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For the most anticipated Fresno Grizzlies home opener in years, 13,415 fans poured through the gates at Chukchansi Park, the 16th-largest crowd in the history of the facility.
Celebrating 4 years of being chosen “The Best Mexican Restaurant in the Valley”  For the past four years you have given us this honor and we would like to thank you by offering the first 40 people at each of our locations a meal on us on April 4th, 2016 4 p.m. FRESNO, CA – Mayor Ashley Swearengin today joined City leaders, staff and hundreds of supporters in downtown Fresno to officially break ground on the Fulton Mall Reconstruction Project, which will restore two-way traffic to the heart of downtown Fresno.
A type of personal emergency response button worn around the neck poses a choking hazard, the U.S. Between 1998 and 2009, there were six reports of serious injury or death, including four deaths in the United States, after the cord on the Philips Lifeline Personal Help Button became entangled on other objects, the FDA said.
The choking risk is greatest for people with mobility limitations or for those who use wheelchairs, walkers, beds with guard rails, or other objects that could entangle with the device’s neck cord. Users and caregivers should consult with health-care providers to determine which style of emergency button is best for an individual patient, the FDA said. In 2004 and 2005, the Federal Highway Administration (FHWA) and the Intelligent Transportation Systems Joint Program Office (ITS-JPO) conducted a project called Application of Technology to Transportation Operations in Biohazard Situations.
FHWA and ITS-JPO would like to thank the members of American Association of State Highway and Transportation Officials (AASHTO) Special Committee on Transportation Security (SCOTS) for their support in reviewing earlier drafts of the operations concept. Each state Department of Transportation (DOT) is charged with the provision of an efficient and safe transportation system that enhances economic competitiveness and livability in the state. These events may stem from the spread of microorganisms (bacteria, viruses, fungi) or toxins through the air as aerosols or in food or drink.
During response to these events, personnel from DOT districts and departments must coordinate with personnel from various public health, public safety, and emergency management agencies to perform a range of services. The Transportation Biohazard Operational Concept has been developed to support the efforts of state DOTs in defining their organizational structure, roles and responsibilities, processes and policies for managing a biohazard event.
The operational concept should provide a blueprint for building consensus among transportation, emergency management, public health, agriculture and veterinary medicine, and public safety stakeholders on critical issues involved in biohazard events. The operational concept will set a common vision to guide management of the transportation network during these events. The Transportation Biohazard Operational Concept is designed to provide guidance for state DOTs in addressing each of these sections.
A Glossary is also provided with definitions for key terms typically used in planning for biohazard events. This section of the Transportation Biohazard Operational Concept describes the existing response framework within which the state DOT’s operational concept must be integrated. To address these elements, response to any event involving biohazards will most likely occur within the emerging federal, state and local framework specified in the National Response Plan (December 2004) and the National Incident Management System (March 2004). The Base Plan describes the structure and processes comprising the state’s approach to domestic incident management designed to integrate the efforts and resources of federal, state, local, tribal, private-sector, and nongovernmental organizations.
Appendixes provide other relevant, more detailed supporting information, including terms, definitions, acronyms, authorities, and a compendium of supporting interagency plans. The Emergency Support Function (ESF) Annexes detail the missions, policies, structures, and responsibilities of state agencies for coordinating resource and programmatic support in 15 specified functional areas. The Support Annexes provide guidance and describe the functional processes and administrative requirements necessary to ensure efficient and effective implementation of the EOP’s incident management objectives. The Incident Annexes address contingency or hazard situations requiring specialized application of the NRP. State EOPs, compliant with NRP requirements were supposed to be developed by April 30, 2005 or, at the latest, during the state’s next established cycle for updating its EOP. In the Base Plan and the ESF Annexes, the state and its executive agencies, including state DOTs, must also address adoption of the National Incident Management System (NIMS).
To support the typing, categorization and management of resources, NIMS also adopts the 15 ESFs in the NRP. Based on this new federal framework, many state DOTs have developed (or are in the process of developing) EOPs and supporting procedures for their agencies.
For each state DOT, the Transportation Biohazard Operational Concept must interface with the existing (or soon to be developed) EOP, building on established terminology, practices and employee training and expectations. Assuring conformance to these documents builds on the state DOT’s existing capabilities and guarantees that a single, unified message is provided to employees and other agencies who work with the state DOT. These agencies have specialized resources and authorities to manage public health emergencies, including authorities to issue isolation and quarantine orders, to confiscate and destroy contaminated property, and to specify other actions to protect the public. Figure 2 provides an example of the issues involved in the distribution of medicine using the SNS. Modular Emergency Medical System: The MEMS concept is implemented at the local or regional level, and calls for the rapid organization of two types of expandable patient care modules, the Neighborhood Emergency Help Centers (NEHC) and the Acute Care Center (ACC). This section of the Transportation Biohazard Operational Concept provides background on the types of events to be managed during biohazard emergencies.
The United States has limited experience with emergencies caused by the intentional or accidental release of biohazard agents. Unlike most any other event, a biohazard emergency could simultaneously require minimizing mobility (preventing the movement of infected or potentially infected populations or preventing access to a contaminated area) and maximizing mobility(facilitating the rapid delivery of vaccines and supplies or maintaining mobility around a restricted area). To address these challenges, this section of the operational concept provides background on both the nature of biohazard agents and key transportation considerations in addressing potential biohazard emergencies. Biohazards are often colorless, odorless, and are most easily spread undetected as an aerosol. Figure 5 provides more detail on the biological agents categorized by the CDC as the most serious.
A deliberate release of a biohazard directed at humans is generally recognized to be the type of biohazard event that poses the greatest risk to human health and national security.
In a covert attack, there is often no forewarning, making the prediction of when and how an attack might occur impossible. Food or water, especially ready-to-eat food (vegetables, salad bars) could be intentionally contaminated with pathogens or toxins.
Human carriers could spread transmissible agents by coughing, through body fluids, or by contaminating surfaces. Infected animals can cause people to become ill through contact with the animals or contaminated animal products. Insects naturally spread some agents such as plague bacteria (vector borne illnesses) and potentially could be used in an attack. An accidental release of biohazards could occur by mishandling of biomedical waste or an accident associated with a laboratory that studies contagious diseases or biological threats. Despite the public hazards of an accidental release of a bioagent, the public health impact is likely to be less severe than for a deliberate release.
Accidental releases can also affect agriculture, contaminating livestock, crops and processed food. Bacteria, viruses, and biological toxins that are harmful to humans and animals frequently spread naturally through populations. Another naturally occurring biohazard source is the mishandling and improper sanitation of food and water. Overt biological attacks could be confused with naturally occurring outbreaks, especially in food-borne diseases and those spread by animals. Airborne non-communicable threats such as anthrax, tularemia, and viral hemorrhagic fevers. Introduction of infectious animal or plant diseases or viruses in shipped livestock and goods, e.g.
During a biohazard event, the state DOT will be a supporting player, providing resources and services to state and local public health agencies, as well as hospitals and members of the outpatient medical community.
The law enforcement function during a biohazard event will play a critical role in maintaining order and reducing panic among affected and potentially affected populations.
To manage the public health impacts of a biohazard situation, the state DOT understands that the local and state public health, public safety, and emergency management communities have identified a set of activities that they would perform to identify, manage and resolve an outbreak resulting from a biohazard agent. Public health strategies for isolation, quarantine and the confiscation and destruction of property may be conducted on a voluntary basis or be compelled on a mandatory basis through legal authority. Closures of highways, passenger transportation systems, arterials, bridges, tunnels, turnpikes and toll roads and re-routing of all area-wide traffic around affected area.
Creation of ad hoc transportation systems to support movement of prophylaxis, other medical supplies, equipment, food and water, and medical and public safety personnel to specified locations near or within an affected area. Creation of ad hoc transportation systems to support the movement of potentially affected persons to centers for medical evaluation, vaccination and prophylaxis. Creation of ad hoc transportation system to support a Modular Emergency Medical System established within an affected area. These activities may be coordinated with not only state and local law enforcement and public health, but also with the National Guard.
The potential introduction of biohazards into livestock and crops is managed by local, county, state and federal departments of agriculture and veterinary medicine and other federal agencies with responsibility for regulating the import and trade of livestock, plants and agricultural goods. There are several response options in the event of contamination, ranging from isolation of affected livestock and crops, to vaccination of livestock, to quarantines established around affected farms, facilities or production centers. On-going coordination with motor carriers and railroads, public health agencies, and agricultural officials. Additional support may be obtained in managing these situations from enforcement personnel within local, state and federal departments of agriculture, as well as the Veterinary Medical Assistance Teams (VMAT) and the Regional Emergency Animal Disease Eradication Organization (READEO) under the auspices of the U.S.
This section of the Transportation Biohazard Operational Concept should identify state DOT authorities in supporting response to a biohazard event.
In developing this section, state DOTs may want to consider two types of authorities: emergency and other. Issuance of highway clearances, permits, and waivers for equipment, personnel, and contaminated materials (to support removal of carcasses, contaminated plant matter and foodstuffs, etc.).
Coordination of and support for emergency evacuation and population re-location, including contra-flow operations, public transit systems, and the management of pedestrians on roadways. Coordination of transportation for victims to support mass casualty management and care operations. Coordination of transportation services for special populations, including persons with disabilities, incarcerated persons, children in daycare centers and schools, the elderly, and those who may be ill or infirm (not related to the biohazard situation).
Emergency procurement, including equipment and services necessary to support implementation of public health strategies, removal of contaminated materials, and decontamination of transportation facilities and equipment. Damage assessment (from contamination, lost revenue, etc.) and specialized engineering services. Freight management, including interstate and intrastate commerce, through coordination with commercial motor vehicle carriers, pipelines, airports, ports, railroads, and freight and transportation logistics associations. Authorities or responsibilities specified in agreements with public works and utilities agencies and companies. Support provided for maintaining passenger transportation systems or creating ad hoc systems to serve specific functions.
This section of the Transportation Biohazard Concept of Operations describes the planning situations and assumptions used by the state DOT in establishing its biohazard response capabilities. A disease outbreak of exceptional nature could occur affecting the citizens served by the state DOT transportation network. The transportation network could function to spread a deliberately released biological agent or could be a target of a deliberate release.
Deliberate releases involving the transportation network may or may not be detected at the time of release. Transportation personnel are trained in recognizing suspicious packages, conditions, behavior and equipment on transportation property. Procedures have been developed for reporting and investigating suspicious packages, conditions, behavior and equipment and making notification to local emergency response agencies.
Covert releases most likely will not be identified until symptoms begin presenting in affected individuals and they are examined and treated by the medical community.
The state DOT will rely on local, state and federal resources to identify biological agents and develop treatment and decontamination protocols, and to develop emergency response plans within appropriate local, state and federal authorities. The state DOT will support these plans and actions through activation of existing transportation plans, mutual aid agreements, and by making requests to other transportation systems and agencies.
In the event the state DOT is overwhelmed (through absenteeism or sick employees), it may implement its Continuity of Operations plan. Other situations may emerge in which state DOT employees or organizational elements are located within areas of restricted mobility or quarantine. Based on current capabilities, local jurisdictions within the state’s transportation network anticipate that, at a minimum, support will be required from mutual aid partners and the state for reception and movement of medical supplies, equipment and personnel.
Local jurisdictions within the state’s transportation network assume that the Strategic National Stockpile (SNS) will be available through requests and will be delivered through a strategy established by the affected jurisdiction in coordination with appropriate state and federal officials.
The state DOT will be available to support transportation and distribution of SNS resources, as specified in the terms of cooperative agreements established with the U.S.
Based on current capabilities, local jurisdictions within the state’s transportation network also anticipate that support will be required for traffic control, logistics, law enforcement, crowd control, and other activities associated with implementation of certain public health strategies that restrict or limit mobility.
Local jurisdictions within the state’s transportation network assume that disease surveillance will provide information such as trends, patient presentations, signs and symptoms, lab results and clinical diagnoses that will be critical to an effective response. Figure 7 (on the next page) identifies the basic response activities to be performed in response to a biohazard event.
Figure 8 (in the right-hand column) identifies whether transportation support may be required to perform these basic response activities. Below, a brief discussion is provided for each response activity to illustrate how the state DOT may coordinate with local, regional and state public health, law enforcement and emergency management authorities to support these activities within its available resources. Medical surveillance needs to operate continuously and provide non-specific detection of medical activities above established baselines in order to improve the chances of detecting unusual medical events sooner rather than later.
Preliminary medical diagnosis would be undertaken locally with samples sent to the Centers for Disease Control and Prevention, U.S. Epidemiological investigation would include interviews and diagnoses to determine the distribution of medical cases.
Criminal investigation, in addition to meeting the law enforcement needs in the event of an intentional release, could complement the epidemiological investigation. Medical prophylaxis involves the distribution and medical application of appropriate antibiotics, vaccines, or other medications in order to prevent disease and death in exposed victims.
Residual hazard assessment and mitigation encompasses a set of activities that would assess and protect the population from further exposure to the biohazard agent. Control of affected area and population is divided into two major sub-elements: physical control and public information and rumor control.
Control and operation of the Modular Emergency Medical System, along with medical prophylaxis, forms the backbone of effective response to a biohazard emergency.
Resource and logistic support will ensure that mobilization centers and distribution points are established for incoming supplies. Fatality management includes the conversion of local or regional morgues to provide rapid central processing of remains and the establishment of long-term storage facilities using refrigerated containers to hold remains for final disposition. Continuity of infrastructure may be necessary to activate local continuity of operations plans when disaster-related absenteeism exceeded critical thresholds. Family support services would provide information hotlines and implement central coordination of volunteer service organizations. This section of the Transportation Biohazard Operational Concept identifies the activities that may be performed by the state DOT in response to a biohazard emergency. This section presents the activities to be performed by the state DOT during a biohazard emergency.
Build relationships with local, regional, and State Emergency Management Agencies (EMAs), Emergency Operations Center (EOC) managers and personnel, and Local Emergency Planning Committees (LEPCs) and State Emergency Response Commissions (SERCs).
Will enhance their understanding of the transportation agency and the agency’s ability to provide supporting services. A municipal evacuation plan will help streamline the evacuation process by providing an organized framework for the activities involved in coordinating and conducting an evacuation. The aim of an evacuation plan is to allow for a safe, effective, and coordinated evacuation of people from an emergency area.
A municipal evacuation plan may be a stand-alone plan or part of a larger, overarching municipal emergency response plan. Municipal Evacuation Plans should outline how needed functions will be performed and by what organization (e.g.
Consider the characteristics of the municipality that may affect the execution of an incident-specific evacuation plan.
Is the municipality single, upper, or lower tier and how will that affect responsibilities during an evacuation?
Is the location of the municipality and the populated areas likely to impose particular challenges for an evacuation?
List hazards that have the greatest potential to require an evacuation (Refer to the municipal Hazard Identification and Risk Assessment (HIRA) or Community Risk Profile). Does the hazard have the potential to migrate outside of municipal boundaries or does it start elsewhere and migrate into the municipal boundaries?
Identify the process for conducting real-time threat assessments and how the real-time threat assessment will inform the decision to evacuate. Since the presence of contaminants in an emergency area will greatly complicate evacuation operations, a municipality’s evacuation plan should take into account procedures and equipment for these situations. In addition to the effects on emergency responders, residents may also be limited in their ability to move through the affected area safely. In order to prevent the spread of contamination, evacuees may need to be isolated from unaffected locations and populations until being decontaminated.
Emergency managers must understand the makeup of the population who are to be evacuated before they can make decisions about transportation modes, route selections, hosting destinations, and the many other elements of an evacuation. For planning purposes it may be advisable to increase the estimate of evacuees to account the evacuation shadow (these are the people who evacuate though they are not officially requested to do so.) This is a spontaneous evacuation, conducted when people feel they are in danger and begin to leave in advance of official instructions to do so or in spite of advice to shelter-in-place.
Details on populations that may require special assistance during an evacuation may be obtained from the departments and organizations involved in planning, such as public health, social services, etc.
To ensure that considerations such as advance warning and transportation are factored into the planning, areas with high concentrations of people needing additional assistance to evacuate should be identified.
Long-term care residents may require vehicles equipped to serve riders in wheelchairs or medical transportation.
An evacuation involving incarcerated individuals would require secure transport and hosting arrangements. In municipalities where the majority of evacuees make their own transportation and shelter arrangements, it may not be necessary to compile lists of evacuees according to categories (Ideally, evacuees would still register to allow for tracking and inquiry). Evacuations may take place prior to (pre-emptive), during (no-notice), or after (post-incident) an incident has occurred. Given adequate warning about a hazard, sufficient resources, and a likely threat, it is advisable to conduct pre-emptive evacuations. It may be advisable to carry out an evacuation even while a threat is affecting a community. Partial evacuations typically are localized to a specific area of a municipality and may be caused by fires, hazardous materials incidents, etc.
Incidents that precipitate a wide-spread evacuation typically cause far-reaching damage and are therefore more likely to compromise critical infrastructure in a manner that hinders evacuee movement.
An internal evacuation is where evacuees are hosted at another location within the same municipality as opposed to being hosted by another municipality. Spontaneous evacuation (self-evacuation) is when people choose to evacuate without explicit direction to do so.
If the present location affords adequate protection against the particular incident, emergency managers should consider having people shelter-in-placevii to reduce the number of persons who become part of an evacuation.
Once emergency managers have determined the number and geographic distribution of potential evacuees, these statistics can be analyzed against the transportation network. What is the distribution of the evacuating population with respect to roadways and highways? What planning, operational staff, systems, and activities are needed to implement the chosen tactics during an evacuation?
Should lanes be dedicated for high occupancy vehicles and any other special population groups (i.e. Recognize that different traffic management tactics (and different routes) may be more or less appropriate for certain types of situations. These figures are average and do not take into consideration an emergency situation or other factors that may be present during an evacuation.
Pre-planning assists decision-makers in determining suitable transportation options for inclusion in the incident-specific plan. The traffic management section outlines tactics that may be used to move traffic more efficiently.
For incidents of longer duration, these assembly points can serve as collection points for evacuees who have walked or ridden transit from the at-risk area, and who now must wait for transport (buses, etc.) to longer-term sheltering facilities. The ability of a sheltering facility to accommodate such special needs groups will depend on its on-site design and capabilities.
By comparing shelter capabilities and capacities with the anticipated evacuation population, a jurisdiction can ensure it has made adequate sheltering arrangements, including the appropriate staffing levels for each shelter.
By pre-identifying sheltering facilities, their locations can be evaluated in relation to proposed evacuation routes and other components of the transportation network.
In terms of First Nation evacuations, JEMS Service-level Evacuation Standardsx defines short-term shelter services as a period between 1 and 14 days. Municipalities may set-up and support shelters with municipal staff or they may have an agreement with another organization (e.g. Geographic Information Systems (GIS) can be used to analyze available data, including highlighting key aspects of the potential evacuation populations. Pre-planning can be used to help determine specific evacuation strategies should one of the pre-identified incidents occur.
The plan must state who has the authority to initiate the notification process and implement the plan. Evacuation should be considered when other response measures are insufficient to ensure public safety. The urgency of an evacuation is determined based on the immediacy of the threat to the community (life, safety, health, and welfare), the resilience of the community, and (depending on the nature of the threat) the availability of resources for evacuation or shelter-in-place.
Pre-planning and analysis conducted in the development of the municipal evacuation plan will be instrumental in creating an incident-specific plan (IAP). Based on the outcome of the real-time threat assessment, consider the type of evacuation required or if shelter-in-place is appropriate. Staging resources and phasing evacuations may alleviate some of the above complicating factors. Information may be pre-scripted and included as part of the Municipal Evacuation Plan or elsewhere (i.e.
Consider including information regarding language and communications barriers for at-risk populations. Ongoing communications should be maintained through the length of the evacuation until the return is completed. Detail what departments, organizations, and individuals would have a role in the implementation of the plan and list specific responsibilities. What are the roles and responsibilities of the lead and other response organizations involvedxii?
Who are the partners (additional subject matter experts required in the EOC to provide additional expertise)? If a third party is contracted by a municipality to provide services in an evacuation, its roles and responsibilities should be outlined within the agreement (e.g.
Requests for additional assistance should be made through the PEOC (including requests for Government of Canada assistance). A municipality may choose to identify an Evacuation Coordinator to lead an evacuation with minimum delay and confusion in the event of an emergency.
Regardless of the stage of the evacuation operation there are four roles a municipality may assume while involved in an evacuation effort. Identify resources needed to support the evacuation and the process for acquiring them (e.g.
When the emergency that prompted the evacuation has been resolved it will be necessary to plan for the return of evacuees. Since the degree of damage will likely vary within the affected area it might be beneficial to initiate a phased re-entry process. Evacuees who self-evacuated using their own means of transportation should be able to return on their own.
What media sources can evacuees use for the most up-to-date information on re-entry procedures?
Following the return of evacuees, consider when to terminate the declaration of emergency – reference the Municipal Emergency Response Plan. Discuss who generates the above, when they will be created, to whom they will be presented, and how the lessons learned will be incorporated into the evacuation plan. Successful efforts for public education include community seminars and preparedness pamphlets distributed to residents and businesses. Based on recommended practices, consider including COOP as part of the risk management process. This municipal evacuation plan will help streamline the evacuation process by providing an organized framework for the activities involved in coordinating and conducting an evacuation.
The aim of this evacuation plan is to allow for a safe, effective, and coordinated evacuation of people from an emergency area in [insert the Name of the Municipality]. Persons using assistive technology might not be able to fully access information in this file. Please note: This report has been corrected and replaces the electronic PDF version that was published on December 30, 2005.
The material in this report originated in the National Center for HIV, STD, and TB Prevention, Kevin Fenton, MD, PhD, Director; and the Division of Tuberculosis Elimination, Kenneth G. In 1994, CDC published the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, 1994.
The TB infection-control measures recommended by CDC in 1994 were implemented widely in health-care facilities in the United States.
Given the changes in epidemiology and a request by the Advisory Council for the Elimination of Tuberculosis (ACET) for review and update of the 1994 TB infection-control document, CDC has reassessed the TB infection-control guidelines for health-care settings. In 1994, CDC published the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health Care Facilities, 1994 (1). The 1994 guidelines, which followed CDC statements issued in 1982 and 1990 (1,6,7), presented recommendations for TB infection control based on a risk assessment process. The TB infection-control measures recommended by CDC in 1994 were implemented widely in health-care facilities nationwide (8–15).
Despite the general decline in TB rates in recent years, a marked geographic variation in TB case rates persists, which means that HCWs in different areas face different risks (10). Given the changes in epidemiology and a request by the Advisory Council for the Elimination of Tuberculosis (ACET) for review and updating of the 1994 TB infection-control document, CDC has reassessed the TB infection-control guidelines for health-care settings. CDC prepared the guidelines in this report in consultation with experts in TB, infection control, environmental control, respiratory protection, and occupational health. The risk assessment process includes the assessment of additional aspects of infection control. The term "tuberculin skin tests" (TSTs) is used instead of purified protein derivative (PPD). The frequency of TB screening for HCWs has been decreased in various settings, and the criteria for determination of screening frequency have been changed. The scope of settings in which the guidelines apply has been broadened to include laboratories and additional outpatient and nontraditional facility-based settings. These recommendations usually apply to an entire health-care setting rather than areas within a setting. New terms, airborne infection precautions (airborne precautions) and airborne infection isolation room (AII room), are introduced. Recommendations for annual respirator training, initial respirator fit testing, and periodic respirator fit testing have been added. Information on ultraviolet germicidal irradiation (UVGI) and room-air recirculation units has been expanded. In accordance with relevant local, state, and federal laws, implementation of all recommendations must safeguard the confidentiality and civil rights of all HCWs and patients who have been infected with M. The 1994 CDC guidelines were aimed primarily at hospital-based facilities, which frequently refer to a physical building or set of buildings. Inpatient settings include patient rooms, emergency departments (EDs), intensive care units (ICUs), surgical suites, laboratories, laboratory procedure areas, bronchoscopy suites, sputum induction or inhalation therapy rooms, autopsy suites, and embalming rooms. Outpatient settings include TB treatment facilities, medical offices, ambulatory-care settings, dialysis units, and dental-care settings.
In addition, HCWs who perform any of the following activities should also be included in the TB screening program.
In the United States, LTBI has been diagnosed traditionally based on a PPD-based TST result after TB disease has been excluded. Additional cytokine-based immunoassays are under development and might be useful in the diagnosis of M. Close contacts are persons who share the same air space in a household or other enclosed environment for a prolonged period (days or weeks, not minutes or hours) with a person with pulmonary TB disease (39).
In addition to close contacts, the following persons are also at higher risk for exposure to and infection with M. HCWs with unprotected exposure to a patient with TB disease before the identification and correct airborne precautions of the patient.
Certain populations who are medically underserved and who have low income, as defined locally. Populations at high risk who are defined locally as having an increased incidence of TB disease.
Persons who use tobacco or alcohol (40,41), illegal drugs, including injection drugs and crack cocaine (42–47), might also be at increased risk for infection and disease.
HIV infection is the greatest risk factor for progression from LTBI to TB disease (22,39,48,49). All HCWs should be informed regarding the risk for developing TB disease after being infected with M. The percentage of patients with TB disease who are HIV-infected is decreasing in the United States because of improved infection-control practices and better diagnosis and treatment of both HIV infection and TB.

Vaccination with BCG probably does not affect the risk for infection after exposure, but it might decrease the risk for progression from infection with M. Inadequate local or general ventilation that results in insufficient dilution or removal of infectious droplet nuclei.
Of the reported TB outbreaks in health-care settings, multiple outbreaks involved transmission of MDR TB strains to both patients and HCWs (56,57,70,87,91–94).
After the release of the 1994 CDC infection-control guidelines, increased implementation of recommended infection-control measures occurred and was documented in multiple national surveys (13,15,98,99). Less information is available regarding the implementation of CDC-recommended TB infection-control measures in settings other than hospitals. All health-care settings need a TB infection-control program designed to ensure prompt detection, airborne precautions, and treatment of persons who have suspected or confirmed TB disease (or prompt referral of persons who have suspected TB disease for settings in which persons with TB disease are not expected to be encountered). The first and most important level of TB controls is the use of administrative measures to reduce the risk for exposure to persons who might have TB disease. The second level of the hierarchy is the use of environmental controls to prevent the spread and reduce the concentration of infectious droplet nuclei in ambient air. Secondary environmental controls consist of controlling the airflow to prevent contamination of air in areas adjacent to the source (AII rooms) and cleaning the air by using high efficiency particulate air (HEPA) filtration or UVGI. Every health-care setting should have a TB infection-control plan that is part of an overall infection-control program. The TB infection-control program should consist of administrative controls, environmental controls, and a respiratory-protection program.
Assign supervisory responsibility for the TB infection-control program to a designated person or group with expertise in LTBI and TB disease, infection control, occupational health, environmental controls, and respiratory protection. Develop a written TB infection-control plan that outlines a protocol for the prompt recognition and initiation of airborne precautions of persons with suspected or confirmed TB disease, and update it annually. Conduct a problem evaluation (see Problem Evaluation) if a case of suspected or confirmed TB disease is not promptly recognized and appropriate airborne precautions not initiated, or if administrative, environmental, or respiratory-protection controls fail. Perform a contact investigation in collaboration with the local or state health department if health-care–associated transmission of M.
Collaborate with the local or state health department to develop administrative controls consisting of the risk assessment, the written TB infection-control plan, management of patients with suspected or confirmed TB disease, training and education of HCWs, screening and evaluation of HCWs, problem evaluation, and coordination. Implement and maintain environmental controls, including AII room(s) (see Environmental Controls). Perform ongoing training and education of HCWs (see Suggested Components of an Initial TB Training and Education Program for HCWs). Create a plan for accepting patients who have suspected or confirmed TB disease if they are transferred from another setting.
Settings in which TB patients might stay before transfer should still have a TB infection-control program in place consisting of administrative, environmental, and respiratory-protection controls. Develop a written TB infection-control plan that outlines a protocol for the prompt recognition and transfer of persons who have suspected or confirmed TB disease to another health-care setting.
Conduct a problem evaluation (see Problem Evaluation) if a case of suspected or confirmed TB disease is not promptly recognized, separated from others, and transferred. Perform an investigation in collaboration with the local or state health department if health-care–associated transmission of M. Collaborate with the local or state health department to develop administrative controls consisting of the risk assessment and the written TB infection-control plan.
Every health-care setting should conduct initial and ongoing evaluations of the risk for transmission of M. Review the community profile of TB disease in collaboration with the state or local health department.
Consult the local or state TB-control program to obtain epidemiologic surveillance data necessary to conduct a TB risk assessment for the health-care setting. Review the number of patients with suspected or confirmed TB disease who have been encountered in the setting during at least the previous 5 years.
Determine if persons with unrecognized TB disease have been admitted to or were encountered in the setting during the previous 5 years.
Determine which HCWs need to be included in a TB screening program and the frequency of screening (based on risk classification) (Appendix C).
Ensure the prompt recognition and evaluation of suspected episodes of health-care–associated transmission of M. Identify areas in the setting with an increased risk for health-care–associated transmission of M. Determine the types of environmental controls needed other than AII rooms (see TB Airborne Precautions). Review the community profile of TB disease in collaboration with the local or state health department. Determine if persons with unrecognized TB disease were encountered in the setting during the previous 5 years.
Determine the types of environmental controls that are currently in place, and determine if any are needed in the setting (Appendices A and D). Document procedures that ensure the prompt recognition and evaluation of suspected episodes of health-care–associated transmission of M. Risk classification should be used as part of the risk assessment to determine the need for a TB screening program for HCWs and the frequency of screening (Appendix C). The three TB screening risk classifications are low risk, medium risk, and potential ongoing transmission. The classification of medium risk should be applied to settings in which the risk assessment has determined that HCWs will or will possibly be exposed to persons with TB disease or to clinical specimens that might contain M.
If uncertainty exists regarding whether to classify a setting as low risk or medium risk, the setting typically should be classified as medium risk. All HCWs should receive baseline TB screening upon hire, using two-step TST or a single BAMT to test for infection with M. The classification of potential ongoing transmission should be used as a temporary classification only. The following hypothetical situations illustrate how assessment data are used to assign a risk classification.
HCWs transferring from low- or medium-risk settings to settings with a temporary classification of potential ongoing transmission.
Calculate a conversion rate by dividing the number of conversions among HCWs in the setting in a specified period (numerator) by the number of HCWs who received tests in the setting over the same period (denominator) multiplied by 100 (see Use of Conversion Test Data for M. Conversion rates above the baseline level (which will be different in each setting) should instigate an investigation to evaluate the likelihood of health-care–associated transmission. Evaluation of HCWs for LTBI should include information from a serial testing program, but this information must be interpreted as only one part of a full assessment. Annual evaluations of the TB infection-control plan are needed to ensure the proper implementation of the plan and to recognize and correct lapses in infection control. Number of visits to outpatient setting from the start of symptoms until TB disease was suspected (for outpatient settings). Work practices related to airborne precautions should be observed to determine if employers are enforcing all practices, if HCWs are adhering to infection-control policies, and if patient adherence to airborne precautions is being enforced.
Data from the most recent environmental evaluation should be reviewed to determine if recommended environmental controls are in place (see Suggested Components of an Initial TB Training and Education Program for HCWs).
Environmental control maintenance procedures and logs should be reviewed to determine if maintenance is conducted properly and regularly. Environmental control design specifications should be compared with guidelines from the American Institute of Architects (AIA) and other ventilation guidelines (117,118) (see Risk Classification Examples) and the installed system performance.
Environmental data should be used to assist building managers and engineers in evaluating the performance of the installed system. The number of AII rooms should be suitable for the setting based on AIA Guidelines and the setting risk assessment.
Symptoms and signs of TB disease and the importance of a high index of suspicion for patients or HCWs with these symptoms. Indications for initiation of airborne precautions of inpatients with suspected or confirmed TB disease.
Principles of treatment for LTBI and for TB disease (indications, use, effectiveness, and potential adverse effects). Rationale for infection-control measures and documentation evaluating the effect of these measures in reducing occupational TB risk exposure and M. Responsibility of HCWs to promptly report a diagnosis of TB disease to the setting's administration and infection-control program. Responsibility of clinicians and the infection-control program to report to the state or local health department a suspected case of TB disease in a patient (including autopsy findings) or HCW.
Responsibilities and policies of the setting, the local health department, and the state health department to ensure confidentiality for HCWs with TB disease or LTBI.
Responsibility of the setting to inform EMS staff who transported a patient with suspected or confirmed TB disease.
Responsibilities and policies of the setting to ensure that an HCW with TB disease is noninfectious before returning to duty. Importance of completing therapy for LTBI or TB disease to protect the HCW's health and to reduce the risk to others. Proper implementation and monitoring of environmental controls (see Environmental Controls). Required Occupational Safety and Health Administration (OSHA) record keeping on HCW test conversions for M. Proper use of (see Respiratory Protection) and the need to inform the infection-control program of factors that might affect the efficacy of respiratory protection as required by OSHA.
Success of adherence to infection-control practices in decreasing the risk for transmission of M. Available tests and counseling and referrals for persons with HIV infection, diabetes, and other immunocompromising conditions associated with an increased risk for progression to TB disease. Procedures for informing employee health or infection-control personnel of medical conditions associated with immunosuppression.
Role of the local and state health department's TB-control program in screening for LTBI and TB disease, providing treatment, conducting contact investigations and outbreak investigations, and providing education, counseling, and responses to public inquiries.
Availability of information, advice, and counseling from community sources, including universities, local experts, and hotlines. Responsibility of the setting's clinicians and infection-control program to promptly report to the state or local health department a case of suspected TB disease or a cluster of TST or BAMT conversions. Responsibility of the setting's clinicians and infection-control program to promptly report to the state or local health department a person with suspected or confirmed TB disease who leaves the setting against medical advice.
The primary TB risk to HCWs is the undiagnosed or unsuspected patient with infectious TB disease. Within health-care settings, protocols should be implemented and enforced to promptly identify, separate from others, and either transfer or manage persons who have suspected or confirmed infectious TB disease.
A diagnosis of respiratory TB disease should be considered for any patient with symptoms or signs of infection in the lung, pleura, or airways (including larynx), including coughing for ?3 weeks, loss of appetite, unexplained weight loss, night sweats, bloody sputum or hemoptysis, hoarseness, fever, fatigue, or chest pain. Immunocompromised persons, including those who are HIV-infected, with infectious TB disease should be physically separated from other persons to protect both themselves and others.
Within health-care settings, TB airborne precautions should be initiated for any patient who has symptoms or signs of TB disease, or who has documented infectious TB disease and has not completed antituberculosis treatment. The classification of the risk assessment of the health-care setting is used to determine how many AII rooms each setting needs, depending on the number of TB patients examined.
Settings that plan to evaluate and manage patients with TB disease should have at least one AII room or enclosure that meets AII requirements (see Environmental Controls; and Supplement, Environmental Controls). The goal of this project was to develop a more comprehensive and actionable understanding of the role of transportation during a biohazard emergency so that communities across the country can better plan for, respond to, and recover from such an incident.
It builds on the results of an extensive literature review, a dedicated program of outreach with members of the affected transportation, emergency management, public health and public safety communities, and a validation workshop conducted in July 2005 and sponsored by the Wisconsin Department of Transportation.
State DOTs occasionally are subject to emergencies and disasters that can threaten a safe and secure environment for travel.
A release affecting people could cause illness, death, fear, societal disruption, and economic damage. In these situations, unfamiliar tasks may have to be carried out in potentially threatening environments to protect motorists, employees, emergency responders, DOT vehicles and property, and surrounding communities. The operational concept clarifies the transportation functions to be performed during a biohazard situation by specifying the processes through which these functions are accomplished. It will be used to seek support from the emergency and transportation management communities, and to enhance the capabilities of current Intelligent Transportation System (ITS) technology to support these events. It builds on existing transportation and community emergency response plans, emergency response procedures, training, drills and exercises. Specifies links between the Transportation Biohazard Operational Concept and the state and state DOT Emergency Operations Plans and supporting agreements developed to address requirements in the National Response Plan and National Incident Management System. Identifies those types of biohazard events of greatest concern to the transportation agency, and provides an overview of the activities that may be required to address them. Also identifies the primary coordinating functions of other state, local and federal agencies in working with the state DOT to obtain transportation resources and support. State DOTs, which vary widely in their organizations, authorities and resources, may use the text provided in each section of the operational concept as a model, tailoring it to reflect their own unique characteristics and conditions. Appendix A provides a Fact Sheet prepared by the Centers for Disease Control and Prevention regarding the Strategic National Stockpile. State DOTs may choose to use some or all of the information provided below to support development of this section in their operational concepts. This framework creates a standardized approach for incident management that enables the timely integration of federal resources into state and local response activities. The Base Plan includes planning assumptions, roles and responsibilities, concept of operations, incident management actions, and plan maintenance instructions. Each ESF Annex also summarizes the functions of ESF coordinators and primary and support agencies. The Incident Annexes describe the missions policies, responsibilities, and coordination processes that govern the interaction of public and private entities engaged in incident management and emergency response operations across a spectrum of potential hazards.
Requirements for NIMS implementation have been conveyed to state governments through a series of activities performed by the Federal Emergency Management Agency (FEMA), a department now located within the Department of Homeland Security (DHS).
Building on these ESFs, the states and their executive agencies can identify coordinating, primary and support agencies. Further, many state DOTs have also committed to a program of training, drills and exercises to reinforce and test the effectiveness of their EOPs and procedures.
Formalization of these agreements is required in NIMS, and many local, regional and state authorities have already established these legal documents to govern the request for and sharing of resources during emergency events.
Department of Health and Human Services (HHS) will transfer authority for the SNS materiel to the state and local authorities once it arrives at the designated receiving and storage site.
These two modules will aid in the triage of healthcare needs to support surge capacity issues that are likely to be encountered within communities. State DOTs may want to use some or all of the following information to develop this section of their operational concepts. However, research and thorough evaluation of those events which have occurred demonstrate that these emergencies present unique challenges for state DOTs. Should such an event take place, delivery of these concurrent (and potentially conflicting) transportation strategies poses significantly different types of challenges to transportation decision-makers.
As indicated in Figure 4, bioagents are typically of three main types: bacteria, viruses, and biological toxins. Such an event could be overt (immediately recognized) or covert (unrecognized at the time of release).
The response in an overt situation could be immediate, increasing the chances of limiting those exposed.
Due to the delayed onset of most diseases caused by bioagents, there might be no indication of intentional release until days or even weeks after it occurred. The water supply is less vulnerable because dilution, filtration, and the addition of chlorine can kill most disease-causing organisms. Most agents would make people ill or incapacitated before they become highly contagious, thereby reducing transmission of the disease.
The results of this type of attack can include major economic crises, loss of confidence in food supplies and government protections, and possibly human casualties.
These releases may involve accidents during transportation of waste material, damage to laboratory facilities where diseases are studied, or accidental release of laboratory animals infected with diseases.
For example, an ecological research ship passed within nine miles of a smallpox testing site off the coast of the former Soviet Union in 1971.
When large populations are affected or biological responses are sufficiently severe, naturally occurring biohazard events can cause a major public health problem.
In the case of food, a single source such as a restaurant that fails to thoroughly cook its meat could cause a localized threat to public health. The detection and identification process would be the same as described above for a deliberate release.
Each mode has specific characteristics that affect its potential role in the release and spread of biohazards. State DOTs will coordinate with their partners in law enforcement and the National Guard to support activities that may be implemented to protect public health.
In general, isolation refers to the separation of persons who have a specific infectious illness from those who are healthy and the restriction of their movement to stop the spread of that illness. A relatively new approach to stemming the spread of communicable disease, social distancing imposes voluntary and mandatory restrictions on movement within a given geographic area. Generally refers to the separation and restriction of movement of persons who, while not yet ill, have been exposed to an infectious agent and therefore may become infectious. Material, plants, animals, facilities and other goods that have been determined to be harmful to human health can be confiscated and destroyed. These orders reduce the time required to dispense prophylaxis and vaccines to affected or potentially affected persons by providing a universal prescription for their use among citizens in a specific locality or state.
Using these authorities, state and local agencies may authorize specific facilities or elements of a Modular Medical Emergency System to dispense medicine to affected persons, freeing hospitals and other medical facilities to deal with symptomatic patients. When using state or local authorities, these public health strategies are typically issued as court orders or warrants and are carried out by the appropriate law enforcement agency.
Other state and federal medical response teams may also be used, such as the Disaster Medical Assistance Teams (DMAT) and the Disaster Mortuary Operational Response Teams (DMORT). Existing detection and surveillance programs, inspections, research and training support the safety of livestock and foods. In the event of quarantine, typically the depopulation and destruction of livestock and crops is required, along with indemnity payments to farmers, and immediate suspension of trade.
Authorities should be specified, including references to state codes, enabling legislation, or other statutes. In these situations, transportation employees may be able to support services within the restricted area. State DOT support may be requested to aid in the movement and distribution of these resources. Based on the results of this surveillance, the state DOT will provide information and support to manage transportation in and around any affected areas. Army Medical Research Institute of Infectious Diseases, or other state, or local specialty laboratories for identification and confirmation. Since transportation can be the target or vector in a biohazard release, the state DOT will provide resources and personnel to support investigation, inspection, testing, and evaluation as needed. The results of these multiple investigations would be utilized by local officials to first assess whether a major health event is occurring, and then to help determine the potential cause and identify the population at risk.
Because of uncertainties as to who was exposed, treatment may be applied to a much greater number of people than those actually exposed and may even be given to the entire city population. The risks from residuals are small compared to the prime attack but may still warrant attention.
Physical control would provide crowd control and security at hospitals, emergency medical facilities, fatality handling sites, and other vital installations such as airports, utility sites, bridges, and tunnels, as well as patrol of affected areas to maintain security.
To cope with potentially high numbers casualties and those that think they are casualties (the worried well) the Modular Emergency Medical System may be established.
Within this structure, a unified medical branch will be established, and representatives from local, state, and federal agencies will be requested at the local and state EOCs. In most cases, a central reception center would receive incoming State and Federal support personnel and provide instructions, accreditation and assignments. The state DOT has developed a continuity of operations capability and plan, and has identified minimum functions to be performed, lines of succession, delegations of emergency authority, alternate facilities, and procedures for communicating with employees, supporting critical transportation systems, and protecting critical records and information.
Due to the confidential nature of this activity, it is unlikely that state DOTs would play much of a role.
State DOTs may want to use some or all of the following information in developing this section for their operational concepts. Standard phases of emergency management are used to guide transportation activities for a biohazard event.
Damage to property or the environment may also trigger an evacuation if it poses a risk to the safety, health, and welfare of people. The aim is achieved by detailing evacuation considerations, hosting arrangements, transportation management, and return planning. This includes details on the municipality, hazards that may necessitate an evacuation, and demographics. Emergency responders may not be able to enter an area without subjecting themselves to an unreasonable level of risk, or they may need to wear and use specialized personal protective equipment (PPE) to protect themselves. Decontamination could necessitate specialized screening and cleaning resources, and expertise, and may be required before people are transported to advanced care and sheltering facilities. All activities and efforts should be focused on moving these people from the at-risk area to places of safety in a timely manner. It has been estimated that between 5 and 20 percent of people will anticipate an evacuation and self-evacuate. This list should contain the names of persons needed to restart systems that must be in place before evacuees can return home (e.g. A pre-emptive evacuation may be undertaken when it is clear that if delayed, conditions (weather or other hazard) would impede evacuation. There is often on-scene activity by emergency response personnel who may direct the evacuation.
Evacuations of this type often involve a large number of evacuees, possibly from more than one municipality. Structural damage to the transportation system, such as bridges, tunnels, and highway systems may render them unsafe for use. While the primary goal of any response action is to save lives, the ability to evacuate people quickly and efficiently should be weighed against the risks of remaining in place. Their understanding of the regional transportation network enables them to identify ways to improve the carrying capacity of roadways and transit systems in a safe manner. In most evacuation scenarios, the majority of evacuee movements will take place on roadways and highways, in both personal vehicles and transit vehicles. The plan may identify a number of options, but requires planners to select and implement only certain tactics based on the specific circumstances during the evacuation. The real-time threat assessment, type of evacuation, resources available and needed, and the number of people to be evacuated will dictate what transportation options are best.
The challenge lies in identifying those tactics that provide the greatest increase in carrying capacity while being realistic in terms of time and resource requirements.
Due to the uncertain nature of incidents that trigger evacuations, the evacuees may be able to return directly to their residence or place of employment from the assembly point once it is safe to do so. Evacuation planners should determine which special needs groups should be routed to particular shelters, and how to incorporate such direction into the evacuation plan. Planners should assess shelters’ locations, as well as their capabilities and capacities, facilities and resources, in relation to how evacuee traffic will be routed.
Municipalities may use this standard as a guide for selecting shelters and planning for shelter services. Based on the location and type of hazard, a municipality can prioritize which areas (sectors) should evacuate first, and have pre-identified decision points and triggers for declaring an evacuation.
That authority may lie with key individuals, such as any member of the Municipal Emergency Control Group or a department head. For known site-specific risks, incident-specific information may be added to the municipal evacuation plan. Determine the evacuation area given the emergency situation and estimate the time and resources required to safely evacuate the area. In addition, consider public education campaigns to advise the public on plans to re-unify families in the event of separation during an emergency.
For example, once a building has been evacuated make a mark on the front door or most visible location. These phases include pre-warning, evacuation, ongoing communications, and return (discussed in the Return section).
It is important to ensure that they contain realistic expectations of each municipality’s capabilities. The municipality should work with its records management staff to review its registration and inquiry practices to ensure that they permit the disclosure of evacuee information to relevant parties (i.e.
The Evacuation Coordinator may be responsible for making arrangements for shelter, food, clothing, and other essentials. This includes restoring the physical infrastructure where possible or desirable as well as addressing the emotional, social, economic and physical well-being of those involved. If a municipality provided transportation to shelters, it may have to organize return transportation for those evacuees. Consider locations of municipal services, facilities and infrastructure as they may be affected by an evacuation.
It assigns responsibilities to municipal employees, by position, for implementation of the [insert Name of the Municipality] Evacuation Plan.
Jensen, PhD, Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, 1600 Clifton Rd., NE, MS E-10, Atlanta, GA 30333.
The guidelines were issued in response to 1) a resurgence of tuberculosis (TB) disease that occurred in the United States in the mid-1980s and early 1990s, 2) the documentation of several high-profile health-care–associated (previously termed "nosocomial") outbreaks related to an increase in the prevalence of TB disease and human immunodeficiency virus (HIV) coinfection, 3) lapses in infection-control practices, 4) delays in the diagnosis and treatment of persons with infectious TB disease, and 5) the appearance and transmission of multidrug-resistant (MDR) TB strains. The result has been a decrease in the number of TB outbreaks in health-care settings reported to CDC and a reduction in health-care–associated transmission of Mycobacterium tuberculosis to patients and health-care workers (HCWs). This report updates TB control recommendations reflecting shifts in the epidemiology of TB, advances in scientific understanding, and changes in health-care practice that have occurred in the United States during the preceding decade. The guidelines were issued in response to 1) a resurgence of tuberculosis (TB) disease that occurred in the United States in the mid-1980s and early 1990s, 2) the documentation of multiple high-profile health-care–associated (previously "nosocomial") outbreaks related to an increase in the prevalence of TB disease and human immunodeficiency virus (HIV) coinfection, 3) lapses in infection-control practices, 4) delays in the diagnosis and treatment of persons with infectious TB disease (2,3), and 5) the appearance and transmission of multidrug-resistant (MDR) TB strains (4,5). In this process, health-care facilities were classified according to categories of TB risk,with a corresponding series of environmental and respiratory-protection control measures.
As a result, a decrease has occurred in 1) the number of TB outbreaks in health-care settings reported to CDC and 2) health-care–associated transmission of M. This report updates TB-control recommendations, reflecting shifts in the epidemiology of TB (27), advances in scientific understanding, and changes in health-care practice that have occurred in the United States in the previous decade (28). This report replaces all previous CDC guidelines for TB infection control in health-care settings (1,6,7). Other settings in which suspected and confirmed TB patients might be encountered might include cafeterias, general stores, kitchens, laundry areas, maintenance shops, pharmacies, and law enforcement settings. Part time, temporary, contract, and full-time HCWs should be included in TB screening programs. A suspect TB patient is a person in whom a diagnosis of TB disease is being considered, whether or not antituberculosis treatment has been started. However, because of multiple other potential risk factors that commonly occur among such persons, use of these substances has been difficult to identify as separate risk factors. Therefore, voluntary HIV counseling, testing, and referral should be routinely offered to all persons at risk for LTBI (1,50,51). With increased voluntary HIV counseling and testing and the increasing use of treatment for LTBI, TB disease will probably continue to decrease among HIV-infected persons in the United States (58).
The majority of the patients and certain HCWs were HIV-infected, and progression to TB and MDR TB disease was rapid. In a survey of approximately 1,000 hospitals, a TST program was present in nearly all sites, and 70% reported having an AII room (13). One study identified major barriers to implementation that contribute to the costs of a TST program in health departments and hospitals, including personnel costs, HCWs' time off from work for TST administration and reading, and training and education of HCWs (100). Such a program is based on a three-level hierarchy of controls, including administrative, environmental, and respiratory protection (86,107,108).
In addition, HCWs with TB disease should be allowed to return to work when a physician knowledgeable and experienced in managing TB disease determines that HCWs are noninfectious (see Treatment Procedures for LTBI and TB Disease). The specific details of the TB infection-control program will differ, depending on whether patients with suspected or confirmed TB disease might be encountered in the setting or whether patients with suspected or confirmed TB disease will be transferred to another health-care setting.
Every setting in which services are provided to persons who have suspected or confirmed infectious TB disease, including laboratories and nontraditional facility-based settings, should have a TB infection-control plan. Give the supervisor or supervisory body the support and authority to conduct a TB risk assessment, implement and enforce TB infection-control policies, and ensure recommended training and education of HCWs. The plan should indicate procedures to follow to separate persons with suspected or confirmed infectious TB disease from other persons in the setting until the time of transfer. The risk classification for the setting should help to make this determination, depending on the number of TB patients examined. The classification of low risk should be applied to settings in which persons with TB disease are not expected to be encountered, and, therefore, exposure to M. If greater than or equal to six TB patients for the preceding year, classify as medium risk. If greater than or equal to three TB patients for the preceding year, classify as medium risk. The risk classifications are for settings in which patients with suspected or confirmed infectious TB disease are expected to be encountered.
A hospital located in a large city admits 35 patients with TB disease per year, uses QFT-G to measure M.
The setting is an ambulatory-care center associated with a large health maintenance organization (HMO).
A home health-care agency employs 125 workers, many of whom perform duties, including nursing, physical therapy, and basic home care.

Infection-control plans should address HCWs who transfer from one health-care setting to another and consider that the transferring HCWs might be at an equivalent or higher risk for exposure in different settings. TST or BAMT conversion criteria for administrative (surveillance) purposes are not applicable for medical evaluation of HCWs for the diagnosis of LTBI (see Supplement, Surveillance and Detection of M. Previous hospital admissions and outpatient visits of patients with TB disease should be noted before the onset of TB symptoms.
Data from the case reviews and observations in the annual risk assessment should be used to determine the need to modify 1) protocols for identifying and initiating prompt airborne precautions for patients with suspected or confirmed infectious TB disease, 2) protocols for patient management, 3) laboratory procedures, or 4) TB training and education programs for HCWs. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has adapted the AIA guidelines when accrediting facilities (118). A high index of suspicion for TB disease and rapid implementation of precautions are essential to prevent and interrupt transmission. The index of suspicion for TB disease will vary by geographic area and will depend on the population served by the setting.
Patients with symptoms suggestive of undiagnosed or inadequately treated TB disease should be promptly referred so that they can receive a medical evaluation. For patients placed in AII rooms because of suspected infectious TB disease of the lungs, airway, or larynx, airborne precautions may be discontinued when infectious TB disease is considered unlikely and either 1) another diagnosis is made that explains the clinical syndrome or 2) the patient has three consecutive, negative AFB sputum smear results (109–112,123). At least one AII room is needed for settings in which TB patients stay while they are being treated, and additional AII rooms might be needed depending on the magnitude of patient-days of persons with suspected or confirmed TB disease (118).
These settings should develop written policies that specify 1) indications for airborne precautions, 2) persons authorized to initiate and discontinue airborne precautions, 3) specific airborne precautions, 4) AII room-monitoring procedures, 5) procedures for managing patients who do not adhere to airborne precautions, and 6) criteria for discontinuing airborne precautions. If a patient has suspected or confirmed TB disease, airborne precautions should be promptly initiated. This operational concept was used to develop a set of recommended practices and a learning tool for state Departments of Transportation (DOTs). Jeffrey Western of the Wisconsin Department of Transportation for hosting the validation workshop, and for sharing with the research team the activities being performed in Wisconsin to address biohazard events.
While state DOTs have developed Emergency Operations Plans (EOPs) and incident specific annexes, procedures and training to address many potential emergencies, there is the perceived need for additional guidance in managing events related to the accidental or intentional release of biological agents.
A release affecting agricultural plants and animals may primarily cause economic damage, loss of confidence in the food supply, and possible loss of life. It also builds on recommendations from the public health, agriculture, and veterinary medicine communities regarding how best to manage these types of emergencies.
Appendix B provides a sample State Appendix to an Emergency Operations Plan describing the activities to be performed by various state agencies, including state DOTs, to request, receive, warehouse, deliver and dispense medicines and materials from the Strategic National Stockpile. EOPs developed by state DOTs will be coordinated with (and referenced in) state-wide EOPs and will govern how transportation aspects of emergencies requiring state resources will be managed for ESFs led and supported by state DOTs. The mission of the NEHC is to direct casualties, especially non-critical and asymptomatic, potentially exposed patients, away from the hospitals, allowing them to continue to remain open in some capacity.
First responders would be those traditionally involved in an emergency – police, firefighters, and Emergency Medical Services (EMS) personnel. Exposed individuals likely would begin to report generic symptoms accompanied by a fever to healthcare personnel at local hospital and medical centers.
A recent example of a lab-related accidental release occurred last year when three lab workers at a Boston University research facility contracted tularemia after being exposed to the virus through their research. A single crew member became infected, presumably through inhalation of the disease, and carried the virus back to port. Contaminated food could also originate from a single feedlot or a cattle-dense region that distributes animal products across the country, potentially resulting in numerous, scattered outbreaks.
However, in the event of a natural occurrence, the public health impact is likely to be less severe than for a deliberate release. These characteristics include the physical characteristics of the system and the way the system typically is used. At the first suspicion of an intentional release of a disease-causing microbe or toxin, law enforcement agencies will be alerted.
Isolation is a standard procedure used in hospitals today for patients with tuberculosis and certain other infectious diseases. Both isolation and quarantine can require confinement to an individual’s home, a hospital, a medical center, or another facility designated by local, state or federal officials.
Transportation also has access to freight management information systems to support tracking of potentially contaminated goods or vehicles. Transportation will be required to obtain, store, and move medical equipment and medicine, perhaps requiring refrigerated vehicles. Assessment and mitigation can include environmental sampling, decontamination, and insect and animal control measures as applicable.
Physical control would extend to enforcing isolation and quarantine orders and supporting social distancing strategies. Under this concept, public and private area hospitals would admit casualties until they approach full capacity while operating under their internal emergency operations plans. The state DOT has developed an Incident Management System compliant with NIMS to integrate effectively into field response led by public health and public safety responders.
This process will follow the procedures specified in the local and state Emergency Operations Plans and in the National Response Plan. The guideline presents evacuation planning concepts that may be applied for various scales of evacuations and sizes of municipalities. The plan also sets out the procedures for notifying the members of the Municipal Emergency Control Group, municipal and other responders, the public, the province, neighbouring communities, and as required, other impacted and interested parties, of the emergency. Decisions should be made on the review and revision cycle of the plan, and who is responsible for it. Evacuations are often multi-jurisdictional activities, making extensive coordination amongst numerous departments and governments necessary. More research and analysis will likely be undertaken in the pre-planning phase than is reported in the plan.
Sectors may also be established by using census or enumeration areas, or natural geographic barriers. The nature of the contaminants will vary and different contaminants may require different approaches to decontamination and treatment.
As a result, hazardous materials (HAZMAT) procedures should be incorporated into the evacuation plan.
In such scenarios, sheltering in place must be considered as a strategy for protecting public safety (see the Shelter-in-Place section 2.5).
The size and demographics of the population are significant factors in determining how to conduct an evacuation. A partial evacuation is most often internal – that is the evacuees are hosted elsewhere within the municipality, rather than being hosted in a separate municipality.
Decision-makers must be willing to make decisions with whatever information is available at the time. This will require intensive effort by emergency management personnel to coordinate, transport, and shelter the affected populations, and will place greater demands on staff and resources.
If these sites are located on evacuation routes, those routes may be unavailable, and alternatives will need to be identified. Partners that could be involved include the local police service, Ontario Provincial Police, Ministry of Transportation, municipal transportation departments, etc.
Given the potentially large numbers of vehicles that will be accessing the roadway network at the same time, it is important to consider what can be done to increase the capacity of roadways. If possible, transportation staff should employ traffic modeling to test the routes and tactics to be included in the evacuation plan.
Assembly points are typically well-known landmarks that have the capacity to handle large numbers of people, have bus access, and an indoor sheltering area.
As part of the planning process, planners should estimate the number of evacuees that may require shelter compared to those who will make their own arrangements. If shelters are run by another organization, it is advisable for municipal staff to work closely with shelter operators to provide regular updates on the emergency situation and for the municipality to be aware of the status of evacuation operations. Significant evacuee populations may be mapped against the proposed evacuation transportation and sheltering network to determine projected demand levels on their chosen travel routes. The person responsible for maintaining the notification list for internal personnel and external partners should be clearly indicated.
Determine the population requiring evacuation based on the type of evacuation required, the delineation of the evacuation area, and the population statistics compiled and analysed during pre-planning. Public alerting may be the responsibility of the Community Emergency Management Coordinator, the Emergency Information Officer, an Evacuation Coordinator, or other as identified by the municipality and outlined in the plan.
The agreement should also define the anticipated costs or fees associated with the delivery of the services. Evacuation operations will remain under the overall direction of the Municipal Emergency Control Group. As with the initial evacuation, numerous resources, especially personnel and transportation related resources will be required to successfully return evacuees to the affected area.
This plan also sets out the procedures for notifying the members of the Municipal Emergency Control Group, municipal and other responders, the public, the province, neighbouring communities, and as required, other impacted and interested parties, of the emergency. The 1994 guidelines, which followed statements issued in 1982 and 1990, presented recommendations for TB-infection control based on a risk assessment process that classified health-care facilities according to categories of TB risk, with a corresponding series of administrative, environmental, and respiratory-protection control measures. Concurrent with this success, mobilization of the nation's TB-control programs succeeded in reversing the upsurge in reported cases of TB disease, and case rates have declined in the subsequent 10 years.
Primary references citing evidence-based science are used in this report to support explanatory material and recommendations. In certain settings, this change will decrease the number of HCWs who need serial TB screening.
Setting has been chosen instead of "facility" to expand the scope of potential places for which these guidelines apply (Appendix A). All HCWs who have duties that involve face-to-face contact with patients with suspected or confirmed TB disease (including transport staff) should be included in a TB screening program. Future FDA-licensed products in combination with CDC-issued recommendations might provide additional diagnostic alternatives. The risk for progression of LTBI to TB disease is highest during the first several years after infection (36–38). Health-care settings should be particularly aware of the need for preventing transmission of M. Although HIV infection increases the likelihood of progression from LTBI to TB disease (39,49), whether HIV infection increases the risk for becoming infected if exposed to M. The magnitude of the risk varies by setting, occupational group, prevalence of TB in the community, patient population, and effectiveness of TB infection-control measures. Factors contributing to these outbreaks included delayed diagnosis of TB disease, delayed initiation and inadequate airborne precautions, lapses in AII practices and precautions for cough-inducing and aerosol-generating procedures, and lack of adequate respiratory protection. Other surveys have documented improvement in the proportion of AII rooms meeting CDC criteria and proportion of HCWs using CDC-recommended respiratory protection and receiving serial TST (15,98). In the United States, the problem of MDR TB, which was amplified by health-care–associated transmission, has been substantially reduced by the use of standardized antituberculosis treatment regimens in the initial phase of therapy, rapid drug-susceptibility testing, directly observed therapy (DOT), and improved infection-control practices (1).
These control levels also reduce, but do not eliminate, the risk for exposure in the limited areas in which exposure can still occur. Implementation of the TB infection-control guidelines described in this document is essential for preventing and controlling transmission of M. Administrators making this distinction should obtain medical and epidemiologic consultation from state and local health departments. Evaluate the plan annually, if possible, to ensure that the setting remains one in which persons who have suspected or confirmed TB disease are not encountered and that they are promptly transferred. The TB risk assessment determines the types of administrative, environmental, and respiratory-protection controls needed for a setting and serves as an ongoing evaluation tool of the quality of TB infection control and for the identification of needed improvements in infection-control measures. At least one AII room is needed for settings in which TB patients stay while they are being treated, and additional AII rooms might be needed, depending on the magnitude of patient-days of cases of suspected or confirmed TB disease. Repeat radiographs are not needed unless symptoms or signs of TB disease develop or unless recommended by a clinician (39,116). After a determination that ongoing transmission has ceased, the setting should be reclassified as medium risk. During the preceding year, the hospital admitted two patients with a diagnosis of TB disease. During the preceding year, care was delivered to six patients with TB disease and approximately 50 persons with LTBI. The hospital admits an average of 150 patients with TB disease each year, comprising 35% of the city burden. The patient volume is high, and the HMO is located in the inner city where TB rates are the highest in the state. The agency did not care for any patients with suspected or confirmed TB disease during the preceding year. Infection-control plans might need to be customized to balance the assessed risks and the efficacy of the plan based on consideration of various logistical factors.
On a case-by-case basis, expert medical opinion might be needed to interpret results and refer patients with discordant BAMT and TST baseline results.
The setting should have ongoing communication with the local or state health department regarding incidence and epidemiology of TB in the population served and should ensure that timely contact investigations are performed for HCWs or patients with unprotected exposure to a person with TB disease. Medical records of a sample of patients with suspected and confirmed TB disease who were treated or examined at the setting should be reviewed to identify possible problems in TB infection control. The medical evaluation should include an interview conducted in the patient's primary language, with the assistance of a qualified medical interpreter, if necessary. The index of suspicion should be substantially high for geographic areas and groups of patients characterized by high TB incidence (26). These patients should not be kept in the setting any longer than required to arrange a referral or transfer to an AII room. Each of the three sputum specimens should be collected in 8–24-hour intervals (124), and at least one specimen should be an early morning specimen because respiratory secretions pool overnight. Additional rooms might be considered if options are limited for transferring patients with suspected or confirmed TB disease to other settings with AII rooms.
Persons with suspected or confirmed TB disease who are inpatients should remain in AII rooms until they are determined to be noninfectious and have demonstrated a clinical response to a standard multidrug antituberculosis treatment regimen or until an alternative diagnosis is made. The operational concept was also be presented to the National Intelligent Transportation System (ITS) Architecture Team for consideration in defining addition functional requirements and user service agreements.
A biohazard event could be caused by a terrorist attack or by an accidental release or contamination.
Concurrent to SNS transport, the SNS Program will deploy its Technical Advisory Response Unit (TARU). SNS TARU members will remain on site in order to assist and advise state and local officials in putting the SNS assets to prompt and effective use.
In addition, the NEHC will render basic medical evaluation and triage while also providing limited treatment including the stabilization and distribution of prophylaxis, medication, self-help information, and instruction. The introduction of an infected plant or animal or its fluids could spread disease through the rest of the crop or livestock. The public was not informed of the accidental release until three months after tularemia was confirmed as the infectious source. The Soviet government has never admitted to aerial smallpox testing; however, a 2002 report prepared by the Monterey Institute of International Studies suggests that an outbreak ensued, killing three people and infecting many, some of whom had been previously vaccinated. Leaking septic systems or deficient water sanitation systems could cause water contamination, leading to localized biohazard events. The most important characteristics relate to the degree to which the system concentrates people, the distance and speed of travel, and mechanisms for controlled access. In hazardous conditions, law enforcement officers and medical personnel are required to use appropriate personal protective gear when issuing isolation or quarantine orders. Finally, transportation personnel will ensure safe access for medical investigators to transportation facilities and equipment. This is particularly likely if a request is made for medicines from the Strategic National Stockpile.
State DOTs will support this activity through the provision of traffic control (at a specific location), traffic and freight information, access to available hazardous materials clean-up contractors, engineering support (if needed) and management of clearances and waivers for the shipment of contaminated materials.
Public information and rumor control would inform and instruct the population in ways that enhance emergency response and avoid panic. Existing clinics would be expanded into neighborhood emergency help centers (NEHC) to provide the primary point of entry into the emergency medical system for biohazard patients and the worried well. The state DOT will assign representatives to the appropriate local and state EOCs, and will also coordinate with these EOCs from the State Transportation Emergency Operations Center. In a major biohazard emergency, it is likely that most, if not all, 15 of the Emergency Support Functions under the National Response Plan would be activated.
The detail required in a Municipal Evacuation Plan may vary according to the needs of the municipality.
The plan should identify lead departments and considerations for the development of incident-specific plans (Incident Action Plans). They may have little or no time to wait for additional information because any delay may have a significant impact on public safety.
Emergency responders may require personal protective equipment, as responder safety will be critical. In cases where the transportation network is severely restricted by such damage, sheltering in place may be a safer short-term alternative. This will provide data to help quantify the benefits of different strategies and support an informed decision as to the best ones for the particular region and transportation network.
Pre-identifying sufficient assembly points in relation to the transportation network and evacuation routes will allow these locations to be incorporated into the evacuation plan. In addition, planners should consider special needs that may need to be accommodated within a shelter (e.g. A clear and succinct notification process must show who is responsible for making the notification contacts and list the primary and secondary notification methods. List details of the population to be evacuated including numbers of evacuees and special requirements.
It may be necessary to establish agreements with other communities when an emergency is threatening or occurring if mutual assistance agreements are not in place or may be insufficient to address the emergency.
If the municipality contracts registration to a third party, the municipality is still responsible for disclosure of the evacuee information.
This plan also identifies lead departments and outlines considerations for the development of incident-specific plans (Incident Action Plans).
Concurrent with this success, mobilization of the nation's TB-control programs succeeded in reversing the upsurge in reported cases of TB disease, and case rates have declined in the subsequent 10 years (4,5). Review articles, which include primary references, are used for editorial style and brevity.
Persons infected with HIV who are already severely immunocompromised and who become newly infected with M. A survey of New York City hospitals with high caseloads of TB disease indicated 1) a decrease in the time that patients with TB disease spent in EDs before being transferred to a hospital room, 2) an increase in the proportion of patients initially placed in AII rooms, 3) an increase in the proportion of patients started on recommended antituberculosis treatment and reported to the local or state health department, and 4) an increase in the use of recommended respiratory protection and environmental controls (99). CDC-recommended TB infection-control measures are implemented in correctional facilities, and certain variations might relate to resources, expertise, and oversight (104–106). DOT is an adherence-enhancing strategy in which an HCW or other specially trained health professional watches a patient swallow each dose of medication and records the dates that the administration was observed. Part of the risk assessment is similar to a program review that is conducted by the local TB-control program (42). Additional AII rooms might be considered if options are limited for transferring patients with suspected or confirmed TB disease to other settings with AII rooms. Examples of assigning risk classifications have been provided (see Risk Classification Examples).
This classification should also be applied to HCWs who will never be exposed to persons with TB disease or to clinical specimens that might contain M. This screen should be accomplished by educating the HCW about symptoms of TB disease and instructing the HCW to report any such symptoms immediately to the occupational health unit. The details should include date of blood draw, result in specific units, and the laboratory interpretation (positive, negative, or indeterminate—and the concentration of cytokine measured, for example, interferon-gamma [IFN-?]). One was admitted directly to an AII room, and one stayed on a medical ward for 2 days before being placed in an AII room.
During the preceding year, one patient who was known to have TB disease was evaluated at the center. Approximately 30% of the agency's workers are foreign-born, many of whom have immigrated within the previous 5 years. Therefore, infection-control programs should keep all records when documenting previous test results. If transmission seems to be ongoing, consider including the HCW in the screenings every 8–10 weeks until a determination has been made that ongoing transmission has ceased.
The review should be based on the factors listed on the TB Risk Assessment Worksheet (Appendix B). HCWs who are the first point of contact should be trained to ask questions that will facilitate detection of persons who have suspected or confirmed infectious TB disease. While in the setting, symptomatic patients should wear a surgical or procedure mask, if possible, and should be instructed to observe strict respiratory hygiene and cough etiquette procedures (see Glossary) (120–122).
Generally, this method will allow patients with negative sputum smear results to be released from airborne precautions in 2 days. For example, for a hospital with 120 beds, a minimum of one AII room is needed, possibly more, depending on how many TB patients are examined in 1 year. If the alternative diagnosis cannot be clearly established, even with three negative sputum smear results, empiric treatment of TB disease should strongly be considered (see Supplement, Estimating the Infectiousness of a TB Patient). Appendix D provides representative scenarios, illustrating how state DOTs could respond in three (3) representative biohazard events. The TARU staff will coordinate with state and local officials so that the SNS assets can be efficiently received and distributed upon arrival at the site. An ACC is designed to treat patients who need inpatient treatment but do not require mechanical ventilation. These centers would provide triage and distribute medical prophylaxis, medications, and self-help information.
The state DOT will perform its resource and logistic support functions as designated in these plans. By providing information about planning techniques, strategies, and tactics, the guideline aids emergency management staffi in determining what information should be considered when creating an evacuation plan.
Different types of hazards may dictate variations in the criteria for these categories (e.g. The Provincial Emergency Operations Centre (PEOC) should be notified of an evacuation as soon as possible. CDC prepared the current guidelines in consultation with experts in TB, infection control, environmental control, respiratory protection, and occupational health. The closer the proximity and the longer the duration of exposure, the higher the risk is for being infected.
Because various interventions were implemented simultaneously, the effectiveness of each intervention could not be determined. Reports of increased implementation of recommended TB infection controls combined with decreased reports of outbreaks of TB disease in health-care settings suggest that the recommended controls are effective in reducing and preventing health-care–associated transmission of M. DOT is the standard of care for all patients with TB disease and should be used for all doses during the course of therapy for TB disease and for LTBI whenever feasible.
The TB Risk Assessment Worksheet (Appendix B) can be used as a guide for conducting a risk assessment. A contact investigation of exposed HCWs by hospital infection-control personnel in consultation with the state or local health department did not identify any health-care–associated transmission.
Risk classification: medium risk (Correctional facilities should be classified as at least medium risk). However, on annual testing, three of the 20 respiratory therapists tested had QFT-G conversions, for a rate of 15%. The person was recognized as a TB patient on his first visit and was promptly triaged to an ED with an AII room capacity. All patients are screened for TB disease upon enrollment, and airborne precautions are promptly initiated for anyone with respiratory complaints while the patient is being evaluated.
At baseline two-step testing, four had a positive initial TST result, and two had a positive second-step TST result. For example, an infection-control program using a BAMT strategy should request and keep historic TST results of a HCW transferring from a previous setting.
When the setting is reclassified back to medium-risk, annual TB screening should be resumed.
For assistance with language interpretation, contact the local and state health department. Outpatients with suspected or confirmed infectious TB disease should remain in AII rooms until they are transferred or until their visit is complete. Both the NEHC and ACC have associated transportation requirements that should be addressed in ESF#8 and the Biological Incident Annex. Department of Agriculture has similar authorities related to the inspection, confiscation and destruction of food and animal products. State DOTs will support this activity through coordinating the provision of vehicles, barricades, traffic control devices, personnel, traffic information, traffic management services, and transportation public information systems.
A community outreach function would be performed by law enforcement, firefighters, community health personnel, and other officials to link home-bound patients to these centers. This guideline aligns with the Template for the Development of a Municipal Evacuation Plan (Appendix 1).
Health-care settings include inpatient settings, outpatient settings, and nontraditional facility-based settings.
After the droplet nuclei are in the alveoli, local infection might be established, followed by dissemination to draining lymphatics and hematogenous spread throughout the body (33).
Persons with LTBI are asymptomatic (they have no symptoms of TB disease) and are not infectious.
Use of respiratory protection can further reduce risk for exposure of HCWs to infectious droplet nuclei that have been expelled into the air from a patient with infectious TB disease (see Respiratory Protection). This worksheet frequently does not specify values for acceptable performance indicators because of the lack of scientific data. All of the respiratory therapists who tested positive received medical evaluations, had TB disease excluded, were diagnosed with LTBI, and were offered and completed a course of treatment for LTBI.
While in the ambulatory-care center, the patient was held in an area separate from HCWs and other patients and instructed to wear a surgical or procedure mask, if possible. During the preceding year, seven patients who were encountered in the clinic were subsequently determined to have TB disease.
Even if the HCW is transferring from a setting that used BAMT to a setting that uses BAMT, historic TST results might be needed when in the future the HCW transfers to a setting that uses TST.
Animals and farms can also be subject to legal authorities involving isolation and quarantine.
Community outreach personnel would provide limited medical care by mobilizing citizen home care efforts and would assist in quickly distributing medical prophylaxis and self- help information. The term "health-care setting" includes many types, such as inpatient settings, outpatient settings, TB clinics, settings in correctional facilities in which health care is delivered, settings in which home-based health-care and emergency medical services are provided, and laboratories handling clinical specimens that might contain M.
QFT-G was used for infection-control surveillance purposes, and a contact investigation was conducted among exposed staff, and no QFT-G conversions were noted. All patients were promptly put into an AII room, and no contact investigations were performed. Similarly, historic BAMT results might be needed when the HCW transfers from a setting that used TST to a setting that uses BAMT.
If five of the 10 HCWs whose test results converted were among the 100 HCWs employed in the ICU of Hospital X (in Medical Center A), then the ICU setting-specific conversion rate for 2004 is 5%.
In the event that the National Guard or other agencies require clearances or waivers for vehicles, the state DOT will provide them. Acute care centers (ACC) would be established in structures close to the area hospitals to provide definitive and supportive care for acutely ill patients that exceed hospital capacity. Risk classification: medium risk (with close ongoing surveillance for episodes of transmission from unrecognized cases of TB disease, test conversions for M.
The home health-care agency is based in a major metropolitan area and delivers care to a community where the majority of persons are poor and medically underserved and TB case rates are higher than the community as a whole. Hospital patients not affected by the biohazard situation and that were not in a critical condition could be moved to other hospitals outside of the impacted area in order to provide additional hospital space for biohazard patients. The term "setting" has been chosen over the term "facility," used in the previous guidelines, to broaden the potential places for which these guidelines apply. Persons with TB pleural effusions might also have concurrent unsuspected pulmonary or laryngeal TB disease.
The problem evaluation revealed that 1) the respiratory therapists who converted had spent part of their time in the pulmonary function laboratory where induced sputum specimens were collected, and 2) the ventilation in the laboratory was inadequate.
Risk classification: low risk (because HCWs might be from populations at higher risk for LTBI and subsequent progression to TB disease because of foreign birth and recent immigration or HIV-infected clients might be overrepresented, medium risk could be considered). Mobility restriction for an affected area could also require significant re-routing of traffic around the affected area to ensure the on-going mobility for freight transportation. The state DOT appreciates the critical mission performed by the Modular Emergency Medical System during a biohazard emergency. CDC recommendations for the United States regarding QFT and QFT-G have been published (34,35). Because this field is rapidly evolving, in this report, BAMT will be used generically to refer to the test currently available in the United States. State DOTs will coordinate with state and local agencies to ensure that access routes are available for these critical resources.

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