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hile most work environments are at low risk for transmission of tuberculosis (TB),business managers, union leaders and worksite health professionals should be aware that the incidence of TB is rising. Clearly,employers should be prepared to address employee concerns. Accurate information should be provided to employees to dispel any apprehension that may arise from misinformation. Tuberculosis is a contagious disease. There are, however, two forms of TB: latent infection and active. Only an individual with active TB of the lungs or airways can spread the disease by coughing and sneezing. This transmission is most likely to occur when individuals are in close proximity for extended periods of time. Most office settings and worksites do not involve such sustained close contact. Many of the current cases of TB are found in those workplaces that bring people into close contact with others who have active TB, such as health care facilities, correctional institutions, and homeless shelters. Since the risk of exposure to TB is very low in most worksites, TB is rarely a problem in the general workplace.

Employees with suppressed immune systems, such as those infected with the human immunodeficiency virus (HIV) and those undergoing chemotherapy, are at higher risk for reactivating a latent TB infection or for rapidly developing active TB after acquiring a new infection. How employers handle a case of TB requires careful preparation. Managing concerns about TB as a workplace consideration parallels and resembles dealing with HIV infection and AIDS in the workplace. Specific issues that need to be addressed include proper care of employees who are infected, protection of confidentiality, assurance of non-discrimination, adequate protection of non-infected employees, and employee education The following questions and answers provide employers and union leaders with clear guidance on how to deal with questions and concerns about TB, HIV infection, and AIDS in the general workplace.




What is Tuberculosis (TB)?
Tuberculosis is an infectious disease caused by the organism Mycobacterium tuberculosis, a kind of bacterium. The infection is spread by airborne droplets expelled when a person with active tuberculosis coughs or sneezes. Individuals exposed to air contaminated by a person with active TB may breathe in TB bacteria. This is more likely to occur in poorly ventilated, closely confined spaces. Even though active TB is a communicable disease, it is usually treatable when diagnosed promptly.

How do people find out if they have latent TB infection or active TB ?
A tuberculin skin test will produce a measurable reaction (bump at the test site) in most people who have been infected with the TB bacteria. Some immuno-suppressed persons will not have a reaction to a tuberculin skin test; other diagnostic tests can be used to help determine their TB status. Individuals with positive tuberculin skin tests have TB infection but do not necessarily have active TB. Active TB is diagnosed with chest x-rays, sputum analysis, and sometimes with other tests.

What is latent TB infection!
After individuals are infected with the Mycobacterium tuberculosis, they generally remain infected for years but normally do not develop active tuberculosis or show signs of illness. A person with a healthy immune system is usually able to contain the infection and not become ill with TB. This condition is referred to as "latent tuberculosis infection."
Only about I in 10 persons with latent TB infection will ever develop active TB, and this risk can be reduced even further by taking preventive therapy. It is estimated that about 10 to 15 million people in this country have latent TB infection. The U.S. Centers for Disease Control and Prevention (CDC) has guidelines establishing who should receive preventive treatment for latent TB infection. This treatment will decrease the chance of developing active TB later in life. Persons with latent TB infection are not infectious, meaning they cannot transmit TB infection to others.What is active TB?Active TB occurs when an individual's immune system fails to contain the TB organism, the organisms become reactivated, and the person becomes ill. The disease can involve almost any organ in the body, but most commonly involves the lungs or airways. A person with active TB of the lungs or airways is capable of spreading the disease to others by coughing and sneezing. Most TB in this country is responsive to anti-tuberculosis drugs and can be cured if diagnosed and treated properly.

How is active TB treated?
Active TB of the lungs or airways is considered to be contagious and requires immediate medical treatment. TB treatment involves taking several drugs. After 2-4 weeks of treatment with the appropriate drugs, most people are no longer infectious and cannot transmit the disease to others. However, cure of TB requires 6-12 months of continuous treatment, or longer, in some cases. People must complete the entire prescribed course of treatment to avoid relapse and/or the risk of developing drug-resistant TB.

What is drug-resistant TB?
Drug-resistant strains of rnycobacterium tuberculosis are those strains which do not respond to treatment with some or all available anti-TB drugs. Most of these drug-resistant strains result from incomplete or interrupted treatment of TB in individuals who start out with drug-susceptible TB. With only a portion of the bacteria destroyed, the surviving bacteria may develop resistance to standard drugs and become more difficult to destroy. In some cases, the organisms may become resistant to many drugs. Thus, people who do not complete their course of treatment risk developing drug-resistant tuberculosis, which is usually much more difficult to treat effectively than drug-susceptible TB. These individuals also may transmit drug-resistant TB to others.

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Is there any connection between immune deficiency and TB?
For some people, yes. An individual with a significantly suppressed immune system (due to poor health, chronic abuse of alcohol or drugs, old age, chemotherapy for cancer, or HIV infection) is more likely than a healthy person to develop active TB disease if they already have latent TB infection or if they are exposed to a new TB infection. The risk of developing active TB in an individual who has latent TB infection but has an intact immune system is very low (10 percent over a lifetime). However, the risk of developing active TB in an individual with both HIV and latent TB infection is much greater (8 percent per year).

TB in the Workplace

What is the risk of transmission
of TB in the workplace?

Most work environments are considered low risk for the transmission of TB. The CDC has determined that there are only a few settings where the incidence of active TB may be cause for special concern. Examples of such settings include health care facilities, correctional institutions, homeless shelters, long-term care facilities, and drug treatment centers. Individuals employed in these settings, therefore, have a potentially increased risk for exposure to TB. The CDC has developed recommendations on how to avoid TB transmission in these potentially high-risk occupational settings. Consultation on these issues can be obtained through state and local TB control programs and through the CDC. The general workplace is not a likely place for transmitting TB.

IsTB transmission a greater risk in the food/restaurant industry?
No. Since TB is not transmitted via food, the risk of TB transmission in the food/restaurant industry is no greater than in other general work settings. If a worker in these industries has active TB, transmission may occur by the airborne route, as previously described, and the health department should be notified (as described below).


What should employers do when faced with a case of active TB? Employers and health care providers must immediately report any case of active TB to the local or state public health department. The health department will then initiate case management, investigate the possibility that others could be infected, and evaluate the risk of TB transmission in that workplace. In some states, latent TB infection must also be reported. Employers should contact their local and state health authorities regarding laws and regulations in their area. Employers may wish to obtain written confirmation of specific recommendations received from the health department.

When can employees with active TB safely return to work?
When employees are no longer infectious, and are able to work, they may return to the workplace. In most cases, TB is no longer contagious after 2-4 weeks of effective drug therapy. However, return to work should be based on medical clearance by competent health care professionals. Health care personnel or an employee's private physician should ensure that employees returning to work adhere to ongoing treatment for TB.

Should employers offer mass TB screening to employees?
Mass TB screening (skin tests) is not recommended in most general workplace environments. According to the CDC and TB medical experts, there is no indication for mass TB screening of employees in low-risk occupational settings. In the event that an employee develops active TB, local public health authorities should be informed so they can contact other people who may have been exposed in the household or the workplace. In some work environments, the risk of TB transmission may be higher than in the general workplace (e.g., hospitals, correctional facilities). An employer-organized TB skin testing program should be available in those specific settings.




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What should employees
know about TB?

An education program for employees should include, at a minimum, the following:

•  Cause of TB and how it is transmitted

•  Distinction between latent TB infection and active TB

•  Purpose and interpretation of TB skin testing

•  Signs and symptoms of TB

•  When treatment of latent TB infection is indicated

•  Purpose and importance of adhering to and completing TB therapy

•  Risk factors for latent TB infection progressing to active TB

•  How active TB is treated and the importance of completing treatment

•  Origin and prognosis of drug-resistant TB

•  Importance of maintaining the confidentiality of a co-worker's medical condition and medical records

•  Link between TB and HIV and other immuno-suppressive conditions

•  Company's policy on illness in the workplace

•  Where assistance and further information can be obtained
A TB education program, which may be part of a wellness program or other worksite activity, will reduce employee apprehension and misinformation. Contact the American Lung Association or other organizations listed on page 6 for educational resources.

HIV Infection, AIDS & TB

What are HIV infection and AIDS?
The human immunodeficiency virus (HIV) is the cause of acquired immunodeficiency syndrome (AIDS). HIV infection weakens the body's natural ability to fight diseases. As the immune system fails, a person infected with HIV may develop a variety of life-threatening illnesses such as pneumonia, cancer extensive damage to the nervous system, or have other evidence of a severe deficiency of the immune system. The person would then be diagnosed as having AIDS. However, HIV-infected individuals may not show signs of illness for many years and should continue to be productive members of the workforce.

How is HIV infection transmitted?
HIV is transmitted when blood or body fluids from someone who is HIV-positive enters someone else's blood stream. HIV is most commonly transmitted in four body fluids: blood, semen, vaginal secretions, and, in rare instances, breast milk. Activities that are known to transmit HIV include having unprotected sex or sharing needles or syringes with someone infected with HIV HIV is not spread through casual contact and is not transmitted through air, food, or water.

Are employees with HIV infection or AIDS at greater risk if TB is present in the workplace?
Yes. While employees with HIV infection or AIDS are just as susceptible as other employees to developing infection after exposure to TB, they are at much greater risk of developing active TB if they become infected with the TB bacteria. These primary progressive TB infections (when initial infection goes directly into active disease) may develop very rapidly and can be life threatening for the HIV-infected employee. Therefore, employers should encourage employees with HIV infection to be evaluated for latent TB infection. Employees with HIV infection or AIDS carry latent TB infection at the same rate as other HIV-negative employees from similar backgrounds (country of origin, socio-economic status, etc.) However, HIV-positive individuals who are infected with the TB organism develop active TB at a higher rate than HIV-negative employees because of their suppressed immune systems. These conditions do not justify treating persons with HIV infection differently from other job applicants or employees. Fear of TB contagion should not be used to discriminate against HIV-positive employees.

Do special precautions have to be taken if it is known that employees with HIV infection or AIDS are in the general workplace?
No. Good workplace practices and standard first aid procedures that promote a healthy workplace will protect HIV-positive and HIV-negative employees alike.

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The Americans with Disabilities Act (ADA)

How does the ADA affect employers?
Under the ADA, enacted in 1990, an employer cannot discriminate against a qualified individual 1) who has a disability, 2) who had a disability, or 3) who is perceived to have a disability on the basis of that disability. The ADA protects both applicants and employees with disabilities against discrimination in such areas as hiring, firing, discipline, assignments, compensation and benefits.
A "qualified individual with a disability" is a person who 1) meets the job requirements (e.g., skills, education, work experience) and 2) can perform the essential functions of the job. "Essential functions" are the primary tasks critical to successful performance of a job. An employer does not have to hire or retain individuals whose disabilities prevent them from performing the essential job functions.

Does the ADA apply to TB,

Individuals with HIV infection, AIDS, and active TB have disabilities covered by the ADA. Individuals with latent TB infection would be protected by the ADA if an employer discriminates against them on the basis of their TB status. Limiting the job responsibilities of an employee with latent TB infection will violate the ADA, since this employee does not pose a significant risk of transmission to anyone else.
Individuals with active TB do pose a "direct threat" of transmission to others. This fact, however, does not entitle employers to refuse to hire or to fire such individuals. Rather, employers have an obligation under the ADA to provide reasonable accommodation) that removes the direct threat. For example employers should consider as reasonable accommodation permitting employees with active TB sufficient leave from work to undergo treatment, thereby removing the risk of infection. Under appropriate circumstances, employers should consider permitting employees to continue to work at home while undergoing treatment. Employers do not have to provide a specific accomodation if it imposes an "undue hard­ship" (significant difficulty or expense) on the employer.

Medical authorities agree that in most cases individuals with active TB require 2-4 weeks away from the workplace to undergo treatment and eliminate the risk of transmission. Once treatment has begun, and the employee has been determined to be non infectious by a competent medical expert, and provided the individual continues with the course of treatment, most individuals will no longer pose a "direct threat" to others and can return to the workplace. An employer who treats a person with HIV infection or AIDS differently because of concerns that the individual may have TB and may infect others will violate the ADA because there is no evidence of direct threat. In addition to the ADA, other federal and state anti-discrimination laws offer protection to persons with active or latent TB infection.

Should employees be notified if a co-worker has latent TB?
No. In the case of employees with latent TB infection, they do not present a significant risk to others on the basis of their latent infection. Moreover, the ADA has strict confidentiality requirements, including keeping medical records separate from all other personnel records and limiting access to medical records. Supervisors and managers may be informed about an individual's TB status only if, as a result of the disability, the individual presents a significant risk to others or requires reasonable accommodation.

Should employees be notified if a co-worker has active TB?
As a general rule, based on both legal and practical concerns, employers and supervisors should not reveal an employees medical condition to others. Once an employee is diagnosed with active TB, it is the employer's obligation, as stated above, to notify the local health department. Health officials are responsible for investigating reports and notifying other employees who may have been exposed. Counseling about potential risk for TB infection should be done by trained medical or public health officers. Throughout this process, the confidentiality of the employee with active TB must be protected.

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Guidelines for Tuberculosis and
HIV in the General Workplace


General workplace environments pose low risk for the transmission of TB and virtually no risk for the transmission of HIV There are, however, a number of measures that can be taken to keep TB risks low and to reassure the workforce. The following guidelines apply to the general workplace, not settings that the Centers for Disease Control and Prevention (CDC) or state or local health authorities have determined may have a higher risk for the transmission of TB (e.g., health care facilities, correctional institutions, long-term care facilities, drug treatment centers, and homeless shelters.)
•  The highest levels of management and union leadership should actively support appropriate education programs about both TB and HIV and provide these programs to all employees. Providing sound information is essential in overcoming unreasonable anxiety.

•  Workplace policy should be based on scientific and epidemiological evidence, e.g., that most workplaces pose low risk for TB transmission, and that people with latent TB infection pose no risk of transmission as long as the bacterium remains latent.

•  Employees with active TB should immediately seek medical treatment and should not return to the workplace until they have been cleared to do so by their health care provider.

•  There is no medical indication for mass skin testing to detect latent TB infection or HIV screening in the general workforce, according to the CDC and other TB experts. Under the Americans with Disabilities Act (ADA), there are strict limitations on the timing and use of medical screening including HIV and skin testing for TB.

•  Since active TB is a communicable disease, employers should verify that employees with active TB have undergone and completed appropriate treatment. Employers may determine this through certification from the employee's health care provider.
   Workplace policy should always encourage employees to seek medical treatment when they are ill and get advice from competent health care professionals when they have questions concerning their health.
•  Contact the local or state public health department for assistance in the event of a possible or confirmed case of active TB in the workforce. No special workplace action is necessary for employees with latent TB infection, although such persons may benefit from preventive therapy.

•  Workplace policy regarding return to work for employees with active TB should be based on individual medical clearance by competent health professionals. Employees with active TB should be allowed to come back to work once they present evidence of adherence to ongoing drug therapy and when judged to be non-infectious by competent medical personnel.

•  Employees with active TB and/or HIV infection are protected under the ADA, and may not be discriminated against because of their disabilities. Persons with latent TB infection also will be protected if an employer discriminates against such individuals on the basis of having latent TB. It is not illegal, however, for employers to remove employees with active TB from the workplace until they are no longer infectious.

•  Workplace policies and practices must protect the confidentiality of employees" medical and health insurance information.

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For Additional Information Contact:

"  Public Health Department

Check your phone book for local
or state office.

American Lung Association

1740 Broadway New York, NY 10019-4374 212 315-8700 Check your phone book for local chapter.

American Red Cross

Check your phone book for local chapter.

Centers for Disease Control and Prevention

Division of Tuberculosis Elimination National Center for Prevention Services 1600 Clifton Road, NE, Mail Stop E-10 Atlanta, GA 30333 404 639-2503

Occupational Safety and Health Administration

Check your phone book for regional office.

Your International or National Union

Occupational Health and Safety Division Check your phone book for number.

Equal Employment Opportunity Commission

1801 L Street, NW Washington, DC 20507 800 669-EEOC

National AIDS Clearinghouse

Business Responds to AIDS Service 800 458-5231

National Leadership Coalition on AIDS

1730 M Street, NW, Suite 905 Washington, DC 20036 202 429-0930


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These guidelines are the product of the contributions, comments, and deliberations of the following individuals who participated in a symposium in New York City on September 16, 1992. Affiliations are listed solely for purposes of identification. Colin Baigel, M.D., Director of Employee Health Services, Bristol-Myers Squibb Mark Barnes, Esq., Associate Health Commissioner, City of New York Ronald Bayer, Ph.D., Professor, Columbia University School of Public Health Rosalind Brannigan, M.PH., Director, Workplace Resource Center, National Leadership Coalition on AIDS Katherine Cox, M.PH., M.Ed., Health and Safety Specialist, Department of Research, American Federation of State, County & Municipal Employees James Craig, M.D., M.PH., Vice President & Director, Health and Safety Services, General Mills, Inc. Robert J. Darga, M.D., Director of Programs, National Association of People with AIDS Samuel W Dooley, Jr., M.D., Assistant Director for Science, Division of Tuberculosis Elimination, National Center for Prevention Services, the Centers for Disease Control and Prevention (Consultant) Katy Lind Evelyn, R.N., M.S., N.P, Manager, Occupational Health Services, Syntex (USA) Inc. Glenn Haughie, M.D., M.PH., IBM Director of Health, IBM Corporation Donald J. Kennedy, M.D., Associate Professor of Internal Medicine, Division of Infectious Diseases and Center for Vaccine Development, St. Louis University School of Medicine Sheldon Landesman, M.D., Professor of Medicine, SUNY Health Science Center at Brooklyn. Consultant for Tuberculosis, New York City Department of Health Carol Levine, M.A., Executive Director, The Orphan Project, Fund for the City of New York David C Logan, M.D., M.PH., Clinical Toxicologist, Mobil Oil Corporation Maria Lyzen, R.N., M.S. COHN, Co-Director, AIDS Education, UAW-GM Center for Health and Safety Jeff T. Monford, Manager, Workplace Resource Center, National Leadership Coalition on AIDS Robert Refowitz, M.D., Ph.D., Regional Head, Preventive Medicine, Kaiser-Permanente, Ohio Region Robert S. Rhodes, M.D., M.PH., FACOEM, Regional Medical Director, General Motors LeonJ. Warshaw, M.D., F.A.C.R, Executive Director, New York Business Group on Health, Inc. Karen Widhelm, Director, Health Care Consulting, Southwestern Bell


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Appreciation is extended to the following reviewers:           
Special appreciation to:

Roy L. DeHart, M.D., M.PH., FACOEM, President, American College of Occupational and Environmental Medicine

Lee B. Reichman, M.D., M.PH., President (1992-93), American Lung Association

Shane McDermott, Deputy Director, National Programs, American Lung Association

Scott Clay, Associate, Infectious Lung Disease, American Lung Association

Mitcheal A. Metzner, Workplace HIV/AIDS Program, Office of HIV/AIDS Program, American Red Cross

Jerald A. Breitman, Director, Professional Relations, Burroughs Wellcome Co.

Ken Castro, M.D., Assistant Director for TB and HIV Office of the Associate Director (HIV/AIDS), the Centers for Disease Control and Prevention

Laura Long, M.S., Coordinator, Professional Education Program, Gay Men's Health Crisis

Jon T. O'Neal, M.D., M.PH., Occupational Medicine Resident, Harvard University

Pat Christen, Executive Director, San Francisco AIDS Foundation

Gwynn Akin, Ph.D., Vice President for Public Policy, Syntex (USA) Inc.

Michael R. Lauber, President, Tusco Manufacturing, Inc.

Mario DiStasio, Senior Policy Analyst, U.S. Department of Labor

Barney Singer, J.D., Office of Advocacy, U.S. Small Business Administration


Barbara Darraugh, Editor John Rodgers, Graphic Designer Callie Norton, Production Coordinator Lettercomm, Inc., printing

Reprints of this brochure obtainable through: National Leadership Coalition on AIDS 1730 M Street, NW Suite 905 Washington, DC 20036 202/429-0930 FAX: 202/872-1977

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