become infected with the bacteria. An effective TB infection-control program requires early identification, isolation, and treatment of persons who have active TB.

A. TB is not distributed evenly throughout all segments of the U.S. population. Some subgroups or persons have a higher risk for TB, either because they are more likely than other persons in the general population to have been exposed to and infected with M. tuberculosis or because their infection is more likely to progress to active TB after they have been infected. In some cases, both of these factors may be present. Groups of persons known to have a higher prevalence of TB infection include:

1. Contacts of person who have active TB.

2. Foreign-born persons from areas of the world with a high prevalence of TB (e.g., Asia, Africa, the Caribbean, and Latin America).

3. Medically underserved populations (e.g., African-Americans, Hispanics, Asians and Pacific Islanders, American Indians, and Alaskan Natives).

4. Homeless persons.

5. Current or former correctional-facility inmates.

6. Alcoholics.

7. Injecting-drug users.

8. The elderly

A. Tuberculosis is carried in airborne particles, or droplet nuclei, that can be generated when persons who have pulmonary or laryngeal TB do the following:

1. Sneeze

2. Speak

3. Cough

4. Sing

 B. Transmission occurs when a susceptible person inhales droplet nuclei containing TB and these droplet nuclei traverse the mouth or nasal passages, upper respiratory tract, and bronchi to reach the alveoli of the lungs. Once in the alveoli, the organisms are taken up by alveolar macrophages and spread throughout the body. Usually within 2-10 weeks after initial infection with M. tuberculosis, the immune response limits further multiplication and spread of the tuberculosis, the immune response limits further multiplication and spread of the tubercle bacilli; however, some of the bacilli remain dormant and viable for many years. This condition is referred to as latent TB infection. (Persons with latent TB infection usually have positive purified protein derivative (PPD)-tuberculin skin-test results, but they do not have symptoms of active TB, and they are not infectious.)

A. In general, persons who become infected with M. tuberculosis have approximately a 10% risk for developing active TB during their lifetimes. This risk is greatest during the first 2 years after infection.

B. The probability that a person who is exposed to M. tuberculosis will become infected depends primarily on:

1. The concentration of infectious droplet nuclei in the air;

2. The duration of exposure; and

3. Status of ones own immune system.

C. Environmental factors that enhance the likelihood of transmission include:

1. Exposure in relatively small, enclosed spaces;

2. Inadequate local or general ventilation that results in insufficient dilution and/or removal of infectious droplet nuclei; and

3. Re-circulation of air containing infectious droplet nuclei

A. In general, persons who have been infected previously with M. tuberculosis may be less susceptible to subsequent infection. However, re-infection can occur among previously infected persons, especially if they are severely immuno-compromised.

A. Immuno-compromised persons have a greater risk for the progression of latent TB infection to active TB disease; HIV infection is the strongest known risk factor for this progression. Persons with latent TB infection who become co-infected with HIV have approximately an 8%-10% risk per year for developing active TB, i.e. progressing from latent TB infection to active TB.

A. Persons with medical risk factors that increase the risk of developing clinically active tuberculosis once infection has occurred should also be tuberculin tested, and their skin test status should be clearly noted on their medical record. These medical risk factors include:

1. HIV infection

2. Silicosis

3. Abnormal chest radiograph showing fibrotic lesions that are likely to represent old healed TB.

4. Diabetes mellitus

5. Prolonged corticosteroid therapy

6. Immunosuppressive therapy

7. Hematological and reticuloendothelial diseases (e.g. leukemia and Hodgkin’s disease)

8. End stage renal disease

9. Intestinal bypass

10. Post-gastrectomy

11. Chronic mal-absorption syndromes

12. Carcinomas of the oropharynx and upper gastrointestinal tract

13. 10 percent or more below ideal body weight

A. Persistent productive cough

B. Weight loss

C. Anorexia (loss of appetite)

D. Fatigue

E. Hemoptysis (spitting up blood)

F. Night sweats

G. Fever

A. The vaccination, Bacillus Calmette-Guerin (BCG) is a TB vaccine used in many parts of the world, but not usually in the U.S. Many countries use BCG as part of their TB control programs. A history of vaccination with BCG should not alter the guidelines for the interpretation of the tuberculin skin test.

A. BCG vaccination may produce a PPD reaction that cannot be distinguished reliably from a reaction caused by infection with M. tuberculosis. This reaction will usually wan over time.

B. For a person who was vaccinated with BCG, the probability that a PPD test reaction results from infection with M. tuberculosis increases when:

1. The size of the reaction increases

2. The person is a contact of a person with TB

3. The person’s country of origin has a high prevalence of TB

4. The length of time between vaccination and PPD testing increases.

C. For example, a PPD test reaction of.> 10 mm probably can be attributed to M. tuberculosis infection in an adult who was vaccinated with BCG as a child and who is from a country with a high prevalence of TB. Such persons should be evaluated for isoniazid preventive therapy.

A. Persons with HIV infection

B. Close contact with infectious tuberculosis cases.

C. Persons with medical conditions that increase the risk of tuberculosis.

D. Foreign-born persons from high prevalence countries.

A. Low-income populations, including high-risk minorities.

B. Alcoholics and intravenous drug users.

C. Residents of long-term care facilities (including prisons).

D. Populations identified locally as being at increased risk for tuberculosis e.g., healthcare workers in some areas.

A. The PPD test, like all medical tests, is subject to variability, but many of the variations in administering and reading PPD tests can be avoided proper training and careful attention to details.

A. The intracutaneous (Mantoux) administration of a measured amount of PPD-tuberculin is currently the preferred method for doing the test. The PPD is injected just beneath the surface of the skin on the dorsal surface of the forearm. A discrete, pale elevation of the skin (i.e., a wheal) that is 6-10 mm (1/3”) in diameter should be produced.

A. Between 48 and 72 hours after injection, designated, trained personnel should read PPD test results. HCW self-reading of PPD test results should not be accepted. The result of the test is based on the presence or absence of an induration at the injection site. Redness or erythema should not be measured. The transverse diameter of induration should be recorded in millimeters.

A. In accordance with OSHA’s proposed TB Exposure Control Guidelines, all employees must be provided with written indication of their PPD test result, including a negative result. This written documentation must also inform the employee that “HIV infection and other medical conditions may cause a tuberculin skin test to be negative”. This form must be completed and given to each employee when the PPD is read.

A. To prevent TB from becoming active.

B. HCWs with positive PPD test results should be evaluated for preventive therapy regardless of their ages if they are:

1. Recent converters

2. Close contacts of persons who have active TB

3. Have a medical condition that increases the risk for TB

4. Have HIV infection

5. Use injecting drugs

C. HCWs with positive PPD test results who do not have these risk factors should be evaluated for preventive therapy if they are

A. The type of treatment will depend on the following:

1. TB INFECTION (non-active TB)

(1) This is usually treated with a drug called “INH”.

(2) This is usually preventive.

2. TB DISEASE (active TB)

(1) This usually treated with “INH” plus other drugs.

A. Special masks called “respiratory” masks are to be used when caring for a person known or suspected to have TB.

B. Check with your director, manager or supervisor for the correct type of mask.

C. OSHA has developed the criteria for these special masks.

D. Users of these special masks must first be fit tested before they are initially used to assure that the mask fits the user properly.

E. Fit testing is required by OSHA to assure that the user can breathe properly when wearing the mask, and that the mask has a correct seal around the edges.

F. People with beards usually cannot maintain a proper seal around the edges of the mask.

G. Surgical masks do not give the user the proper protection from TB.

A. Latent TB infection or TB infection:

B. Infectious TB or Active TB or Clinically Active TB: A condition in which living tubercle bacilli are present in the body but the disease is not clinically active. Infected persons usually have positive tuberculin reactions, but they have no symptoms related to the infection and active disease unless preventive therapy is given. A condition in which living tubercle bacilli are

C. Multi-drug-resistant tuberculosis (MDR-TB):

present in the body; the disease is clinically active and the person is capable of spreading the disease. Active TB caused by M. tuberculosis organisms

that are resistant to more than one anti-TB drug. In practice, often refers to organisms that are resistant to both INH and rifampin with or without resistance to other drugs.

D. Mantoux test: A method of skin testing that is performed by injecting 0.1ml of PPD tuberculin (containing 5 tuberculin units) into the dermis of the forearm with a needle and syringe. This test is the most reliable and standardized technique for tuberculin testing.

3. List three ways that particles of TB can be transmitted.

6. List four signs or symptoms that might indicate that a person has TB.

Purpose:

The purpose of this policy is to set forth The Health Trust policy and procedure regarding unlawful harassment and harassment of a general nature in the workplace.

Applicability:

This policy applies to all of The Health Trust volunteers.

Policy:

THT is committed to providing an environment free of unlawful harassment. THT maintains a strict policy prohibiting all forms of unlawful harassment and harassment because of race, religious creed, color, national origin, ancestry, physical or mental disability, marital status, age or any other basis, protected by federal, state or local law, ordinance or regulation. Corrective action will be taken promptly with any volunteer or employee who engages in harassment of any nature or who retaliates against any volunteer or employee for having reported or having threatened to report harassment of any nature.

I. Unlawful harassment because of any protected basis includes, but is not limited to:

A. Verbal conduct such as epithets, derogatory comments, slurs or unwanted unlawful advances, invitations or comments.

B. Visual conduct such as derogatory posters, photography, cartoons, drawings or gestures.

C. Physical conduct such as assault, unwanted touching, blocking normal movement or interfering with work directed at an individual because of their sex or race or any other protected basis.

D. Threats and demands to submit to unlawful requests in order to keep your job or avoid some other loss, and offers of job benefits in return for unlawful favors; and/or retaliation for having reported or threatened to report harassment.

II. Specifically unlawful harassment includes, but is not limited to perceived or actual unwelcome unlawful advances, requests for unlawful favors, and other verbal, visual or physical conduct of a unlawful nature where either.

A. Submission to such conduct is made an explicit or implicit term or condition of employment;

B. Submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting such individual;

C. Such conduct has the purpose or effect of substantially interfering with an individual’s work performance;

D. Such conduct has the purpose or effect of creating an intimidating, hostile, or offensive working environment.

Procedure:

Any volunteer who has a complaint involving unlawful harassment or harassment of a general nature should report it immediately to the Community Partnerships department or their supervisor, if appropriate. Prompt, impartial investigation and resolution of the complaint will follow.

I. Internal reporting

A. All harassment complaints should be immediately reported to the Community Partnerships department and/or the volunteer’s immediate supervisor or any of the management team, if appropriate.

B. If a department head/supervisor/manager is aware of, or has knowledge of, a situation which could involve unlawful harassment or conduct which has the purpose or effect of creating an intimidating, hostile or offensive environment, he or she must report any information known to the Community Partnerships department.

C. Volunteers reporting such complaints will be assured by the investigating party that, to the extent possible, confidentiality will be maintained and that retaliation is not permissible.

II. Internal Investigating

A. The Community Partnerships department will interview those individuals determined to be necessary to the investigation, including any person(s) who may have witnessed or have knowledge relating to the complaint.

B. Throughout the process, written documentation of the investigation and any resulting action taken will be maintained.

C. Appropriate management will be kept informed and involved in the investigation. After completion of the investigation, the Community Partnerships Department will recommend any corrective action to the appropriate administrator.

D. All parties involved will be informed of the results of the investigation and any action taken.

E. If no corrective action results from the investigation, a brief summary of the investigation and resulting action will be placed in a separate Community Partnerships Unlawful Harassment Complaints file. If corrective action takes place, the corrective action notice, which references the act of unlawful harassment, will be included in the harasser’s file.

Unwanted Behaviors That May Constitute Unlawful Harassment:

With my signature, I hereby declare that I have read and understand the Unlawful Harassment Policy.

I understand that failure to comply with the above policy may be cause for immediate dismissal and possible legal action.

What is HIPAA?

• Health Insurance Portability & Accountability Act of 1996
• A set of Federal healthcare regulations which are intended to:
  • Protect Patient/Client Privacy
  • Provide Standards across healthcare entities
  • Streamline Administrative processes
  • Increase efficiency in healthcare

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In healthcare Privacy is important because...

• Patients/clients may share very personal and sensitive information when they come to a Health Trust program
• Sharing this private information with anyone else could cause harm to the patient/client
• Protecting patient privacy is part of every healthcare worker's job and is now required by the law

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What patient/client information must be protected?

• Anything that can be used to identify the patient/client
• –Name, address, social security number, medical record number, birth date, etc.
• Anything about the patient/client’s past, present or future medical conditions and treatment

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What does HIPAA mean to you?

• Big changes are coming!
  • Changes in how information is accessed
  • Changes in how information is used
  • Changes in how information is disclosed
• Everyone will be affected!
  • Clinical providers
  • Administrative & clinical personnel
  • Volunteers, Service & Support personnel
  • Patients/Clients & Visitors

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HIPAA Disclosure Changes

• Patient/client information can be disclosed for treatment, payment and healthcare operations only – or if required by federal or state law
• All other types of disclosure require an authorization from the patient/client
  • Time limited
    Specific both in to whom the information can be disclosed and what can be disclosed
  • Patient/client signature required

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How will the privacy changes affect you?

• Your job duties will change to make you responsible for keeping patient/client health information private and confidential
• Your job duties will change with regard to what information you can access, how you can use patient/client information, and to whom you can disclose the information to
• Your job duties will include promoting privacy practices such as reporting privacy problems and assisting with corrective actions

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The Health Trust will protect patient privacy by...

• Assigning a privacy officer
• Implementing written policies & procedures to help associates understand the new privacy rules
• Providing Privacy Training to all associates
• Implementing ways to protect health information from being misused
• Providing a method for patients/clients & associates to file complaints
• Disciplining & counseling associates for those who don’t follow the privacy practices

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Patients/Clients will be aware of their privacy rights

• Our facility’s ‘Notice of Privacy Practices’ (NPP) will contain information on how patient/client information is used and to whom it may be given
• Patients/clients may request and will receive a copy of the NPP
• The NPP will be posted in all patient areas
• The NPP will be posted on The Health Trust web site

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Privacy Breaches hurt...

• The Health Trust when they result in civil actions – The Office of Civil Rights is responsible for enforcement of the privacy rules
• The Associate by resulting in possible counseling, disciplining or penalties

What can you do?

• Become privacy focused
• Know and follow our facility’s privacy policies & procedures
• Understand the importance of privacy & be willing to change your behavior
• Be sensitive to the patient’s/client’s privacy needs and protect their health information
• Remember – it could be your health information someone is talking about.

Please complete the post-test and sign the non-disclosure agreement.

Non-Disclosure Agreement

With my signature, I hereby declare that I have completed the HIPAA Privacy Training Volunteer Program and I have a basic understanding of the Health Insurance Portability & Accountability Act of 1996 as it applies to my volunteer service.

I shall hold in confidence any and all information pertaining to clients of Programs of The Health Trust made available or otherwise discovered by me through my volunteer service.

I understand that any identifying information I am given or learn pertaining to clients is privileged information, that there may be legal limitations on its use and disclosure, and that it becomes my responsibility to exercise great care concerning this information.

I shall not disclose, reveal or disseminate any names, places of residence, or any other information pertaining to clients, staff or volunteers outside of the staff and/or management with whom I participate as a volunteer.

I understand that acts contrary to any of the above may be cause for immediate dismissal and possible legal action.