Prevention and Control of Tuberculosis in Correctional and Detention Facilities: Recommendations from CDC

Endorsed by the Advisory Council for the Elimination of Tuberculosis, the National Commission on Correctional Health Care, and the American Correctional Association

Disclosures

Morbidity and Mortality Weekly Report. 2006;55(27):1-44. 

In This Article

Respiratory Protection

Respiratory protection is used when administrative (i.e., identification and isolation of infectious TB patients) and environmental controls alone have not reduced the risk for infection with M. tuberculosis to an acceptable level. The use of respiratory protection is most appropriate in specific settings and situations within correctional facilities. For example, protection is warranted for inmates and facility staff when they enter AII rooms, transport infectious inmates, and participate in cough-inducing procedures.

Respirators should be selected from those approved by CDC/National Institute for Occupational Safety and Health (NIOSH) under the provisions of Title 42, Part 84 of the Code of Federal Regulations.[86] Decisions regarding which respirator is appropriate for a particular situation and setting should be made on the basis of a risk assessment of the likelihood for TB transmission.** For correctional facilities, a CDC/NIOSH-approved N95 air-purifying respirator will provide adequate respiratory protection in the majority of situations that require the use of respirators. If a higher level of respiratory protection is warranted, additional information on other classes of air-purifying respirators and powered air-purifying respirators (PAPRs) is available.[71] The overall effectiveness of respiratory protection is affected by 1) the level of respiratory protection selected (i.e., the assigned protection factor), 2) the fitting characteristics of the respirator model, 3) the care taken in donning the respirator, and 4) the effectiveness of the respiratory protection program, including fit testing and worker training.

All facilities should develop, implement, and maintain a respiratory-protection program for health-care workers or other staff who use respiratory protection. Respiratory-protection programs are required for facilities covered by the U.S. Occupational Safety and Health Administration (OSHA).[71,87,88,89] The key elements of a respiratory protection program include 1) assignment of responsibility, 2) training, and 3) fit testing.[71,87,90,91] All correctional facility staff who use respirators for protection against infection with M. tuberculosis must participate in the facility's respiratory protection program (e.g., understand their responsibilities, receive training, receive medical clearance, and engage in fit testing).[71] In addition to staff members, visitors to inmates with TB disease should be offered respirators to wear while in AII rooms and instructed on proper use. Certain regular visitors (e.g., law enforcement officials, social workers, ministers and other religious representatives, and attorneys and other legal staff) might be there in an occupational capacity. Each facility, regardless of TB risk classification (i.e., minimal or nonminimal), should develop a policy on the use of respirators by visitors of patients.

Recommended precautions to take when transporting patients between facilities have been published.[71] Patients with suspected or confirmed infectious TB disease should be transported in an ambulance whenever possible. The ambulance ventilation system should be operated in the nonrecirculating mode and the maximum amount of outdoor air be provided to facilitate dilution. If the vehicle has a rear exhaust fan, it should be used during transport. If the vehicle is equipped with a supplemental recirculating ventilation unit that passes air through HEPA filters before returning it to the vehicle, this unit should be used to increase the number of ACH. Airflow should be from the cab (i.e., front of vehicle) over the patient and out the rear exhaust fan. If an ambulance is not used, the ventilation system for the vehicle should bring in as much outdoor air as possible, and the system should be set to nonrecirculating. If possible, the cab should be physically isolated from the rest of the vehicle, and the patient should be placed in the rear seat. Drivers or other persons who are transporting patients with suspected or confirmed infectious TB disease in an enclosed vehicle should wear at least an N95 disposable respirator. If the patient has signs or symptoms of infectious TB disease (i.e., positive AFB sputum-smear result), consideration might be given to having the patient wear a surgical or procedure mask, if possible, during transport, in waiting areas, or when others are present.

** Surgical masks should never be worn in place of a respirator. Surgical masks often fit so poorly that they provide only minimal protection from any airborne hazard, including M. tuberculosis. Surgical masks are designed to protect others from the wearer; they are not designed or tested to provide respiratory protection to the wearer.

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