Alabama Administrative Code
Title 420 - ALABAMA STATE BOARD OF HEALTH
Chapter 420-5-10 - NURSING FACILITIES
Section 420-5-10-.17 - Infection Control

1. Investigates, controls, and prevents infections in the facility;

2. Decides what procedures, such as isolation should be applied to an individual resident; and

3. Maintains a record of incidents and corrective actions related to infections.

1. When the infection control program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident.

2. The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease.

3. The facility must require staff to wash their hands after each direct resident contact for which handwashing is indicated by accepted professional practice.

1. As part of the resident admission procedure, a two-step tuberculin (PPD-Mantoux) skin test shall be administered prior or upon admission to all new residents unless there is documentation of a previous positive reaction. The two-step method should detect the boosting phenomenon that might be misinterpreted as a skin test conversion. Testing administered prior to admission shall be within 30 days of admission date. Results shall be recorded in the permanent records of the facility.

2. History of Bacille Calmetta Guerin (BCG) vaccination does not preclude an initial screening test, and a reaction of 10 mm or more induration shall be managed as a tuberculous infection.

3. At the time of admission any resident found to have a significant tuberculin skin test reaction (10 mm or greater) or with symptoms suggestive of TB shall be evaluated for active TB disease by clinical examination and chest roentgenogram. Sputum specimen, if obtainable, shall be collected and sent to the State Health Department Laboratory for smear and culture studies. Routine chest roentgenogram at admission remains an option at the discretion of the nursing facility. In the absence of clinical symptoms, annual chest roentgenograms are not recommended.

4. Sputum of acid-fast smear and mycobacerial culture shall be obtained promptly on any tuberculin reactor who develops a persistent cough or fever, or manifests an abnormal chest roentgenogram compatible with TB. Any resident, regardless of skin test results, with a persistent cough or fever or other symptoms suggestive of TB shall first have sputum collected and submitted immediately to the State Health Department Laboratory for smear and culture studies, followed by a clinical examination and chest roentgenogram.

5. Residents who have a documented history of a positive (greater than 10 mm induration) PPD tuberculin test, adequate treatment for disease, or adequate preventive therapy for infection shall be exempt from further screening unless they develop signs or symptoms suggestive of TB.

6. Routine annual TB skin testing of residents is not recommended for every nursing facility. The Infection Control Plan for each facility shall establish the need and frequency of repeat or annual TB skin testing based upon the risk of transmission of TB infection in that facility and the surrounding community.

7. All residents with a documented negative tuberculin test shall be retested within seven working days after notice of exposure to a suspected or diagnosed case, using the single-step Mantoux method. Contacts having a tuberculin skin test with a 5 mm or greater induration, and tuberculin converters should have follow-up examinations including a chest roentgenogram and clinical evaluation. Converters are defined as newly infected persons, without documented exposure information, whose tuberculin skin test increases as follows:

1. As part of the pre-employment procedure, a two step tuberculin (PPD-Mantoux) skin test shall be administered to all new employees as soon as employment begins unless there is documentation of a previous positive reaction or documentation of a negative skin test within the past 12 months. A single-step skin test is sufficient for new employees with documented negative test within the previous 12 months. The two-step tuberculin skin testing should detect the boosting phenomenon that might be misinterpreted as a skin test conversion. Results shall be recorded in the permanent records of the facility.

2. A history of BCG vaccination does not preclude an initial screening test, and a reaction of 10 mm or more induration shall be managed as a TB infection.

3. Any health care worker (HCW), at the time of employment, found to have a significant tuberculin skin test reaction (10 mm or greater) or with symptoms suggestive of TB shall be evaluated by clinical examination and chest roentgenogram. Sputum specimen, if obtainable, shall be collected and sent to the State Health Department Laboratory for smear and culture.

4. HCWs who have a documented history of a positive PPD test, adequate treatment for disease, or adequate preventive therapy for infection shall be exempt from further screening unless they develop signs or symptoms suggestive of TB.

5. Routine annual TB skin testing of HCWs is not recommended for every nursing facility. PPD-negative HCWs shall undergo repeat PPD testing at regular intervals as determined by the nursing facility's risk assessment. The Infection Control Plan for each facility should establish the need and frequency of repeat or annual TB skin testing based upon the risk of transmission of TB in that facility and surrounding community.

6. All HCWs with documented negative tuberculin test shall be retested using the single step Mantoux method within seven working days after notice of exposure to a suspected or diagnosed case of TB if appropriate precautions were not in place at the time of exposure. All HCWs with newly recognized positive PPD test results shall be evaluated promptly for active TB. Contacts having a tuberculin skin test with a 5 mm or greater induration, and tuberculin converters shall have follow-up examinations including a chest roentgenogram and clinical evaluation. Sputum specimen, if obtainable, should be sent to the State Health Department Laboratory for smear and culture. Converters are defined as newly infected persons, without documented exposure information, whose tuberculin test increases as follows:

(7) Routine chest radiographs are not required for asymptomatic, PPD-negative HCWs. HCWs with positive PPD test results shall have chest radiographs as part of the initial evaluation of their PPD test; if negative, repeat chest radiographs are not needed unless symptoms develop that could be attributed to TB. However, more frequent monitoring for symptoms of TB may be considered for recent converters and other PPD-positive HCWs who are at increased risk for developing active TB (e.g., HIV-infected or otherwise severely immunocompromised HCWs).

1. Infected employees and residents with no current disease, who are 34 years of age and under, shall be offered preventive therapy (isoniazid) in accordance with the American Thoracic Society, Center for Disease Control, American College of Chest Physicians and the Alabama State TB Control Program Guidelines. Employees and residents aged 35 and over who have significant skin tests may be offered preventive therapy depending upon each individual's complete evaluation.

1. Any employee or resident with suspected or diagnosed TB disease must be reported to the local health department immediately.

2. Epidemiologic investigation will be performed by trained health department staff on all employees and residents with diagnosed or suspected disease.

3. Further information regarding TB screening of employees and residents may be obtained by contacting the local county health department or the Division of TB Control of the State Health Department.

1. Nursing homes may choose to use either of the methods outlined below when administering the two-step (test-retest) tuberculin skin test. The Infection Control Plan for each facility shall designate which method is more appropriate for the facility and that method must be consistently utilized. The use of the two-step tuberculin skin test should detect the boosting phenomenon that might be misinterpreted as a skin test conversion. The process is particularly important when repeat testing is likely.

Method 1:

Apply first test

Read result in 7 days

If result is positive (greater than 10 mm of induration), follow recommendation for appropriate follow-up of positive skin test

If result is negative (0-9 mm of induration), apply second test (same day)

Read result of second test 48-72 hours later

Use result of second test as baseline

Method 2:

Apply first test

Read test in 48-72 hours

If result is positive (greater than 10 mm of induration), follow recommendation for appropriate follow-up of positive skin test

If result is negative (0-9 mm of induration), apply second test

1-3 weeks later

Read result of second test 48-72 hours later

Use result of second test as baseline

Authors: Patricia E. Ivie, Jimmy D. Prince