DIVISION OF OCCUPATIONAL SAFETY AND HEALTH
POLICY AND PROCEDURES MANUAL
INTERIM TUBERCULOSIS
CONTROL ENFORCEMENT
GUIDELINES
P&P C-47

Issue Date: 12/1/92
Revised: 8/1/94,
7/1/95,
4/11/97

AUTHORITY: California Labor Code §§6305, 6309, 6317, 6400, 6401, 6401.7, 6402, 6403 and 6404 and Title 8 California Code of Regulations §§332.2, 3203, 5079, 5141, 5143, 5144 and 14300.11.

POLICY: It is the policy of the Division of Occupational Safety and Health to ensure that compliance District Offices make a record of, and respond to, any complaint alleging employee exposure to tuberculosis, conduct an appropriate investigation of tuberculosis exposure, work cooperatively with Cal/OSHA Medical Unit consultants, local public health officers and tuberculosis controllers, as well as with the Tuberculosis Control Branch of the California Department of Health Services, and issue citations, notices or Special Orders based on sound evidentiary evaluation of the work setting where a tuberculosis hazard is alleged to exist.

 

PROCEDURES:

 

A. OCCUPATIONAL TUBERCULOSIS

Tuberculosis (TB) is a disease caused by Mycobacterium tuberculosis. TB bacilli are spread from person to person by means of airborne particles, called droplet nuclei, which can be generated when persons with infectious TB sneeze, cough, speak or sing. The particles are so small (1-5 microns in diameter) that normal air currents can keep them airborne for hours, and spread them throughout a room or building. Infection occurs when a susceptible person inhales droplet nuclei containing TB bacteria, and the bacteria become established in the lungs and then spread throughout the body.

Two to ten weeks after initial infection, the body's immune response usually limits further multiplication and spread of TB bacteria. However, in a small proportion of cases (usually <1%), initial infection rapidly progresses to clinical illness or active TB. For another group (approximately 5-10%), active TB develops after an interval of months, years or decades. The risk of progression to active TB is markedly increased for persons infected with the human immunodeficiency virus (HIV), the causative agent of AIDS.

Although there are some situations in which active TB cases are not infectious, it should be presumed that any active case is infectious unless there is evidence to the contrary. The only sign exhibited by most TB-infected persons who are not suffering from active TB is a positive response to a TB skin test, also called a PPD (purified protein derivative), or tuberculin, skin test.

Historically, the strategy used to control tuberculosis in the United States has been based on: (1) identifying, isolating and treating all persons with infectious TB to prevent them from spreading TB to others; and (2) identifying those who are infected with TB and providing them with preventive therapy before they develop active TB. From the l950s through the mid-l980s this strategy worked well and the number of TB cases in the U.S. steadily declined. Recently, however, the picture has changed. Since l985, instead of a decline, there has been an increase in the number of TB cases nationwide. In California, between l985 and l991, the number of reported cases increased 51%. A number of factors have contributed to the recent increase.

First, the AIDS epidemic has contributed significantly to the TB epidemic because persons infected with HIV and Mycobacterium tuberculosis are especially susceptible to developing active TB. Second, the U.S. in the last decade has experienced increased immigration from countries with high TB prevalence. Third, crowded living conditions in prisons and jails, shelters for the homeless, and some residential care facilities have increased the number of TB cases because crowding promotes person-to-person spread of TB. Fourth, inadequate TB control programs have also contributed to the TB epidemic. Lastly, the hazard associated with TB exposure has also been exacerbated recently by the appearance of strains of TB bacilli which are resistant to the currently available antibiotics used to treat TB. These strains of TB are called "multi-drug resistant TB," or MDR-TB.

The following are populations at increased risk for TB: HIV-infected persons, intravenous drug abusers, recent immigrants from countries with a high TB prevalence, prison and jail facility inmates, and the homeless. Therefore, several types of workplaces have been generally recognized by the Centers for Disease Control and Prevention (CDC) as having the potential to be at "increased risk" for transmission of infectious TB. These include: (1) prisons and jails; (2) residential facilities for HIV-infected persons (e.g., hospices or group housing); (3) residential facilities for the elderly; (4) shelters for the homeless; (5) drug treatment clinics; (6) hospitals and mycobacteriology laboratories; and (7) other facilities which utilize medical procedures resulting in aerosolization of respiratory secretions from patients, or primarily treat populations at increased risk for TB.

Other types of work or work settings in which there is potential for employees to come into prolonged regular contact with such populations, or which may involve significant exposure to TB infection, should also be considered to be potential increased-risk work environments. Examples include, but are not limited to, the provision of emergency medical services, hospices, home healthcare settings and medical offices and clinics.

For the purposes of Division investigations, all of the above categories of work and workplaces will be presumed to involve increased-risk work environments unless a competent and current risk assessment demonstrates otherwise. Whether or not the above-listed categories of work environments truly belong in the increased-risk category depends on the actual rate of TB transmission for those present in the work environment. This in turn depends on the extent to which infectious TB cases are present and the effectiveness of exposure control measures in place when infectious TB cases are present.

 

B. PRINCIPLES OF TUBERCULOSIS EXPOSURE CONTROL

 

1. Effective TB exposure control is a multi-step procedure involving the following general public and occupational health principles:

a. Assessment of the degree of risk of TB transmission in the work environment;

b. Screening for the presence of TB infection and early recognition of TB symptoms utilizing procedures such as PPD skin tests, chest x-rays, and sputum examinations followed by prompt medical evaluation;

e. Antibiotic treatment of confirmed TB cases and in some instances, suspect TB cases;

f. Where appropriate, preventive therapy for people determined to be TB-infected but without active TB;

g. Use of specialized work practices;

h. Design and implementation of appropriate engineering controls to remove or isolate TB-contaminated air, or to reduce the concentration of TB droplet nuclei; and

i. Use of appropriate respiratory protective equipment.

2. Increased-Risk Work Environments

In increased-risk work environments, the employer must implement effective measures to protect employees from TB. These measures must consist of surveillance, containment, employee training and ongoing assessment.

a. Surveillance

(1) PPD Testing of Employees

Surveillance shall include regular PPD testing of employees, in accordance with current criteria recommended by the Centers for Disease Control and Prevention (CDC). CDC address two major subject-areas with respect to PPD testing--how the tests are to be conducted, and how frequently they are to be performed.

(a) Conducting PPD Testing

Compliance personnel should be aware that a recent addition to CDC criteria for conducting the test is the recommendation to use "two-step" testing for any person receiving a PPD for the first time, or receiving a PPD test more than one year after the most recent previous PPD. The two-step procedure minimizes the possibility of a false-negative result. Additional major considerations in evaluating the adequacy of the PPD testing procedure used by the employer are the CDC criteria for deciding whether the result is positive or negative, and the CDC recommendation that the PPD test be read by qualified medical personnel only, and never by the person, whether qualified or not, to whom the PPD test has been given.

NOTE: See CDC "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, 1994," MMWR 43:RR-13; October 28, 1994, especially pp. 59-63 and "Prevention and Control of Tuberculosis in Correctional Facilities," MMWR 45:RR-8; June 7, 1996, especially pp. 6-14.

(b) Frequency of PPD Testing

CDC recommendations for PPD test frequency vary according to the type of employee and the exposure potential associated with the activities of the employee. In general, all employees in increased-risk environments must receive PPD testing at least annually. In the healthcare industry, where exposure potential is particularly high, the required testing frequency can be more frequent, depending upon the degree of risk of transmission of TB in the specific workplace for the category of work being performed.

NOTE: See CDC "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, 1994," MMWR 43:RR-13; October 28, 1994, especially Table 2, pp. 14-15.

(2) Suspect Cases

(a) Individual Assessment

Surveillance must also include the development of criteria to identify individuals who are "suspect" cases, i.e., those who are suspected to have infectious TB. The identification of a suspect case, for the purposes of this P&P, is a mechanism that triggers an employer's requirement to implement exposure control procedures. The employer's surveillance criteria must include identification of the following individuals:

(1) Any person who is known, or with reasonable diligence should be known by the employer to be infected with TB, and has signs or symptoms of pulmonary or laryngeal TB;

(2) Any person who has a positive acid-fast bacilli (AFB) smear, or any other positive test result, obtained for the purpose of diagnosing pulmonary or laryngeal TB; and

(3) Any person meeting the employer's criteria for a suspect case.

NOTE: In addition to developing the criteria described by Items (1) and (2) for identification of a suspect case, the employer must develop its own criteria based only on signs and symptoms, to be used when PPD status and laboratory-generated information is not available.

(b) "Rule Out TB"

The diagnostic category "rule out TB (often written as R/O TB)" does not, by itself, provide a basis for concluding that an employer has, or should have, identified a patient as a suspect case.

b. Containment of TB Infection

Where appropriate, containment of TB infection must include measures such as the following:

(1) Prompt medical evaluation of persons with symptoms suggestive of TB.

(2) Atmospheric isolation (or reasonably prompt referral to a facility which can provide atmospheric isolation) of patients, inmates, residents, or clients known or suspected to have infectious TB.

NOTE: Atmospheric isolation means that the patient is kept in a room or other containment which has negative pressure and dilution ventilation or HEPA scrubbing of the air at a rate of at least 12 air changes per hour. Usually, isolation rooms used for this purpose have a toilet and bathing facilities, and an anteroom which aids in maintaining the constancy of negative pressure.

(3) Use of effective local exhaust ventilation in connection with high-risk procedures.

NOTE: High-risk procedures include: (i) aerosolized pentamidine administration on any patient, or (ii) any of the following if performed on a suspect or confirmed infectious TB case: (1) sputum induction; (2) bronchoscopy; (3) tissue handling procedures such as specimen processing and autopsy; (4) operative procedures such as tracheotomy, thoracotomy and aspiration and excision biopsy; (5) respiratory care procedures such as intubation, suctioning, and tracheostomy and endotracheal tube care; and (6) other aerosol treatments, cough-inducing procedures or aerosol-generating procedures.

(4) Use of respiratory protection to prevent employee exposure to TB bacilli must be used in the following situations:

(a) When entering an isolation room;

(b) When in the presence of an unmasked suspect or confirmed TB case;

(c) When transporting a suspect or confirmed case in an enclosed vehicle; and

(d) When in the presence of high-risk procedures.

EXCEPTION: Where the procedure is performed by isolating the patient in an enclosed booth or room, respiratory protection is not required.

c. Employee Training

Training of employees about the prevention and hazards associated with TB exposure must be conducted.

d. Ongoing Assessment

Ongoing assessment of the effectiveness of the employer's TB prevention program must be conducted.

 

C. INSPECTION PROCEDURES

All District Managers, compliance personnel and Medical Unit consultants shall adhere to the following inspection procedures whenever performing a TB-related inspection.

1. Injury and Illness Prevention (IIP) Program and Other Documentation

The inspection must include reviewing the employer's IIP Program and any other pertinent documentation, including employee training materials, the employer's Cal/OSHA 200 Log, medical records, PPD skin test results, ventilation records, exposure records and TB exposure control procedures. Careful examination of the facility's procedures for TB control is the core element of these inspections.

2. Sources of Exposure

The industrial hygienist and Medical Unit staff must identify the sources of possible TB exposure for each increased-risk worksite. In hospital settings, the industrial hygienist and Medical Unit staff must determine whether high-risk procedures are performed. Isolation rooms can be potential sources of TB exposure, especially if negative pressure ventilation is ineffective, or proper patient care practices, e.g., keeping the door closed and ensuring that the patient covers his or her mouth when coughing, are not followed.

3. Employee Interviews

The industrial hygienist and Medical Unit staff must select employees from appropriate areas of the workplace to interview in order to determine the accuracy of the Cal/OSHA 200 Log entries, the effectiveness of employee training, and the employer's compliance with its own infection control procedures. Employees who have had exposure incidents, PPD skin test conversions, or infectious tuberculosis should be interviewed, preferably by a Medical Unit consultant, to determine the work-relatedness of their TB infection or disease.

4. Review of Medical Records

Review of pertinent medical records can be an important source of information regarding the effectiveness of the employer's TB infection control procedures. Usually, the Medical Unit consultants will perform this function.

5. Walkthrough

The industrial hygienist and Medical Unit consultants must evaluate engineering controls, work practices and respiratory protection used to prevent occupational TB exposure, through direct observation where feasible. The industrial hygienist and Medical Unit consultants shall take the necessary precautions to avoid close contact with any confirmed or suspect case of infectious TB. The industrial hygienist and Medical Unit staff should not enter work areas while high-risk medical procedures are being performed. Should it be necessary to enter such work areas, appropriate respiratory protection shall be used in accordance with P&P C-172 and the Division's Respiratory Protection Program.

6. Evaluation of Engineering Controls

The industrial hygienist shall determine whether effective engineering controls are in place in all exposure source areas, i.e., areas where suspect or confirmed infectious TB cases are present, or where high-risk procedures are performed. Where applicable, the evaluation should include:

a. Confirming that all air returned to the ventilation system from exposure source areas is HEPA-filtered. Emergency departments and hospital waiting areas are not considered exposure source areas unless they are actually occupied by a patient who has, or should have, been determined by the employer to be a suspect case.

b. Evaluating the maintenance and safety of air filtration and UV germicidal equipment when utilized as a supplement to ventilation;

c. Confirming negative pressure in exposure source areas by means of velometer measurements, smoke tubes, or other reliable indicators of air pressure or air flow;

d. Assessing the sufficiency of isolation room dilution ventilation or air cleansing by HEPA filtration in isolation rooms (at least twelve (12) air changes per hour); and

e. Determining whether exhaust air ducts are sufficiently separated from fresh air intakes to prevent contamination of intake air.

7. Evaluation of Respiratory Protection

The industrial hygienist shall also determine whether the employer has, and enforces, effective procedures for use of respiratory protection. This determination shall include an evaluation of the employer's respiratory protection program for compliance with §5144, including the requirement to conduct fit testing. When engineering controls are not sufficient to protect employees from exposure to droplet nuclei containing TB bacilli, employer shall provide and require the use of a respirator with current certification by the National Institute for Occupational Safety and Health (NIOSH).

NOTE: Effective 10 July 1995, NIOSH implemented new particulate respirator certification criteria. See 42 Code of Federal Regulations (CFR), Part 84, Subpart K. Under these criteria, particulate respirators receive a letter designation of N, P, or R, followed by a number designation of 95, 99, or 100. A respirator designated N-95, P-95, or R-95 has a filtration efficiency of at least 95% for particles having an aerodynamic diameter smaller than one (1) micrometer (Ám), and thus is acceptable for protection against TB. Employers may also use respirators having the 99 and 100 designations which provide greater filtration efficiency. The 100 designation is equivalent to the former "HEPA" designation.

8. Respiratory Protection for Compliance Personnel

When entry into potentially hazardous areas is necessary to perform an effective inspection, the industrial hygienist and Medical Unit staff shall be equipped with respiratory protection as they determine necessary. The minimum respiratory protection used shall consist of a particulate respirator with any current NIOSH certification under 42 CFR, Part 84, Subpart K. In addition, compliance personnel shall ensure that the level of respiratory protection they select does not fall below the minimum required by the employer being inspected. Each District Office must make appropriate respiratory protection available to field staff conducting TB inspections.

9. Patient, Inmate, Resident and Client Privacy

The confidentiality of employees and non-employees who are identified as PPD skin test converters or persons with infectious TB must be protected by the industrial hygienist and Medical Unit staff.

The industrial hygienist and Medical Unit staff shall also use appropriate discretion when entering areas in which patients, inmates, residents or clients are present. When visiting such areas, the industrial hygienist and Medical Unit staff will respect the privacy of all patients, inmates, residents or clients who are present. Photographing patients, inmates, residents or clients in a manner which makes them personally identifiable should not be necessary. In no case shall a photograph be taken without the consent of the photographed party. Any photographic effort shall maintain respect for confidentiality.

 

D. CITATION POLICY

1. Citation Issuance

a. Rationale

The Division's TB citation policy is based primarily on CDC recommendations as referenced in Section B.2.a.(1)(a)NOTE, the current official CDC recommendations regarding TB control as of the most recent date of this P&P. Every TB-related violation to be alleged shall be supported by a determination that the particular employer practice identified as a violation is clearly inconsistent with practices recommended by the CDC for TB prevention and control. If an employer practice is identified as a TB hazard but is not directly addressed by CDC recommendations, then a citation may be issued if recognition of the condition as a TB hazard is clearly consistent with the rationales upon which current CDC recommendations are based.

b. Applicable Title 8 Safety Orders

Whenever an employer is found to have inadequate procedures for TB exposure control, 8 CCR §§5141, 3203, 5143, 5144, 5079, 14300.11 and/or 332.2 shall be cited according to the criteria in this P&P. Each alleged violation shall identify the specific conditions which constitute a violation, including the type and location of the exposure source, if any.

c. Professional Expertise

Determining whether and how to cite for TB-related violations requires a high degree of professional judgment on the part of the industrial hygienist. Prisons, jails, hospitals, clinics, and homeless shelters each constitute fundamentally distinct work environments that present different problems in TB exposure control. Consequently, the issuance of citations must be guided by a sound understanding of tuberculosis exposure control principles in general as well as careful consideration of how they apply to the individual employer's circumstances.

d. Regional Review

The District Manager shall ensure that any enforcement action arising out of an investigation involving tuberculosis is reviewed by the Regional Manager, or his or her designee, prior to issuance.

2. 8 CCR §5141

§5141 applies in any instance where harmful exposures are not prevented by means of engineering controls, administrative controls, and/or respiratory protection. Exposure to respiratory secretions containing TB shall be cited as a harmful exposure under §5141. The evidence necessary to establish such exposure consists of a confirmed diagnosis of infectious TB in the source individual, e.g., patient, inmate, resident, or client, and inadequate measures to control the exposure of employees to air contaminated by a source individual. §5141 cannot be cited when a source individual is only suspected of having infectious TB. Situations where §5141 applies include each of the following:

a. Engineering Controls -- §5141(a)

Employers must provide engineering controls in the form of atmospheric isolation for infectious TB cases. This section would be citable if an employer fails to implement engineering controls in the form of local exhaust ventilation for high-risk procedures on infectious TB cases or atmospheric isolation for infectious TB cases.

NOTE: To be effective, atmospheric isolation must be designed to minimize the need for source individuals to leave, and for employees to enter, the negative pressure area. Isolation must continue until there is a medical determination that the patient is no longer infectious.

b. Administrative Controls -- §5141(b)

Employers must provide effective administrative controls when engineering controls are not feasible. This subsection would be citable if an employer fails to mask an infectious TB case when the patient is brought outside of an area of atmospheric isolation.

c. Respiratory Protection -- §5141(c)

Employers are required to provide respiratory protection before engineering controls are implemented, in emergencies, or in situations where engineering controls are inadequate to prevent harmful exposure. This section would be citable if an employer fails to provide respiratory protection when employees are exposed to an unmasked infectious TB case, e.g., when entering an isolation room, or being present during the performance of a high-risk procedure when local exhaust ventilation is not sufficiently effective to eliminate the need for a respirator.

NOTE: An employee must use respiratory protection when transporting an infectious TB case in an enclosed vehicle even if the employee is masked.

3. 8 CCR §3203

The requirement to address TB exposure control through the employer's Injury and Illness Prevention Program (IIPP) is inferred in §3203 by the requirement for employers to have an effective injury and illness prevention program. The term "effective" in §3203 has at least two important consequences with respect to TB exposure control.

First, in any workplace where there is an increased risk of TB transmission, the employer's IIP Program must include TB transmission among the hazards it addresses. From the Division's perspective, this means that an alleged violation of §3203 must be supported by evidence that there is an increased risk of TB transmission in the employer's workplace. In contrast to §5141, this does not necessarily mean that an infectious TB case must be present for §3203 to apply, although such a situation is perhaps the clearest evidence of increased risk. In the absence of evidence that an infectious TB case was present at the time of the alleged violation, there must be other credible evidence that protection of employees from the risk of TB exposure is reasonably necessary. In almost all cases, this will mean either (1) evidence of a confirmed infectious TB case being present at some point in the recent past in that workplace, or (2) evidence that the workplace fits generic criteria indicating a substantial likelihood that employees will be exposed to an infectious TB case if precautions are not taken, e.g., a county hospital in a county documented by the California Department of Health Services or some other credible source to have a high prevalence of TB.

Second, the consequence of the term "effective" in §3203 is its applicability to evaluating the sufficiency of the employer's compliance with any specific requirement stated in §3203. Thus, in increased-risk worksites, §3203 requires an employer to have procedures to effectively address enforcement, communication, surveillance, containment and employee training as follows:

a. Enforcement -- §3203(a)(2)

Employers must have effective procedures for enforcing their own TB-control procedures.

b. Communication -- §3203(a)(3)

Employers must ensure that the status of all suspected or confirmed TB cases is known to those employees who require this information in order to take proper precautions against TB exposure.

c. Surveillance -- §3203(a)(4) and (5)

In increased risk worksites, surveillance of employees and inmates for TB is an essential part of identifying and evaluating workplace hazards as required by §3203(a)(4), and investigating occupational disease as required by §3203(a)(5).

The necessary elements of surveillance include each of the following:

(1) Prompt initial symptom screening of new prison or jail inmates.

(2) Prompt initial PPD screening of new prison inmates, new long-term inmates at jails or other temporary incarceration facilities, and new employees of any increased risk workplace.

(3) Periodic PPD screening of employees and long term inmates;

NOTE ONE: See Section B.2.a.(1)(a) and (b) for details on how PPD tests must be conducted and how often they must be administered.

NOTE TWO: If an increased risk employer has specific employee job categories for which there is a low probability of TB exposure, those employees need not be PPD screened. Examples include a hospital secretarial employee whose work does not involve being in close proximity to patients or an employee working in a clinic that is operated by a hospital but is not an increased-risk workplace.

(4) Adequate tracking of tuberculin skin test results to determine whether those individuals who test positive have recently converted. A recent tuberculin skin test conversion may be evidence that TB is being transmitted in the workplace.

(5) Prompt medical evaluation of any employee or inmate who is discovered to have symptoms of infectious TB or has been exposed to a confirmed or suspect infectious TB case.

NOTE: In situations where an employee is exposed to a suspect case, medical evaluation is not necessary for the exposed employee, if, after the exposure incident, the suspect case is diagnosed conclusively not to have TB, and the diagnosis is obtained with sufficient promptness that the employee's health is not compromised by waiting for the diagnosis.

c. Containment -- §3203(a)(6)

Where a confirmed or suspected case of infectious TB is present, procedures for correction of unsafe and unhealthy conditions or work practices, as required by §3203 (a)(6), must include the same measures outlined above in connection with §5141 (See Section D.2.)

NOTE: In contrast to §5141, §3203(a)(6) is citable even if an employee's exposure to a suspect case (which constitutes the basis of the citation) is followed by a diagnosis concluding that the suspect case did not actually have infectious TB. The same will be true when, despite its best efforts, the Division cannot develop evidence confirming that the suspect case was later diagnosed to have infectious TB. This is because the violation is procedural, i.e., the employer's procedures are ineffective, as evidenced by the failure to respond appropriately to the suspect case.

d. Training of Employees Including Supervisors -- §3203(a)(7)

§3203(a)(7) requires that effective training be provided by the employer. When evaluating the effectiveness of TB prevention training, the following guidelines should generally be used.

(1) Materials for employee TB prevention training must be appropriate in content and vocabulary for the educational level, literacy skills, and language ability of the employees.

(2) Training should address the following subjects:

(a) Groups at occupational risk for TB, especially immunocompromised workers;

(b) Modes of TB transmission;

(c) Symptoms of infectious TB;

(d) The employer's and employee's responsibility under the employer's TB exposure control procedures;

(e) Use and limitations of methods that will prevent TB exposure including engineering controls, work practice controls, and personal protective equipment;

(f) Decontamination and disposal of personal protective equipment;

(g) TB screening and chemoprophylaxis; and

(h) An opportunity for interactive questions and answers with the person conducting the training session.

4. 8 CCR §5143

In increased-risk occupational settings, §5143 provides a basis for issuance of citations for inadequate local exhaust and dilution ventilation systems used to prevent harmful exposure to TB droplet nuclei. Like §5141, this section is applicable only when a confirmed infectious TB case is involved. In particular, §5143 requires the following with respect to control of harmful exposure to TB:

a. Local Exhaust Ventilation of Sufficient Volume and Velocity to Prevent Harmful Exposure -- §5143(a)(1)

This section applies when employers are required to use (1) ventilation to achieve negative pressure and sufficient air changes in an area of atmospheric isolation, or (2) local exhaust systems in conjunction with high-risk procedures. It is citable when the exhaust system used fails to perform in a competent manner to prevent harmful exposure. The industrial hygienist must use professional judgement to determine whether the local exhaust system used by the employer is adequate. This determination shall be supported by quantitative and qualitative measurements wherever appropriate.

b. Testing -- §5143(a)(5)

Ventilation systems used to prevent harmful exposures must be tested by the employer by means of a pitot traverse, or equally effective test, after installation, alteration, maintenance, and at least annually. Records of each test must be kept for at least five years.

c. Continual Operation -- §5143(b)

The exhaust system must be continually operated throughout the execution of the high-risk procedure or the period during which an infectious TB case is present in an area of atmospheric isolation. In addition, this section requires the system to continue operating for "some time" after cessation of the circumstances which can generate harmful exposures, the purpose being to ensure the clearing of contaminants from the air. Professional judgement and good industrial hygiene practice must be used to determine the minimum length of time the system must be operated after cessation of the procedure. However, even a short length of post-procedure operational time, if adhered to reliably by the employer in connection with a well-designed and well-maintained system, should be acceptable, in the absence of clear evidence to the contrary.

d. Discharge of Exhaust Air -- §5143(c)(1)

The exhaust system must discharge to outside air in a manner that will not cause contamination of other work spaces or recontamination of the source work space. If the employer chooses to HEPA filter the exhaust air and recirculate, this section will apply if inadequate design or maintenance of the system allows contaminated air to reenter work spaces.

5. 8 CCR §5144

§5144(a) requires the use of respirators during emergencies and when engineering controls are impracticable to remove TB droplet nuclei at their source. §5144(b) requires the use of a NIOSH approved respirator. Subsections (c), (d), and (e) of 5144 cover education, fit testing, training, maintenance, sanitation and the requirement to have a written program pertaining to respirator use.

6. 8 CCR §5079

§5079 provides a basis for issuance of citations pertaining to unsafe operation of ultraviolet germicidal irradiation (UVGI) systems.

7. 8 CCR §14300.11

8 CCR §14300.11 requires recording on the Log 300 any case of an employee occupationally exposed to anyone with a known case of active tuberculosis who subsequently develops a tuberculosis infection, as evidenced by a positive skin test or diagnosis by a physician or other licensed health care professional.  When recording a case of TB on the Log 300 a check shall be made in the column for "respiratory condition."  Section 14300.11 should be consulted for three specific exceptions to recording an apparent case of occupational TB infection.

8 CCR§ 14300.29 requires that tuberculosis cases recorded on the Log 300 be treated as privacy cases.  See §14300.29(b)(6) and (b)(7) for details.

NOTE: Employers are not required to record on their Cal/OSHA Log 300 the results of PPD skin tests in millimeters of induration. However, as a matter of complying with 8 CCR §3203(a)(4) and (5), employers are expected to maintain records of all PPD skin test results in millimeters of induration for review during a compliance inspection.

8. 8 CCR §332.2 (Special Order)

Issuance of a Special Order pursuant to 8 CCR §332.2 can be used to address unique circumstances requiring enforcement action which are not covered in Section D.

9. Classification of Violations

Violations of §§5141, 5144, 5143, and 3203(a)(6) based on failure to prevent exposure or potential exposure to TB will usually be classified as serious where the employer has not exercised reasonable diligence to discover the violation. Other violations should be classified on a case-by-case basis.

10. Multiple Violations

a. Standards Cited Together as Part of One Violation

In some cases, a particular employer practice may violate provisions of more than one section of Title 8, e.g., §§3203, 5141, and 5144. In situations where a TB violation involves both §3203 and some other standard, e.g., 3203(a)(6) and 5141(a) for failure to implement engineering controls to prevent employee exposure to a confirmed infectious TB case, one violation should be alleged, referencing both provisions. The same procedure should be followed with respect to 5141(c) and 5144(a), which both require the use of respiratory protection to prevent harmful exposure.

b. Other Violations Based on the Same Hazard

The general procedure for multiple violations based on the same hazard shall be followed for other violations which may involve more than one regulatory provision. That is, the violations shall be cited separately, and where appropriate, penalties shall be reduced based on 8 CCR §336(k). Compliance personnel and District Managers shall ensure that penalties reflect the degree of an employer's noncompliance with any particular section. This is particularly important when several subsections of a regulation are cited because the employer has not fully complied with the regulation. These situations create the potential for multiple citations with cumulative penalties that are much higher than the penalty resulting from complete failure to comply with a requirement.