Appendix B



Risk and Community Risk Assessment: From the case below, complete the risk assessment with the available information provided in the case below regarding Duval County M. tuberculosis.

CDC, Notes from the Field: Tuberculosis Cluster Associated with Homelessness — Duval County, Florida, 2004–2012. Notes from the Field: Tuberculosis Cluster Associated with Homelessness — Duval County, Florida, 2004–2012. July 20, 2012 / 61(28); 539-540

This module you begin your second skills assessment, i.e., a community risk assessment. The next two pages of this document are a case study and then the assessment survey form makes up the remaining pages of the document. You will use the Duval Case and assume you are from Duval County, FL. There is a lot of information available from the TB surveillance and epidemiological field work completed in this county on the Internet. Assume your facility is the Golden Retreat Assisted-Living Facility and you are part of the risk management team that is responsible for performing the risk assessment surveys.

|Example: In November 2008, the local health department discovered an outbreak of tuberculosis in a Jacksonville assisted-living facility, |

|Golden Retreat. The CDC was called in to assist the health department and found 18 active cases of TB (, 2012). |

|  |

A suggestion regarding work flow is to print out the two pages of the case, and use it and the supplemental links below to fill in the survey form. Know that you need to fill it out to the best of your ability based on the case information available. You may not have information for every box on the survey form. However, you may make some logical assumptions when filling it out based on what you find (in other words, abstract and report as the information found will allow). The goal here is to learn what type of information is in the various risk assessment surveys.

If you need help finding Duval County, FL statistics, here are some links:

LINK:

LINK: Duvall County Epidemiology Comprehensive Surveillance Reports 

LINK: DCHD Tuberculosis Epi-Aid Investigation Update 

Article on Golden Retreat Assisted-Living Facility Palm Beach County. (2012). Center of TB outbreak often cited, rarely punished.

Tuberculosis Cluster Associated with Homelessness — Duval County, Florida, 2004–2012

Despite a decrease in incidence of tuberculosis (TB) in Duval County, Florida, from 102 cases (11.2 per 100,000 population) in 2008 to 71 cases (8.2 per 100,000) in 2011,* analysis of Mycobacterium tuberculosis genotyping data revealed a substantial increase in the percentage of TB cases with the same genotype.† That percentage increased from 27% (10 of 37) of genotyped cases in 2008 to 51% (30 of 59) of genotyped cases in 2011 (Florida Department of Health, unpublished data, 2012). During this period, the percentage of patients with this genotype who were homeless or who abused substances also increased. Because of concern over potential ongoing TB transmission involving these hard-to-reach populations, the Duval County Health Department, Florida Department of Health, and CDC conducted an investigation during February 15–March 13, 2012. As of March 13, review of medical records and interviews with TB patients had identified 99 cases related to the cluster based on matching genotype results and epidemiologic links (48 cases), matching genotype only (22), epidemiologic links only (22), or common social risk factors for TB (e.g., homelessness, incarceration, or substance abuse within 1 year of TB diagnosis) and suspected epidemiologic links (seven). The first known case with a matching genotype occurred in 2004.

Among the 99 TB cases during 2004–2012, a total of 96 (97%) patients were U.S.-born; 78 (79%) were male; 76 (77%) were black; 78 (79%) had a history of homelessness, incarceration, or substance abuse (i.e., alcohol or illicit substances); and 43 (43%) had been homeless within 1 year of TB diagnosis. Three patients were children aged 1 year, changing TB epidemiology of the community or setting, the occurrence of a TB | |

|outbreak, change in state or local TB policy, or other factors related to a change in risk for | |

|transmission of M. tuberculosis)? | |

|Does the health-care setting have an infection-control committee (or another committee with infection|Yes No |

|control responsibilities)? | |

|If yes, which groups are represented on the infection-control committee? | |

|(Check all that apply.) |( Laboratory personnel |

|( Physicians |( Health and safety staff |

|( Nurses |( Administrator |

|( Epidemiologists |( Risk assessment |

|( Engineers |( Quality control (QC) |

|( Pharmacists |( Others (specify)_________ |

|If no, what committee is responsible for infection control in the setting? | |

5. Implementation of TB Infection-Control Plan Based on Review by Infection-Control Committee

|Has a person been designated to be responsible for implementing an |Yes No |

|infection-control plan in your health-care setting? If yes, list the name: | |

|_________________________ | |

|Based on a review of the medical records, what is the average number of days for the following: |

|Presentation of patient until collection of specimen _____ |

|Specimen collection until receipt by laboratory _____ |

|Receipt of specimen by laboratory until smear results are provided to health-care provider _____ |

|Diagnosis until initiation of standard antituberculosis treatment _____ |

|Receipt of specimen by laboratory until culture results are provided to health-care provider _____ |

|Receipt of specimen by laboratory until drug-susceptibility results are provided to |

|health-care provider |

|_____ |

|Receipt of drug-susceptibility results until adjustment of antituberculosis treatment, |

|if indicated |

|_____ |

|Admission of patient to hospital until placement in airborne infection isolation (AII) _____ |

|Through what means (e.g., review of TST or BAMT conversion rates, patient | |

|medical records, and time analysis) are lapses in infection control | |

|recognized? | |

|What mechanisms are in place to correct lapses in infection control? | |

|Based on measurement in routine QC exercises, is the infection-control plan |Yes No |

|being properly implemented? | |

|Is ongoing training and education regarding TB infection-control practices |Yes No |

|provided for HCWs? | |

6. Laboratory Processing of TB-Related Specimens, Tests, and Results Based on Laboratory Review

|Which of the following tests are either conducted in-house at your health-care setting’s |In-house |Sent out |

|laboratory or sent out to a reference laboratory? | | |

|Acid-fast bacilli (AFB) smears | | |

|Culture using liquid media (e.g., Bactec and MB-BacT) | | |

|Culture using solid media | | |

|Drug-susceptibility testing | | |

|Nucleic acid amplification (NAA) testing | | |

|What is the usual transport time for specimens to reach the laboratory for the following tests? |

|AFB smears ___________ |

|Culture using liquid media (e.g., Bactec, MB-BacT) ___________ |

|Culture using solid media ___________ |

|Drug-susceptibility testing ___________ |

|Other (specify) ___________ |

|NAA testing ___________ |

|Does the laboratory at your health-care setting or the reference laboratory used by your |Yes No |

|health-care setting report AFB smear results for all patients within 24 hours of receipt of |______________________ |

|specimen? What is the procedure for weekends? |______________________ |

7. Environmental Controls

|Which environmental controls are in place in your health-care setting? (Check all that apply and describe) |

| |

|Environmental control Description |

|( AII rooms _____________________ |

|( Local exhaust ventilation (enclosing devices and exterior devices) _____________________ |

|( General ventilation (e.g., single-pass system, recirculation system.) _____________________ |

|( Air-cleaning methods (e.g., high-efficiency particulate air [HEPA] filtration and ultraviolet germicidal irradiation [UVGI]) |

|___________________________________________________________ |

|What are the actual air changes per hour (ACH) and design for various rooms in the setting? |

| |

|Room ACH Design |

|_____________________________________________________________________________________ |

|_____________________________________________________________________________________ |

|_____________________________________________________________________________________ |

|_____________________________________________________________________________________ |

|_____________________________________________________________________________________ |

|Which of the following local exterior or enclosing devices such as exhaust ventilation devices are used in your health-care |

|setting? (Check all that apply) |

|( Laboratory hoods |

|( Booths for sputum induction |

|( Tents or hoods for enclosing patient or procedure |

|What general ventilation systems are used in your health-care setting? (Check all that apply) |

|( Single-pass system |

|( Variable air volume (VAV) |

|( Constant air volume (CAV) |

|( Recirculation system |

|( Other____________________ |

|What air-cleaning methods are used in your health-care setting? (Check all that apply) |

|HEPA filtration |

|( Fixed room-air recirculation systems |

|( Portable room-air recirculation systems |

|UVGI |

|( Duct irradiation |

|( Upper-air irradiation |

|( Portable room-air cleaners |

|How many AII rooms are in the health-care setting? | |

|What ventilation methods are used for AII rooms? (Check all that apply) |

|Primary (general ventilation): |

|( Single-pass heating, ventilating, and air conditioning (HVAC) |

|( Recirculating HVAC systems |

| |

|Secondary (methods to increase equivalent ACH): |

|( Fixed room recirculating units |

|( HEPA filtration |

|( UVGI |

|( Other (specify) _________________ |

|Does your health-care setting employ, have access to, or collaborate with an environmental engineer (e.g., |Yes No |

|professional engineer) or other professional with appropriate expertise (e.g., certified industrial | |

|hygienist) for consultation on design specifications, installation, maintenance, and evaluation of | |

|environmental controls? | |

|Are environmental controls regularly checked and maintained with results recorded in maintenance logs? |Yes No |

|Are AII rooms checked daily for negative pressure when in use? |Yes No |

|Is the directional airflow in AII rooms checked daily when in use with smoke tubes or visual checks? |Yes No |

|Are these results readily available? |Yes No |

|What procedures are in place if the AII room pressure is not |______________________________________ |

|negative? | |

|Do AII rooms meet the recommended pressure differential of 0.01-inch water column negative to surrounding |Yes No |

|structures? | |

8. Respiratory-Protection Program

|Does your health-care setting have a written respiratory-protection program? |Yes No |

|Which HCWs are included in the respiratory protection program? |( Janitorial staff |

|(Check all that apply) |( Maintenance or engineering staff |

|( Physicians |( Transportation staff |

|( Mid-level practitioners (NPs and PAs) |( Dietary staff |

|( Nurses |( Students |

|( Administrators |( Others (specify)_________________ |

|( Laboratory personnel |_______________________________ |

|( Contract staff |_______________________________ |

|( Construction or renovation staff |_______________________________ |

|( Service personnel |_______________________________ |

|Are respirators used in this setting for HCWs working with TB patients? If yes, include manufacturer, model, and specific |

|application (e.g., ABC model 1234 for bronchoscopy and DEF model 5678 for routine contact with infectious TB patients). |

|Manufacturer Model Specific application |

|__________________________________________________________________________________________________________________________________|

|________________________________________________________________________________________________________________________________ |

|______________________________________________________________________________________ |

|Is annual respiratory-protection training for HCWs performed by a person with advanced training in |Yes No |

|respiratory protection? | |

|Does your health-care setting provide initial fit testing for HCWs? | Yes No |

|If yes, when is it conducted? ____________________________ | |

|Does your health-care setting provide periodic fit testing for HCWs? | Yes No |

|If yes, when and how frequently is it conducted? ____________________________ | |

|What method of fit testing is used? Describe. |

|__________________________________________________________________________________________________________________________________|

|__________________________________________ |

|Is qualitative fit testing used? |Yes No |

|Is quantitative fit testing used? |Yes No |

9. Reassessment of TB risk

|How frequently is the TB risk assessment conducted or updated in the health-care setting? | |

|When was the last TB risk assessment conducted? | |

|What problems were identified during the previous TB risk assessment? |

|__________________________________________________________________________________________________________________________________|

|________________________ |

|_____________________________________________________________________________ |

|_____________________________________________________________________________ |

|_____________________________________________________________________________ |

|_____________________________________________________________________________ |

| |

|_____________________________________________________________________________ |

|_____________________________________________________________________________ |

|_____________________________________________________________________________ |

|_____________________________________________________________________________ |

|What actions were taken to address the problems identified during the previous TB risk assessment? |

|__________________________________________________________________________________________________________________________________|

|________________________ |

|_____________________________________________________________________________ |

|_____________________________________________________________________________ |

|_____________________________________________________________________________ |

|_____________________________________________________________________________ |

|_____________________________________________________________________________ |

|_____________________________________________________________________________ |

|_____________________________________________________________________________ |

|_____________________________________________________________________________ |

|Did the risk classification need to be revised as a result of the last TB risk assessment? |Yes No |

* If the population served by the health-care facility is not representative of the community in which the facility is located, an alternate comparison population might be appropriate.

† Test conversion rate is calculated by dividing the number of conversions among HCWs by the number of HCWs who were tested and had prior negative results during a certain period (see Supplement, Surveillance and Detection of M. tuberculosis infections in Health-Care Settings).

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