The 1994 CDC guidelines include recommendations for assignment of responsibility for tuberculosis control. A risk assessment for the facility (and potentially for individual wards and areas within the facility) is suggested. This risk assessment takes into account the number of tuberculosis patients seen at the facility, the number of tuberculosis patients in the surrounding community, and whether or not there is evidence of increased health care worker PPD skin test conversions. The extent to which other control actions are taken would then depend on the risk of the facility. For example, a baseline PPD test for new employees is recommended for essentially all facilities, but the frequency of routine serial testing would be determined by the risk assessment. The guidelines also suggest health care worker education consistent with the duties/training of the employee. Good cooperation with local health departments is also stressed. Although the bulk of the guidelines are targeted to acute-care hospitals, tuberculosis control in other settings such as dental clinics, physicians’ offices, and long-term-care facilities are also briefly discussed.
The core of the 1994 CDC guidelines is a series of control measures for handling patients suspected of having tuberculosis. Three categories of controls are described: administrative, engineering, and personal respiratory protection. Administrative controls include prompt recognition of patients who may have tuberculosis with subsequent rapid isolation of these patients, efficient diagnostic evaluation, and criteria for releasing patients from isolation. Other administrative controls include practices such as keeping patients on tuberculosis isolation in their room unless medically necessary. Engineering controls involve primarily ventilation, tuberculosis isolation rooms should have negative pressure, ≥ six air changes per hour (ACH), and exhaust air directly to the outside (or HEPA filter the air before recirculation if this is not possible). Engineering controls also include having good general ventilation, especially in areas where patients may congregate. Ultraviolet germicidal irradiation (UVGI) may be used as an adjunct to both general ventilation and tuberculosis isolation room ventilation. Finally, the guidelines discuss personal respiratory protection for health care workers who are likely to be exposed to tuberculosis aerosols (e.g., while in a tuberculosis isolation room). The respirator should be compliant with Occupational Safety and Health Administration (OSHA) requirements, and used as part of a comprehensive respiratory protection program.
The author was directed to “prepare a technical background paper reviewing the literature and data on the effects of the CDC guidelines on tuberculosis control in health care facilities.” This paper is being written as background for an Institute of Medicine report on occupational expo-