Health hazard evaluation report: HETA-2000-0040-2800, Hawaii State Department of Health, Honolulu, Hawaii.
In December 1999, at the request of the Hawaii State Department of Health (HDOH), National Institute for Occupational Safety and Health (NIOSH) personnel visited the Lanakila Health Center Tuberculosis (TB) Clinic in Honolulu, Hawaii, to evaluate their TB prevention program and review proposed design changes intended to make this a model clinic. The NIOSH evaluation included a ventilation assessment, measurement of ultraviolet (UV) radiation emitted by germicidal lamps, respirator fit testing, a review of proposed ventilation and clinic layout changes, a review of the employee tuberculin skin test (TST) data, and employee interviews. Design changes to the sputum rooms, waiting areas, and reception areas were evaluated. Changes made in the main waiting area were effective in moving air from a "clean" to "less clean" area, minimizing employee exposures to infectious droplet nuclei. Changes to the sputum rooms were not sufficient because the rooms were not maintained under negative pressure. However, reports of work performed subsequent to the NIOSH visit indicate that the sputum rooms now meet applicable guidelines. The UV radiation measurements indicated that under usual conditions, employees would not be exposed to UV radiation in excess of occupational exposure limits. Several employees did not achieve an acceptable fit with the available respirators. Forty-three of the 44 employees had at least one documented TST in the clinic’s database. Twenty (47%) had reactions documented at >/=10 millimeters (mm) in size, considered "positive" according to HDOH policy. However, only eight of these positive employees had a documented prior negative TST, and five of those eight had only two documented TSTs and were positive on their second test, making it possible that the "positive" test could have been due to a booster effect. Two of the other three positive employees had complicated TST histories, making their results difficult to interpret. The final positive employee had two negative (0 mm) tests and then one test with a reaction of 10 mm. This indicated that the employee was most likely a true converter. Numerous environmental and programmatic changes have been made at the Lanakila Health Center TB Clinic to improve TB prevention efforts. Future renovation efforts should include separating areas where individuals with known or suspected infectious TB are seen or evaluated from areas of general TST screening, and the provision of a sufficient number of negative pressure rooms for exams and interviews with clients. To improve the capabilities of the HDOH to assess TST conversion rates in employees, it would be helpful to document baseline two-step TSTs in all employees at the time they are hired, and then to provide periodic TSTs to the employees with negative tests. Recommendations addressing these issues are included in this report.