Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Scope and
Application.
(1) Scope. This section applies
to work in the following facilities, service categories, or operations:
(A) Each of the following health care
facilities, services, or operations:
1.
Hospitals
2. Skilled nursing
facilities
3. Clinics, medical
offices, and other outpatient medical facilities
4. Facilities where high hazard procedures,
as defined in subsection (b), are performed
5. Home health care
6. Long term health care facilities and
hospices
7. Medical outreach
services
8. Paramedic and emergency
medical services including these services when provided by firefighters and
other emergency responders
9.
Medical transport
(B)
Facilities, services, or operations that are designated to receive persons
arriving from the scene of an uncontrolled release of hazardous substances
involving biological agents, as defined in Section
5192, Hazardous Waste Operations
and Emergency Response, of these orders.
(C) Police services, provided during
transport or detention of persons reasonably anticipated to be cases or
suspected cases of aerosol transmissible diseases; and police services provided
in conjunction with health care or public health operations.
(D) Public health services, such as
communicable disease contact tracing or screening programs that are reasonably
anticipated to be provided to cases or suspected cases of aerosol transmissible
diseases, and public health services rendered in health care facilities or in
connection with the provision of health care.
(E) The following facilities, services or
operations that are identified as being at increased risk for transmission of
aerosol transmissible disease (ATD) infection:
1. Correctional facilities and other
facilities that house inmates or detainees
2. Homeless shelters
3. Drug treatment
programs
(F) Facilities,
services or operations that perform aerosol-generating procedures on cadavers
such as pathology laboratories, medical examiners' facilities, coroners'
offices, and mortuaries.
(G)
Laboratories that perform procedures with materials that contain or are
reasonably anticipated to contain aerosol transmissible pathogens -- laboratory
(ATP-L) or zoonotic aerosol transmissible pathogens as defined in Section
5199.1.
(H) Any other facility, service or operation
that has been determined in writing by the Chief of the Division of
Occupational Safety and Health through the issuance of an Order to Take Special
Action, in accordance with Section
332.3 of these orders, to require
application of this standard as a measure to protect employees.
(I) Maintenance, renovation, service, or
repair operations involving air handling systems or equipment or building areas
that may reasonably be anticipated to be contaminated with aerosol
transmissible pathogens (ATPs) or ATPs-L, including:
1. Areas in which Airborne Infectious Disease
(AirID) cases and suspected cases are treated or housed.
2. Air handling systems that serve airborne
infection isolation rooms or areas (AIIRs).
3. Equipment such as laboratory hoods,
biosafety cabinets, and ventilation systems that are used to contain infectious
aerosols.
NOTES to subsection (a)(1):
(1) Employers who conduct hazardous waste and
emergency response operations, as defined in Section
5192 of these orders, shall also
comply with the applicable requirements of Section
5192.
(2) Occupational exposure to animals infected
by aerosol transmissible pathogens which cause human disease are regulated by
Section 5199.1 of these
orders.
(2) The following are not covered by this
standard:
(A) Outpatient dental clinics or
offices are not required to comply with this standard if they meet all of the
following conditions:
1. Dental procedures are
not performed on patients identified to them as ATD cases or suspected ATD
cases.
2. The Injury and Illness
Prevention Program includes a written procedure for screening patients for ATDs
that is consistent with current guidelines issued by the Centers for Disease
Control and Prevention (CDC) for infection control in dental settings, and this
procedure is followed before performing any dental procedure on a patient to
determine whether the patient may present an ATD exposure risk.
3. Employees have been trained in the
screening procedure in accordance with Section
3203.
4. Aerosol generating dental procedures are
not performed on a patient identified through the screening procedure as
presenting a possible ATD exposure risk unless a licensed physician determines
that the patient does not currently have an ATD.
(B) Outpatient medical specialty practices
whose policy is not to diagnose or treat ATDs are not required to comply with
this standard if they meet all of the following conditions:
1. The medical specialty practice does not
perform aerosol-generating procedures on cases or suspected cases of
ATD;
2. The Injury and Illness
Prevention Program includes written screening procedures to identify potential
ATD cases, and then refer those patients for further evaluation to an
appropriate medical provider;
3.
Employees have been trained in the screening procedure in accordance with
Section 3203.
(3) Application.
(A) Referring Employers. A referring employer
is required only to comply with the provisions of subsection (a), subsection
(c), including all parts of Section
5199 referred to in subsection (c),
and subsection (j). To be a referring employer, the operation, service or
facility must conform to each of the following, as indicated:
1. Screen persons for airborne infectious
diseases (AirID).
2. Refer any
person identified as a case or suspected case of AirID.
3. Not intend to provide further medical
services to AirID cases and suspected cases beyond first aid, initial treatment
or screening and referral as described in subsections (a)(3)(A)1 and (a)(3)(A)2
immediately above.
4. Not provide
transport, housing, or airborne infection isolation (as defined in subsection
(b)) 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.
(B)
Laboratories. A laboratory facility or operation in which employees do not have
direct contact with cases or suspected cases of ATD or with potentially
infected cadavers is required to comply only with the provisions of subsection
(a), subsection (f), all provisions of Section
5199 referred to in subsection (f),
subsection (i) and subsection (j).
(C) Work settings, operations, or facilities
included within the scope of this standard that are not identified in
subsections (a)(3)(A) or (a)(3)(B) shall comply with subsections (a), (d), (e),
(f), (g), (h), (i), and (j).
(4) The employer shall provide all safeguards
required by this section, including provision of personal protective equipment,
respirators, training, and medical services, at no cost to the employee, at a
reasonable time and place for the employee, and during the employee's working
hours.
(b) Definitions.
Accredited laboratory. A laboratory that is licensed by
the CDPH pursuant to Title 17 of the California Code of Regulations (CCR), or
which has received a certification of competence based on participation in a
quality assurance program administered by a governmental or private
organization that tests and certifies laboratories.
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 A.
Aerosol transmissible pathogen -- laboratory (ATP-L). A
pathogen that meets one of the following criteria:
(1) the pathogen appears on the list in
Appendix D,
(2) the Biosafety in
Microbiological and Biomedical Laboratories (BMBL) recommends biosafety level 3
or above for the pathogen,
(3) the
biological safety officer recommends biosafety level 3 or above for the
pathogen, or
(4) the pathogen is a
novel or unknown pathogen.
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 subsection (e)(5)(D) of this
standard.
Airborne infectious disease (AirID).
Either:
(1) an aerosol
transmissible disease transmitted through dissemination of airborne droplet
nuclei, small particle aerosols, or dust particles containing the disease agent
for which AII is recommended by the CDC or CDPH, as listed in Appendix A,
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 aerosol
transmissible pathogen 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 A,
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.
Biological safety officer(s). A person who is qualified
by training and/or experience to evaluate hazards associated with laboratory
procedures involving ATPs-L, who is knowledgeable about the facility biosafety
plan, and who is authorized by the employer to establish and implement
effective control measures for laboratory biological hazards.
Biosafety level 3. Compliance with the criteria for
laboratory practices, safety equipment, and facility design and construction
recommended by the CDC in Biosafety in Microbiological and Biomedical
Laboratories for laboratories in which work is done with indigenous or exotic
agents with a potential for aerosol transmission and which may cause serious or
potentially lethal infection.
Biosafety in Microbiological and Biomedical
Laboratories (BMBL). Biosafety in Microbiological and Biomedical Laboratories,
Fifth Edition, CDC and National Institutes for Health, 2007, which is hereby
incorporated by reference for the purpose of establishing biosafety
requirements in laboratories.
CDC. United States Centers for Disease Control and
Prevention.
CDPH. California Department of Public Health and its
predecessor, the California Department of Health Services (CDHS).
Case. Either of the following:
(1) A person who has been diagnosed by a
health care provider who is lawfully authorized to diagnose, using clinical
judgment or laboratory evidence, to have a particular disease or
condition.
(2) A person who is
considered a case of a disease or condition that satisfies the most recent
communicable disease surveillance case definitions established by the CDC and
published in the Morbidity and Mortality Weekly Report (MMWR) or its
supplements.
Chief. The Chief of the Division of Occupational Safety
and Health of the Department of Industrial Relations, or his or her designated
representative.
CTCA. The California Tuberculosis Controllers
Association.
Droplet precautions. Infection control procedures as
described in Guideline for Isolation Precautions designed to reduce the risk of
transmission of infectious agents through contact of the conjunctivae or the
mucous membranes of the nose or mouth of a susceptible person with
large-particle droplets (larger than 5 µm in size) containing
microorganisms generated from a person who has a clinical disease or who is a
carrier of the microorganism.
Drug treatment program. A program that is (A) licensed
pursuant to Chapter 7.5 (commencing with Section 11834.01), Part 2, Division
10.5 of the Health and Safety Code; or Chapter 1 (commencing with Section
11876), Part 3, Article 3, Division 10.5 of the Health and Safety Code; or (B)
certified as a substance abuse clinic or satellite clinic pursuant to Section
51200, Title 22, CCR, and which
has submitted claims for Medi-Cal reimbursement pursuant to Section
51490.1, Title 22, CCR, within the
last two calendar years or (C) certified pursuant to Section
11831.5
of the Health and Safety Code.
Emergency medical services. Medical care provided
pursuant to Title 22, Division 9, by employees who are certified EMT-1,
certified EMT-II, or licensed paramedic personnel to the sick and injured at
the scene of an emergency, during transport, or during interfacility
transfer.
Epidemiology and Prevention of Vaccine-Preventable
Diseases. Epidemiology and Prevention of Vaccine-Preventable Diseases. Centers
for Disease Control 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, which is
hereby incorporated by reference.
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.
Exposure incident (laboratory). A significant exposure
to an aerosol containing an ATP-L, without the benefit of applicable exposure
control measures required by this section.
Field operation. An operation conducted by employees
that is outside of the employer's fixed establishment, such as paramedic and
emergency medical services or transport, law enforcement, home health care, and
public health.
Guideline for Isolation Precautions. The Guideline for
Isolation Precautions: Preventing Transmission of Infectious Agents in
Healthcare Settings, June 2007, CDC, which is hereby incorporated by reference
for the sole purpose of establishing requirements for droplet and contact
precautions.
Guidelines for Preventing the Transmission of
Mycobacterium tuberculosis in Health-Care Settings. The
Guidelines for Preventing the Transmission of Mycobacterium
tuberculosis in Health-Care Settings, December 2005, CDC, which is
hereby incorporated by reference for the sole purpose of establishing
requirements for airborne infection isolation.
Health care provider. A physician and surgeon, a
veterinarian, a podiatrist, a nurse practitioner, a physician assistant, a
registered nurse, a nurse midwife, a school nurse, an infection control
practitioner, a medical examiner, a coroner, or a dentist.
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 described in subsection (a)(1)(D).
High hazard procedures. Procedures performed on a
person who is a case or suspected case of an aerosol transmissible disease or
on a specimen suspected of containing an ATP-L, in which the potential for
being exposed to aerosol transmissible pathogens 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 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 or contains 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 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.
Laboratory. A facility or operation in a facility where
the manipulation of specimens or microorganisms is performed for the purpose of
diagnosing disease or identifying disease agents, conducting research or
experimentation on microorganisms, replicating microorganisms for distribution
or related support activities for these processes.
Latent TB infection (LTBI). Infection with M.
tuberculosis in which bacteria are present in the body, but are
inactive. Persons who have LTBI but who do not have TB disease are
asymptomatic, do not feel sick and cannot spread TB to other persons. They
typically react positively to TB tests.
Local health officer. The health officer for the local
jurisdiction responsible for receiving and/or sending reports of communicable
diseases, as defined in Title 17, CCR.
NOTE: Title 17, Section
2500 requires that reports be made
to the local health officer for the jurisdiction where the patient
resides.
M. tuberculosis. Mycobacterium
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.
Medical specialty practice. A medical practice other
than primary care, general practice, or family medicine.
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.
NIOSH. The Director of the National Institute for
Occupational Safety and Health, CDC, or his or her designated
representative.
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.
Novel or unknown ATP. A pathogen capable of causing
serious human disease meeting the following criteria:
(1) There is credible evidence that the
pathogen is transmissible to humans by aerosols; and
(2) The disease agent is:
(a) A newly recognized pathogen, or
(b) A newly recognized variant of a known
pathogen and there is reason to believe that the variant differs significantly
from the known pathogen in virulence or transmissibility, or
(c) A recognized pathogen that has been
recently introduced into the human population, or
(d) A not yet identified pathogen.
NOTE: Variants of the human influenza virus that
typically occur from season to season are not considered novel or unknown ATPs
if they do not differ significantly in virulence or transmissibility from
existing seasonal variants. Pandemic influenza strains that have not been fully
characterized are novel pathogens.
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 ATPs-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 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 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. It is the task of employers covered by
this standard to 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 subsection (a)(1)(E) are considered to cause
occupational exposure. Employees working in laboratory areas in which ATPs-L
are handled or reasonably anticipated to be present are also considered to have
occupational exposure.
Physician or other licensed health care professional
(PLHCP) means an individual whose legally permitted scope or practice (i.e.,
license, registration, or certification) allows him or 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) In regards to tuberculosis, applicable
guidelines published by the CTCA and/or CDPH as follows, which are hereby
incorporated by reference:
(A) Guidelines for
Tuberculosis (TB) Screening and Treatment of Patients with Chronic Kidney
Disease (CKD), Patients Receiving Hemodialysis (HD), Patients Receiving
Peritoneal Dialysis (PD), Patients Undergoing Renal Transplantation and
Employees of Dialysis Facilities, May 18, 2007.
(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) California Tuberculosis Controllers
Association 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 Control of
Tuberculosis in California 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) In regards to
vaccine-preventable diseases, the publication cited in the definition of
Epidemiology and Prevention of Vaccine-Preventable Diseases.
(3) In regards to any disease or condition
not addressed by the above guidelines, recommendations made by the CDPH or the
local health officer pursuant to authority granted under the Health and Safety
Code and/or Title 17, California Code of Regulations.
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.
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. General
acute care hospitals are not referring employers. 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
local health officer, in accordance with Title 17 CCR, Division 1, Chapter 4,
and which meets the definition of an aerosol transmissible disease
(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 subsection (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.
Screening (health care provider). The initial
assessment of persons who are potentially AirID or ATD cases by a health care
provider in order to determine whether they need airborne infection isolation
or need to be referred for further medical evaluation or treatment to make that
determination. Screening does not include high hazard procedures.
Screening (non health care provider). The
identification of potential ATD cases through readily observable signs and the
self-report of patients or clients. Screening does not include high hazard
procedures.
Significant exposure. An exposure to a source of ATPs
or ATPs-L in which the circumstances of the exposure make the transmission of a
disease sufficiently likely that the employee requires further evaluation by a
PLHCP.
Source control measures. The use of procedures,
engineering controls, and other devices or materials to minimize the spread of
airborne particles and droplets from an individual who has or exhibits signs or
symptoms of having an ATD, such as persistent coughing.
Surge. A rapid expansion beyond normal services to meet
the increased demand for qualified personnel, medical care, equipment, and
public health services in the event of an epidemic, public health emergency, or
disaster.
Susceptible person. A person who is at risk of
acquiring an infection due to a lack of immunity as determined by a PLHCP in
accordance with applicable public health guidelines.
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.
TB conversion. A change from negative to positive as
indicated by TB test results, based upon current CDC or CDPH guidelines for
interpretation of the TB test
Test for tuberculosis infection (TB test). Any test,
including the tuberculin skin test and blood assays for M.
Tuberculosis (BAMT) such as interferon gamma release assays (IGRAs)
which:
(1) has been approved
by the Food and Drug Administration 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 LTBI is required by Title
22, CCR, the TB test must be approved for this use by the CDPH.
Tuberculosis (TB). A disease caused by M.
tuberculosis.
UVGI. Ultraviolet germicidal
irradiation.
(c)
Referring Employers. In facilities, services, or operations in which there is
occupational exposure and which meet the criteria specified by (a)(3)(A),
employers are only required to comply with the following provisions:
(1) The employer shall designate a person as
the administrator who will be responsible for the establishment, implementation
and maintenance of effective written infection control procedures to control
the risk of transmission of aerosol transmissible diseases. The administrator
shall have the authority to perform this function and shall be knowledgeable in
infection control principles as they apply specifically to the facility,
service or operation. The administrator shall also identify in writing the job
categories in which employees have occupational exposure to ATDs. When the
administrator is not on site, there shall be a designated person with full
authority to act on his or her behalf. The infection control procedures shall
include procedures for the cleaning and disinfection of work areas, vehicles,
and equipment that may become contaminated with ATPs and pose an infection risk
to employees. The written procedures shall be available at the
worksite.
(2) The employer shall
establish, implement, and maintain effective written source control procedures.
For fixed health care and correctional facilities, and in other facilities,
services, and operations to the extent reasonably practicable, these procedures
shall incorporate the recommendations contained in the Respiratory
Hygiene/Cough Etiquette in Health Care Settings. These procedures shall include
the method of informing persons with whom employees will have contact of the
employer's source control measures.
(3) The employer shall establish, implement,
and maintain effective written procedures for the screening and referral of
cases and suspected cases of AirIDs to appropriate facilities.
(A) Transfers shall occur within 5 hours of
the identification of the case or suspected case, unless:
(1) the initial encounter with the case or
suspected case occurs after 3:30 p.m. and prior to 7 a.m., in which event the
employer shall ensure that transfer occurs no later than 11:00 a.m.;
or
(2) the employer has contacted
the local health officer, determined that there is no facility that can provide
appropriate AII, and complied with all of the conditions in (e)(5)(B)2.;
or
(3) the case meets the
conditions of either of the exceptions to subsection
(e)(5)(B).
(B) When
screening is provided by persons who are not health care providers, the
employer shall meet the requirements of this section by establishing criteria
and procedures for referral of persons to a health care provider for further
evaluation within the timeframes in subsection (c)(3)(A). Referrals shall be
provided to persons who do any of the following:
1. Have a cough for more than three weeks
that is not explained by non-infectious conditions.
2. Exhibit signs and symptoms of a flu-like
illness during March through October, the months outside of the typical period
for seasonal influenza, or exhibit these signs and symptoms for a period longer
than two weeks at any time during the year. These signs and symptoms generally
include combinations of the following: coughing and other respiratory symptoms,
fever, sweating, chills, muscle aches, weakness and malaise.
3. State that they have a transmissible
respiratory disease, excluding the common cold and seasonal
influenza.
4. State that they have
been exposed to an infectious ATD case, other than seasonal influenza.
NOTES to subsection (c)(3):
1. Seasonal influenza does not require
referral.
2. Appendix F contains
sample criteria for screening that may be adopted by employers in non-medical
settings for the purpose of meeting the requirements of this
subsection.
(4)
The employer shall establish, implement, and maintain effective written
procedures to communicate with employees, other employers, and the local health
officer regarding the suspected or diagnosed infectious disease status of
referred patients. These shall include procedures to receive information from
the facility to which patients were referred and to provide necessary infection
control information to employees who were exposed to the referred
person.
(5) The employer shall
establish, implement and maintain effective written procedures to reduce the
risk of transmission of aerosol transmissible disease, to the extent feasible,
during the period the person requiring referral is in the facility or is in
contact with employees. In addition to source control measures, these
procedures shall include, to the extent feasible:
(A) placement of the person requiring
referral in a separate room or area;
(B) provision of separate ventilation or
filtration in the room or area; and
(C) employee use of respiratory protection
when entering the room or area in which the person requiring referral is
located, if that person is not compliant with source control measures.
Respirator use shall meet the requirements of subsection (g) and Section
5144, Respiratory Protection, of
these orders.
EXCEPTION to subsection (c)(5)(C): 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:
i. A solid partition separates
the passenger area from the area where employees are located;
ii. The employer implements written
procedures that specify the conditions of operation, including the operation of
windows and fans;
iii. 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;
iv. The employer records the results of the
tests and maintains the results in accordance with subsection (j)(3)(F);
and
v. The person performing the
test is knowledgeable about the assessment of ventilation
systems.
(6)
The employer shall establish a system of medical services for employees which
meets the following requirements:
(A) The
employer shall make available to all health care workers with occupational
exposure all vaccinations recommended by the CDPH as listed in Appendix E in
accordance with subsection (h). These vaccinations shall be provided by a PLHCP
at a reasonable time and place for the employee.
(B) The employer shall develop, implement,
and maintain effective written procedures for exposure incidents in accordance
with subsections (h)(6) through (h)(9).
(C) The employer shall establish, implement,
and maintain an effective surveillance program for LTBI in accordance with
subsections (h)(3) and (h)(4).
(D)
The employer shall establish, implement, and maintain effective procedures for
providing vaccinations against seasonal influenza to all employees with
occupational exposure, in accordance with subsection (h)(10).
EXCEPTION to subsection (c)(6)(D): Seasonal influenza
vaccine shall be provided during the period designated by the CDC for
administration and need not be provided outside of those
periods.
(7)
Employers shall ensure that all employees with occupational exposure
participate in a training program. Training shall be provided at the time of
initial assignment to tasks where occupational exposure may take place and at
least annually thereafter. Additional training shall be provided when there are
changes in the workplace or when there are changes in procedures that could
affect worker exposure to ATPs. The person conducting the training shall be
knowledgeable in the subject matter covered by the training program as it
relates to the workplace. Training material appropriate in content and
vocabulary to the educational level, literacy, and language of employees shall
be used. This training shall include:
(A) A
general explanation of ATDs including the signs and symptoms that require
further medical evaluation;
(B)
Screening methods and criteria for persons who require referral;
(C) The employer's source control measures
and how these measures will be communicated to persons the employees
contact;
(D) The employer's
procedures for making referrals in accordance with subsection (c)(3);
(E) The employer's procedures for temporary
risk reduction measures prior to transfer;
(F) Training in accordance with subsection
(g) and Section
5144 of these orders, when
respiratory protection is used;
(G)
The employer's medical services procedures in accordance with subsection (h),
the methods of reporting exposure incidents, and the employer's procedures for
providing employees with post-exposure evaluation;
(H) Information on vaccines the employer will
make available, including the seasonal influenza vaccine. For each vaccine,
this information shall include the efficacy, safety, method of administration,
the benefits of being vaccinated, and that the vaccine and vaccination will be
offered free of charge;
(I) How
employees can access the employer's written procedures and how employees can
participate in reviewing the effectiveness of the employer's procedures in
accordance with subsection (c)(8); and
(J) An opportunity for interactive questions
and answers with a person who is knowledgeable in the subject matter as it
relates to the workplace that the training addresses and who is also
knowledgeable in the employer's infection control procedures. Training not
given in person shall provide for interactive questions to be answered within
24 hours by a knowledgeable person.
(8) The employer shall ensure that the
infection control procedures are reviewed at least annually by the
administrator and by employees regarding the effectiveness of the program in
their respective work areas, and that deficiencies found are
corrected.
(9) The employer shall
establish and maintain training records, vaccination records, records of
exposure incidents, and records of inspection, testing, and maintenance of
non-disposable engineering controls, in accordance with subsection (j). If the
employer utilizes respirators, the employer shall maintain records of
implementation of the Respiratory Protection Program in accordance with Section
5144, Respiratory Protection, of
these orders.
(d) Aerosol
Transmissible Diseases Exposure Control Plan.
(1) The employer shall establish, implement,
and maintain an effective, written ATD Exposure Control Plan (Plan) which is
specific to the work place or operation(s), and which contains all of the
elements in subsection (d)(2).
EXCEPTION to subsection (d)(1): Employers with
laboratory operations in which employees do not have direct patient contact may
establish, implement and maintain an effective, written Biosafety Plan meeting
the requirements of subsection (f) in lieu of an Exposure Control Plan for
those operations.
(2) The
Plan shall contain all of the following elements:
(A) The name(s) or title(s) of the person(s)
responsible for administering the Plan. This person shall be knowledgeable in
infection control principles and practices as they apply to the facility,
service or operation.
(B) A list of
all job classifications in which employees have occupational
exposure.
(C) A list of all high
hazard procedures performed in the facility, service or operation, and the job
classifications and operations in which employees are exposed to those
procedures.
(D) A list of all
assignments or tasks requiring personal or respiratory protection.
(E) The methods of implementation of
subsections (e), (g), (h), (i) and (j) as they apply to that facility, service
or work operation. Specific control measures shall be listed for each operation
or work area in which occupational exposure occurs. These measures shall
include applicable engineering and work practice controls, cleaning and
decontamination procedures, and personal protective equipment and respiratory
protection. In establishments where the Plan pertains to laboratory operations,
it also shall contain the methods of implementation for subsection (f), unless
those operations are included in a Biosafety Plan.
(F) A description of the source control
measures to be implemented in the facility, service or operation, and the
method of informing people entering the work setting of the source control
measures.
(G) The procedures the
employer will use to identify, temporarily isolate, and refer or transfer AirID
cases or suspected cases to AII rooms, areas or facilities. These procedures
shall include the methods the employer will use to limit employee exposure to
these persons during periods when they are not in airborne infection isolation
rooms or areas. These procedures shall also include the methods the employer
will use to document medical decisions not to transfer patients in need of AII
in accordance with subsection (e)(5)(B).
(H) The procedures the employer will use to
provide medical services, including recommended vaccinations and follow-up, as
required in subsection (h). This shall include the procedures the employer will
use to document the lack of availability of a recommended vaccine.
(I) The procedures for employees and
supervisors to follow in the event of an exposure incident, including how the
employer will determine which employees had a significant exposure, in
accordance with subsections (h)(6) through (h)(9).
(J) The procedures the employer will use to
evaluate each exposure incident, to determine the cause, and to revise existing
procedures to prevent future incidents.
(K) The procedures the employer will use to
communicate with its employees and other employers regarding the suspected or
confirmed infectious disease status of persons to whom employees are exposed in
the course of their duties, in accordance with subsection (h).
(L) The procedures the employer will use to
communicate with other employers regarding exposure incidents, including
procedures for providing or receiving notification to and from health care
providers about the disease status of referred or transferred patients, in
accordance with subsection (h).
(M)
The procedures the employer will use to ensure that there is an adequate supply
of personal protective equipment and other equipment necessary to minimize
employee exposure to ATPs, in normal operations and in foreseeable
emergencies.
(N) The procedures the
employer will use to provide initial and annual training in accordance with
subsection (i) to employees in job categories identified in subsection
(d)(2)(B).
(O) The procedures the
employer will use for recordkeeping, in accordance with subsection
(j).
(P) An effective procedure for
obtaining the active involvement of employees in reviewing and updating the
exposure control plan with respect to the procedures performed in their
respective work areas or departments in accordance with subsection
(d)(3).
(Q) Surge procedures.
Employers of employees who are designated to provide services in surge
conditions, and employers of employees who are designated to provide services
to persons who have been contaminated as the result of a release of a
biological agent as described in subsection (a)(1)(B), shall include procedures
for these activities in the plan. The plan shall include work practices,
decontamination facilities, and appropriate personal protective equipment and
respiratory protection for such events. The procedures shall include how
respiratory and personal protective equipment will be stockpiled, accessed or
procured, and how the facility or operation will interact with the local and
regional emergency plan.
(3) The ATD Plan shall be reviewed at least
annually by the program administrator, and by employees regarding the
effectiveness of the program in their respective work areas. Deficiencies found
shall be corrected. The review(s) shall be documented in writing, in accordance
with subsection (j)(3)(A).
(4) The
Plan shall be made available to employees, employee representatives, the Chief
and NIOSH for examination and copying, in accordance with subsection
(j)(4).
(e) Engineering
and Work Practice Controls, and Personal Protective Equipment.
(1) General. Employers shall use feasible
engineering and work practice controls to minimize employee exposures to ATPs.
Where engineering and work practice controls do not provide sufficient
protection (e.g., when an employee enters an AII room or area) the employer
shall provide, and ensure that employees use, personal protective equipment,
and shall provide respiratory protection in accordance with subsection (g) to
control exposures to AirIPs.
(A) Work
practices shall be implemented to prevent or minimize employee exposures to
airborne, droplet, and contact transmission of aerosol transmissible pathogens
(ATP), in accordance with Appendix A, and where not addressed by Appendix A, in
accordance with the Guideline for Isolation Precautions. Droplet and contact
precautions shall be in accordance with Guideline for Isolation Precautions.
Airborne precautions shall be in accordance with Guidelines for Preventing the
Transmission of
Mycobacterium tuberculosis in Health-Care
Settings.
NOTE: These work practices may include, but are not
limited to; handwashing and gloving procedures; the use of anterooms; and
cleaning and disinfecting contaminated surfaces, articles and
linens.
(B) Each employer
shall implement written source control procedures. For fixed health care and
correctional facilities, and in field operations to the extent that it is
reasonably practicable, these procedures shall incorporate the recommendations
contained in the Respiratory Hygiene/Cough Etiquette in Health Care Settings.
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 the
employer.
(C) Employers shall
develop and implement engineering and work practice controls to protect
employees who operate, use, or maintain vehicles that transport persons who are
ATD cases or suspected cases. The employer shall give consideration to
implementing barriers and air handling systems, where feasible. Employers shall
document the results and the basis for the results of their consideration
process. These control measures shall be included in the annual review of the
Plan, in accordance with subsection (d)(3).
(2) The employer shall develop and implement
effective written decontamination procedures, including appropriate engineering
controls, for the cleaning and decontamination of work areas, vehicles,
personal protective equipment, and other equipment.
(3) The employer 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.
(4) Engineering controls
shall be used in workplaces that admit, house, or provide medical services to
AirID cases or suspected cases, except in settings where home health care or
home-based hospice care is being provided.
(5) AirID cases or suspected cases shall be
identified, and except in field operations and in settings where home health
care or home-based hospice care is being provided, these individuals shall be:
(A) Provided with disposable tissues and hand
hygiene materials and masked or placed in such a manner that contact with
employees who are not wearing respiratory protection is eliminated or minimized
until transfer or placement in an AII room or area can be accomplished
and;
(B) Placed in an AII room or
area or transferred to a facility with AII rooms or areas. The employer shall
ensure that this placement or transfer is effected in a timely manner.
1. Transfers within facility. Transfers to
airborne infection isolation rooms or areas within the facility shall occur
within 5 hours of identification. If there is no AII room or area available
within this time, the employer shall transfer the individual to another
suitable facility in accordance with subsection (e)(5)(B)2.
2. Transfers to other facilities. Transfers
to other facilities shall occur within 5 hours of identification, unless the
employer documents, at the end of the 5-hour period, and at least every 24
hours thereafter, each of the following:
a.
The employer has contacted the local health officer.
b. There is no AII room or area available
within that jurisdiction.
c.
Reasonable efforts have been made to contact establishments outside of that
jurisdiction, as provided in the Plan.
d. All applicable measures recommended by the
local health officer or the Infection Control PLHCP have been
implemented.
e. All employees who
enter the room or area housing the individual are provided with, and use,
appropriate personal protective equipment and respiratory protection in
accordance with subsection (g) and Section
5144, Respiratory Protection of
these orders.
EXCEPTIONS to subsection (e)(5)(B):
(1) Where the treating physician determines
that transfer would be detrimental to a patient's condition, the patient need
not be transferred. In that case the facility shall ensure that employees use
respiratory protection when entering the room or area housing the individual.
The patient's condition shall be reviewed at least 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).
(2) Where it is not
feasible to provide AII rooms or areas to individuals suspected or confirmed to
be infected with or carriers of novel or unknown ATPs, the employer shall
provide other effective control measures to reduce the risk of transmission to
employees, which shall include the use of respiratory protection in accordance
with subsection (g) and Section
5144, Respiratory Protection of
these orders.
(C) High-hazard procedures shall be conducted
in AII rooms or areas, such as a ventilated booth or tent. Persons not
performing the procedures shall be excluded from the area, unless they use the
respiratory and personal protective equipment required for employees performing
these procedures.
EXCEPTION to subsection (e)(5)(C): Where no AII room or
area is available and the treating physician determines that it would be
detrimental to the patient's condition to delay performing the procedure, high
hazard procedures may be conducted in other areas. In that case, employees
working in the room or area where the procedure is performed shall use
respiratory protection, in accordance with subsection (g) and Section
5144, Respiratory Protection of
these orders, and shall use all necessary personal protective
equipment.
(D) Specific
requirements for AII rooms and areas.
1.
Hospital isolation rooms constructed in conformance with Title 24, California
Code of Regulations, 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.
2.
Negative pressure shall be maintained in AII rooms or areas. The ventilation
rate shall be 12 or more air changes per hour (ACH). The required ventilation
rate may be achieved in part by using in-room high efficiency particulate air
(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.
3. Negative
pressure shall be visually demonstrated by smoke trails or equally effective
means daily while a room or area is in use for AII.
4. 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 UVGI is used, it shall be used,
maintained, inspected and controlled in accordance with Guidelines for
Preventing 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.
5. 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).
6. 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.
7. 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.
8. Doors and windows of AII rooms or areas
shall be kept closed while in use for airborne infection isolation, except when
doors are opened for entering or exiting and when windows are part of the
ventilation system being used to achieve negative pressure.
9. 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.
(f) Laboratories.
(1) This subsection applies to laboratory
operations where employees perform procedures capable of aerosolizing ATPs-L.
NOTE: Employers with laboratory operations in which
employees have direct contact with cases or suspected cases are also required
to comply with applicable portions of subsections (d), (e), (g), (h), (i) and
(j).
(2) The biological
safety officer shall perform a risk assessment in accordance with the
methodology included in Section II of the BMBL for each agent and procedure
involving the handling of ATPs-L. The biosafety officer shall record the safe
practices required for each evaluated agent/procedure in the Biosafety
Plan.
(3) The employer shall
implement feasible engineering and work practice controls, in accordance with
the risk assessment performed in subsection (f)(2), to minimize employee
exposures to ATPs-L. Where exposure still remains after the institution of
engineering and work practice controls, the employer shall provide, and ensure
that employees use, personal protective equipment and, where necessary to
control exposure, respiratory protection. Control measures shall be consistent
with the recommendations in BMBL.
(4) Biosafety Plan (BSP). The employer shall
establish, implement, and maintain an effective written Biosafety Plan to
minimize employee exposures to ATPs-L that may be transmitted by laboratory
aerosols. The BSP may be incorporated into an existing Exposure Control Plan
for bloodborne pathogens or an ATD Exposure Control Plan as described in
subsection (d), and shall do all of the following:
(A) Identify a biological safety officer(s)
with the necessary knowledge, authority and responsibility for implementing the
BSP.
(B) Include a list of all job
classifications in which all or some employees have occupational exposure, and
a list of all tasks and procedures in which employees have occupational
exposure.
(C) Include a list of
ATPs-L known or reasonably expected to be present in laboratory materials and
the applicable biosafety measures.
(D) Include a requirement that all incoming
materials containing ATPs-L are to be treated as containing the virulent or
wild-type pathogen, until procedures have been conducted at the laboratory to
verify that a pathogen has been deactivated or attenuated.
(E) Identify and describe the use of
engineering controls, including containment equipment and procedures, to be
used to minimize exposure to infectious or potentially infectious laboratory
aerosols.
(F) Establish safe
handling procedures and prohibit practices, such as sniffing in
vitro cultures, that may increase employee exposure to infectious
agents.
(G) Establish effective
decontamination and disinfection procedures for laboratory surfaces and
equipment.
(H) Identify and
describe the use of the appropriate personal protective equipment to be used to
minimize exposure to infectious or potentially infectious laboratory
aerosols.
(I) Identify any
operations or conditions in which respiratory protection will be required. The
use of respiratory protection shall be in accordance with subsection (g) and
Section 5144 of these orders.
(J) Establish emergency procedures for
uncontrolled releases within the laboratory facility and untreated releases
outside the laboratory facility. These procedures shall include effective means
of reporting such incidents to the local health officer.
(K) Include a medical services program
consistent with subsection (h), including the provision of all vaccinations as
recommended by applicable public health guidelines for the specific laboratory
operations, and the methods for providing investigation and medical follow up
for exposure incidents (laboratory).
EXCEPTION to subsection (f)(4)(K): Research and
production laboratories in which it is not reasonably anticipated that
materials containing M. Tuberculosis will be present need not
provide surveillance for LTBI.
(L) Include procedures for communication of
hazards and employee training that complies with subsection (i). This shall
include training in the employer's Biosafety Plan and emergency
procedures.
(M) Include an
effective procedure for obtaining the active involvement of employees in
reviewing and updating the Biosafety Plan with respect to the procedures
performed by employees in their respective work areas or departments on an
annual (or more frequent) basis.
(N) Include procedures for the biological
safety officer(s) to review plans for facility design and construction that
will affect the control measures for ATPs-L.
(O) Include procedures for inspection of
laboratory facilities, including an audit of biosafety procedures. These
inspections shall be performed at least annually. Hazards found during the
inspection, and actions taken to correct hazards, shall be
recorded.
(5)
Recordkeeping shall be in accordance with subsection (j).
(h) Medical Services.
(1) Each employer who has any employee with
occupational exposure shall provide the employee with medical services for
tuberculosis and other ATDs, and infection with ATPs and ATPs-L, in accordance
with applicable public health guidelines, for the type of work setting and
disease. When an employer is also acting as the evaluating health care
professional, the employer shall advise the employee following an exposure
incident that the employee may refuse to consent to vaccination, post-exposure
evaluation and follow-up from the employer-health care professional. When
consent is refused, the employer immediately shall make available a
confidential vaccination, medical evaluation or follow-up from a PLHCP other
than the exposed employee's employer.
(2) Medical services, including vaccinations,
tests, examinations, evaluations, determinations, procedures, and medical
management and follow-up, shall be:
(A)
Performed by or under the supervision of a PLHCP;
(B) Provided according to applicable public
health guidelines; and
(C) Provided
in a manner that ensures the confidentiality of employees and patients. Test
results and other information regarding exposure incidents and TB conversions
shall be provided without providing the name of the source
individual.
(3) The
employer shall make assessment for latent tuberculosis infection (LTBI)
available to all employees with occupational exposure. Assessment procedures
shall be in accordance with applicable public health guidelines.
(A) TB tests and other forms of TB assessment
shall be provided at least annually, and more frequently, if applicable public
health guidelines or the local health officer recommends more frequent testing.
Employees with baseline positive TB test shall have an annual symptom
screen.
(B) The employer shall
refer employees who experience a TB conversion to a PLHCP knowledgeable about
TB for evaluation.
1. The employer shall
provide the PLHCP with a copy of this standard and the employee's TB test
records. If the employer has determined the source of the infection, the
employer shall also provide any available diagnostic test results including
drug susceptibility patterns relating to the source patient.
2. The employer shall request that the PLHCP,
with the employee's consent, perform any necessary diagnostic tests and inform
the employee about appropriate treatment options.
3. The employer shall request that the PLHCP
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:
a. Inform the employee and the local health
officer in accordance with Title 17.
b. Consult with the local health officer and
inform the employer of any infection control recommendations related to the
employee's activity in the workplace.
c. Make a recommendation to the employer
regarding precautionary removal due to suspect active disease, in accordance
with subsection (h)(8), and provide the employer with a written opinion in
accordance with subsection (h)(9).
(C) TB conversions shall be recorded in
accordance with California Code of Regulations, Title 8, Section
14300 et seq.
(D) Unless it is determined that the TB test
conversion is not occupational, the employer shall investigate the
circumstances of the conversion, and correct any deficiencies found during the
investigation. The investigation shall be documented in accordance with
subsection (j).
EXCEPTION to subsection (h)(3): Research and production
laboratories in which M. tuberculosis containing materials are
not reasonably anticipated to be present, need not provide assessment for LTBI
infection.
(4)
Laboratory tests shall be conducted by an accredited laboratory.
(5) The employer shall make available to all
susceptible health care workers with occupational exposure all vaccine doses
listed in Appendix E. Employees in laboratory operations outside of health care
settings, and within the scope of subsection (f), shall be provided with
vaccines in accordance with the BMBL for the specific laboratory operations.
The requirements in subsection (h)(5) will become effective on September 1,
2010.
(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
10 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;
or
2. A PLHCP has determined that
the employee is immune in accordance with applicable public health guidelines;
or
3. 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.
(D)
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 10 working days of receiving a written request from the
employee.
(E) The employer shall
ensure that employees who decline to accept a recommended and offered
vaccination sign the statement in Appendix C1 for each declined
vaccine.
(F) The employer shall
request the PLHCP administering a vaccination or determining immunity to
provide only the following information to the employer:
1. The employee's name and employee
identifier.
2. The date of the
vaccine dose or determination of immunity.
3. Whether the employee is immune to the
disease, and whether there are any specific restrictions on the employee's
exposure or ability to receive vaccine.
4. Whether an additional vaccination dose is
required, and if so, the date the additional vaccination dose should be
provided.
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.
(6) Exposure Incidents.
(A) A health care provider, or the employer
of a health care provider who determines that a person is an RATD case or
suspected case shall report, or ensure that the health care provider reports,
the case to the local health officer, in accordance with Title 17.
(B) In addition to the report required in
subsection (h)(6)(A), the employer in the facility, service or operation that
originates the report 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 case or suspected case while
performing activities within the scope of this section. The employer shall
notify the other employer(s) within a timeframe that will both 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 local 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 notifying employer shall
not provide the identity of the source patient to the other employers.
NOTE 1 to subsection (h)(6)(B): These employees may
include, but are not limited to, paramedics, emergency medical technicians,
emergency responders, home health care personnel, homeless shelter personnel,
personnel at referring health care facilities or agencies, and corrections
personnel.
NOTE 2 to subsection (h)(6)(B): Some diseases, such as
meningococcal disease, require prompt prophylaxis of exposed individuals to
prevent disease. Some diseases, such as varicella, have a limited window in
which to administer vaccine to non-immune contacts. Exposure to some diseases
may create a need to temporarily remove an employee from certain duties during
a potential period of communicability. For other diseases such as tuberculosis
there may not be a need for immediate medical intervention, however prompt
follow up is important to the success of identifying exposed
employees.
(C) Each employer
who becomes aware that his or her employees may have been exposed to an RATD
case or suspected case, or to an exposure incident involving an ATP-L shall do
all of the following:
1. Within a timeframe
that is reasonable for the specific disease, as described in subsection
(h)(6)(B), but in no case later than 72 hours following, as applicable, the
employer's report to the local health officer or the receipt of notification
from another employer or the local health officer, conduct an analysis of the
exposure scenario to determine which employees had significant exposures. This
analysis shall be conducted by an individual knowledgeable in the mechanisms of
exposure to ATPs or ATPs-L, and shall record the names and any other employee
identifier used in the workplace of persons who were 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 determined that the employee is
immune to the infection in accordance with applicable public health guidelines.
The exposure analysis shall be made available to the local health officer upon
request. The name of the person making the determination, and the identity of
any PLHCP or local health officer consulted in making the determination shall
be recorded.
2. Within a timeframe
that is reasonable for the specific disease, as described in subsection
(h)(6)(B), but in no case later than 96 hours of becoming aware of the
potential exposure, notify employees who had significant exposures of the date,
time, and nature of the exposure.
3. As soon as feasible, provide post-exposure
medical evaluation to all employees who had a significant exposure. The
evaluation shall be conducted by a PLHCP 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 determines that it is not feasible.
4. Obtain from the PLHCP a recommendation
regarding precautionary removal in accordance with subsection (h)(8), and a
written opinion in accordance with subsection (h)(9).
5. Determine, to the extent that the
information is available in the employer's records, whether employees of any
other employers may have been exposed to the case or material. The employer
shall notify these other employers within a time frame that is reasonable for
the specific disease, as described in subsection (h)(6)(B), but in no case
later than 72 hours of becoming aware of the exposure incident of the nature,
date, and time of the exposure, and shall provide the contact information for
the diagnosing PLHCP. The notifying employer shall not provide the identity of
the source patient to other employers.
(7) Information provided to the Physician or
Other Licensed Health Care Professional.
(A)
Each employer shall ensure that all PLHCPs responsible for making
determinations and performing procedures as part of the medical services
program are provided a copy of this standard and applicable public health
guidelines. For respirator medical evaluations, the employer shall provide
information regarding the type of respiratory protection used, a description of
the work effort required, any special environmental conditions that exist
(e.g., heat, confined space entry), additional requirements for protective
clothing and equipment, and the duration and frequency of respirator
use.
(B) Each employer shall ensure
that the PLHCP who evaluates an employee after an exposure incident is 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;
and
4. 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.
(8)
Precautionary removal recommendation from the physician or other licensed
health care professional.
(A) Each employer
who provides a post-exposure evaluation in accordance with this Section, or an
evaluation of an employee's TB conversion in accordance with subsection (h)(3)
shall request from the PLHCP 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. The employer shall request that the PLHCP convey to the employer any
recommendation for precautionary removal immediately via phone or fax and that
the PLHCP document the recommendation in the written opinion as required in
subsection (h)(9).
(B) Where the
PLHCP recommends precautionary removal, or where the local health officer
recommends precautionary removal, the employer shall maintain until the
employee is determined to be noninfectious, 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.
EXCEPTION to subsection (h)(8)(B): Precautionary
removal provisions do not extend to any period of time during which the
employee is unable to work for reasons other than precautionary
removal.
(9)
Written opinion from the physician or other licensed health care professional.
(A) Each employer shall obtain, and provide
the employee with a copy of, the written opinion of the PLHCP within 15 working
days of the completion of all medical evaluations required by this
section.
(B) For respirator use,
the physician's opinion shall have the content required by Section
5144(e)(6) of
these orders.
(C) For TB
conversions and all RATD and ATP-L exposure incidents, 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;
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 employee has been
told about any medical conditions resulting from exposure to TB, other RATD, or
ATP-L 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.
(D) All other findings or diagnoses shall
remain confidential and shall not be included in the written
report.
(10) The employer
shall make available seasonal influenza vaccine to all employees with
occupational exposure. The employer shall ensure that each employee who
declines to accept the seasonal influenza vaccine signs the statement in
Appendix C2.
EXCEPTION 1 to subsection (h)(10): Seasonal influenza
vaccine shall be provided during the period designated by the CDC for
administration, and need not be provided outside of those periods.
EXCEPTION 2 to subsection (h)(10): In lieu of the
statement in Appendix C2, the employer may utilize an influenza vaccine
declination statement acceptable to the CDPH in accordance with Health and
Safety Code Section
1288.7.
(i) Training.
(1) Employers shall ensure that all employees
with occupational exposure participate in a training program.
(2) Employers shall provide training as
follows:
(A) At the time of initial assignment
to tasks where occupational exposure may take place;
(B) At least annually thereafter, not to
exceed 12 months from the previous training;
(C) For employees who have received training
on aerosol transmissible diseases in the year preceding the effective date of
the standard, only training with respect to the provisions of the standard that
were not included previously need to be provided.
(D) When changes, such as introduction of new
engineering or work practice controls, modification of tasks or procedures or
institution of new tasks or procedures, affect the employee's occupational
exposure or control measures. The additional training may be limited to
addressing the new exposures or control measures.
(3) Training material appropriate in content
and vocabulary to the educational level, literacy, and language of employees
shall be used.
(4) The training
program shall contain at a minimum the following elements:
(A) An accessible copy of the regulatory text
of this standard and an explanation of its contents.
(B) A general explanation of ATDs including
the signs and symptoms of ATDs that require further medical
evaluation.
(C) An explanation of
the modes of transmission of ATPs or ATPs-L and applicable source control
procedures.
(D) An explanation of
the employer's ATD Exposure Control Plan and/or Biosafety Plan, 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.
(E) An explanation of the appropriate methods
for recognizing tasks and other activities that may expose the employee to ATPs
or ATPs-L.
(F) An explanation of
the use and limitations of methods that will prevent or reduce exposure to ATPs
or ATPs-L including appropriate engineering and work practice controls,
decontamination and disinfection procedures, and personal and respiratory
protective equipment.
(G) An
explanation of the basis for selection of personal protective equipment, its
uses and limitations, and the types, proper use, location, removal, handling,
cleaning, decontamination and disposal of the items of personal protective
equipment employees will use.
(H) A
description of the employer's TB surveillance procedures, including the
information that persons who are immune-compromised may have a false negative
test for LTBI.
EXCEPTION: Research and production laboratories do not
need to include training on surveillance for LTBI if M.
tuberculosis containing materials are not reasonably anticipated to be
present in the laboratory.
(I) Training meeting the requirements of
Section 5144(k) of these
orders for employees whose assignment includes the use of a
respirator.
(J) Information on the
vaccines made available by the employer, including information on their
efficacy, safety, method of administration, the benefits of being vaccinated,
and that the vaccine and vaccination will be offered free of charge.
(K) An explanation of 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.
(L) Information on the
employer's 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 personal protective equipment and
respirators, decontamination facilities and procedures, and how to coordinate
with emergency response personnel from other agencies.
(5) Every training program shall include an
opportunity for interactive questions and answers with a person 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 the
employer's ATD exposure control or biosafety plan. Training not given in person
shall fulfill all the subject matter requirements of subsections (i)(4) and
shall provide for interactive questions to be answered within 24 hours by a
knowledgeable person as described above.
(j) Recordkeeping.
(1) Medical records.
(A) The employer shall establish and maintain
an accurate medical record for each employee with occupational exposure, in
accordance with Section
3204, Access to Employee Exposure
and Medical Records, of these orders.
NOTE to subsection (j)(1)(A): This record may be
combined with the medical record required by Section
5193, Bloodborne Pathogens, of
these orders, but may not be combined with non-medical personnel
records.
(B) This record
shall include:
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 the information provided by the
PLHCP in accordance with subsection (h)(5)(F), any vaccine record provided by
the employee, and any signed declination forms;
EXCEPTION to subsection (j)(1)(B)2.: As to seasonal
influenza vaccine, the medical record need only contain a declination form for
the most recent seasonal influenza vaccine.
3. A copy of all written opinions provided by
a PLHCP 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 as
required by subsection (h)(7)(B).
(C) Confidentiality. The employer shall
ensure that all employee medical records required by this section are:
1. Kept confidential; and
2. Not disclosed or reported without the
employee's express written consent to any person within or outside the
workplace except as permitted by this section or as may be required by law.
NOTE to subsection (j)(1)(C): These provisions do not
apply to records that do not contain individually identifiable medical
information, or from which individually identifiable medical information has
been removed.
(D)
The employer shall maintain the medical records required by this section for at
least the duration of employment plus 30 years in accordance with Section
3204, Access to Employee Exposure
and Medical Records, of these orders.
(2) Training records.
(A) Training records shall include the
following information:
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; and
4. The names and job
titles of all persons attending the training sessions.
(B) Training records shall be maintained for
3 years from the date on which the training occurred.
(3) Records of implementation of ATD Plan
and/or Biosafety Plan.
(A) Records of annual
review of the ATD Plan and Biosafety Plan shall include the name(s) of the
person conducting the review, the dates the review was conducted and completed,
the name(s) and work area(s) of employees involved, and a summary of the
conclusions. The record shall be retained for three years.
(B) Records of exposure incidents shall be
retained and made available as employee exposure records in accordance with
Section 3204. 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 local health officer
and/or PLHCP consulted;
6. The date
of the evaluation; and
7. 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.
(C) Records of
the unavailability of vaccine shall include the name of the person who
determined that the vaccine was not available, the name and affiliation of the
person providing the vaccine availability information, and the date of the
contact. This record shall be retained for three years.
(D) Records of the unavailability of AII
rooms or areas shall include the name of the person who determined that an AII
room or area was not available, the names and the affiliation of persons
contacted for transfer possibilities, and the date of the contact, the name and
contact information for the local health officer providing assistance, and the
times and dates of these contacts. This record, which shall not contain a
patient's individually identifiable medical information, shall be retained for
three years.
(E) Records of
decisions not to transfer a patient to another facility for AII for medical
reasons shall be documented in the patient's chart, and a summary shall be
provided to the Plan administrator providing only the name of the physician
determining that the patient was not able to be transferred, the date and time
of the initial decision and the date, time and identity of the person(s) who
performed each daily review. The summary record, which shall not contain a
patient's individually identifiable medical information, shall be retained for
three years.
(F) 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 and shall include the name(s)
and affiliation(s) of the person(s) performing the test, inspection or
maintenance, the date, and any significant findings and actions that were
taken.
(G) Records of the
respiratory protection program shall be established and maintained in
accordance with Section
5144, Respiratory Protection, of
these orders. Employers who provide fit-test screening, in accordance with the
exception to subsection (g)(6)(B)3 shall retain the screening record for two
years.
(4) Availability.
(A) The employer shall ensure that all
records, other than the employee medical records more specifically dealt with
in subsection (j)(4)(C), required to be maintained by this section shall be
made available upon request to the Chief and NIOSH and the local health officer
for examination and copying.
(B)
Employee training records, the exposure control plan and/or biosafety plan, and
records of implementation of the ATD exposure control plan and biosafety plan,
other than medical records containing individually identifiable medical
information, shall be made available as employee exposure records in accordance
with Section
3204(e)(1) to
employees and employee representatives.
(C) 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 local health officer,
and to the Chief and NIOSH in accordance with Section
3204 of these orders, Access to
Employee Exposure and Medical Records, for examination and
copying.
(5) Transfer of
Records.
(A) The employer shall comply with
the requirements involving the transfer of employee medical and exposure
records that are set forth in Section
3204, Access to Employee Exposure
and Medical Records, of these orders.
(B) If the employer ceases to do business and
there is no successor employer to receive and retain the records for the
prescribed period, the employer shall notify the Chief 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.
1. New
section filed 7-6-2009; operative 8-5-2009 (Register 2009, No. 28). For prior
history, see Register 87, No. 51.
2. Amendment of subsection
(g)(3)(B) -- EXCEPTION 2 filed 8-1-2013; operative 10-1-2013 (Register 2013,
No. 31).
Note: Authority cited: Sections
142.3 and
6308, Labor
Code. Reference: Sections
142.3 and
6308, Labor
Code; and 8 CCR
332.3.
