LIST OF ACRONYMS - California Correctional Health Care ...€¦ · Web viewVaricella disease (chickenpox, shingles)/Varicella zoster and Herpes zoster viruses, disseminated disease

CDCR/CCHCS AEROSOL TRANSMISSIBLE DISEASE EXPOSURE CONTROL PLAN

Aerosol Transmissible Diseases Exposure Control Plan

California Department of Corrections and Rehabilitation California Correctional Health Care Services

CDCR/CCHCS Aerosol Transmissible Diseases Exposure Control Plan

2017

Table of Contents

LIST OF ACRONYMS.....................................................................................................................................2

DEFINITIONS..................................................................................................................................................3

CUSTOMIZED WORKSHEET FOR YOUR INSTITUTION........................................................................8

PLAN’S SCOPE AND APPLICATION.........................................................................................................14

A. REFERRING UNITS................................................................................................................................15

B. ENGINEERING AND WORK PRACTICE CONTROLS AND PERSONAL PROTECTIVE EQUIPMENT...........................................................................................................................................17

C. RESPIRATORY PROTECTION..............................................................................................................24

D. MEDICAL SERVICES.............................................................................................................................26

E. TRAINING................................................................................................................................................31

F. RECORDKEEPING..................................................................................................................................32

APPENDICES

Exposure Incident Requirements.................................................................................................................36

Aerosol Transmissible Diseases/Pathogens (Mandatory)...........................................................................38

Aerosol Transmissible Disease Vaccination Recommendations for Susceptible Health Care Workers (Mandatory).................................................................................................................................................40

Cleaning and Disinfection of ATD Contaminated Work Areas, Vehicles and Equipment........................41

Respiratory Hygiene/Cough Etiquette in Healthcare Settings....................................................................42

Face/Surgical Mask Information.................................................................................................................44

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LIST OF ACRONYMS

ACH Air Changes per Hour

AII Airborne Infection Isolation

AIIR Airborne Infection Isolation Room

AirID Airborne Infectious Disease

AirIP Airborne Infectious Pathogen

ATD Aerosol Transmissible Disease

ATP Aerosol Transmissible Pathogen

ATP-L Aerosol Transmissible Pathogens - Laboratory

CCHCS California Correctional Health Care Services

CCR California Code of Regulations

CDC Centers for Disease Control and Prevention

CDCR California Department of Corrections and Rehabilitation

CDPH California Department of Public Health

CEO Chief Executive Officer

CME Chief Medical Executive

CPR Cardiopulmonary Resuscitation

CTCA California Tuberculosis Controllers Association

HCPOP Health Care Placement Oversight Program

HEPA High Efficiency Particulate Air (filter)

LOP Local Operating Procedures

LTBI Latent Tuberculosis Infection

NIOSH National Institute for Occupational Safety and Health

PAPR Powered Air Purifying Respirator

PLHCP Physician or Other Licensed Health Care Professional

PPE Personal Protective Equipment

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RATD Reportable Aerosol Transmissible DiseaseRTWC Return to Work Coordinator

TB Tuberculosis

DEFINITIONS

Aerosol Transmissible Disease (ATD) or Aerosol Transmissible Pathogen (ATP): A disease or pathogen for which droplet or airborne precautions are required, as listed in Appendix B.

Airborne Infection Isolation (AII): Infection control procedures as described in Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health Care Settings. These procedures are designed to reduce the risk of transmission of airborne infectious pathogens, and apply to patients known or suspected to be infected with epidemiologically important pathogens that can be transmitted by the airborne route.

Airborne Infection Isolation Room or Area (AIIR): A room, area, booth, tent, or other enclosure that is maintained at negative pressure to adjacent areas in order to control the spread of aerosolized M. tuberculosis and other airborne infectious pathogens and that meets the requirements stated in California Code of Regulations (CCR), Title 8, Section 5199, subsection (e)(5)(D) of this standard.

Airborne Infectious Disease (AirID): Either: (1) an ATD transmitted through dissemination of airborne droplet nuclei, small particle aerosols, or dust particles containing the disease agent for which AII is recommended by the Centers for Disease Control (CDC) or California Department of Public Health (CDPH), as listed in Appendix B, or (2) the disease process caused by a novel or unknown pathogen for which there is no evidence to rule out with reasonable certainty the possibility that the pathogen is transmissible through dissemination of airborne droplet nuclei, small particle aerosols, or dust particles containing the novel or unknown pathogen.

Airborne Infectious Pathogen (AirIP) : Either: (1) an ATP transmitted through dissemination of airborne droplet nuclei, small particle aerosols, or dust particles containing the infectious agent, and for which the CDC or CDPH recommends AII, as listed in Appendix B, or (2) a novel or unknown pathogen for which there is no evidence to rule out with reasonable certainty the possibility that it is transmissible through dissemination of airborne droplet nuclei, small particle aerosols, or dust particles containing the novel or unknown pathogen.

Exposure Incident: An event in which all of the following have occurred: (1) An employee has been exposed to an individual who is a case or suspected case of a reportable ATD, or to a work area or to equipment that is reasonably expected to contain ATPs associated with a reportable ATD; and (2) The exposure occurred without the benefit of applicable exposure controls required by this section; and (3) It reasonably appears from the circumstances of the exposure that transmission of disease is sufficiently likely to require medical evaluation.

Guideline for Isolation Precautions: The Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007, CDC, is hereby incorporated by reference for the sole purpose of establishing requirements for droplet and contact precautions.

Health Care Worker: A person who works in a health care facility, service or operation, or who has occupational exposure in a public health service environment.

High Hazard Procedures: Procedures performed on a person who is a case or suspected case of an ATD on a specimen suspected of containing an ATP-Laboratory (ATP-L), in which the potential for being exposed to ATPs is increased due to the reasonably anticipated generation of aerosolized pathogens. Such procedures include, but are not limited to, sputum induction, bronchoscopy, aerosolized administration of pentamidine or other

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medications, and pulmonary function testing. High Hazard Procedures also include, but are not limited to, autopsy, clinical, surgical and laboratory procedures that may aerosolize pathogens.Individually Identifiable Medical Information: Medical information that includes any element of personal identifying information sufficient to allow identification of the individual, such as the patient's name, address, electronic mail address, telephone number, or social security number, or other information that, alone or in combination with other publicly available information, reveals the individual's identity.

Infection Control PLHCP: A Physician or Other Licensed Health Care Professional (PLHCP) who is knowledgeable about infection control practices, including routes of transmission, isolation precautions and the investigation of exposure incidents.

Initial Treatment: Treatment provided at the time of the first contact a health care provider has with a person who is potentially an AirID case or suspected case. Initial treatment does not include High Hazard Procedures.

County Health Officer: The health officer for the local jurisdiction responsible for receiving and/or sending reports of communicable diseases, as defined in CCR, Title 17.NOTE: CCR, Title 17, Section 2500 requires that reports be made to the local health officer for the jurisdiction where the patient resides. This is the County Health Officer for the California Correctional Health Care Services (CCHCS) institution sites.

Mycobacterium tuberculosis (M. tuberculosis): M. tuberculosis complex, which includes M. tuberculosis, M.bovis, M. africanum, and M. microti. M. tuberculosis is the scientific name of the group of bacteria that cause tuberculosis.

N95 Filtering Facepiece Respirator: A mechanical filter that filters at least 95 percent of all airborne particles.

Negative Pressure: A relative air pressure difference between two areas. The pressure in a containment room or area that is under negative pressure is lower than adjacent areas, which keeps air from flowing out of the containment facility and into adjacent rooms or areas.

National Institute for Occupational Safety and Health (NIOSH): The Director/Designee of the NIOSH, CDC, or his or her designated representative.

CDC Non-Medical Transport: The transportation by employees other than health care providers or emergency medical personnel during which no medical services are reasonably anticipated to be provided.

Occupational Exposure: Exposure from work activity or working conditions that is reasonably anticipated to create an elevated risk of contracting any disease caused by ATPs or ATP-L if protective measures are not in place. In this context, “elevated” means higher than what is considered ordinary for employees having direct contact with the general public outside of the facilities, service categories and operations listed in CCR, Title 8, Section 5199, subsection (a)(1) of this standard. Occupational exposure is presumed to exist to some extent in each of the facilities, services and operations listed in CCR, Title 8, Section 5199, subsection (a)(1)(A) through (a)(1)(I). Whether a particular employee has occupational exposure depends on the tasks, activities, and environment of the employee, and therefore, some employees of a covered employer may have no occupational exposure. For example, occupational exposure typically does not exist where a hospital employee works only in an office environment separated from patient care facilities, or works only in other areas separate from those where the risk of ATD transmission, whether from patients or contaminated items, would be elevated without protective measures. CCHCS shall identify those employees who have occupational exposure so that appropriate protective measures can be implemented to protect them as required. Employee activities that involve having contact with, or being within exposure range of cases or suspected cases of ATD, are always considered to cause occupational exposure. Similarly, employee activities that involve contact with, or routinely being within exposure range of, populations served by facilities identified in CCR, Title 8, Section 5199 subsection (a)(1)(E)

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are considered to cause occupational exposure. Since the entire CCHCS staff at all or nearly all institutions are routinely within exposure range of inmates, they and other CCHCS personnel with inmate contact are considered occupationally exposed. Contracted Physician or Other Licensed Health Care Professional: A contracted individual or group (such as Emeryville Occupational Medical Center) whose legally permitted scope or practice (i.e., license, registration, or certification) allows him/her to independently provide, or be delegated the responsibility to provide, some or all of the health care services required by this section.

Public Health Guidelines: (1) With regard to TB, applicable guidelines published by the California Tuberculosis Controllers Association (CTCA) and/or CDPH as follows, which are hereby incorporated by reference:

a. Guidelines for TB Screening and Treatment of Patients with Chronic Kidney Disease, Patients Receiving hemodialysis, Patients Receiving Peritoneal Dialysis, Patients Undergoing Renal Transplantation and Employees of Dialysis Facilities, February 22, 2008.

b. Guidelines for the Treatment of Active Tuberculosis Disease, April 15, 2003 including related material: Summary of Differences Between 2003 California and National Tuberculosis Treatment Guidelines, 2004, Amendment to Joint CDHS/CTCA Guidelines for the Treatment of Active Tuberculosis Disease, May 12, 2006, Appendix 3 – Algorithm for MDR-TB Cases and Hospital Discharge, May 12, 2006.

c. Targeted Testing and Treatment of Latent Tuberculosis Infection in Adults and Children, May 12, 2006.

d. CTCA Position Statement: The Utilization of QuantiFERON - TB Gold in California, May 18, 2007.

e. Guidelines for Mycobacteriology Services in California, April 11, 1997.

f. Guidelines for the Placement or Return of Tuberculosis Patients into High Risk Housing, Work, Correctional or In-Patient Settings, April 11, 1997.

g. Contact Investigation Guidelines, November 12, 1998.

h. Source Case Investigation Guidelines, April 27, 2001.

i. Guidelines on Prevention and CTCA Long-Term Health Care Facilities, October 2005.

j. Guidelines for Reporting Tuberculosis Suspects and cases in California, October 1997.

k. CTCA recommendations for serial TB testing of Health Care Workers (CA Licensing and Certification), September 23, 2008.

(2) With regard to vaccine-preventable diseases, refer to the following publication: CDC and Prevention, Atkinson W, Hamborsky J, McIntyre L, Wolfe S, eds. 10th ed. 2nd printing, including chapters from the 9th edition on Anthrax and Smallpox, Washington DC: Public Health Foundation, 2008.

(3) With regard to any disease or condition not addressed by the above guidelines, refer to recommendations made by the CDPH or the county health officer pursuant to authority granted under the Health and Safety Code and/or CCR, Title 17.

Referral: The directing or transferring of a possible ATD case to another facility, service or operation for the purposes of transport, diagnosis, treatment, isolation, housing or care.

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Referring Employer: Any employer that operates a facility, service, or operation in which there is occupational exposure and which refers AirID cases and suspected cases to other facilities. Referring facilities, services and operations do not provide diagnosis, treatment, transport, housing, isolation or management to persons requiring AII. Law enforcement, corrections, public health, and other operations that provide only non-medical transport for referred cases are considered referring employers if they do not provide diagnosis, treatment, housing, isolation or management of referred cases.

Reportable Aerosol Transmissible Disease (RATD): A disease or condition which a health care provider is required to report to the county health officer, in accordance with CCR, Title 17, Division 1, Chapter 4, and which meets the definition of an ATD.

Respirator: A device which has met the requirements of 42 CFR Part 84, has been designed to protect the wearer from inhalation of harmful atmospheres, and has been approved by NIOSH for the purpose for which it is used.

Respirator User: An employee who in the scope of their current job may be assigned to tasks which may require the use of a respirator, in accordance with CCR, Title 8, Section 5199, subsection Respiratory Protection (g).

Respiratory Hygiene/Cough Etiquette in Health Care Settings: Respiratory Hygiene/Cough Etiquette in Health Care Settings, CDC, November 4, 2004, which is hereby incorporated by reference, for the sole purpose of establishing requirements for source control procedures.

Suspected case: Either of the following:

1. A person whom a health care provider believes, after weighing signs, symptoms, and/or laboratory evidence, to probably have a particular disease or condition listed in Appendix A.

2. A person who is considered a probable case, or an epidemiologically-linked case, or who has supportive laboratory findings under the most recent communicable disease surveillance case definition established by CDC and published in the Morbidity and Mortality Weekly Report (MMWR) or its supplements as applied to a particular disease or condition listed in Appendix A.

Test for Tuberculosis Infection (TB test): Any test, including the tuberculin skin test and Blood Assays for M. Tuberculosis such as Interferon Gamma Release Assays which: (1) has been approved by the Food & Drug Administration (FDA) for the purposes of detecting tuberculosis infection, and (2) is recommended by the CDC for testing for TB infection in the environment in which it is used, and (3) is administered, performed, analyzed and evaluated in accordance with those approvals and guidelines.

NOTE: Where surveillance for latent TB infection (LTBI) is required by CCR, Title 22, the TB test must be licensed by the FDA and recommended by the CDC.

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INSTRUCTIONS

Pages 8 through 13, the local operating procedure’s (LOP) “Customized Worksheet for your Institution” section is a fillable worksheet that will auto-populate the appropriate fields in the remainder of the LOP for your institution as you fill in the blanks by answering the questions in the worksheet.

Once the Customization Worksheet, and thus the LOP is complete, California Department of Corrections and Rehabilitation (CDCR) and CCHCS will require that the Program Administrator and back-up are responsible to implement this plan by reading and becoming familiar with all of the regulations and requirements in CCR, Title 8, Section 5199, the completed LOP itself, and the LOP’s appendices.

This document will update or supplement your current procedures that are associated with the ATD Requirements (e.g., maintenance of airborne infection isolation rooms and cleaning and disinfection of ATD contaminated work areas). Requirements can be found in the following sections of the ATD ECP:

A. Referring Units; B. Engineering and Work Practice Controls and Personal Protective Equipment; C. Respiratory Protection; D. Medical Services; E. Training; F. Recordkeeping; and Appendix D, Cleaning and Disinfecting of ATD Contaminated Work Areas, Vehicles and Equipment.

General ATD informational materials (brochures, posters and a newsletter bulletin and quiz) are available to institutions from the HQ Employee Health Unit for use in awareness training and various aspects of ATDs. Training for institutional employees on vaccination requirements and an offer to provide vaccinations at the institutions will be provided through a contract developed by CDCR and CCHCS.

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CUSTOMIZED WORKSHEET FOR YOUR INSTITUTION

Complete pages 8 through 13 to customize the ATD ECP LOP template for your institution.

1. Name of institution:

2. Manager or designee responsible for the ATD program. Please list a job title, not an individual’s name, if possible:

3. Manager or designee’s back-up person responsible for the ATD program. Please list a job title, not an individual’s name, if possible:

4. Web link where the institution’s ATD ECP LOP is available :

5. Within CDCR, the determination whether a facility, unit, service, or operation is or is not a referring unit is made on a unit-by-unit basis by the Warden, CME, Nursing Executive, and/or CEO or designee and may change under surge conditions on an hourly basis (e.g., as housing units are converted to/from isolation for inmates). Institutions, yards and buildings may have both referring and non-referring units.

List institution’s current Non-Referring Units (any unit with a room used for negative pressure/AII room):

List institution’s current Referring Units (usually units without an AII/negative pressure room, (e.g., all yards and housing units, except those listed above are non-referring):

6. AirID patients are transferred to an AIIR within an institution within five hours of suspecting or identifying the condition. If the institution has no designated room available, the Health Care Placement Oversight Program (HCPOP) is contacted to seek an AIIR at another CDCR facility. The sending physician or designee seeks a bed at an outside facility. If no AIIR is available via those resources, the county public health officer participates in locating or guiding the transfer of the patient to another facility.

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If no appropriate AIIR is promptly available in the institution, please list where the AirID patient is kept (usually where isolation, ventilation, respirators, and staffing are optimal) until the patient is transferred to another facility within five hours of identifying the condition:

7. Each institution shall assess their clinical practice and pursuant to CCR, Title 8, Section 5199 (d)(2)(C), provide a list of both a) aerosol generating procedures the institution intends to perform on individuals with suspected ATD (patients to be housed in AIIR) and b) procedures where “the employer determines that powered air purifying respirator (PAPR) use would interfere with the successful performance of the required task or tasks” (Cardiopulmonary Resuscitation [CPR] falls in the latter category per some experts and the CCHCS Headquarters ATD Committee).

Please note that procedures that were either specified as aerosol generating by CalOSHA or suggested to be aerosol generating per World Health Organization (WHO), University of California San Francisco (UCSF), Kaiser Southern California, and other groups, have been listed in the table below.

If your institution does not reasonably anticipate performing the procedures on an individual with known or suspected ATD as listed in the table, please state not applicable (N/A) under job classifications and operations/activities. For the remaining procedures, list the job classes and operations/activities in which employees are exposed to those procedures.

High Hazard Procedures/Tasks Requiring Personal or Respiratory Protection IF PERFORMED ON AN ATD SUSPECT OR CASE

Job Classifications Exposed to this Procedure

Operations/Activities Exposed to this Procedure

Aerosolized administration of albuterol, pentamidine, or other medications

Pulmonary function testing (Note if this only includes peak flow tests)

Sputum induction or other deliberate induction of cough

Bronchoscopy

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Upper airway endoscopy beyond bronchoscopy

Other procedures with “reasonably anticipated generation of aerosolized pathogens.”

Giving humidified oxygen at >40% O2.

Collecting lower respiratory tract specimens (e.g., bronchial and tracheal aspirates).

Cardiopulmonary resuscitation PAPR use would interfere with successful performance of the required task per headquarters ATD committee.

PAPR use would interfere with successful performance of the required task per headquarters ATD committee.

Respiratory and airway suctioning (including tracheostomy care and open suctioning with invasive ventilation).

Intubation, extubation, noninvasive, bag-valve mask, oscillatory, or manual ventilation, or any procedure involving manipulation of open ventilator tubing in a mechanically ventilated patient.

Additional procedures to include:

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8. List the name or the title of the person responsible for maintaining PAPR respirators.

9. Institutions shall inform persons entering the facility, being transported by employees, or otherwise in close contact with employees, about source control practices (e.g., washing hands, wearing masks, respiratory etiquette) by posting placards such as “Cover Your Cough” and “Important Notice to All” linked from www.cdc.gov and found at the following website: http://www.health.state.mn.us/divs/idepc/dtopics/infectioncontrol/cover/.List the locations within the facility where source control placards such as “Cover Your Cough” and “Important Notice to All” are posted (e.g., at all entrances):

10. Controls are implemented to protect employees who operate/maintain vehicles that transport persons with ATD. Provide barriers and air handling systems where feasible; if this is not feasible, employees must wear at least an N95 (or better) respirator while transporting persons with suspected ATD. For this institution, feasible transport-related exposure limitation measures include (please put an X next to all that apply):

Having the person with suspected ATD wear at least a surgical or ear-loop mask or, if unavailable, an N95 respirator and practice respiratory etiquette.

Driving golf carts or similar vehicles with as much ventilation, barriers, and distance between the employees and persons with suspected ATD, as feasible.

11. Below are documented considerations and the basis for decisions regarding engineering, mechanical systems, and work practice controls to protect employees who operate, use, or maintain vehicles that transport persons with known or suspected ATD. Barriers, air handling systems, and work practices that are considered feasible at this institution include the following (please put an X next to all that apply):

Minimizing time with, proximity to, and respiratory etiquette violations by the individual with known or suspected ATD.

Maximizing staying upwind, ventilation, and sunlight in confined spaces with the individual with known or suspected ATD.

Having the person with known or suspected ATD wear at least a surgical or ear-loop mask. Employee use of NIOSH-certified N95 (or better) respirators with proper fit testing, if needed. Law enforcement or corrections personnel who transport a person requiring referral in a vehicle

need not use respiratory protection if all of the following conditions are met:a. A solid partition separates the passenger area from the area where employees are located.b. The employer implements written procedures that specify the conditions of operation, including

the operation of windows and fans.c. The employer tests (e.g., by the use of smoke tubes) the airflow in a representative vehicle (of the

same model, year of manufacture, and partition design) under the specified conditions of operation, and finds that there is no detectable airflow from the passenger compartment to the employee area.

d. The employer records the results of the tests and maintains the results in accordance with CCR, Title 8, Section 5199 (j)(3)(F).

e. The person performing the test is knowledgeable about the assessment of ventilation systems.

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12. Vaccination for seasonal influenza will be offered to all occupationally exposed CDCR and CCHCS employees annually as recommended by the CDPH. Every year, employees who decide not to be vaccinated against seasonal influenza when the vaccine is offered, will be asked to sign a Vaccination Declination form mandated by CalOSHA. If the employee declines to sign the form, this choice shall be noted on the form by the CEO/Warden’s designee.

Please provide the job title of the CEO/Warden’s designee responsible for collecting these Vaccination Declination forms as mentioned above:

13. In addition to the seasonal influenza vaccination, the MMR vaccine (protects against Measles, Mumps and Rubella), Tdap vaccine (protects against Diphtheria, Tetanus and Pertussis), and Varicella vaccine (protects against chickenpox) are recommended and offered to occupationally exposed CCHCS employees and CDCR health care access workers and others at the Warden’s request. Employees are requested to provide evidence of immunity to those diseases. Employees without proof of immunity, who decline the offer of vaccination, will be asked to sign a Vaccination Declination form mandated by CalOSHA for each vaccine being declined. If the employee declines to sign the form, this choice shall be noted on the form by the CEO/Warden's designee.

Please provide the job title or name of the CEO/Warden’s designee responsible for collecting the Tdap, Varicella, and MMR vaccination declination forms as mentioned above:

14. In accordance with Penal Code 6006 et seq., CCR, Title 8, Section 5199; and applicable public health guidelines, the CDCR and CCHCS through its contractor shall make available to employees an annual assessment for latent TB infection.

In the case where the employee assessed for latent TB infection shows results of a new positive TB symptom or test, please list the title of the person the employee should contact (e.g., the Return to Work Coordinator [RTWC]):

This contact person will make a referral for workers’ compensation evaluation to a PLHCP for individuals who believe the cause of the positive TB symptom or test is job related.

15. In accordance with recordkeeping requirements, new positive TB tests shall be recorded in an exposure log. Please list the job title of the person responsible for maintaining the exposure log:

16. Employees’ reportable ATD cases shall generally be diagnosed offsite, reported to the local health officer and other possibly exposed employers recorded by their treating clinician pursuant to CCR, Title 8, Section 5199 (h)(6)(A) and (B), and investigated through county health officer assistance if necessary by:

(e.g., the RTWC whose skills and confidential non-personnel recordkeeping qualify them for this task).

17. List the person who is responsible for reviewing the ATD ECP on a scheduled basis (at least annually). Please list a job title, not an individual’s name, if possible:

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18. List the person (e.g., a Warden, CEO or staff member) responsible for maintaining the review schedule, review process, and records of who reviewed the plan. Please list a job title, not an individual’s name, if possible:

19. List the person (e.g., RTWC) designated to retain exposure incident (and related) records. Please list a job title, not an individual’s name, if possible:

CDCR Warden (print name)

(Signature) ________________________________________________Date:________________CDCR Warden

CCHCS Chief Executive Officer (print name)

(Signature) ________________________________________________Date:________________CCHCS Chief Executive Officer

Onsite ATD Plan Administrator (print name/title)

(Signature) ________________________________________________Date:________________ATD Plan Administrator

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PLAN’S SCOPE AND APPLICATION

This document shall serve as the CCHCS and CDCR ATD ECP and LOP as required by CCR, Title 8, Section 5199, ATD Regulations.

The designated administrator (please list job title, not an individual’s name if possible), is responsible for the ATD program, while (please list job title, not an individual’s name if possible) serves as the backup.

The overall a) statewide ATD ECP and b) template for the local institutions’ ATD ECP/LOP are administered by the joint CDCR/CCHCS advisory committee for the CDCR Employee Health Unit. The statewide plan and this template for institution-specific plans and LOP are available to all employees under the Administrative Policies tab at:http://lifeline/PolicyandAdministration/PolicyandRiskManagement/IMSPP/Pages/Resources.aspx

The institution’s ATD ECP LOP is available at: the HQ CDCR Employee Health Unit.

Occupational exposure is defined as exposure from work activity or working conditions that are reasonably anticipated to create an elevated risk of contracting any disease caused by ATPs, if protective measures are not in place. Occupational exposure is presumed to exist to some extent in correctional facilities and other facilities that house inmates. CDCR and CCHCS have determined that all job categories are routinely within exposure range of inmates, thus all CDCR and CCHCS job classifications assigned to the institutions and all other CDCR and CCHCS job classifications with similar inmate exposure, may cause employees to have occupational ATD exposure.

CDCR and CCHCS with assistance from its contractor shall provide all safeguards required by this section, including provision of personal protective equipment (PPE), respirators, training, and medical services, at no cost to such potentially exposed employees, at a reasonable time and place for the employee, and during the employee’s working hours.

In addition to this first section, Scope and Application, this written plan contains the following sections:

A. Referring Units; B. Engineering and Work Practice Controls and Personal Protective Equipment; C. Respiratory Protection; D. Medical Services; E. Training; and F. Recordkeeping.

This institution-specific plan provides an overview of the requirements set forth by CCR, Title 8, Section 5199. To ensure that CDCR and CCHCS are in compliance with the regulations, those responsible to implement this plan should refer to the relevant regulations (e.g., www.dir.ca.gov/title8/5199.html).

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A. REFERRING UNITS

A referring unit is an operation, service or facility that:

1. Screens persons for AirID;

2. Refers any person identified as a case or suspected case of AirID;

3. Does not intend to provide further medical services to AirID cases and suspected cases beyond first aid, initial treatment or screening and referral; and

4. Does not provide transport, housing, or AII to any person identified as an AirID case or suspected case, unless the transport provided is only non-medical transport in the course of a referral.

Within CDCR institutions, the determination whether a facility, unit, service, or operation is or is not a referring unit is made on a unit-by-unit basis by the Warden, CME, Nursing Executive, and/or CEO or designee and may change under surge conditions on an hourly basis (e.g., as housing units are converted to/from isolation for inmates). Institutions, yards, and buildings may have both referring and non-referring units.

CDCR and CCHCS’ Referring Units under normal (non-surge) conditions include: Camps; Yards and housing units that refer rather than provide even simple nebulizer (e.g., albuterol) or peak flow

meter care for ATD suspect and case patients; and Housing units that do not have negative-pressure or isolation rooms.

At this institution the referring units are:

The CEO/Warden of exclusively referring units is only required to do the following (generally by using the written source control, screening and referral, communication, risk reduction, training, review, medical service, and recordkeeping procedures in this document):

1. Designate knowledgeable managers as the ATD administrators to be responsible for the establishment, implementation and maintenance of effective written infection control procedures to control the risk of ATDs;

2. Designate position(s) or individual managers with full authority to act on the ATD administrator(s) behalf for when the latter are not on site;

3. Establish, implement, and maintain effective written source control procedures;

4. Establish, implement, and maintain effective written procedures for the screening and referral of cases and suspected cases of AirIDs to appropriate facilities (e.g., “Symptomatic patients are screened for AirIDs by health care workers, and referred as needed per the timelines below);

5. Establish, implement, and maintain effective written procedures to communicate with employees, other employers, and the county health officer regarding the suspected or diagnosed infectious disease status of referred patients;

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6. Establish, implement and maintain effective written procedures to reduce the risk of transmission of ATD, to the extent feasible, during the period the person requiring referral is in the facility or is in contact with employees;

7. Establish a system of medical services for employees;

8. Ensure that all employees with occupational exposure participate in a training program;

9. Ensure that the infection control procedures are reviewed at least annually; and

10. Establish and maintain training records, vaccination records, records of exposure incidents, and records of inspection, testing, and maintenance.

The remainder of this plan, beyond the written source control, screening and referral, communication, risk reduction, training, review, medical service, and recordkeeping procedures, is for CDCR and CCHCS’ non-referring units. At this institution the non-referring units are:

The following methods are used to prevent exposures to ATD/pathogens:

Posting of Respiratory Hygiene/Cough Etiquette placards and requesting, for waiting areas for patients and visitors:

1. Tissues and no-touch receptacles for used tissue disposal; 2. Conveniently located dispensers of alcohol-based hand rub (request from CDCR for settings where

practical e.g., where supervised); and 3. Where sinks are available, ensuring that supplies for hand washing (i.e., soap, disposable towels) are

consistently available.

Promptly identifying patients suspected of ATD. Placing at least a surgical or ear-loop mask on the patient suspected of ATD and educating him/her on why and how to keep the mask on to avoid consequences including contamination of the room air and other individuals. As feasible, since CalOSHA does not require a surgical mask for referring institutions, especially for an individual with suspected ATD who is coughing heavily or unmasked in a room for over 10-20 minutes, either have staff:

1. Avoid entering the room the patient suspected of ATD was in before masking, 2. Wear an appropriate respirator if entering that room, OR 3. Isolate the patient with suspected ATD in a new single room. That allows possible contaminants in the

initial room to be removed by ventilating for at least seven air changes, e.g., at least 1.7 hours in a four air changes per hour (ACH) room per the CDC at www.cdc.gov/mmwr/pdf/rr/rr5417.pdf (Review page 20, Table 1 within this document for ACH).

Transfers to an AIIR within the institution for AirID patients are accomplished within five hours of suspecting or identifying the condition. If no room is available, contact HCPOP by phone at 916-204-0321 (8 a.m. - 4 p.m.), to seek an AIIR at another CDCR facility. The sending physician or designee seeks a bed at an outside facility. If no AIIR is available via those resources, the county public health officer participates in locating or guiding the transfer of the patient to another facility.

1. If no AIIR is promptly available in the unit, the patient is kept in (usually where isolation, ventilation, respirators, and staffing are optimal) until the patient is transferred to another facility within

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five hours of identifying the condition. At the end of five hours and every 24 hours thereafter, the reason why the transfer did not occur shall be documented. Exception: Some patients may be too ill to transfer. The treating physician determines transfer is detrimental to the patient's condition and documents the reason the patient cannot be transported/transferred to another facility.

2. When it is not feasible to provide airborne isolation rooms for a novel disease, other effective control measures shall be provided, i.e., PPE, cohort patients, hand hygiene, social distancing, keeping individuals six feet apart.

Portable high efficiency particulate air (HEPA) filter units may be used to increase the number of rooms, diagnostic areas available to treat ATD patients, and/or ATP.

The CCHCS Transmission-Based Precautions policy and procedure can be accessed at the following links:http://lifeline/PolicyandAdministration/PolicyandRiskManagement/IMSPP/IMSPP/IMSPP-v10-ch09.1.pdfand http://lifeline/PolicyandAdministration/PolicyandRiskManagement/IMSPP/IMSPP/IMSPP-v10-ch09.2.pdf

B. ENGINEERING AND WORK PRACTICE CONTROLS AND PERSONAL PROTECTIVE EQUIPMENT

CDCR and CCHCS use work practice controls and existing engineering and mechanical systems to minimize CDCR and CCHCS employee exposures to ATPs. Where engineering and mechanical systems and work practice controls provide insufficient protection, such as when an employee enters an AIIR or area, CDCR and CCHCS shall provide and ensure that employees use PPE and respiratory protection. Additionally, CDCR and CCHCS shall implement work practices to prevent or minimize employee exposures to airborne, droplet, and contact transmission of ATP. These work practices include, but are not limited to:

1. Prompt identification of patients with suspected ATD;

2. Promptly offering, and educating individuals with known or suspected ATD to wear at least a surgical or ear-loop mask;

3. Transfers to an AIIR within the institution for AirID patient are accomplished within five hours of suspecting or identifying the condition.

a. If no AIIR is available at the institution, contact HCPOP by phone at 916-204-0321 (8 a.m. – 4.p.m.) to seek an AIIR at another CDCR facility. The sending physician seeks a bed at an outside facility. If no AIIR is available via those resources, the county public health officer participates in locating or guiding the transfer of the patient to another facility within five hours of identifying the condition. By five hours and every 24 hours thereafter, the reason transfer did not occur and the implementations shall be documented. Exception: Some patients may be too ill to transfer. The treating physician reviews the patient’s condition and determines within five hours if transfer is detrimental to the patient’s condition and documents the reason the patient cannot be transported/transferred to another facility. Updates every 24 hours are required: 1) The employer has contacted the local health officer. Reasonable efforts have been made to

contact establishments outside of that jurisdiction, as provider in the Plan. 2) All applicable measures recommended by the local health officer, or the Infection Control

PLHCP have been implemented. 3) All employees who enter the room or area housing the individual are provided with, and use,

appropriate PPE and respiratory protection in accordance with subsection (g) and Section 5144, Respiratory Protection of these orders.

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b. The patient’s condition shall be reviewed at lease every 24 hours to determine if transfer is safe, and the determination shall be recorded as described in the Plan in accordance with (d)(2)(G). Once transfer is determined to be safe, transfer must be made within the time period set forth in subsection (e)(5)(B).

c. When it is not feasible to provide airborne isolation rooms for a novel disease, other effective control measures shall be provided, i.e., PPE, cohort patients, hand hygiene, social distancing, keeping individuals six feet apart, and/or portable HEPA filter units which may be used to increase the number of rooms and diagnostic areas available to treat ATD patients and/or ATP.

4. Hand washing and gloving procedures;

5. The use of anterooms; and

6. Cleaning and disinfecting contaminated surfaces, articles, and linens.

7. Assignments or tasks requiring personal or respiratory protection are:a. Entry into AIIR during and within one hour after occupancy by ATD suspect or case;b. Approach within six feet of a droplet precaution

Work Practice Controls - Department managers who shall enforce employee work practice controls.

The following work practice controls are implemented to prevent exposure to airborne pathogens:

1. Employees taking care of patients with suspected or confirmed airborne diseases must wear appropriate respiratory protection.

2. Patients with communicable airborne diseases must wear a surgical or ear-loop mask during transport and other times when patients are out of designated isolation rooms (unless the patient is intubated).

3. ATD patients/suspects in airborne isolation rooms must have the doors closed at all times except briefly on entries and exits.

Each institution shall assess their clinical practice and pursuant to CCR, Title 8, Section 5199 (d) (2) (C) shall list the following:

1. Aerosol generating procedures the institution intends to perform on individuals with known or suspected ATD (who are to be housed in airborne isolation rooms); and

2. Procedures where “the employer determines that PAPR use would interfere with the successful performance of the required task or tasks” (CPR falls in that category per some experts and CCHCS HQ ATD Committee). Procedures specified as aerosol generated by CalOSHA or suggested by WHO, UCSF, Kaiser Southern California training materials, and other groups have been provided in Table 1.

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Table 1: High hazard/aerosol generating procedures that we reasonably anticipate performing ON ATD SUSPECTS OR CASES

High Hazard Procedure IF PERFORMED ON ATD SUSPECTS/CASES

Aerosol Generating Or High Hazard Pursuant to:

Job Classifications Exposed To This Procedure:

Operations/Activities Exposed To This Procedure:

Aerosolized administration of albuterol , pentamidine , or other medications

CalOSHA CCR, Title 8, Section 5199

Pulmonary function testing (Note if this only includes peak flow tests)


Sputum induction or other deliberate induction of cough

CalOSHA CCR, Title 8 Section 5199/Researchers

Bronchoscopy CalOSHA CCR, Title 8, Section 5199

Upper airway endoscopy beyond bronchoscopy Researchers

Other procedures with “reasonably anticipated generation of aerosolized pathogens.”


Given humidified oxygen at >40% O2 Researchers

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Collecting lower respiratory tract specimens (e.g., bronchial and tracheal aspirates)

WHO

Cardiopulmonary resuscitation UCSF, WHO PAPR use would interfere with successful performance of the required task per headquarters ATD committee.

PAPR use would interfere with successful performance of the required task per headquarters ATD committee.

Respiratory and airway suctioning (including care of tracheostomy and open suctioning with invasive ventilation)

WHO, researchers

Intubation, extubation, noninvasive, bag-valve mask, oscillatory, or manual ventilation, or any procedure with manipulation of open ventilator tubing in a mechanically ventilated patient

WHO, UCSF, researchers

Additional procedures to include:

CalOSHA. http://www.dir.ca.gov/title8/5199.html WHO. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3571988/table/pone-0056278-t001/

UCSF. http://infectioncontrol.ucsfmedicalcenter.org/node/351

Kaiser. http://kpnursing.org/_SCAL/professionaldevelopment/orientation/baldwinpark/inpatient.html

Researchers. http://wwwnc.cdc.gov/eid/article/19/4/pdfs/11-1812.pdf

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http://kpnursing.org/_SCAL/professionaldevelopment/orientation/baldwinpark/inpatient.html

http://infectioncontrol.ucsfmedicalcenter.org/node/351

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Source Control

CDCR and CCHCS shall implement written source control procedures. The procedures shall include methods to inform individuals entering the facility, being transported by employees, or otherwise in close contact with employees, of the source control practices implemented by CDCR and CCHCS.

1. Via “Cover Your Cough” and “Important Notice to All“ placards (See links at: http://www.health.state.mn.us/divs/idepc/dtopics/infectioncontrol/cover/) posted at:

, we inform persons entering the facility about our source control practices; visitors are to wash hands, use respiratory etiquette and wear mask when indicated.

2. Respiratory etiquette is taught to patients, visitors, and employees suspected of ATD. They are to wear at least a surgical or ear-loop mask and follow the donning and doffing procedures in Appendix E and cover coughs/sneezes.

3. Controls are implemented to protect employees who operate/maintain vehicles that transport persons with ATD. Provide barriers and air handling systems where feasible; if this is not feasible, employees wear an N95 (or better) respirator while transporting persons with suspected ATD. For this institution, feasible transport-related exposure limitation measures may include (checked):

Having the person with suspected ATD wear at least a surgical or ear-loop mask or, if unavailable, an N95 respirator and practice respiratory etiquette.

Err

Driving golf carts or similar vehicles with as much ventilation, barriers, and distance between the employees and persons with suspected ATD, as feasible.

4. Respirators shall not be used when an employee is operating a vehicle for which the respirator may interfere with the safe operation of the vehicle. The employer shall provide barriers or source control measures.

5. Conduct High Hazard Procedures in airborne isolation rooms, booths or tents. When this is not feasible, use appropriate PPE.

6. Patients with the same respiratory AirID diagnosis may be placed in a cohort on a designated isolation unit during times of high census, such as a pandemic.

7. Air disinfection measures (e.g., increased exhaust ventilation and/or HEPA filter unit use) will be requested from CDCR when general housing is repurposed for isolation in surge circumstances.

8. Specific requirements for AII rooms and areas:a. Hospital isolation rooms constructed in accordance with CCR, Title 24, Section 417, et. seq., and

which are maintained to meet those requirements shall be considered to be in compliance with subsection (e)(5)(D)2.

b. Negative pressure shall be maintained in AII rooms or areas. The ventilation rate shall be 12 or more ACH. The required ventilation rate may be achieved in part by using in-room HEPA filtration or other air cleaning technologies, but in no case shall the outdoor air supply ventilation rate be less than six ACH. Hoods, booths, tents and other local exhaust control measures shall comply with Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings.

c. Negative pressure shall be visually demonstrated daily by smoke trails or equally effective means while a room or area is in use for AII.

d. Engineering controls shall be maintained, inspected and performance monitored for exhaust or recirculation filter loading and leakage at least annually, whenever filters are changed, and more often if necessary to maintain effectiveness. Where Ultraviolet Germicidal Irradiation is used, it shall be used, maintained, inspected and controlled in accordance with Guidelines for Preventing

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the Transmission of Mycobacterium tuberculosis in Health-Care Settings. Problems found shall be corrected in a reasonable period of time. If the problem(s) prevent the room from providing effective AII, then the room shall not be used for that purpose until the condition is corrected.

e. Ventilation systems for AII rooms or areas shall be constructed, installed, inspected, operated, tested, and maintained in accordance with Section 5143, General Requirements of Mechanical Ventilation Systems, of these orders. Inspections, testing and maintenance shall be documented in writing, in accordance with subsection (j)(3)(F).

f. Air from AII rooms or areas, and areas that are connected via plenums or other shared air spaces shall be exhausted directly outside, away from intake vents, employees, and the general public. Air that cannot be exhausted in such a manner or that must be recirculated must pass through HEPA filters before discharge or recirculation.

g. Ducts carrying air that may reasonably be anticipated to contain aerosolized M. tuberculosis or other AirIP shall be maintained under negative pressure for their entire length before in-duct HEPA filtration or until the ducts exit the building for discharge.

h. When a case or suspected case vacates an AII room or area, the room or area shall be ventilated according to Table 1 in the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings for a removal efficiency of 99.9% before permitting employees to enter without respiratory protection.

The following source controls shall be established: 1. Law enforcement personnel transporting an airborne infectious case do not use respiratory

protection if a solid partition separates the passenger area from the employee area.

2. All referring employers (agencies employing emergency medical technicians, police, fire) who transport patients are required to follow the same the procedures CalOSHA requires for institutions to follow in order to ensure their employees are protected.

Below are documented considerations and the basis for decisions regarding engineering mechanical systems and work practice controls to protect employees who operate, use, or maintain vehicles that transport persons with known or suspected ATD. Barriers, air handling systems, and work practices that were considered feasible include the following (checked):

Minimizing time with, proximity to, and respiratory etiquette violations by the individual with known or suspected ATD.

Maximizing staying upwind, ventilation, and sunlight in confined spaces with the individual with known or suspected ATD.

Having the person with known or suspected ATD wear at least a surgical or ear-loop mask. Employee use of NIOSH-certified N95 (or better) respirators with proper fit testing, if needed. Law enforcement or corrections personnel who transport a person requiring referral in a vehicle need

not use respiratory protection if all of the following conditions are met:a. A solid partition separates the passenger area from the area where employees are located; b. The employer implements written procedures that specify the conditions of operation, including

the operation of windows and fans; c. The employer tests (e.g., by the use of smoke tubes) the airflow in a representative vehicle (of the

same model, year of manufacture, and partition design) under the specified conditions of operation, and finds that there is no detectable airflow from the passenger compartment to the employee area;

d. The employer records the results of the tests and maintains the results in accordance with CCR, Title 8, Section 5199, subsection (j)(3)(F); and

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e. The person performing the test is knowledgeable about the assessment of ventilation systems.

These control measures shall be included in the annual review of the Plan.

Appendix D contains effective written decontamination procedures, including appropriate engineering and mechanical system controls, for the cleaning and decontamination of work areas, vehicles, PPE, and other equipment.

CDCR and CCHCS shall provide information about infectious disease hazards to any contractor who provides temporary or contract employees who may be reasonably anticipated to have occupational exposure so that the contractors can institute precautions to protect their employees.

CDCR and CCHCS’ engineering and mechanical systems or work practice controls shall be used, when appropriate, in workplaces that admit, house, or provide medical services to individuals with known or suspected AirID. CDCR and CCHCS shall identify individuals with known or suspected AirID, which shall then be treated in accordance with the regulations.

C. RESPIRATORY PROTECTION

Respiratory Protection

1. Respirators are NIOSH approved.Fit testing occurs in accordance with CCR, Title 8, Sections 5144 and 5199. A fit test program with a wider scope may be established in an emergency incident (i.e., an influenza pandemic).

2. Extended use or reuse/re-donning of N95 respirators will occur when there is a need, lack of available inventory of suitable respirators, and CalOSHA guidance accepting extended or repeat respirator use (i.e., due to a pandemic or epidemic). The N95 can be worn for one shift of work or more often depending on the need. The N95 is not to be worn if it is damaged in any way. As an alternative, powered air purifying or elastomeric respirators may be used when there is a shortage of disposable N95s.

3. Each institution shall assess their clinical activities and determine if the activity includes High Hazard Procedures, and either a) note the absence of, and not perform, High Hazard Procedures, or b) provide a PAPR with HEPA filters or a respirator providing equivalent protection for employees performing High Hazard Procedures on individuals with known or suspected AirID (unless the patient is placed in a booth, hood or other ventilated enclosure not entered by the employee during and for sufficient air changes [at least seven air changes (or 35 minutes in a 12 ACH space) per www.cdc.gov/ mmwr /pdf/ rr / rr5417 .pdf Table 1and CCR, Title 8, Section 5199 (e)(D)9.] after the end of any procedure-related coughing and aerosol generation).

4. Employees must wash hands after removal of gloves.CDCR and CCHCS shall establish, implement and maintain an effective, written respiratory protection program. This is incorporated into the ATD ECP and shall provide a sufficient number of respirator models (2+) and sizes (2+) so that the respirator is acceptable to and correctly fits the user . N95 respirator makes and models offered should be selected on the basis of fitting diverse face types.

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Respirators provided for compliance with this section shall be approved by NIOSH for the purpose for which they are used. The respirator shall be at least as effective as an N95 filtering facepiece respirator, unless CDCR or CCHCS’ evaluation of respiratory hazards determines that a more protective respirator is necessary; in which case, the more protective respirator shall be provided.

CDCR and CCHCS shall provide a PAPR with a HEPA filter(s), or a respirator providing equivalent or greater protection, to employees who are unable to wear an N95 mask and perform High Hazard Procedures on known or suspected AirID cases, unless CDCR or CCHCS determines that this use would interfere with the successful performance of the employee’s required task or tasks. This determination shall be documented in accordance with the ATD Plan and shall be reviewed annually. No fit test is needed for loose fitting respirators like most PAPR’s.

CDCR and CCHCS Clinical Executive Teams at institutions shall provide and ensure that employees use an adequately fit-tested respirator when the employee:

1. Enters an AIIR or area in use for AII;2. Is present during the performance of procedures or services for an AirID case or suspected

case;3. Repairs, replaces, or maintains air systems or equipment that may contain or generate

aerosolized pathogens; 4. Is working in an area occupied by an AirID case or suspected case, during decontamination

procedures after the person has left the area, and as required by the Engineering and Mechanical and Work Practice Controls, and Personal Protective Equipment section;

5. Is working in an area where an individual with known or suspected AirId is present;6. Is performing a task for which the ECP requires the use of respirators; or7. Transports an individual with known or suspected AirID within the facility or in an enclosed

vehicle (i.e., van, car, ambulance, or helicopter) when the patient is not masked.

Medical Evaluation

CDCR and CCHCS through their contractors shall provide a medical evaluation in accordance with CCR, Title 8, Section 5144(e), to determine the employee's ability to use a respirator before the employee is fit tested or required to use the respirator.

Fit Testing for Tight Fitting Respirators

CCHCS’ contractor and CDCR’s Respiratory Protection Program administrator are responsible for the fit testing which shall be performed on the same size, make, model and style of respirator as the employees will use. When quantitative fit testing is performed, CDCR and CCHCS shall not permit an employee to wear a filtering facepiece respirator or other half-facepiece respirator, unless a minimum fit factor of one hundred (100) is obtained. When fit testing single-use respirators, a new respirator shall be used for each employee.

CDCR and CCHCS shall ensure that each employee who is assigned to use a filtering facepiece or other tight-fitting respirator passes a fit test:

1. At the time of initial fitting;2. When a different size, make, model or style of respirator is used; and3. At least annually.

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CDCR and CCHCS shall conduct an additional fit test when the employee reports, or CDCR, CCHCS, PLHCP/Designee, supervisor, or program administrator makes, visual observations of changes in the employee's physical condition that could affect respirator fit. Such conditions include, but are not limited to, facial scarring, dental changes, cosmetic surgery, or an obvious change in body weight. If, after passing a fit test, the employee subsequently notifies CDCR, CCHCS, program administrator, supervisor, or PLHCP/Designee that the fit of the respirator is unacceptable, the employee shall be given a reasonable opportunity to select a different respirator facepiece and to be retested.

Training

CDCR and CCHCS through its contractor shall ensure that each respirator user is provided with initial and annual training in accordance with the training section of this plan and the regulations upon which this plan is based.

D. MEDICAL SERVICES

A contractor designated by CDCR and CCHCS shall provide medical services to CCHCS employees for TB and other ATDs and ATPs.

Medical services, including vaccinations, tests, examinations, evaluations, determinations, procedures, and medical management and follow-up, shall be:

1. Performed by or under the supervision of a PLHCP/Designee;2. Provided according to applicable public health guidelines; and3. Provided in a manner that ensures the confidentiality of employees and patients. Test results and

other information regarding exposure incidents and new positive TB tests shall be provided without providing the name of the source individual.

Written opinion from the PLHCP. CDCR/CCHCS shall obtain, and provide the employee a copy of, the written opinion of the

PLHCP within 15 working days of the completion of all medical evaluations required by this section.

For respirator use, the physician’s opinion shall have the content required by Section 5144(e)(6) of these orders

If CDCR and CCHCS begin to provide post-exposure clinical evaluations and treatment independently, rather than through a contractor, then following an exposure incident in a referring unit, the health care professional shall advise the employee that they may refuse to consent to vaccination, post-exposure evaluation and follow-up from the employer-health care professional. When consent is refused, the health care professional shall (e.g., RTWC and/or workers compensation) immediately make available a confidential vaccination, medical evaluation or follow-up from a PLHCP/Designee other than one employed by CCHCS or CDCR.

Tests and Assessments

CDCR and CCHCS through its contractor shall make available the following tests:1. Assessments for LTBI available to all employees with occupational exposure.2. Annual Tuberculin Skin Testing and symptom screening for employees with baseline negative tests. 3. Only annual symptom screening for those employees with a history of prior positive TB test.

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(Note: Assessment for TB infection is required for any employee with known significant exposure to TB at work or other significant TB risks.

Vaccinations – All occupationally exposed CDCR and CCHCS Employees

Vaccination for seasonal influenza will be offered annually to all occupationally exposed CDCR and CCHCS employees as recommended by the CDPH. Every year, employees that decide not to be vaccinated against seasonal influenza when the vaccine is offered, will be asked to sign a Vaccination Declination Form mandated by CalOSHA.

If the employee declines to sign the form, this choice shall be noted on the form by the CEO/Warden’s designee, , who is tasked with collecting the declination forms from employees.

The employer shall make available to all susceptible health care workers with occupational exposure all vaccine doses listed in Appendix C. The requirements in subsection (h)(5) have become effective.

A. Recommended vaccinations shall be made available to all employees who have occupational exposure after the employee has received the training required in subsection (c) or (i) and within ten working days of initial assignment unless:1. The employee has previously received the recommended vaccination(s) and is not due to

receive another vaccination dose; or2. A PLHCP has determined that the employee is immune in accordance with applicable public

health guidelines; or3. The vaccine(s) is contraindicated for medical reasons.

B. The employer shall make additional vaccine doses available to employees within 120 days of the issuance of new applicable public health guidelines recommending the additional dose.

C. The employer shall not make participation in a prescreening serology program a prerequisite for receiving a vaccine, unless applicable public health guidelines recommend this prescreening prior to administration of the vaccine.

If the employee initially declines a vaccination but at a later date, while still covered under the standard, decides to accept the vaccination, the employer shall make the vaccination available in accordance with subsection (h)(5)(A) within ten working days of receiving a written request from the employee. (Exception: to subsection (h)(5): Where the employer cannot implement these procedures because of the lack of availability of vaccine, the employer shall document efforts made to obtain the vaccine in a timely manner and inform employees of the status of the vaccine availability, including when the vaccine is likely to become available. The employer shall check on the availability of the vaccine at least every 60 calendar days and inform employees when the vaccine becomes available.)

Vaccinations – Health Care Employees

There are three vaccines recommended for health care employees, in addition to the seasonal influenza vaccination. These vaccinations are: Measles, Mumps and Rubella with the MMR vaccine; Tdap vaccine (which protects against Diphtheria, Tetanus and Pertussis); and Varicella vaccine (which protects against chickenpox – see Appendix C). All of these recommended vaccinations will be offered by the CEO/Warden’s designee listed in each institution’s LOP. It shall be requested of employees to provide

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proof of immunity to the antigens in these vaccines. Employees without proof of immunity, who decline the offer of vaccination, will be asked to sign a Vaccination Declination form mandated by CalOSHA for each vaccine being declined.

If the employee declines to sign the form, this choice shall be noted on the form by the CEO/Warden’s designee, , who is tasked with collecting declination forms from employees. Until the state approves, no disciplinary action shall be taken against any employee who declines vaccination or to sign the declination form.

TrainingCDCR and CCHCS through its contractor shall ensure that each employee is provided the appropriate vaccination training in accordance with the training section of this plan and the regulations upon which this plan is based.

Procedure Following Exposure Incidents – Immediate Response, Notifications

Medical services will be provided in accordance with applicable public health guidelines for the type of work setting and disease.

All medical services provided by CDCR and CCHCS through its contractor will be performed by or under the supervision of a PLHCP/Designee, provided according to applicable public health guidelines, and provided in a manner that ensures confidentiality of the employee. The identity of the infectious source will not be disclosed on documentation of exposure incidents and new positive TB tests.

Tuberculosis Control

A contractor designated by CDCR and CCHCS shall provide to employees annual assessment for LTBI in accordance with Penal Code 6006 et seq., CCR, Title 8, Section 5199, and applicable public health guidelines.1. TB tests and/or other forms of TB assessment shall be provided at least annually, and more

frequently, if applicable public health guidelines or the county health officer recommends more frequent testing. Employees with a baseline positive TB test shall have a symptom screen. Note that this requirement is consistent with Penal Code 6006 et seq. which makes assessment for TB infection and infectiousness a condition of employment for CCHCS employees.

2. The institution will refer employees who experience a new positive TB test to , who makes the CCR, Title 8, Section 5199 specified referral to a PLHCP/Designee knowledgeable about TB for evaluation (using the Penal Code 6006 et seq. –specified referral for workers’ compensation evaluation for those who believe the cause of the positive test result is job-related) a. CDCR and CCHCS shall provide the PLHCP/Designee with a copy of the ATD Standard and the

employee’s TB test records. If CDCR and CCHCS have determined the source of the infection, CDCR and CCHCS shall also provide any available diagnostic test results including drug susceptibility patterns relating to the source patient.

b. CDCR and CCHCS shall request that the PLHCP/Designee, with the employee’s consent, perform any necessary diagnostic tests and inform the employee about appropriate treatment options.

c. CDCR and CCHCS shall request that the PLHCP/Designee determine if the employee is a TB case or suspected case, and to do all of the following, if the employee is a case or suspected case:1) Immediately inform the employee, employer, and the county health officer in accordance

with CCR, Title 17 and CCR, Title 8, Section 5199. 2) Inform CDCR and CCHCS of any known infection control recommendations related to the

employee’s activity in the workplace.

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3) Make a recommendation to CDCR and CCHCS regarding precautionary removal due to suspect active disease, and provide the employer with a written opinion.

d. TB tests conversion shall be recorded in an exposure log maintained by CDCR and CCHCS’ in accordance with recordkeeping requirements summarized in Section F (Recordkeeping) in this plan.

e. Unless it is determined that the TB test conversion is not occupational, CDCR and CCHCS in collaboration with HQ Occupational Health staff shall investigate the circumstances of the conversion, and correct any deficiencies found during the investigation. The investigation shall be documented in accordance with CCR, Title 8, Section 5199, subsection (j).

Exposure Incidents

In the event that CDCR and CCHCS or its contractor determines that there has been a significant occupational exposure to a person known or suspected of having a reportable ATD, CDCR and CCHCS or their contractors shall take the necessary steps as listed in the sections below.

Immediate Response, Notifications

For inmate cases, the diagnosing clinician shall report to their supervisor and the Public Health Nurse shall report (or ensure that the health care provider responsible for treatment of the source reports) the case to the county health officer, in accordance with CCR, Title 17.

Employee RATD cases shall be diagnosed generally offsite, reported to the local health officer and other possibly exposed employers recorded by their treating clinician per CCR, Title 8, Sections 5199 (h)(6) A and B, and investigated through county health officer assistance if need be by , whose skills and confidential non-personnel recordkeeping qualify them for this task.

Report to other Employers

CDCR and CCHCS’ delegated teams shall determine, to the extent that the information is available in the employer’s records, whether the employee(s) of any other employer(s) may have had contact with the individual with known or suspected ATD. If it is determined or suspected that other employee(s) have been exposed, CDCR and CCHCS’ delegated teams shall notify the other employer(s) within a time frame that will provide reasonable assurance that there will be adequate time for the employee to receive effective medical intervention to prevent disease or mitigate the disease course, and will also permit the prompt initiation of an investigation to identify exposed employees. In no case shall the notification be longer than 72 hours after the report to the county health officer. The notification shall include the date, time, and nature of the potential exposure, and provide any other information that is necessary for the other employer(s) to evaluate the potential exposure of his or her employees. The identity of the source patient shall not be provided to the other employers.

Analysis of the Exposure Scenario

Within 72 hours following CCHCS’ report to the county health officer or the receipt of notification from another employer or the county health officer, a manager at the institution in collaboration with a contractor and/or the CCHCS Headquarters Public Health Branch shall conduct an analysis of the exposure scenario to determine which CDCR and CCHCS employees had significant exposures as defined by CalOSHA. This analysis shall be conducted by an individual knowledgeable in the

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mechanisms of exposure to ATPs or ATPs-L, and shall record the names and any other employee identifier used in the workplace of persons included in the analysis. The analysis shall also record the basis for any determination that an employee need not be included in post-exposure follow-up because the employee did not have a significant exposure or because a PLHCP/Designee determined that the employee is immune to the infection in accordance with applicable public health guidelines. The exposure analysis shall be provided to the institutional CCHCS executive staff, analyzed annually in combination with the year’s other exposure analyses, and made available to the county health officer upon request. The name of the person making the determination, and the identity of any PLHCP/Designee or county health officer consulted in making the determination shall be recorded.

The institution will inform the Public Health Unit and designated occupational health manager (Bruce Leistikow, MD, as of August 2016) at CCHCS headquarters of the exposure incident. The headquarters’ occupational health manager and his/her Designee(s) will assist the institution in carrying out the investigation. The occupational health manager will also ensure that the CCHCS Public Health Unit is notified of any ATDs that are identified among employees, so that appropriate steps can be taken to respond to inmates who may have been exposed to infectious employees.

Notification of Employees

Within 96 hours of becoming aware of the potential exposure, CDCR and CCHCS shall notify employees who had significant exposures of the date, time, and nature of the exposure.

Medical Evaluations and Written Recommendations

As soon as feasible, teams designated by CDCR and CCHCS and their contracted PLHCP shall provide post-exposure medical evaluation to all employees who had a significant exposure. The evaluation shall be conducted by a PLHCP/Designee knowledgeable about the specific disease, including appropriate vaccination, prophylaxis and treatment. For M. tuberculosis, and for other pathogens where recommended by applicable public health guidelines, this shall include testing of the isolate from the source individual or material for drug susceptibility, unless the PLHCP/Designee determines that it is not feasible.

The teams designated by CDCR and CCHCS shall obtain from the PLHCP/Designee a recommendation regarding precautionary removal, and a written opinion.

Each employer shall obtain and provide the employee a copy of the written opinion of the PLHCP within 15 working days of the completion of all medical evaluations required by this section.

Returning to Work

Employees who are referred for ATD post-exposure medical evaluation are required to obtain written clearance to return to work from a physician or other licensed healthcare provider and submit the clearance to the return to work or occupational health coordinator designated by the CEO/Warden or for their institution or division. The coordinator will consider the information submitted and authorize the employee to resume work as appropriate and guided by the information contained within Appendix A.

Information provided to the Physician or Other Licensed Health Care Professional

CDCR and CCHCS’ delegated teams shall ensure that all PLHCP/Designees responsible for making determinations and performing procedures as part of the medical services program are provided a copy of

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this standard and applicable public health guidelines. For respirator medical evaluations, CDCR and CCHCS shall provide information regarding the type of respiratory protection used, a description of the work effort required, any special environmental conditions that exist (i.e., heat, confined space entry), additional requirements for protective clothing and equipment, and the duration and frequency of respirator use.PLHCP/Designees who evaluate employees after an exposure incident shall be provided the following information:

1. A description of the exposed employee's duties as they relate to the exposure incident;2. The circumstances under which the exposure incident occurred;3. Any available diagnostic test results, including drug susceptibility pattern or other information

relating to the source of exposure that could assist in the medical management of the employee; and4. All of the employer’s medical records for the employee that are relevant to the management of the

employee, including tuberculin skin test results and other relevant tests for ATP infections, vaccination status, and determinations of immunity.

Precautionary removal recommendation from the PLHCP

When a PLHCP/Designee has provided a post-exposure evaluation or an evaluation of an employee’s new positive TB test, the PLHCP/Designee shall provide an opinion regarding whether precautionary removal from the employee’s regular assignment is necessary to prevent spread of the disease agent by the employee and what type of alternate work assignment may be provided. CDCR and CCHCS shall request that the PLHCP/Designee convey to the RTWC any recommendation for precautionary removal immediately via phone or fax and that the PLHCP/Designee document the recommendation in the written opinion.

The written opinion shall be limited to the following information:

1. The employee's TB test status or applicable RATD test status for the exposure of concern;2. The employee's infectivity status; a statement that the employee has been informed of the results of

the medical evaluation and has been offered any applicable vaccinations, prophylaxis, or treatment;3. A statement that the employee has been told about any medical conditions resulting from exposure to

TB or other RATD that require further evaluation or treatment and that the employee has been informed of treatment options; and

4. Any recommendations for precautionary removal from the employee’s regular assignment.

Where the PLHCP/Designee or county health officer recommends precautionary removal, CDCR and CCHCS shall maintain the following, until the employee is determined to be noninfectious:

1. The employee’s earnings;2. Seniority; and3. All other employee rights and benefits, including the employee’s right to his or her former job status,

as if the employee had not been removed from his or her job or otherwise medically limited.

E. TRAINING

CDCR and CCHCS shall ensure that all employees with occupational exposure participate in a training program. The ATD training program shall include a section that explains the procedure to follow if an exposure incident occurs, including the method of reporting the incident, the medical follow-up that will be made available, and post-exposure evaluation.

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1. The training will take place at the time of hire for newly hired employees where occupational exposure may take place. For current employees, the training will take place at least annually. Additional training will take place for employees who have received prior training when there are changes in the workplace or changes in procedures. This additional training may be limited to addressing the new exposure or control measures. All training material must be appropriate in content and vocabulary to the educational level, literacy, and language of the employees.

2. CDCR and CCHCS shall provide an accessible copy of the regulation and an explanation of the following:a. Its contents, including the signs and symptoms of ATDs that require further medical evaluation;b. The modes of transmission of ATPs and applicable source control procedures;c. The ATD ECP, and the means by which the employee can obtain a copy of the written plan and

how they can provide input as to its effectiveness;d. The appropriate methods for recognizing tasks and other activities that may expose the employee

to ATPs.3. The use and limitations of methods that will prevent or reduce exposure to ATPs including:

a. Appropriate engineering and work practice controls, decontamination and disinfection procedures;

b. Personal and respiratory protective equipment;4. Basis for selection of PPE, its uses and limitations, and the types, proper use, location, removal,

handling, cleaning, decontamination and disposal of the items of PPE employees will use;5. The description of CDCR and CCHCS’ TB surveillance procedures, including the information that

persons who are immune-compromised may have a false negative test for LTBI;6. Training that meets the requirements of CCR, Title 8, Section 5144(k) of these orders for employees

whose assignment includes the use of a respirator; and7. Information on CDCR and CCHCS’ surge plan as it pertains to the duties that employees will

perform. As applicable, this training shall cover the plan for surge receiving and treatment of patients, patient isolation procedures, surge procedures for handling of specimens, including specimens from persons who may have been contaminated as the result of a release of a biological agent, how to access supplies needed for the response including PPE and respirators, decontamination facilities and procedures, and how to coordinate with emergency response personnel from other agencies.

8. Recommended vaccinations will be made available after training at least twice per year (along with TB screening, fit testing, and/or flu vaccination) after assignment to a post with occupational exposure unless a licensed healthcare professional determines that the employee is immune, currently fully vaccinated, or that the vaccine is contraindicated.

9. CDCR and CCHCS shall provide information on the vaccines and their efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge by CDCR and CCHCS.

10. CDCR and CCHCS’ training program shall include an opportunity for interactive questions and answers with a person provided by a contractor who is knowledgeable in the subject matter of the training as it relates to the workplace that the training addresses and who is also knowledgeable in CDCR and CCHCS’ ATD ECP. Training not given in person shall fulfill all the subject matter requirements and shall provide for interactive questions to be answered within 24 hours by a person provided by a contractor who is knowledgeable in the subject matter as described above.

F. RECORDKEEPING

Medical and Exposure Records

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CDCR and CCHCS shall establish and maintain an accurate medical record for each employee with occupational exposure. These records will be part of the employee TB/Occupational-health files. CDCR and CCHCS shall maintain the employees’ exposure and medical records required by the ECP for at least 30 years and the duration of employment plus 30 years, respectively as CCR, Title 8, Section 5199 incorporates by reference to http://www.dir.ca.gov/title8/3204.html. This plan requires that the medical record contain documentation of vaccination or a declination form for the most recent seasonal influenza vaccine, including the following:1. The employee’s name and any other employee identifier used in the workplace;2. The employee's vaccination status for all vaccines required by this standard, including:

a. The information provided by the PLHCP/Designee;b. Any vaccine record provided by the employee;c. Any signed consent forms; andd. Any signed declination forms.

3. A copy of all written opinions provided by a PLHCP/Designee in accordance with this standard, and the results of all TB assessments; and

4. A copy of the information regarding an exposure incident that was provided to the PLHCP/Designee.

Medical Records: Confidentiality

CDCR and CCHCS shall ensure that all employee medical records be kept confidential and not disclosed or reported without the employee’s express written consent to anyone, with the exception of the records that do not contain individually identifiable medical information, or from which individually identifiable medical information has been removed.

Training Records

CDCR and CCHCS shall maintain ATD training records for three years from the date on which the training occurred. These records shall include:

1. The date(s) of the training session(s);2. The contents or a summary of the training session(s); 3. The names and qualifications of persons conducting the training or who are designated to respond to

interactive questions; and4. The names and job titles of all persons attending the training sessions.

ATD Plan Implementation Records

This Plan is reviewed on a scheduled (at least annual) basis , by the institution’s designated administrator responsible for the ATD program, other administrative representatives designated by the CEO/Warden, selected employees and physicians on a rotating basis, and other committees approving the plan.

The maintains the review schedule, review process, and records of who reviewed the plan.

CDCR and CCHCS shall maintain for three years records of implementation and annual review of the ATD Plan. These plans shall include:

1. The name(s) of the person(s) conducting the review;2. The dates the review was conducted and completed; and

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3. The name(s) and work area(s) of employees involved, and a summary of the conclusions.

Exposure Incident Records

Records of exposure incidents shall be retained by , and made available as employee exposure records in accordance with the regulations.

These records shall include:1. The date of the exposure incident;2. The names, and any other employee identifiers used in the workplace, of employees who were

included in the exposure evaluation;3. The disease or pathogen to which employees may have been exposed;4. The name and job title of the person performing the evaluation;5. The identity of any county health officer and/or PLHCP/Designee consulted;6. The date of the evaluation; and7. The date of contact and contact information for any other employer who either notified the employer

or was notified by the employer regarding potential employee exposure.

Other RecordsThe following records shall likewise be kept by for CDCR and CCHCS:

1. Records of the unavailability of vaccine shall be retained for three years.2. Records of the unavailability of AllR or areas shall be retained for three years.3. Records of decisions not to transfer a patient to another facility for All, for medical reasons, shall be

retained for three years.4. Records of inspection, testing, and maintenance of non-disposable engineering controls including

ventilation and other air handling systems, air filtration systems, containment equipment, biological safety cabinets, and waste treatment systems shall be maintained for a minimum of five years.

5. Records of the respiratory protection program shall be established and maintained for two years.

Availability of Records

CDCR and CCHCS with assistance from its contractor shall ensure that all records, other than the employee medical records, required to be maintained by this section shall be made available upon request to the Chief and NIOSH and the county health officer for examination and copying.

CDCR and CCHCS with assistance from its contractor shall make available to employees and their representatives employee training records, the ECP, and records of implementation of the ATD ECP, other than medical records containing individually identifiable medical information.

Employee medical records required by this subsection shall be provided upon request to the subject employee, anyone having the written consent of the subject employee, the county health officer, and to the Chief and NIOSH in accordance with the regulations for examination and copying.

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Transferring Records

CDCR and CCHCS, with assistance from its contractor shall comply with the requirements involving the transfer of employee medical and exposure records that are set forth in CCR, Title 8, Section 3204, Access to Employee Exposure and Medical Records, of these orders.

If CDCR and CCHCS cease to do business and there is no successor employer to receive and retain the records for the prescribed period, CDCR and CCHCS, shall notify the Chief CalOSHA and NIOSH, at least three months prior to the disposal of the records and shall transmit them to NIOSH, if required by NIOSH to do so, within that three-month period.

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APPENDIX A

Exposure Incident Requirements

Healthcare providers shall report individuals with RATD or individuals with suspected ATD to the County Health Officer in accordance with CCR, Title 17 (see below for Title 17 information).

When CCHCS becomes aware of an individual with RATD, other employers that may have had contact with the individual with RATD will be notified of the potential exposure. Notification will include the date, time, and nature of the potential exposure and other information that may assist CDCR and CCHCS in the evaluation of their employees. Notice shall be timely and provide adequate time for effective medical intervention. The identity of any individual with RATD or source patient should not be revealed to other employers.

When an employee is referred for medical evaluation or treatment, CDCR and CCHCS through their contractor will provide the medical evaluator with a copy of the ATD standard and applicable public health guidelines along with the following information:

1. A description of the exposed employee’s duties as they relate to the exposure incident;

2. The circumstances under which the exposure incident occurred;

3. Any available diagnostic test results, including drug susceptibility pattern or other information relating to the source of exposure that could assist in the medical management of the employee; and

4. All of CDCR and CCHCS’ medical records for the employee that are relevant to the management of the employee, including tuberculin skin test results and other relevant tests for ATP infections, vaccination status, and determinations of immunity.

When referral is for respirator medical evaluation, CDCR and CCHCS through their contractor will provide information regarding the type of respiratory protection used, a description of the work effort required, any special environmental conditions that exist (i.e., heat, confined space entry), additional requirements for protective clothing and equipment, and the duration and frequency of respirator use.

When an employee is referred for post-exposure medical evaluation, CDCR and CCHCS through their contractor will request an opinion from the evaluator regarding the employee’s ability to resume regular work. If regular work is restricted to prevent spread of the disease agent by the employee, then the medical evaluator will contact the RTWC by phone or fax with recommended limitations so that alternative work assignments can be considered based on the medical recommendation.

CDCR and CCHCS will maintain the employee’s earnings, seniority, and all other employee rights and benefits, including the employee's right to his or her former job status, as if the employee had not been removed from his or her job or otherwise medically limited, until determined to be non-infectious. These provisions do not extend to any period of time during which the employee is unable to work for other reasons.

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CDCR and CCHCS require a written opinion from the medical evaluator and a copy of the opinion will be provided to the employee within 15 days of completion. Opinions for respirator use will contain statements required by CCR, Title 8, Section 5144(e)(6).

Opinions for TB test positives and RATD exposure incidents shall be limited to:

1. The employee’s TB test status or applicable RATD test status for the exposure of concern;

2. The employee’s infectivity status;

3. A statement that the employee has been informed of the results of the medical evaluation and has been offered any applicable vaccinations, prophylaxis, or treatment;

4. A statement that the employees has been told about any medical conditions resulting from exposure to TB, or other RATD that require further evaluation or treatment and that the employee has been informed of treatment options; and

5. Any recommendations for precautionary removal from the employee’s regular assignment.

All other findings or diagnoses shall remain confidential and shall not be included in the written report.

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APPENDIX B

Aerosol Transmissible Diseases/Pathogens (Mandatory)

This appendix contains a list of diseases and pathogens which are to be considered aerosol transmissible pathogens or diseases for the purpose of CCR, Title 8, Section 5199. Employers are required to provide the protections required by CCR, Title 8, Section 5199 according to whether the disease or pathogen requires airborne infection isolation or droplet precautions as indicated by the two lists below.

Diseases/Pathogens Requiring Airborne Infection Isolation

Aerosolizable spore-containing powder or other substance that is capable of causing serious human disease (e.g., Anthrax/Bacillus anthracis)

Avian influenza/Avian influenza A viruses (strains capable of causing serious disease in humans)

Varicella disease (chickenpox, shingles)/Varicella zoster and Herpes zoster viruses, disseminated disease in any patient. Localized disease in immunocompromised patient until disseminated infection ruled out

Measles (rubeola)/Measles virus

Monkeypox/Monkeypox virus

Novel or unknown pathogens

Severe acute respiratory syndrome (SARS)

Smallpox (variola)/Varioloa virus

Tuberculosis (TB)/Mycobacterium tuberculosis -- Extrapulmonary, draining lesion; Pulmonary or laryngeal disease, confirmed; Pulmonary or laryngeal disease, suspected

Any other disease for which public health guidelines recommend airborne infection isolation

Diseases/Pathogens Requiring Droplet Precautions

Diphtheria pharyngeal

Epiglottitis, due to Haemophilus influenzae type b

Haemophilus influenzae Serotype b (Hib) disease/Haemophilus influenzae serotype b -- Infants and children Influenza, human (typical seasonal variations)/influenza viruses

MeningitisHaemophilus influenzae, type b known or suspected

Neisseria meningitidis (meningococcal) known or suspected

Meningococcal disease sepsis, pneumonia (see also meningitis)

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Mumps (infectious parotitis)/Mumps virus

Mycoplasmal pneumonia

Parvovirus B19 infection (erythema infectiosum)

Pertussis (whooping cough)

Pharyngitis in infants and young children/Adenovirus, Orthomyxoviridae, Epstein-Barr virus, Herpes simplex virus

Pneumonia

Adenovirus

Haemophilus influenzae Serotype b, infants and children

Meningococcal

Mycoplasma, primary atypical

Streptococcus Group A

Pneumonic plague/Yersinia pestis

Rubella virus infection (German measles)/Rubella virus

Severe acute respiratory syndrome (SARS)

Streptococcal disease (group A streptococcus)

Skin, wound or burn, Major

Pharyngitis in infants and young children

Pneumonia

Scarlet fever in infants and young children

Serious invasive disease

Viral hemorrhagic fevers due to Lassa, Ebola, Marburg, Crimean-Congo fever viruses (airborne infection isolation and respirator use may be required for aerosol-generating procedures)

Any other disease for which public health guidelines recommend droplet precautions

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APPENDIX C

Aerosol Transmissible Disease Vaccination Recommendations for Susceptible Health Care Workers (Mandatory)

Immunity should be determined in consultation with Epidemiology and Prevention of Vaccine-Preventable Diseases.

Source: California Department of Public Health, Immunization Branch

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Vaccine Schedule

Influenza One dose annually

Measles Two doses

Mumps Two doses

Rubella One dose

Tetanus, Diphtheria, and Acellular Pertussis (Tdap)

One dose, booster as recommended

Varicella-zoster (VZV) Two doses


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APPENDIX D

Cleaning and Disinfection of ATD Contaminated Work Areas, Vehicles and Equipment

Interiors (and exteriors as needed) of Institution/Facility based inmate transport vehicles shall be cleaned periodically according to the following guidelines:

1. On a daily basis, the supervisor or Transportation Sergeant responsible for the vehicle used in the transportation of inmates will arrange for or conduct a routine inspection of the vehicle areas that have the potential to be contaminated as a result of contact with aerosol droplets, and if necessary take all appropriate steps necessary to ensure cleanliness and sanitation

2. Following the transport of an inmate with a respiratory infection or other communicable disease, the vehicle shall be taken to the institution garage or transportation hub for decontamination upon returning to the institution and the Associate Warden of Business Services will be notified. Inmate workers assigned to the garage are available to perform this function.

3. At least monthly, as a preventive measure, inmate transport vehicles will be taken to the institution garage/transportation hub for routine service and cleaning to include the decontamination of interior surfaces. A designated disinfecting area shall be assigned for all cleaning and disinfecting. Dirty or blood and body fluid contaminated run-off from cleaning and disinfecting solutions shall be disposed of into a sanitary sewer system.

4. The affected areas shall be sanitized following the guidelines described under Cleaning and Decontamination taking care to follow Correctional Standard Precautions (CSP) when cleaning potentially contaminated vehicles.

5. All disinfectants shall be registered and approved for use by the U.S. Environmental Protection Agency (EPA), be registered as tuberculocidal effective and be used in a manner for which they are approved. A specific list of disinfectants to be used for vehicle surfaces shall be included in the facility’s cleaning and decontamination schedule.

6. A cleaning supply kit containing household utility gloves, labeled plastic spray bottle with cleaning agent, labeled plastic spray bottle with disinfecting solution or a labeled bottle with concentrated household bleach to be diluted with water, disposable towels, plastic bags (red bags and household plastic bags) and a carrying device for the cleaning supplies shall be kept in a central location. The Transportation Sergeant (or local level equivalent) will be responsible for maintaining these supplies.Appropriate protective infection control garments and equipment, such as fluid resistant clothing, splash-resistant eyewear, and disposable gloves, shall be used whenever there is a potential for exposure to bodily fluids or potentially infectious material during cleaning and disinfecting of inmate transport vehicles.

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APPENDIX E

FACT SHEET

Respiratory Hygiene/Cough Etiquette in Healthcare Settingswww.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm)

To prevent the transmission of all respiratory infections in healthcare settings, including influenza, the following infection control measures should be implemented at the first point of contact with a potentially infected person. They should be incorporated into infection control practices as one component of Standard Precautions.

1. Visual Alerts

The CEO/Warden shall ensure that visual alerts (in appropriate languages) are posted in the appropriate areas; such as the entrance to outpatient facilities (i.e., emergency departments, physician offices, outpatient clinics) and, as detailed in individual LOPs, other common areas such as near the mail boxes, on CalOSHA boards, near the workers compensation bulletins, locker rooms and bathrooms to instruct patients and persons who accompany them (i.e., family, friends) to inform health care personnel of symptoms of a respiratory infection when they first register for care and to practice Respiratory Hygiene/Cough Etiquette.

Cover Your Cough (www.cdc.gov/flu/protect/covercough.htm) Tips to prevent the spread of germs from coughing

Stop! Help Protect Our Patients PosterThis poster is for use in clinics and hospitals, asking ill people not to visit(www.health.state.mn.us/divs/idepc/dtopics/infectioncontrol/cover/hcp/stoppat.html)

Information about Personal Protective Equipment Demonstrates the sequences for donning and removing personal protective equipment (www.cdc.gov/HAI/prevent/ppe.html)

2. Respiratory Hygiene/Cough Etiquette

The following measures to contain respiratory secretions are recommended for all individuals with signs and symptoms of a respiratory infection.

Cover your mouth and nose with a tissue when coughing or sneezing;

Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use;

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Perform hand hygiene (i.e., hand washing with non-antimicrobial soap and water, alcohol-based hand rub (request from CDCR for settings where practical [e.g., where supervised], or antiseptic handwash) after having contact with respiratory secretions and contaminated objects/materials.

Healthcare facilities should ensure the availability of materials for adhering to Respiratory Hygiene/Cough Etiquette in waiting areas for patients and visitors.

Provide tissues and no-touch receptacles for used tissue disposal.

Provide conveniently located dispensers of alcohol-based hand rub (request from CDCR for settings where practical, e.g., where supervised); where sinks are available, ensure that supplies for hand washing (i.e., soap, disposable towels) are consistently available.

3. Masking and Separation of Persons with Respiratory Symptoms Respiratory Hygiene/Cough Etiquette in Healthcare Settings

During periods of increased respiratory infection activity in the community (i.e., when there is increased absenteeism in schools and work settings and increased medical office visits by persons complaining of respiratory illness), offer masks (and instructions on using them [Appendix F]) to persons who are coughing (and instruct ATD suspects to keep a mask on as much as possible outside of negative pressure rooms). Either procedure/ear-loop masks or surgical masks (i.e., with ties) may be used to contain respiratory secretions (respirators such as N95 or above are not necessary for this purpose). When space and chair availability permit, encourage coughing persons to sit at least three feet away from others in common waiting areas. Some facilities may find it logistically easier to institute this recommendation year-round.

4. Droplet Precautions

Advise healthcare personnel to observe droplet precautions (i.e., wearing a surgical or ear-loop mask for close contact), in addition to standard precautions, when examining a patient with symptoms of a respiratory infection, particularly if fever is present. These precautions should be maintained until it is determined that the cause of symptoms is not an infectious agent that requires Droplet Precautions http://www.cdc.gov/hicpac/pubs.html.

NOTE: These recommendations are based on the Draft Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC), CDC

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APPENDIX F

Face/Surgical Mask Information

If you are asked to wear a face mask, Please put it on carefully using the directions below and keep it on until you are told to remove it or in a respiratory isolation (negative pressure) room. Replace it if it becomes moist or soiled.

Standard Earloop Mask Standard Tie On Surgical Mask

Photos courtesy of Newton Safety/Sanax and NIOSH What is a face mask used forFacemasks help limit the spread of germs. When someone talks, coughs, or sneezes they may release tiny drops into the air that can infect others. If someone is ill a face mask can reduce the number of germs that the wearer releases and can protect other people from becoming sick. A face mask also protects the wearer's nose and mouth from splashes or sprays of body fluids.

When should a face mask be wornConsider wearing a face mask when you are sick with a cough or sneezing illness (with or without fever) and you expect to be around other people. The face mask will help protect them from catching your illness. Healthcare settings have specific rules for when people should wear face masks. How to put on and remove a face maskDisposable face masks should be used once and then thrown in the trash. You should also remove and replace masks when they become moist. Always follow product instructions on mask use and storage, and procedures for how to put on and remove a mask. If instructions for putting on and removing the mask are not available, then follow the steps below.

How to put on a face mask

1 Clean your hands with soap and water or hand sanitizer before touching the mask.

2 Remove a mask from the box and make sure there are no obvious tears or holes in either side of the mask.

3 Determine which side of the mask is the top. The side of the mask that has a stiff bendable edge is the top and is meant to mold to the shape of your nose.

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How to put on a face mask

4 Determine which side of the mask is the front. The colored side of the mask is usually the front and should face away from you, while the white side touches your face.

5

Follow the instructions below for the type of mask you are using.

Face Mask with Ear loops: Hold the mask by the ear loops. Place a loop around each ear. Face Mask with Ties: Bring the mask to your nose level and place the ties over the crown of

your head and secure with a bow. Face Mask with Bands: Hold the mask in your hand with the nosepiece or top of the mask at

fingertips, allowing the headbands to hang freely below hands. Bring the mask to your nose level and pull the top strap over your head so that it rests over the crown of your head. Pull the bottom strap over your head so that it rests at the nape of your neck.

6 Mold or pinch the stiff edge to the shape of your nose.

7 If using a face mask with ties: Then take the bottom ties, one in each hand, and secure with a bow at the nape of your neck.

8 Pull the bottom of the mask over your mouth and chin.

How to remove a face mask

1 Clean your hands with soap and water or hand sanitizer before touching the mask.

2 Avoid touching the front of the mask. The front of the mask is contaminated. Only touch the ear loops/ties/band.

3

Follow the instructions below for the type of mask you are using.

Face Mask with Ear loops: Hold both of the ear loops and gently lift and remove the mask. Face Mask with Ties: Untie the bottom bow first then untie the top bow and pull the mask

away from you as the ties are loosened. Face Mask with Bands: Lift the bottom strap over your head first then pull the top strap over

your head.

4 Throw the mask in the trash.

5 Clean your hands with soap and water or hand sanitizer.

Source: http://www.sfcdcp.org/facemask.html accessed 10/2016

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Documents

LIST OF ACRONYMS - California Correctional Health Care ...€¦ · Web viewVaricella disease (chickenpox, shingles)/Varicella zoster and Herpes zoster viruses, disseminated disease