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Occupational Expos= ure to Tuberculosis

TB Occurrence<= /b>

TB Occurrence (Con= t’d)

Why Is TB Increasi= ng?

TB Transmission

General Signs and Symptoms of TB

TB Screening

Summary of OSHA TB Enforcement Activities

Summary (Continued= )

Summary (Continued= )

Inspection
Scheduling and Scope

Inspection Schedul= ing and
Scope (Cont’d)

Inspection Schedul= ing
and Scope (Cont’d)

Inspection Schedul= ing
and Scope (Cont’d)

Inspection Procedu= res

Inspection Procedu= res (Cont’d)

Inspection Procedu= res (Cont’d)

Compliance Officer Protection

Compliance Officer Protection – Cont’d

Compliance Officer Protection – Cont’d

Citation Policy

Citation Policy (C= ont’d)

Violations=

General Duty Claus= e

General Duty Clause (Cont’d)

General Duty Clause (Cont’d)

General Duty Clause (Cont’d)

General Duty Clause (Cont’d)

High Hazard Proced= ures

Feasible and Useful Abatement Methods

Feasible and Useful
Abatement Methods (Cont’d)

Feasible and Useful
Abatement Methods (Cont’d)

Feasible and Useful
Abatement Methods (Cont’d)

Feasible and Useful
Abatement Methods (Cont’d)

Feasible and Useful
Abatement Methods (Cont’d)

Feasible and Useful
Abatement Methods (Cont’d)

Feasible and Useful
 Abatement Methods (Cont’d)

Feasible and Useful
Abatement Methods (Cont’d)

Respiratory Protec= tion

Respiratory Protec= tion (Cont’d)

Respiratory Protec= tion (Cont’d)

Respiratory Protec= tion (Cont’d)

Respiratory Protec= tion (Cont’d)

Respiratory Protec= tion (Cont’d)

Respiratory Protec= tion (Cont’d)

Respiratory Protec= tion (Cont’d)

Access to Employee
Medical and Exposure Records

Accident Prevention
   Signs and Tags

Accident Prevention
   Signs and Tags

OSHA 300 Log

What If I’m Expose= d?

What If I’m Expose= d?

What If The Skin T= est Is Negative?

What If The Skin T= est Is Positive?

Cost Does The Serv= ice Cover?

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Occupational Expos= ure to Tuberculosis
The United States = Border Patrol-San Diego Sector and

TB Occurrence<= /b>
Since 1985, the in= cidence of TB in the general population has increased 14% reversing a 30 year downward trend
In 1993, over 25,0= 00 new cases of TB were reported in the U.S.
During 1995 throug= h 1998, however, there was a decrease in TB cases in the U.S. likely due to incr= eased awareness and efforts in prevention and control of TB

TB Occurrence (Con= t’d)
Cases of multi-dru= g resistant (MDR) TB have recently been reported in 40 states
Worldwide, 8 milli= on new TB cases and 3 million deaths occur annually

Why Is TB Increasi= ng?
Multiple contribut= ing factors:
Homelessness
Intravenous drug u= se
Overcrowding in in= stitutional settings
HIV infection
Reduced TB control= and treatment resources
Immigration from h= igh TB prevalence areas

TB Transmission
Infectious disease= cause by the bacterium, Mycobacterium tuberculosis
Spread by airborne= droplets, “droplet nuclei,” 1 to 5 microns in size
Droplet nuclei gen= erated when a person with TB disease coughs, sneezes, speaks, or sing
TB infection occur= s when a susceptible person inhales droplet nuclei containing the bacteria becomes established in the body

General Signs and Symptoms of TB
Lethargy/weakness/= fatigue
Fever
Weight loss=
Persistent product= ive cough
Coughing up blood<= /font>
Loss of appetite
Night sweats

TB Screening
Mantoux tuberculin= skin test detects TB infection
Positive result in= dicate TB infection
other tests are ne= eded to confirm TB disease

Summary of OSHA TB Enforcement Activities
5/92: OSHA Region = 2 issued enforcement guidelines for occupational exposure to TB
Guidelines based o= n CDC 1990 “Guidelines for Preventing the Transmission of Tuberculosis in Health Care Settings = with Special Focus on HIV-Related Issues”
OSHA inspections r= evealed that employers have not fully implemented the CDC guidelines

Summary (Continued= )
10/93: OSHA issued= agency-wide TB enforcement policy guidelines based on the CDC 1990 guidelines. Guide= lines were effective immediately except for respirator requirements which beca= me effective 1/94
2/96: OSHA issued = agency-wide CPL 2.106, “Enforcement Procedures and Scheduling for Occupational Expos= ure to Tuberculosis” which cancels the enforcement policy guidelines<= /td>

Summary (Continued= )
CPL 2.106 is based= on CDC 1994 “Guidelines for Preventing the Transmission of Mycobacterium tuberculosi= s in Health- Care Facilities” issued 10/94
OSHA believes the = guidelines reflect an industry recognition of the hazard as well as appropriate wid= ely accepted standards of practice to be followed by employers in carrying o= ut their responsibilities the OSH Act

Inspection
Scheduling and Scope
The evaluation of = occupational exposure   to TB is conducted in response to:
Employee complaint= s;
Related fatality/c= atastrophes; or
As part of all ind= ustrial hygiene inspections conducted in workplaces identified by the CDC as hav= ing a greater incidence of TB infection than in the general population.=

Inspection Schedul= ing and
Scope (Cont’d)
CDC has identified= the following workplaces as having high incidences of TB:
Healthcare Facilit= ies
Correctional Insti= tutions
Homeless Shelters<= /font>
Long-term Care Fac= ilities for the Elderly
Drug Treatment Cen= ters

Inspection Schedul= ing
and Scope (Cont’d)
Health care facili= ties include hospitals where patients with confirmed or suspect TB are treated or to = which they are transported
Coverage of non-he= alth care setting includes only personnel present during performance of high hazard procedures on suspect or active TB patients
Dental health care= personnel are covered only if they treat suspect or active patients in a hospital, correctional facility, or as part of their practice.

Inspection Schedul= ing
and Scope (Cont’d)

Inspection Procedu= res
Procedures in the = FIRM, Chapter II, are followed except as modified in the following:
Upon entry, CSHO s= hall request the presence of infection control director and employee occupational hea= lth professional responsible for occupational hazard control
CSHO shall establi= sh whether or not the facility had a  suspect = or confirmed TB case within last 6 months to determine coverage under the O= SH Act

Inspection Procedu= res (Cont’d)
If the facility ha= s had a suspect or confirmed TB case within the previous 6 months, the CSHO shall proceed with the TB portion of the inspection
CSHO shall verify = the implementation of the employer’s plans for TB protection through employee interviews and direct observation where feasible

Inspection Procedu= res (Cont’d)
After review of th= e facility plans for worker protection, employee interviews combined with an inspec= tion of the facility shall be used to determine compliance
CSHO who perform s= moke-trail visualization tests should review protocol and be prepared to present employer with MSD for the smoke that is released on a smoke-trail visualization

Compliance Officer Protection
Area Directors or = Assistant Area Directors  shall ensure tha= t CSHOs performing TB related inspections are familiar with the CDC guidelines, terminology, and are adequately trained in health care settings
CSHO shall not ent= er occupied respiratory isolation (acid fast bacilli) rooms unless, in their determination, entry is required to document a violation

Compliance Officer Protection – Cont’d
CSHOs shall exerci= se professional judgment and extreme caution when engaging in activities th= at may involve exposure to TB
On rare occasions = when entry into potentially hazardous areas is judged necessary, CSHOs shall wear negative pressure elastomeric face piece respirators  equipped with a HEPA filter
CSHOs who conduct = TB inspections shall have been offered the TB skin test

Compliance Officer Protection – Cont’d
CSHOs exposed to an individual(s) with active infectious TB shall receive a follow-up examin= ation
If an isolation ro= om is occupied by a patient with confirmed or suspect TB or has not been adequ= ately purged when a smoke-trail is performed, then the CSHO should assume that= the isolation room is not under negative pressure
Under such circums= tances, CSHOs shall wear negative pressure HEPA respirators when performing test or en= try into room is necessary

Citation Policy
The following requ= irements apply when citing hazards found in target workplaces. Employers must com= ply with the provisions of these requirements whenever an employee may be occupationally exposed to TB:
Section 5 (a)(1) -= General Duty Clause and Executive Order 12196, Section 1-201(a) for federal facilitie= s
29 CFR 1910.134 - = Respiratory Protection

Citation Policy (C= ont’d)
29 CFR 1910.145 - = Accident Prevention Signs and Tags
29 CFR 1910.20 - A= ccess to Employee Exposure and Medical Records
29 CFR 1904 - Reco= rding and Reporting Occupational Injuries and Illnesses

Violations=

General Duty Claus= e

General Duty Clause (Cont’d)
Section 5 (a)(1) c= itations must meet the requirements outlined in the FIRM, and shall be issued only when there is no standard that applies to the particular hazard
The hazard, not th= e absence of a particular means of abatement, is the basis for a general duty clause citation
All applicable aba= tement methods identified as correcting the same hazard shall be issued under a single 5 (a)(1) citation

General Duty Clause (Cont’d)
Four required ele= ments necessary for issuing general duty clause violations include:
The employer faile= d to keep the workplace free of a hazard to which employees of that employer were expo= sed
The hazard was rec= ognized
The hazard was cau= sing or was likely to cause death or serious physical harm
There was a feasib= le and useful method to correct the hazard

General Duty Clause (Cont’d)

General Duty Clause (Cont’d)

High Hazard Proced= ures
Characterized by p= otential to generate airborne secretions
Aerosolized medica= tion treatment
Bronchoscopy
Sputum induction
Endotracheal intub= ation and suctioning
Autopsies conducte= d in hospitals

Feasible and Useful Abatement Methods
Protocol for the e= arly identification of individuals with active tuberculosis
Medical surveillan= ce
Case management of= infected employees
Worker training an= d education
Engineering contro= ls

Feasible and Useful
Abatement Methods (Cont’d)
   The protocol for the early identifi= cation of individuals with active TB shall include the following elements:
Assignment of resp= onsibility for the TB infection control program;
Conduct risk asses= sment;
Develop TB infecti= on control plan;
Periodically reass= ess risk;
Identification, ev= aluation, and treatment for patients who may have active TB

Feasible and Useful
Abatement Methods (Cont’d)
Management of pati= ents who may have TB in ambulatory-care settings and emergency departments;
Management of hosp= italized patients who may have TB;
Engineering contro= ls;
Respiratory protec= tion

Feasible and Useful
Abatement Methods (Cont’d)
Cough-inducing and aerosol-generating procedures;
Educating and trai= ning health care workers;
Evaluating health = care workers PPD test conversions and possible nosocomial transmission of M. tubercul= osis; and
Coordination of ef= forts with the public health department

Feasible and Useful
Abatement Methods (Cont’d)
Medical surveillan= ce includes:
Initial examinatio= ns for new and current employees exposed to TB
Periodic TB skin t= est evaluations; and
Reassessment of em= ployees following exposure or change in health

Feasible and Useful
Abatement Methods (Cont’d)
Case management of= infected employees includes:
Protocol for new c= onverters
Work restrictions = for infectious employees

Feasible and Useful
Abatement Methods (Cont’d)
Training and educa= tion include such issues as:
The mode of TB tra= nsmission;
TB signs and sympt= oms;
Medical surveillan= ce and therapy; and
Site specific prot= ocol

Feasible and Useful
 Abatement Methods (Cont’d)
Engineering contro= ls include:
Placement of indiv= iduals with suspected or confirmed infectious TB in a respiratory acid-fast bacilli = (AFB) isolation room;
Maintaining isolat= ion and treatment rooms under negative pressure;
Exhausting air fro= m AFB isolation or treatment rooms outside instead of recirculation into gener= al ventilation system

Feasible and Useful
Abatement Methods (Cont’d)
Engineering contro= ls (continued):
Maintaining under = negative pressure all potentially contaminated air which is ducted through the facility until it is discharges; and
Decontamination of= air from the isolation and treatment rooms before circulation back to the isolation/treatment rooms

Respiratory Protec= tion
Respirators shall = be provided by the employer when such:
equipment is neces= sary to protect the health of the employee
equipment is appli= cable and suitable for the purpose intended
  The establishment and maintenance of= the respiratory protective program shall be the responsibility of the employ= er

Respiratory Protec= tion (Cont’d)
The 1994 CDC Guide= lines specify the following criteria for respirators for exposure to TB:
Ability to filter = 1 micron in size in the unloaded state with a filter efficiency greater than 95%;
ability to be qual= itatively or quantitatively fir tested in a reliable way to obtain face-seal leakage = of less than 10%

Respiratory Protec= tion (Cont’d)
CDC Guidelines (co= ntinued):
The ability to fit= the different facial sizes and characteristics of health care workers which = can usually be met by making the respirators available in at least three siz= es
The ability to be = checked for face piece fit in accordance with OSHA standards and good industrial hyg= iene practice, by health care workers each time they put on their respirator<= /font>

Respiratory Protec= tion (Cont’d)
Under the new NIOS= H criteria, filter materials would be tested at a flow rate of 85 lpm for penetratio= n by particles with a medial aerodynamic diameter of 0.3 um and if certified = would be placed in one of the following categories:
Type 100 (99.7% ef= ficient)
Type 99 (99% effic= ient)
Type 95 (95% effic= ient)

Respiratory Protec= tion (Cont’d)

Respiratory Protec= tion (Cont’d)
Employees must wea= r HEPA or respirators certified under 42 CFR Part 84 Subpart K in the following circumstances:
When workers enter= rooms housing individuals suspected or confirmed TB disease
When workers perfo= rm high hazard procedures on persons who have suspected or confirmed TB disease<= /font>
When emergency res= ponse employees or others must transport in a closed vehicle, an individual wi= th suspected or confirmed TB disease

Respiratory Protec= tion (Cont’d)
When respiratory = protection is required, a complete respiratory protection program must be in place in accordance with 29 CFR 1910.14 (b) and include the following elements:
Written operating = procedures
Proper selection
Training and fitti= ng
Cleaning and disin= fecting

Respiratory Protec= tion (Cont’d)
Respirator program= elements (continued):
Storage
Inspection and mai= ntenance
Work surveillance<= /font>
Inspection/evaluat= ion of program
Approved respirato= rs

Access to Employee
Medical and Exposure Records
A record concernin= g employee exposure to TB is an employee exposure within the meaning of 29 CFR 1910= .1020
A record of TB ski= n test results and medical evaluations and treatments are employee medical reco= rds within the meaning of 29 CFR 1910.1020

Accident Prevention
   Signs and Tags

Accident Prevention
   Signs and Tags

OSHA 300 Log
For OSHA 300 recor= dkeeping purposes, both TB infections (positive TB skin tests) and TB disease are recordable in the high risk settings
If the employee’s = TB infection which was entered on the OSHA 300 log progresses to TB disease during th= e 5 year maintenance period, the original entry for the infection must be up= dated to reflect new information
A positive TB skin= test provided within two weeks of employment does not have to be recorded on = the OSHA 300 form

What If I’m Expose= d?
 If it is con= firmed or suspected that a detainee has TB, you need to protect your health as wel= l as those around you.  Surgical TB masks are available and the suspected person should be provided and required to wear a mask.  While volun= tary, encourage others to wear a mask.  Persons that wear a mask shall be properly fitted, trained and medically cleared  for respirator usag= e. Next you need to contact your personal health care provider or Federal Occupational Health (FOH), (619) 557-5038 and have a TB skin test perfor= med.

What If I’m Expose= d?
Ensure that you re= turn to have the test read (generally three days). This will establish a baseline that shows that you were healthy at the time of exposure.  FOH testing is cost-free. ).  Submit a CA-1 (if you know the date and time of expo= sure.  A CA-2 is utilized if your have a positive skin test during a routine screening.

What If The Skin T= est Is Negative?
If the skin teat i= s negative, you will still need to complete the necessary follow-up test.  The incubation period for TB is ten to twelve weeks after exposure.  If= the follow -up skin test is negative most likely you will not develop TB.

What If The Skin T= est Is Positive?
If the follow-up s= kin test is positive, it does not mean that you have TB. It means that you have the = TB virus in your system.  Even with the virus in your system, you may = never contract TB or become contagious.  Five to six percent of the gener= al population will have a positive skin test result.  The INS average = is four to five percent.  Schedule an appointment with your personal h= ealth care provider for a chest X-ray.  Your doctor determines if you have TB.  He will discuss treatment options and tell you if and how long= you have to be isolated.  TB is treatable and curable but you must comp= lete all medications prescribed.

Cost Does The Serv= ice Cover?
An accurate paperw= ork trail of events and medical documentation is imperative in regard to workers compensation issues.  Exposure incidents are not compensable unless= the employee develops the actual disease and the employee proves that the di= sease was a direct result of a documented work-related exposure.  Contact= the Office of Workers Compensation Program Specialist at Sector Headquarters= for guidance on workers compensation issues.

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Created by: Brian T. Henderson and William Dana         JANUARY 17, 2005
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------=_NextPart_01C51292.D12930F0 content-location: file:///C:/B0F95993/Occupational_Exposure_Tuberculosis_files/pres.xml content-transfer-encoding: quoted-printable content-type: text/xml; charset="utf-8" ------=_NextPart_01C51292.D12930F0 content-location: file:///C:/B0F95993/Occupational_Exposure_Tuberculosis_files/v3_slide0053.htm content-transfer-encoding: quoted-printable content-type: text/html; charset="windows-1252" Occupational Exposure to Tuberculosis (TB)
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Occupational Exposure to
Tuberculosis
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The United States Border Patrol-San Diego Sector and
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H1zxfrPiECO8udtsOlvCNkY+o7/jWHXRlmRVo4n69mEuap0S1Sfe73fRdF57mFfFqUfZ0lZH/9l= ------=_NextPart_01C51292.D12930F0 content-location: file:///C:/B0F95993/Occupational_Exposure_Tuberculosis_files/v3_slide0002.htm content-transfer-encoding: quoted-printable content-type: text/html; charset="windows-1252" Occupational Exposure to Tuberculosis (TB)
<= /td> <= /td>
TB Occurrence
= <= /td> = = = <= /td> =
§ Since 1985, the incidence of TB in the general population has
increased 14% reversing a 30 year downward trend
§ In 1993, over 25,000 new cases of TB were reported in the
U.S.
§ During 1995 through 1998, however, there was a decrease in
TB cases in the U.S. likely due to increased awareness and
efforts in prevention and control of TB
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content-transfer-encoding: quoted-printable content-type: text/html; charset="windows-1252" Occupational Exposure to Tuberculosis (TB)
<= /td> <= /td>
TB Occurrence (Cont’d)
= <= /td> = =
§ Cases of multi-drug resistant (MDR) TB have recently been
reported in 40 states
§ Worldwide, 8 million new TB cases and 3 million deaths
occur annually
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<= /td>
Why Is TB Increasing?
= <= /td> = = = = = =
Multiple contributing factors:
§ Homelessness
§ Intravenous drug use
§ Overcrowding in institutional settings
§ HIV infection
§ Reduced TB control and treatment resources
§ Immigration from high TB prevalence areas
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<= /td> <= /td>
TB Transmission
= <= /td> = = = = = <= /td>
§ Infectious disease cause by the bacterium, Mycobacterium
tuberculosis
§ Spread by airborne droplets, “droplet nuclei,” 1 to 5 microns
in size
§ Droplet nuclei generated when a person with TB disease
coughs, sneezes, speaks, or sing
§ TB infection occurs when a susceptible person inhales
droplet nuclei containing the bacteria becomes established in
the body
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<= /td> <= /td>
General Signs and Symptoms of TB
= <= /td> = = <= /td> = = =
§ Lethargy/weakness/fatigue
§ Fever
§ Weight loss
§ Persistent productive cough
§ Coughing up blood
§ Loss of appetite
§ Night sweats
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<= /td> <= /td>
TB Screening
= <= /td> =
§ Mantoux tuberculin skin test detects TB infection
§ Positive result indicate TB infection
§ other tests are needed to confirm TB disease
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<= /td> <= /td>
Summary of OSHA
TB Enforcement Activities
= <= /td> = = = = <= /td>
§ 5/92: OSHA Region 2 issued enforcement guidelines for
occupational exposure to TB
§ Guidelines based on CDC 1990 “Guidelines for
Preventing the Transmission of Tuberculosis in Health
Care Settings with Special Focus on HIV-Related Issues”
§ OSHA inspections revealed that employers have not fully
implemented the CDC guidelines
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<= /td> <= /td>
Summary (Continued)
= <= /td> = = <= /td> = = =
§ 10/93: OSHA issued agency-wide TB enforcement policy
guidelines based on the CDC 1990 guidelines. Guidelines
were effective immediately except for respirator
requirements which became effective 1/94
§ 2/96: OSHA issued agency-wide CPL 2.106,
“Enforcement Procedures and Scheduling for
Occupational Exposure to Tuberculosis” which cancels
the enforcement policy guidelines
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<= /td> <= /td>
Summary (Continued)
= <= /td> = = = <= /td>
§ CPL 2.106 is based on CDC 1994 “Guidelines for Preventing
the Transmission of Mycobacterium tuberculosis in Health-
Care Facilities” issued 10/94
§ OSHA believes the guidelines reflect an industry recognition
of the hazard as well as appropriate widely accepted
standards of practice to be followed by employers in carrying
out their responsibilities the OSH Act
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<= /td> <= /td>
Inspection
Scheduling and Scope
= <= /td> <= /td> = <= /td> = = <= /td> = <= /td> =
§ The evaluation of occupational exposure   to TB is
conducted in response to:
§ Employee complaints;
§ Related fatality/catastrophes; or
§ As part of all industrial hygiene inspections conducted
in workplaces identified by the CDC as having a
greater incidence of TB infection than in the general
population.
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<= /td> <= /td>
Inspection Scheduling and
Scope (Cont’d)
= <= /td> <= /td> = <= /td> <= /td> <= /td> = <= /td>
§ CDC has identified the following workplaces as having
high incidences of TB:
§ Healthcare Facilities
§ Correctional Institutions
§ Homeless Shelters
§ Long-term Care Facilities for the Elderly
§ Drug Treatment Centers
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<= /td> <= /td>
Inspection Scheduling
and Scope (Cont’d)
= <= /td> = = = = = = <= /td>
§ Health care facilities include hospitals where patients with
confirmed or suspect TB are treated or to which they are
transported
§ Coverage of non-health care setting includes only
personnel present during performance of high hazard
procedures on suspect or active TB patients
§ Dental health care personnel are covered only if they treat
suspect or active patients in a hospital, correctional
facility, or as part of their practice.
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<= /td> <= /td>
Inspection Scheduling
and Scope (Cont’d)
= <= /td>
All inspections in affected workplaces shall include a review of
employer’s plans for employee TB protection, if any. Such plans
may include the infection control program, respiratory protection,<= br>
and skin testing. Employee interviews and site observations are
an integral part of the process evaluation
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<= /td> <= /td>
Inspection Procedures
= <= /td> <= /td> = <= /td> = = = = <= /td> <= /td> <= /td>
§ Procedures in the FIRM, Chapter II, are followed except
as modified in the following:
§ Upon entry, CSHO shall request the presence of
infection control director and employee occupational
health professional responsible for occupational hazard
control
§ CSHO shall establish whether or not the facility had a
suspect or confirmed TB case within last 6 months to
determine coverage under the OSH Act
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<= /td>
Inspection Procedures (Cont’d)
= <= /td> = = <= /td>
§ If the facility has had a suspect or confirmed TB case within
the previous 6 months, the CSHO shall proceed with the TB
portion of the inspection
§ CSHO shall verify the implementation of the employer’s plans
for TB protection through employee interviews and direct
observation where feasible
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<= /td>
Inspection Procedures (Cont’d)
= <= /td> = = <= /td> = <= /td>
§ After review of the facility plans for worker protection,
employee interviews combined with an inspection of the
facility shall be used to determine compliance
§ CSHO who perform smoke-trail visualization tests should
review protocol and be prepared to present employer with
MSD for the smoke that is released on a smoke-trail
visualization
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<= /td>
Compliance Officer Protection
= <= /td> <= /td> <= /td> <= /td> <= /td>
§ Area Directors or Assistant Area Directors  shall ensure that
CSHOs performing TB related inspections are familiar with
the CDC guidelines, terminology, and are adequately trained
in health care settings
§ CSHO shall not enter occupied respiratory isolation (acid fast
bacilli) rooms unless, in their determination, entry is required
to document a violation
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<= /td>
Compliance Officer Protection – Cont’d
= <= /td> = = <= /td> = <= /td> = =
§ CSHOs shall exercise professional judgment and extreme
caution when engaging in activities that may involve
exposure to TB
§ On rare occasions when entry into potentially hazardous
areas is judged necessary, CSHOs shall wear negative
pressure elastomeric face piece respirators  equipped with a
HEPA filter
§ CSHOs who conduct TB inspections shall have been offered
the TB skin test
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<= /td>
Compliance Officer Protection – Cont’d
= <= /td> = = = = = <= /td> <= /td>
§ CSHOs exposed to an individual(s) with active infectious
TB shall receive a follow-up examination
§ If an isolation room is occupied by a patient with
confirmed or suspect TB or has not been adequately
purged when a smoke-trail is performed, then the CSHO
should assume that the isolation room is not under
negative pressure
§ Under such circumstances, CSHOs shall wear negative
pressure HEPA respirators when performing test or entry
into room is necessary
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<= /td> <= /td>
Citation Policy
= <= /td> <= /td> = <= /td> = <= /td> = <= /td> =
§ The following requirements apply when citing hazards
found in target workplaces. Employers must comply with
the provisions of these requirements whenever an
employee may be occupationally exposed to TB:
§ Section 5 (a)(1) - General Duty Clause and Executive
Order 12196, Section 1-201(a) for federal facilities
§ 29 CFR 1910.134 - Respiratory Protection
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<= /td> <= /td>
Citation Policy (Cont’d)
= <= /td> = <= /td>
§ 29 CFR 1910.145 - Accident Prevention Signs and Tags
§ 29 CFR 1910.20 - Access to Employee Exposure and
Medical Records
§ 29 CFR 1904 - Recording and Reporting Occupational
Injuries and Illnesses
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<= /td>
Violations
<= /td>
All elements listed in the citation policy section must be
addressed to ensure adequate protection of employees from
TB hazards. Violations of these OSHA requirements will
normally be classified as serious
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<= /td> <= /td>
General Duty Clause
= = =
Section 5 (a)(1) of the OSH Act states:
“Each employer shall furnish to each of his employees
employment and a place of employment which are free from
recognized hazards that are causing or are likely to cause
death or serious physical harm to his employees”
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<= /td>
General Duty Clause (Cont’d)
= <= /td> = = <= /td> = <= /td> <= /td>
§ Section 5 (a)(1) citations must meet the requirements
outlined in the FIRM, and shall be issued only when there
is no standard that applies to the particular hazard
§ The hazard, not the absence of a particular means of
abatement, is the basis for a general duty clause citation
§ All applicable abatement methods identified as correcting
the same hazard shall be issued under a single 5 (a)(1)
citation
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<= /td>
General Duty Clause (Cont’d)
= <= /td> = <= /td> = = = <= /td> <= /td> <= /td> =
   Four required elements necessary f= or issuing general
duty clause violations include:
§ The employer failed to keep the workplace free of a
hazard to which employees of that employer were
exposed
§ The hazard was recognized
§ The hazard was causing or was likely to cause death
or serious physical harm
§ There was a feasible and useful method to correct the
hazard
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<= /td> <= /td>
General Duty Clause (Cont’d)
= = <= /td> = <= /td> <= /td>
Citations shall be issued to employers with employees working
in one of the workplaces where the CDC has identified workers
as having a higher incidence of TB infection than the general
population, when the employees are not provided appropriate
protection and who have exposure as defined as:
Exposure to the exhaled air of an individual   = with
suspected or confirmed pulmonary TB    di= sease, or
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<= /td> <= /td>
General Duty Clause (Cont’d)
=
Employee exposure without appropriate protection to a high
hazard procedure performed on an individual with suspected or
confirmed infectious TB disease and which has the potential to
generate infectious airborne droplet nuclei
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<= /td> <= /td>
High Hazard Procedures
= <= /td> = = <= /td> =
§ Characterized by potential to generate airborne secretions
§ Aerosolized medication treatment
§ Bronchoscopy
§ Sputum induction
§ Endotracheal intubation and suctioning
§ Autopsies conducted in hospitals
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<= /td>
Feasible and Useful Abatement Methods
= <= /td> = <= /td> = =
§ Protocol for the early identification of individuals with
active tuberculosis
§ Medical surveillance
§ Case management of infected employees
§ Worker training and education
§ Engineering controls
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<= /td> <= /td>
Feasible and Useful
Abatement Methods (Cont’d)
= <= /td> = <= /td> = <= /td> = = =
   The protocol for the early identification of individuals with active
TB shall include the following elements:
§ Assignment of responsibility for the TB infection control program;
§ Conduct risk assessment;
§ Develop TB infection control plan;
§ Periodically reassess risk;
§ Identification, evaluation, and treatment for patients who may have
active TB
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<= /td> <= /td>
Feasible and Useful
Abatement Methods (Cont’d)
= <= /td> <= /td> =
§ Management of patients who may have TB in ambulatory-
care settings and emergency departments;
§ Management of hospitalized patients who may have TB;
§ Engineering controls;
§ Respiratory protection
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<= /td> <= /td>
Feasible and Useful
Abatement Methods (Cont’d)
= <= /td> = = <= /td>
§ Cough-inducing and aerosol-generating procedures;
§ Educating and training health care workers;
§ Evaluating health care workers PPD test conversions and
possible nosocomial transmission of M. tuberculosis; and
§ Coordination of efforts with the public health department
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<= /td> <= /td>
Feasible and Useful
Abatement Methods (Cont’d)
= <= /td> <= /td> = <= /td> = = =
§ Medical surveillance includes:
§ Initial examinations for new and current employees exposed
to TB
§ Periodic TB skin test evaluations; and
§ Reassessment of employees following exposure or change
in health
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<= /td>
Feasible and Useful
Abatement Methods (Cont’d)
= <= /td> <= /td> = <= /td> =
§ Case management of infected employees includes:
§ Protocol for new converters
§ Work restrictions for infectious employees
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<= /td>
Feasible and Useful
Abatement Methods (Cont’d)
= <= /td> <= /td> = <= /td> = = =
§ Training and education include such issues as:
§ The mode of TB transmission;
§ TB signs and symptoms;
§ Medical surveillance and therapy; and
§ Site specific protocol
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<= /td>
Feasible and Useful
 Ab= atement Methods (Cont’d)
= <= /td> <= /td> = <= /td> = = = =
§ Engineering controls include:
§ Placement of individuals with suspected or confirmed infectious
TB in a respiratory acid-fast bacilli (AFB) isolation room;
§ Maintaining isolation and treatment rooms under negative
pressure;
§ Exhausting air from AFB isolation or treatment rooms outside
instead of recirculation into general ventilation system
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<= /td> <= /td>
Fe= asible and Useful
Abatement Methods (Cont’d)
= <= /td> <= /td> = <= /td> = <= /td>
§ Engineering controls (continued):
§ Maintaining under negative pressure all potentially contaminated
air which is ducted through the facility until it is discharges; and
§ Decontamination of air from the isolation and treatment rooms
before circulation back to the isolation/treatment rooms
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<= /td> <= /td>
Respiratory Protection
= <= /td> <= /td> = <= /td> = = <= /td>
§ Respirators shall be provided by the employer when such:
§ equipment is necessary to protect the health of the employee
§ equipment is applicable and suitable for the purpose intended

  The establishment and maintenance of the respiratory
protective program shall be the responsibility of the employer
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<= /td>
Respiratory Protection (Cont’d)
= <= /td> <= /td> = <= /td> = = <= /td>
§ The 1994 CDC Guidelines specify the following criteria for
respirators for exposure to TB:
§ Ability to filter 1 micron in size in the unloaded state with a filter<= br>
efficiency greater than 95%;
§ ability to be qualitatively or quantitatively fir tested in a reliable<= br>
way to obtain face-seal leakage of less than 10%
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<= /td>
Respiratory Protection (Cont’d)
= <= /td> <= /td> = <= /td> = = = <= /td> <= /td>
§ CDC Guidelines (continued):
§ The ability to fit the different facial sizes and characteristics of
health care workers which can usually be met by making the
respirators available in at least three sizes
§ The ability to be checked for face piece fit in accordance with
OSHA standards and good industrial hygiene practice, by health
care workers each time they put on their respirator
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<= /td>
Respiratory Protection (Cont’d)
= <= /td> <= /td> = <= /td> = = =
§ Under the new NIOSH criteria, filter materials would be tested
at a flow rate of 85 lpm for penetration by particles with a
medial aerodynamic diameter of 0.3 um and if certified would
be placed in one of the following categories:
§ Type 100 (99.7% efficient)
§ Type 99 (99% efficient)
§ Type 95 (95% efficient)
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<= /td>
Respiratory Protection (Cont’d)
= <= /td> <= /td> =
The minimal acceptable level of respirator protection for
TB is the Type 95 respirator.  Cl= asses of these air
purifying, particulate respirators to be certified are
described under 42 CFR Part 84 Subpart K
Until these classes of respirators are commercially
available, the minimal acceptable respiratory protection
that meets the criteria will remain the HEPA filter
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<= /td>
Re= spiratory Protection (Cont’d)
= <= /td> <= /td> = <= /td> = <= /td> = = <= /td> <= /td>
§ Employees must wear HEPA or respirators certified under
42 CFR Part 84 Subpart K in the following circumstances:
§ When workers enter rooms housing individuals
suspected or confirmed TB disease
§ When workers perform high hazard procedures on
persons who have suspected or confirmed TB disease
§ When emergency response employees or others must
transport in a closed vehicle, an individual with
suspected or confirmed TB disease
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<= /td>
Respiratory Protection (Cont’d)
= <= /td> = <= /td> = = <= /td> = = =
   When respiratory protection is req= uired, a complete
respiratory protection program must be in place in
accordance with 29 CFR 1910.14 (b) and include the
following elements:
§ Written operating procedures
§ Proper selection
§ Training and fitting
§ Cleaning and disinfecting
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<= /td>
Respiratory Protection (Cont’d)
= <= /td> <= /td> = <= /td> = = = = =
§ Respirator program elements (continued):
§ Storage
§ Inspection and maintenance
§ Work surveillance
§ Inspection/evaluation of program
§ Approved respirators
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<= /td>
Access to Employee
Medical and Exposure Records
= <= /td> = <= /td>
§ A record concerning employee exposure to TB is an
employee exposure within the meaning of 29 CFR 1910.1020
§ A record of TB skin test results and medical evaluations and
treatments are employee medical records within the meaning
of 29 CFR 1910.1020
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<= /td> <= /td>
Accident Prevention
   Signs and Tags
------=_NextPart_01C51292.D12930F0 content-location: file:///C:/B0F95993/Occupational_Exposure_Tuberculosis_files/v3_slide0049_image005.gif content-transfer-encoding: base64 content-type: image/gif R0lGODlhsAFgAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAEABACb AVsAgAAAALKysgL/DI6py+1vnpwUxGgrPqFvrnhf2GziCHLGiIkIWsXyO1Mwcy13Le86nwIKJ75h rWUzJUxKGg7VWUqQzmAzY8xqibEcadsLA3OeUvkVXaZV69Ul2jpn5JZ13V6luuH3Ejb4tyJVJcUS yHXnZTX45+Dys5hIwydHZlcGU9mH1gYIQif5Q/fIxvZ2yTemQgioSIXV1Lna+Oakx5hna/UK2frl 6zcYBwqsS3iFgxs5JxxnLOvcW5sS61mXy3pNLWxMuyuk2Jgsbl19PG6OC8V8W9wb+IF8E79Mjgwb AlqUzU6Of/5vGz9DAwWqA3jQmz2A98Q0NGVtYTeFEBWyOJFMUDuK/+/60EP4jpcyjgE5FiFViBmn cObS+dtk8ky4YicIGoT3qqa7GSzHlczm8srGny9TCjL4MKIneY5AjrzX06m0jCoPmbwZtSnFdjat asUKSeROh0+5dbSYMGg5Lhq7JS36cWwenSRJZq2bkERbtAyBvQXLt6vYXyUJDv47ZWy0nBOzplls tnAwvnhphhzJz+s6Vnf/Rpv67apkeD6jQrbHGOhQV/Vc7Qv2EBOnfExkzR42Gmao0s2OKhVHDPgo wuqCQ12qb2Aq0KU6A/ZohhduL4b0GdeNstLjUcvBeP8OPrx48JkwE349/kh6MOjXu38PP758CJOL Sp1vwzz+xPv7+///D6AWXf1mX4COBGfgWQkuyGCDDj4IYYQSTkhhhRZeiGGGGm7IYYcefghiiCKO SKIG9CnI23/otYdIFycS+B2LPnknY4kNyvjaYBDWyN6L8/Go3xBA2pgeKUo8oklzK+kgG3d4fHJK bZNAow2SMmmS3C9O5nTlY0tCmQmWtWkUpRrbUbKHmUeeSQ+bak6pG21IPIkSnFvSZuabt33pV2Rc oaEYoM8JStk0/9gWUCwzGdYYYGppIxE1m0H66GLUMUIlk33ZMs2ksHh60SyOudWnqJhGlmhYqNr0 aF5EtaSVdJapel5Epq162UuyFqRZo6XW6mtqwO7Dqq+Rwobrr4X/ZSppnV596uyYbSB6qZytzaol ta3IlGxDLp26EipeLhOltv4wVSivNzFJJzZ0lTKbnooa2S06yqa4bq6xmhUXaxNVRdxoqVVa1r/Y KLXRwPXN5M6t9WyK78EMn6WwwcpOXG2+WqI6ow8Oo7trm/U5enHJw04Wm5/uLmxrWiq3bHFdFftI cszpjGuVa4Ga7Kq/mQrl77q+fbEaUg4Peu/BhQZddNKi3awuUaGBm1vCoZ22rbjQwosTTlB0N4yn u8GUptCpdCnWPPFW1PUpu5hrLcLdjS0bdOQOx2lcbO8mbNxwzd3r3thpPR2fRIoh35CHL26j4ow7 rh7jkk+uL+U8/yUOueWaU+js5p5/Dnrooo9Oeummn4566qqvznrrrr8Oe+w81Zh5FitmFl/tMOrY A46XC4m7f7qb6CLiHd4Oo4Ye9/ie4sPHiF97a1ZkZSdo4uPkuWKOyW6Z1pYtOJh9nalL9l97X71v 2cUZCr14WCKlJG5s5WbYU5YHh7gital/Rv3Hm748MQFiiiKUoXQ2rKZRLVLMQk2wKsasdiHlZUAD CkM2E8GpQS1nzVCOqSiDHGMZ8FdBSxS6JijCox1LhcWyIM8glptgFcw8PltgCzUmMOaAMBKtotqk 0pYslxksZD3DiNdwBsK7mOxdSrshtIhBsDzVzFaIap+xvAXDIP8m6Wmg6aHE9PQsvxhRiG+bC5J6 FjGQsDBX39KhEydGRqkdKoj2WtlzsOi0GKIwaU1LGbnOAard0XGPaFRXIGXowimibIZtPJnNFLmD EtawiW5E2M52la8+YmZm3jjk8kRISDWSsYdHkyAkK7kxUC5tVqVsIZd4aENUliddz8LaJJH2R9JM 4gmqbOAtbwaVLfItjoXrHkI6h7YnDM1++qpbPHy5J3YB8GzLWV8ih1nHMipJgGurGzZhppm54e9/ eiEn2dwUzQIlTnZfYeeNaPQ5xKxOnu7cj+6eV6HOxU6f9RTe8PDZz4AKdKAELahBD4rQhCp0oQxt qEMfCtGISnT/ohStqEUvitGManSjHO2oRz8K0pCKdKQkLalJTzqhZ5oyfDRU0yyvMaAwiidzvENR 5Gy3HufNyKY0a1HwwiO9E0KqMk8a6idFo4YgvTN5P41eTo3gO/fE9KkmOuEyN7mQmjZLiVcVhfe2 CSt0cm1J4GsfFBG0RWcOroqBGyb5zjcn/nHJNtmp5tq+eT8wvst9bmORUJHaEddchzNLKWw+CPgx Iq5lFjmsHCx1CU0GPnAubPzaM/jlJ6vtkFI7s8grjfeZhrUzVdf8iGkDBrJ6cfErfjwJxV5osbYo trNyhNVlryjIFe5UbYDNDzcL2bHMCIZoC1yhEaMoLdygknoH/ypqkkjJLVFUhZRsZFljWwXHMwJL cBdBIj31o7e3YBK1ypAkeaP2MaW+0Y46pBV2Y9uPFw5XV5i97R3ByTChSEWB6gwYYe/zNu0u1rBh w5urYJixAq13s5URSBQ1JlsEz7C29XWwFgf8KjqGV7SgLS14FwlO4FhywsC8GoeBSEKMEcqOWDPh iFc7tSyO8LqZJRVkq8tYVjnGr3gKrIFfPDanZPe8hvOmWoWjNWkC7ShnHVo3o7lkCiOnit7Uqx/S imXCmfG387XbXs+GJ4AC6KXqhJyYU9rPMw+UzK7FqeW+Ozo4XzSmkdyCmm+EoHnmGaV87rOf/wzo QAt60IQu9P9oewpUDEmvP3BM0J0lijyqWmjR9mSqoW2HROyBr6z08upaF1VO7vkvrnu7k/jMqmVj 3vWLbMOYdcJU1DlwOsukLuenpXjXuqpvzzvaZQerlGOnbQcseuMsXqAxW9No1mg4lmzNuoxiKn7Q tpIyw7RfxkG3KJFzzOGkCllNXAxvO4kcI3ct5VJuvUy3wiD2bSrPpch3fzu3XswnXVn9YB/Ky8OJ cO6qxqgdAZtQ4LBWrnR3rd2C41rV8t43g3P5ZZXGbV68ltCc9G3uH4LbyXkkJn88id40wnsv8C65 yYuby2w3EuL8afjDledrliPS5foFecv1SCtHnrzLBSE5Bh2CK258pTdmgTuqanE46Vzot9rxljln LYtLY6f2lOfWJaZKGEv7UvZhVsf4aVZedGwnDIFydvT7aH5r/G45KbOO9ab9lnbPftVuYV51cTt9 Plq4HXBtPTJeXU6396Wa7vyEObfheen+OujRwssn9BLPeDdbWnmRB8fzKs/QWO+o4hYqAAA7 ------=_NextPart_01C51292.D12930F0 content-location: file:///C:/B0F95993/Occupational_Exposure_Tuberculosis_files/v3_slide0050.htm content-transfer-encoding: quoted-printable content-type: text/html; charset="windows-1252" Occupational Exposure to Tuberculosis (TB)
<= /td> <= /td>
Accident Prevention
   Signs and Tags
=
Employers are also required to use biological hazard tags
on air transport components which identify TB hazards to
employees associated with working on air systems that
transport contaminated air
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<= /td> <= /td>
OSHA 300 Log
= <= /td> = = <= /td> = = <= /td> =
§ For OSHA 300 recordkeeping purposes, both TB
infections (positive TB skin tests) and TB disease are
recordable in the high risk settings
§ If the employee’s TB infection which was entered on the
OSHA 300 log progresses to TB disease during the 5
year maintenance period, the original entry for the
infection must be updated to reflect new information
§ A positive TB skin test provided within two weeks of
employment does not have to be recorded on the OSHA
300 form
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<= /td> <= /td>
What If I’m Exposed?
= <= /td> = = = <= /td> <= /td> <= /td> <= /td>
§  If it is confirmed or suspecte= d that a detainee has TB,
you need to protect your health as well as those around
you.  Surgical TB masks are available and the suspected
person should be provided and required to wear a
mask.  While voluntary, encourage others to wear a
mask.  Persons that wear a mask shall be properly fitted,
trained and medically cleared  for respirator usage. Next
you need to contact your personal health care provider or
Federal Occupational Health (FOH), (619) 557-5038 and
have a TB skin test performed.
------=_NextPart_01C51292.D12930F0 content-location: file:///C:/B0F95993/Occupational_Exposure_Tuberculosis_files/v3_slide0055.htm content-transfer-encoding: quoted-printable content-type: text/html; charset="windows-1252" Occupational Exposure to Tuberculosis (TB)
<= /td> <= /td>
What If I’m Exposed?
= <= /td> =
§ Ensure that you return to have the test read (generally
three days). This will establish a baseline that shows that
you were healthy at the time of exposure.  FOH testing is
cost-free. ).  Submit a CA-1 (if you know the date and time
of exposure.  A CA-2 is utilized if your have a positive skin=
test during a routine screening.
------=_NextPart_01C51292.D12930F0 content-location: file:///C:/B0F95993/Occupational_Exposure_Tuberculosis_files/v3_slide0056.htm content-transfer-encoding: quoted-printable content-type: text/html; charset="windows-1252" Occupational Exposure to Tuberculosis (TB)
<= /td>
What If The Skin Test Is Negative?
= <= /td> <= /td>
§ If the skin teat is negative, you will still need to complete
the necessary follow-up test.  The incubation period for
TB is ten to twelve weeks after exposure.  If the follow -up<= br>
skin test is negative most likely you will not develop TB.
------=_NextPart_01C51292.D12930F0 content-location: file:///C:/B0F95993/Occupational_Exposure_Tuberculosis_files/v3_slide0057.htm content-transfer-encoding: quoted-printable content-type: text/html; charset="windows-1252" Occupational Exposure to Tuberculosis (TB)
<= /td>
What If The Skin Test Is Positive?
= <= /td> = = <= /td> <= /td> = <= /td> <= /td> <= /td> = <= /td>
§ If the follow-up skin test is positive, it does not mean that
you have TB. It means that you have the TB virus in your
system.  Even with the virus in your system, you may
never contract TB or become contagious.  Five to six
percent of the general population will have a positive skin
test result.  The INS average is four to five
percent.  Schedule an appointment with your personal
health care provider for a chest X-ray.  Your doctor
determines if you have TB.  He will discuss treatment
options and tell you if and how long you have to be
isolated.  TB is treatable and curable but you must
complete all medications prescribed.
------=_NextPart_01C51292.D12930F0 content-location: file:///C:/B0F95993/Occupational_Exposure_Tuberculosis_files/v3_slide0058.htm content-transfer-encoding: quoted-printable content-type: text/html; charset="windows-1252" Occupational Exposure to Tuberculosis (TB)
<= /td>
Cost Does The Service Cover?
= <= /td> = = <= /td> <= /td> = <= /td>
§ An accurate paperwork trail of events and medical
documentation is imperative in regard to workers
compensation issues.  Exposure incidents are not
compensable unless the employee develops the actual
disease and the employee proves that the disease was a
direct result of a documented work-related
exposure.  Contact the Office of Workers Compensation
Program Specialist at Sector Headquarters for guidance
on workers compensation issues.
------=_NextPart_01C51292.D12930F0 content-location: file:///C:/B0F95993/Occupational_Exposure_Tuberculosis_files/slide0053.htm content-transfer-encoding: quoted-printable content-type: text/html; charset="us-ascii" Occupational Exposure to Tuberculosis (TB)
Occupational Exposure to Tuberculosis
The United States Border Patrol-San Diego Sector and
Another partnership project of …. =
=
The National Border Patrol Council-Local 1613= 3;
<= /span>
National Border Patrol
Council
<= /span>
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
TB Occurrence<= /div>
§= Since 1985, the incidence of TB in the general population has increased 14% reversing a 30 year downward trend&= #13;
§= In 1993, over 25,000 new cases of TB were reported in the U.S.
§= During 1995 through 1998, however, there was a decrease in TB cases in the U.S. likely due to increased awar= eness and efforts in preven= tion and control of TB
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n4XurZUh11rdRAIlhuRgAg5DfXlu3OR6Veu/GXhWCzt1OvQlkV1nECgearDGOOcjseveuRurs1r6 HVzUXr+q/wAg0jQLLQ7OaGBZFE7ZuLm4T95ct1CsBwidwmct0OM84/jrxRL4c0CbSzcRvqt4TvEL HYq5Pz4PQnvjHOOOtYur/FiK1tmtvD8MrSsu17qckbjgDdt6ZwB+VeX3d3cX11Jc3UrSzSHLOxyT XTQwkpS5qn/DnPXxSa5Y/wBf8Ey7z/Wj/doovP8AXD/dorSr8bMofCjMHSiiiuI6RU+9TpOgoopd QGUUUUwI3+9+FFFFZvcpH//Z ------=_NextPart_01C51292.D12930F0 content-location: file:///C:/B0F95993/Occupational_Exposure_Tuberculosis_files/slide0003.htm content-transfer-encoding: quoted-printable content-type: text/html; charset="us-ascii" Occupational Exposure to Tuberculosis (TB)
Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
TB Occurrence (Cont’d)
§Cases of multi-drug resistant (MDR) TB have recen= tly been reported in 40 states §Worldwide, 8 million new TB cases and 3 million d= eaths occur annually
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Why Is TB Increasing?
§Multiple contributing factors:
§Homelessness
§Intravenous drug use
§Overcrowding in institutional settings
§HIV infection
§Reduced TB control and treatment resources
§Immigration from high TB prevalence= areas
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
TB Transmissio= n
§= Infectious disease cause by the bacterium, M= ycobacterium tuberculosis&#= 13;
§= Spread by airborne droplets, “droplet nuclei,” 1 to 5 microns in size
§= Droplet nuclei generated when a person with TB disease coughs, sneezes, speaks, or sing
§= TB infection occurs when a susceptible person inhales droplet nuclei containing the bacteria becomes established in the bo= dy
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
General Signs a= nd Symptoms of TB
§= Lethargy/weakness/fatigue
§= Fever
§= Weight loss
§= Persistent productive cough
§= Coughing up blood
§= Loss of appetite
§= Night sweats
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
TB Screening
= §Mantoux tuberculin skin test detects TB infection=
= §Positive result indicate TB infection =
= §other tests are needed to confirm TB disease
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
<= span style=3D'position:absolute;top:2.14%;left:4.49%;width:79.77%;height:9.11%= '>Summary of OSHA
TB Enforcement Activities
§= 5/92: OSHA Region 2 issued enforcement guidelines for occupational exposure to TB
§= Guidelines based on CDC 1990 “Guidelin= es for Preventing the Transmission of Tuberculosis in= Health Care Settings= with Special Focus on HIV-Related Issues”
§= OSHA inspections revealed that employers have not fully implemented the CDC guidelines
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Summary (Conti= nued)
§= 10/93: OSHA issued agency-wide TB enforcement policy guidelines based on the CDC 1990 guidelines. Guid= elines were effective immediately except for respirator = requirements which became effective 1/94
§= 2/96: OSHA issued agency-wide CPL 2.106, “Enforcement Procedures and Scheduling for = Occupational Exposure to Tuberculosis” which cancels the enforcement policy guidelines
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Summary (Conti= nued)
§= CPL 2.106 is based on CDC 1994 “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health- Care Facilities” issued 10/94&#= 13;
§= OSHA believes the guidelines reflect an industry recognition of the hazard as well as appropriate widely accep= ted standards of practice to be followed by employers= in carrying out their responsibilities the OSH Act
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
<= span style=3D'position:absolute;top:2.14%;left:4.49%;width:79.77%;height:9.11%= '>Inspection
Scheduling and Scope
§The evalua= tion of occupational exposure   to TB is conducted in res= ponse to:
§Employee complaints;
§Related fatality/catastrophes; or&= #13;
§As part of all industrial hygiene inspections conducted in workplaces identified by the CDC as having a greater incidence of TB infection = than in the general population.
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
<= span style=3D'position:absolute;top:2.14%;left:4.49%;width:79.77%;height:9.11%= '>Inspection Scheduling and
Scope (Cont’d)
§= CDC has identified the following workplaces as having high incidences of TB:
§= Healthcare Facilities <= /span>
§= Correctional Institutions
§= Homeless Shelters
§= Long-term Care Facilities for the Elderly
§= Drug Treatment Centers
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
<= span style=3D'position:absolute;top:2.14%;left:4.49%;width:79.77%;height:9.11%= '>Inspection Scheduling
and Scope (Cont’d)
§= Health care facilities include hospitals where patients with confirmed or suspect TB are treated or to which t= hey are transported =
§= Coverage of non-health care setting includes only personnel present during performance of high haza= rd procedures on suspect or active TB patients <= /span>
§= Dental health care personnel are covered only if they treat suspect or active patients in a hospital, correct= ional facility, or as part of their practice.
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
<= span style=3D'position:absolute;top:2.14%;left:4.49%;width:79.77%;height:9.11%= '>Inspection Scheduling
and Scope (Cont’d)
All inspections in affected workplaces shall include a review of employer’s plans for employee TB protection, if any. Such plans may include the infection control prog= ram, respiratory protection, and skin testing. Employee interviews = and site observations are an integral part of the process evaluation
Complaints received from state and local government employees outside federal jurisdiction in federal enforcement states are referred to the appropria= te agency by the Area Office

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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Inspection Procedures
§= Procedures in the FIRM, Chapter II, are followed except as modified in the following: <= /div>
§= Upon entry, CSHO shall request the presence of infection control director and employee occupational health professional responsible for occupational hazard control
§<= span style=3D'font-size:138%;color:#B2B2B2'>CSHO shall establish whether or no= t the facility had a  suspect or confirmed TB case withi= n last 6 months to determine coverage under the OSH Act
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Inspection Procedures (Cont’d)
§If the fac= ility has had a suspect or confirmed TB case within the previous 6 months, the CSHO shall proceed wit= h the TB portion of the inspection
§CSHO shall= verify the implementation of the employer’s plans for TB protection through employee interviews and= direct observation where feasible
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Inspection Procedures (Cont’d)
§After revi= ew of the facility plans for worker protection, employee interviews combined with an inspection o= f the facility shall be used to determine compliance= 3;
§CSHO who p= erform smoke-trail visualization tests should review protocol and be prepared to present employ= er with MSD for the smoke that is rel= eased on a smoke-trail visual= ization
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Compliance Offi= cer Protection
§= Area Directors or Assistant Area Directors&nb= sp; shall ensure that CSHOs performing TB related inspections are familiar with the CDC guidelines, terminology, and are adequate= ly trained in health care settings
§= CSHO shall not enter occupied respiratory isolation (acid fast <= span style=3D'position:absolute;top:47.18%;left:9.55%;width:97.94%;height:5.09= %'>bacilli) rooms unless, in their determination, en= try is required to document a vio= lation
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Compliance Off= icer Protection – Cont’d
§CSHOs shall exercise professional judgment and extreme caution when engaging in activities that may invo= lve exposure to TB
§On rare oc= casions when entry into potentially hazardous areas is judged necessary, CSHOs shall wear negat= ive pressure elastomeric face piece respirators  equipped with a HEPA filter
§CSHOs who = conduct TB inspections shall have been offered the TB skin test
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Compliance Offi= cer Protection – Cont’d
§= CSHOs exposed to an individual(s) with active infectious TB shall receive a follow-up examination
§= If an isolation room is occupied by a patient with confirmed or suspect TB or has not been adequatel= y purged when a smoke-trail is performed, then the = CSHO should assume that the isolation room is not unde= r negative pressure
§= Under such circumstances, CSHOs shall wear negative pressure HEPA respirators when performing test or= entry into room is necessary
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Citation Polic= y
§The follow= ing requirements apply when citing hazards found in target workplaces. Employers must comply= with the provisions of these requirements whenever an = employee may be occupationally exposed to TB: = ;
§Section 5 (a)(1) - General Duty Cl= ause and Executive Order 12196, Section 1-201(a) for federal facilities
§29 CFR 1910.134 - Respiratory Prot= ection
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Citation Policy (Cont’d)
= §29 CFR 1910.145 - Accident Prevention Signs and Tags
§29 CFR 1910.20 - Access to Employee Exposure and = Medical Records §29 CFR 1904 - Recording and Reporting Occupationa= l Injuries and Illnesses
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Violations
All elements listed in the citation po= licy section must be addressed to ensure adequate protection of employees from TB hazards. Violations of these OSHA require= ments will normally be classified as serious
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
General Duty C= lause
Section 5 (a)(1) of the OSH Act states: =
“Each employer shall furnish to = each of his employees employment and a place of employment which a= re free from recognized hazards that are causing or are likely to cause= death or serious physical harm to his employees”
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
General Duty C= lause (Cont’d)
§= Section 5 (a)(1) citations must meet the requirements outlined in the FIRM, and shall be issued only wh= en there is no standard t= hat applies to the particular hazard
§= The hazard, not the absence of a particular means of abatement, is the basis for a general duty clause citation
§= All applicable abatement methods identified as correcting the same hazard shall be issued under a single 5 = (a)(1) citation
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
General Duty C= lause (Cont’d)
§<= span style=3D'color:#B2B2B2'> Four required elements necessary for issuing general duty clause violations include:
§= The employer failed to keep the wo= rkplace free of a h= azard to which employees of that employer were exposed
§= The hazard was recognized
§= The hazard was causing or was like= ly to cause death or serious physical harm
§= There was a feasible and useful me= thod to correct the hazard
§
§=
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
General Duty Clause (Cont’d)
Citations shall be issued to employers= with employees working in one of the workplaces where the CDC has identified workers as having a higher incidence of TB infection= than the general population, when the employees are not provided appropriat= e protection and wh= o have exposure as defined as:
Exposure to the exhaled air of an individual with suspected or conf= irmed pulmonary TB disease, = or
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
General Duty C= lause (Cont’d)
Employee exposure without appropriate protection to a high hazard procedure performed on an individual = with suspected or confirmed infectious TB disease and which ha= s the potential to generate infectious airborne droplet nuclei<= /span>
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
High Hazard Procedures
§= Characterized by potential to generate airborne secretions
§= Aerosolized medication treatment
§= Bronchoscopy
§= Sputum induction
§= Endotracheal intubation and suctioning
§= Autopsies conducted in hospitals
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Feasible and U= seful Abatement Methods
§= Protocol for the early identification of individuals with active tuberculosis
§= Medical surveillance
§= Case management of infected employees
§= Worker training and education
§= Engineering controls
§=
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
<= span style=3D'position:absolute;top:3.21%;left:4.3%;width:88.2%;height:8.57%'>= Feasible and Useful
Abatement Methods (Cont’= ;d)
§<= span style=3D'color:#B2B2B2'>   The protocol for the early identification of individuals with active <= /span>TB shall include the following elements:
= 3;
§= Assignment of responsibility for t= he TB infection control program;
§= Conduct risk assessment;
§= Develop TB infection control plan;=
§= Periodically reassess risk;
§= Identification, evaluation, and tr= eatment for patients who may have active TB
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
<= span style=3D'position:absolute;top:3.21%;left:4.49%;width:79.77%;height:8.57%= '>Feasible and Useful
Abatement Methods (Cont’d)
<= span style=3D'position:absolute;top:24.93%;left:9.55%;width:94.0%;height:5.09%= '>§Management of patients who may have TB in ambulat= ory-care settings and emergency departments;
§Management of hospitalized patients who may have TB;
= §Engineering controls;
= §Respiratory protection
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
<= span style=3D'position:absolute;top:3.21%;left:5.99%;width:79.77%;height:8.57%= '>Feasible and Useful
Abatement Methods (Cont’d)
§C= ough-inducing and aerosol-generating procedures;
§E= ducating and training health care workers;
§Evaluating = health care workers PPD test conversions and possible nosocomial transmission of M. tuberculosis; and
§C= oordination of efforts with the public health department
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
<= span style=3D'position:absolute;top:1.87%;left:5.99%;width:79.77%;height:8.57%= '>Feasible and Useful
Abatement Methods (Cont’d)
§M= edical surveillance includes:
§<= span style=3D'font-size:125%;color:#B2B2B2'>Initial examinations for new and c= urrent employees exposed to TB
§Periodic TB skin test evaluations; and
§Reassessment of employees following exposure or change in health
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
<= span style=3D'position:absolute;top:2.14%;left:5.99%;width:79.77%;height:9.11%= '>Feasible and Useful
Abatement Methods (Cont’d)
§C= ase management of infected employees includes:
§Protocol for new converters
§Work restrictions for infectious employees
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
<= span style=3D'position:absolute;top:2.14%;left:4.49%;width:79.77%;height:9.11%= '>Feasible and Useful
Abatement Methods (Cont’d)
§T= raining and education include such issues as:
§The mode of TB transmission; <= /span>
§TB signs and symptoms; =
§Medical surveillance and therapy; and
§Site specific protocol
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
<= span style=3D'position:absolute;top:2.14%;left:4.49%;width:79.77%;height:9.11%= '>Feasible and Useful
 Abatement Met= hods (Cont’d)
§= Engineering controls include:
§= Placement of individuals with susp= ected or confirmed infectious TB in a respiratory acid-fast bacilli (AFB) isolation room;
§= Maintaining isolation and treatmen= t rooms under negative pressure;
§= Exhausting air from AFB isolation = or treatment rooms outside instead of recirculation into general ventilation system
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
<= span style=3D'position:absolute;top:2.14%;left:5.99%;width:79.77%;height:9.11%= '>Feasible and Useful
= Abatement Methods (Cont’d)
§= Engineering controls (continued):
 = ;
§= Maintaining under negative pressur= e all potentially contaminated air which is ducted through the facility until it is discharges; and
§= Decontamination of air from the is= olation and treatment rooms before circulation back to the isolation/treatment rooms
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Respiratory Protection
§= Respirators shall be provided by the employer when such:
§= equipment is necessary to protect = the health of the employee
§= equipment is applicable and suitab= le for the purpose intended
§<= span style=3D'font-size:109%;color:#B2B2B2'>&= nbsp; The establishment and mainten= ance of the respiratory prote= ctive program shall be the responsibility of the employer
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Respiratory Protection (Cont’d)
§= The 1994 CDC Guidelines specify the following criteria for respirators for exposure to TB:
 = ;
§= Ability to filter 1 micron in size= in the unloaded state with a filter efficiency greater than 95%;
§= ability to be qualitatively or quantitatively fir tested in a reliable way to obtain face-seal leakage of= less than 10%
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Respiratory Protection (Cont’d)
§= CDC Guidelines (continued):
 = ;
§= The ability to fit the different f= acial sizes and characteristics of health care workers which can usually be met by making the= respirators available in at least = three sizes
§= The ability to be checked for face= piece fit in accordance with OSHA standards and good industrial hygiene practice, by he= alth care workers each time they put on= their respirator
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Respiratory Protection (Cont’d)
§= Under the new NIOSH criteria, filter materials would be tested at a flow rate of 85 lpm for penetration by parti= cles with a medial aerodynam= ic diameter of 0.3 um and if certified would be placed in one of the following categories:
 = ;
§= Type 100 (99.7% efficient)
§= Type 99 (99% efficient)
§= Type 95 (95% efficient)
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Respiratory Protection (Cont’d)
The minimal acceptable level of respir= ator protection for TB is the Type 95 respirator.  Classes of these air purifying, partic= ulate respirators to be certified are described under 42 CFR Part 84 Subpart K
Until these classes of respirators are commercially available, the minimal acceptable respiratory protection that meets the criteria will remain the HEPA filter
=
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Respiratory Protection (Cont̵= 7;d)
§= Employees must wear HEPA or respirators certified under 42 CFR Part 84 Subpart K in the following circumstances:
§= When workers enter rooms housing individuals suspected or confirmed TB disease
§= When workers perform high hazard procedures on persons who have suspected or confirmed TB disease
§= When emergency response employees = or others must transport in a closed vehicle, an individual with suspected or confirmed TB disease<= /span>
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Respiratory Protection (Cont’d)
§<= span style=3D'color:#B2B2B2'> When respiratory protection is required, a complete respiratory protection program must be in place i= n accordance with 29 CFR 1910.14 (b) and include th= e following elements:
 = ;
§= Written operating procedures <= /span>
§= Proper selection
§= Training and fitting
§= Cleaning and disinfecting
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Respiratory Protection (Cont’d)
§R= espirator program elements (continued):
§Storage
§Inspection and maintenance
§Work surveillance
§Inspection/evaluation of program&#= 13;
§Approved respirators=
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
<= span style=3D'position:absolute;top:2.14%;left:4.49%;width:79.77%;height:9.11%= '>Access to Employee
Medical and Exposure Records
§A record concerning employee exposure to TB is an employee exposure within the meaning of 29 CFR 1910.1020
§A record o= f TB skin test results and medical evaluations and treatments are employee medical records within the meaning of 29 CFR 1910.10= 20
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
= Accident Prevention
   Signs and Tags
In accordance with 1910.145 (f)(8), a warning shall be posted outside the respiratory isolation or treatment room or a message referring one to the nursing station f= or instruction may be posted.
1910.145 (f)(4) requires that a signal= word or biological hazard symbol may be presented as well as a major message
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Employers are also required to use biological hazard tags on air transport components which iden= tify TB hazards to employees associated with working on air sys= tems that transport contaminated air
= Accident Prevention
   Signs and Tags
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
OSHA 300 Log
§= For OSHA 300 recordkeeping purposes, both TB infections (positive TB skin tests) and TB diseas= e are recordable in the high risk settings <= /span>
§= If the employee’s TB infection which was entered on the OSHA 300 log progresses to TB disease during the = 5 year maintenance period, the original entry for t= he infection must be updated to reflect new information
§A positive TB skin test provided within two weeks of employment does not have to be recorded on the OS= HA 300 form
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
What If I̵= 7;m Exposed?
= § If it is confirmed or suspected that a detainee has TB, you need to protect your health as well as those = around you.  Surgical TB masks are available and the suspected person should be provided and required to wear a mask.  While voluntary, encourage others to wear a mask.  Persons that wear a mask shall be pro= perly fitted, trained and medi= cally cleared  for respirator usage. Next you need to contact your personal health care pro= vider or Federal Occupati= onal Health (FOH), (619) 557-5038 and have a TB skin test performed. 
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
What If I̵= 7;m Exposed?
= §Ensure that you return to have the test read (gen= erally three days). This will establish a baseline that = shows that you were healthy= at the time of exposure.  FOH testing is cost-free. ).  Submit a CA-1 (if you know th= e date and time of exposure.&nbs= p; A CA-2 is utilized if your have a positive skin test during a routine screening. 
§
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
What If The Sk= in Test Is Negative?
= §If the skin teat is negative, you will still need= to complete the necessary fo= llow-up test.  The incubation period for TB is ten to twelve weeks after exposure.  I= f the follow -up skin test is neg= ative most likely you will not develop TB. 
<= span style=3D'color:#B2B2B2;visibility:hidden'>§
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
What If The Sk= in Test Is Positive?
§= If the follow-up skin test is positive, it does not mean that you have TB. It means that you have the TB virus = in your system.  Ev= en with the virus in your system, you may never contract TB or become contagious.  Five to six percent of the general population will have a pos= itive skin test result.&nbs= p; The INS average is four to five percent.  Schedule an appointment with your personal health care provider for a chest X-ray.  Your doctor determines if yo= u have TB.  He will discuss treatment options and tell you if and how long you have to be isolated.  TB is treatable and curable but y= ou must complete all medications prescribed. 
§=
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Created by: Brian T. Henderson and William Dana       &nbs= p; JANUARY 17, 2005
Cost Does The Service Cover?
= §An accurate paperwork trail of events and medical= documentation is imperative in regard to workers = compensation issues.  Exposure incidents are= not compensable unless the employee develops the actu= al disease and the employee proves that the disease = was a direct result of a documented work-related exposure.  Contact the Office of Workers Compensation Prog= ram Specialist at Sector Headquarters for guidance on workers compensation issues.  
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Complaints received from state= and local government employees outside federal jurisdiction in federal enforc= ement states are referred to the appropriate agency by the Area Office
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aWFsOmJhc2VsaW5lOw0KCW1zby1hbnNpLWxhbmd1YWdlOkVOLVVTO30NCmE6bGluaw0KCXtjb2xv cjojQ0M2NjAwICFpbXBvcnRhbnQ7fQ0KYTphY3RpdmUNCgl7Y29sb3I6IzAwNjJDOCAhaW1wb3J0 YW50O30NCmE6dmlzaXRlZA0KCXtjb2xvcjojOTkwMDk5ICFpbXBvcnRhbnQ7fQ0K ------=_NextPart_01C51292.D12930F0 content-location: file:///C:/B0F95993/Occupational_Exposure_Tuberculosis_files/script.js content-transfer-encoding: quoted-printable content-type: application/javascript; charset="us-ascii" function LoadSld() { var sld=3DGetObj("SlideObj") if( !g_supportsPPTHTML ) { =09 sld.style.visibility=3D"visible" return } if( MakeNotesVis() ) return runAnimations =3D _InitAnimations(); =09 if( IsWin("PPTSld") ) parent.SldUpdated(GetSldId()) g_origSz=3DparseInt(SlideObj.style.fontSize) g_origH=3Dsld.style.posHeight g_origW=3Dsld.style.posWidth g_scaleHyperlinks=3D(document.all.tags("AREA").length>0) if( g_scaleHyperlinks ) InitHLinkArray() if( g_scaleInFrame||(IsWin("PPTSld") && parent.IsFullScrMode() ) ) document.body.scroll=3D"no" _RSW() if( IsWin("PPTSld") && parent.IsFullScrMode() ) FullScrInit(); =09 MakeSldVis(); ChkAutoAdv() if( runAnimations ) { if( document.all("NSPlay") ) document.all("NSPlay").autoStart =3D false; if( sld.filters && sld.filters.revealtrans ) setTimeout( "document.body.start()", sld.filters.revealtrans.duration * = 1000 ); else document.body.start(); } } function MakeSldVis()=20 { var fTrans=3Dg_showAnimation && SldHasTrans() if( fTrans )=09 { if( g_bgSound ) { idx=3Dg_bgSound.indexOf(","); pptSound.src=3Dg_bgSound.substr( 0, idx ); pptSound.loop=3D -(parseInt(g_bgSound.substr(idx+1))); } SlideObj.filters.revealtrans.Apply()=09 } SlideObj.style.visibility=3D"visible" if( fTrans ) SlideObj.filters.revealtrans.Play() } function MakeNotesVis()=20 { if( !IsNts() ) return false=20 SlideObj.style.display=3D"none" nObj =3D document.all.item("NotesObj") parent.SetHasNts(0) if( nObj ) {=20 nObj.style.display=3D"" parent.SetHasNts(1) } return 1 } function ChkAutoAdv() { if(SldHasTrans()) SlideObj.onfilterchange=3DAutoAdv else AutoAdv() } function AutoAdv() { if(!IsWin("PPTSld") || !gUseSldTimings )return var sld=3DGetCurSld() if( (sld.mAdvDelay>0) && !parent.IsFramesMode() ) setTimeout("parent.GoToNextSld()",sld.mAdvDelay) } function GetObj(id) { if(g_supportsPPTHTML) return document.all(id); else return document.getElementById(id); } function SldHasTrans() { return SlideObj.style.filter !=3D ""; } function GetSldId() { return sId=3Dlocation.href.substring(location.href.la= stIndexOf('/')+1) } function HideMenu() { if( frames["PPTSld"] && PPTSld.document.all.item("ctx= tmenu") && PPTSld.ctxtmenu.style.display!=3D"none" ) { PPTSld.ctxtmenu.styl= e.display=3D'none'; return true } return false } function IsWin( name ) { return window.name =3D=3D name } function IsNts() { return IsWin("PPTNts") } function IsSldOrNts() { return( IsWin("PPTSld")||IsWin("PPTNts") ) } function SupportsPPTAnimation() { return( navigator.platform =3D=3D "Win32"= && navigator.appVersion.indexOf("Windows")>0 ) } function SupportsPPTHTML() { var appVer=3Dnavigator.appVersion, msie=3DappVer.indexOf("MSIE "), ver=3D0 if( msie >=3D 0 ) ver=3DparseFloat( appVer.substring( msie+5, appVer.indexOf(";",msie) ) ) else ver=3DparseInt(appVer) return( ver >=3D 4 && msie >=3D 0 ) } function _RSW() { if( !g_supportsPPTHTML || IsNts() || ( !g_scaleInFrame && (!IsWin("PPTSld") || !parent.IsFullScrMode()) ) ) return var padding=3D0; if( IsWin("PPTSld") && parent.IsFramesMode() ) padding=3D6 cltWidth=3Ddocument.body.clientWidth-padding cltHeight=3Ddocument.body.clientHeight-padding factor=3D(1.0*cltWidth)/g_origW if( cltHeight < g_origH*factor ) factor=3D(1.0*cltHeight)/g_origH newSize =3D g_origSz * factor if( newSize < 1 ) newSize=3D1 s=3DSlideObj.style s.fontSize=3DnewSize+"px" s.posWidth=3Dg_origW*factor s.posHeight=3Dg_origH*factor s.posLeft=3D(cltWidth-s.posWidth+padding)/2 s.posTop=3D(cltHeight-s.posHeight+padding)/2 if( g_scaleHyperlinks ) ScaleHyperlinks( factor ) } function _InitAnimations() { animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined'; isFullScreen =3D (window.name =3D=3D "PPTSld") && !parent.IsFramesMode(); g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc= reen && parent.IsSldVisited()); if( g_animUseRuntime ) { collSeq =3D document.all.tags("seq"); if( collSeq !=3D null ) { for(ii=3D0;ii numSlds ) gSldJumpIdx =3D numSlds; if ( gSldJumpIdx >=3D 0 ) { if ( gSldJumpIdx =3D=3D 0 ) gSldJumpIdx =3D 1; var jumpTo =3D parseInt(gSldJumpIdx); gSldJump =3D 0; gSldJumpIdx =3D ""; win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref ) } } } function _KDH() { if( event.keyCode =3D=3D 8 ) { event.returnValue =3D 0; parent.GoToPrevSld(); } } function DocumentOnClick() { if( IsNts() || parent.HideMenu() ) return; if( ( g_allowAdvOnClick && !parent.IsFramesMode() ) || (event && (event.keyCode=3D=3D32) ) ) parent.GoToNextSld(); } var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""= , g_bgSound=3D"", g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser = =3D 0, gLoopCont =3D 0, gUseSldTimings =3D 1; var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w= indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va= r g_animManager =3D null; var g_animUseRuntime =3D false; var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime; var g_animMainSequence =3D null; var ENDSHOW_MESG=3D"End of slide show, click to exit.", SCREEN_MODE=3D"Fram= es", gIsEndShow=3D0, NUM_VIS_SLDS=3D55, SCRIPT_HREF=3D"script.js", FULLSCR_= HREF=3D"fullscreen.htm"; var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO= tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true window.gPPTHTML=3DSupportsPPTHTML() var gMainDoc=3Dnew Array(new hrefList("slide0053.htm",1,-1,1),new hrefList(= "slide0002.htm",1,-1,1),new hrefList("slide0003.htm",1,-1,1),new hrefList("= slide0004.htm",1,-1,1),new hrefList("slide0005.htm",1,-1,1),new hrefList("s= lide0006.htm",1,-1,1),new hrefList("slide0007.htm",1,-1,1),new hrefList("sl= ide0008.htm",1,-1,1),new hrefList("slide0009.htm",1,-1,1),new hrefList("sli= de0010.htm",1,-1,1),new hrefList("slide0011.htm",1,-1,1),new hrefList("slid= e0012.htm",1,-1,1),new hrefList("slide0015.htm",1,-1,1),new hrefList("slide= 0016.htm",1,-1,1),new hrefList("slide0017.htm",1,-1,1),new hrefList("slide0= 018.htm",1,-1,1),new hrefList("slide0019.htm",1,-1,1),new hrefList("slide00= 20.htm",1,-1,1),new hrefList("slide0021.htm",1,-1,1),new hrefList("slide002= 2.htm",1,-1,1),new hrefList("slide0023.htm",1,-1,1),new hrefList("slide0024= .htm",1,-1,1),new hrefList("slide0025.htm",1,-1,1),new hrefList("slide0026.= htm",1,-1,1),new hrefList("slide0027.htm",1,-1,1),new hrefList("slide0052.h= tm",1,-1,1),new hrefList("slide0028.htm",1,-1,1),new hrefList("slide0029.ht= m",1,-1,1),new hrefList("slide0030.htm",1,-1,1),new hrefList("slide0031.htm= ",1,-1,1),new hrefList("slide0032.htm",1,-1,1),new hrefList("slide0033.htm"= ,1,-1,1),new hrefList("slide0034.htm",1,-1,1),new hrefList("slide0035.htm",= 1,-1,1),new hrefList("slide0036.htm",1,-1,1),new hrefList("slide0037.htm",1= ,-1,1),new hrefList("slide0038.htm",1,-1,1),new hrefList("slide0039.htm",1,= -1,1),new hrefList("slide0040.htm",1,-1,1),new hrefList("slide0041.htm",1,-= 1,1),new hrefList("slide0042.htm",1,-1,1),new hrefList("slide0043.htm",1,-1= ,1),new hrefList("slide0044.htm",1,-1,1),new hrefList("slide0045.htm",1,-1,= 1),new hrefList("slide0046.htm",1,-1,1),new hrefList("slide0047.htm",1,-1,1= ),new hrefList("slide0048.htm",1,-1,1),new hrefList("slide0049.htm",1,-1,1)= ,new hrefList("slide0050.htm",1,-1,1),new hrefList("slide0051.htm",1,-1,1),= new hrefList("slide0054.htm",1,-1,1),new hrefList("slide0055.htm",1,-1,1),n= ew hrefList("slide0056.htm",1,-1,1),new hrefList("slide0057.htm",1,-1,1),ne= w hrefList("slide0058.htm",1,-1,1)); /********************************************* Frameset functions These functions control slide navigation and state of the frameset. **********************************************/ function FullScrInit() { g_allowAdvOnClick =3D GetCurSld().mAdvOnClk document.body.style.backgroundColor=3D"black" document.oncontextmenu=3Dparent._CM; document.onkeydown =3D _KDH; document.ondragstart=3DCancel document.onselectstart=3DCancel self.focus() } function Redirect( frmId ) {=09 var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId() if(idx>=3D0) str=3Dstr.substr(1); if( window.name !=3D frmId && ( sId !=3D str) ) { obj =3D GetObj("Main-File") window.location.href=3Dobj.href+"#"+sId return 1 } return 0 } var MHTMLPrefix =3D CalculateMHTMLPrefix();=20 function CalculateMHTMLPrefix() { if ( document.location.protocol =3D=3D 'mhtml:') {=20 href=3Dnew String(document.location.href)=20 Start=3Dhref.indexOf('!')+1=20 End=3Dhref.lastIndexOf('/')+1=20 if (End < Start)=20 return href.substring(0, Start)=20 else=20 return href.substring(0, End)=20 } return ''; } function GetTags(base,tag) { if(g_supportsPPTHTML) return base.all.tags(tag); else return base.getElementsByTagName(tag); } function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP= refix+GetHrefObj( gCurSld ).mNtsHref ) } function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() } function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() } function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() } function SetHasNts( fVal ) { if( gHasNts !=3D fVal ) { gHasNts=3DfVal UpdNavPane() } } function ToggleOtlText() { gOtlTxtExp=3D!gOtlTxtExp UpdOtlPane() } function ClearMedia() { // Clear any sounds playing before launching another browser window. Other= wise, // in fullscreen mode, you'll continue to hear the sound in the frames mod= e. if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0; } function FullScreen() {=20 if ( PPTSld.g_animUseRuntime ) PPTSld.document.body.pause(); ClearMedia(); var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF = : FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref; if(PPTNav.event.ctrlKey) { var w =3D (window.screen.availWidth * 1.0) / 2.0 var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top= =3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } else { win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } } function ToggleVNarration() { rObj=3DPPTSld.document.all("NSPlay") if( rObj && !PPTSld.g_animUseRuntime ) { if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) ) rObj.Play() else if( rObj.playState =3D=3D 2 ) rObj.Pause() else return; } else if( PPTSld.g_animUseRuntime ) { narObj =3D PPTSld.document.all("narrationID") if( narObj ) narObj.togglePause() } } function GetCurSldNum() { =20 obj=3DGetHrefObj(gCurSld) if( obj.mOrigVis =3D=3D 1 ) return obj.mSldIdx else =20 return gCurSld } function GetNumSlds() { =20 if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 ) return GetSldList().mNumVisSlds; else return GetSldList().mList.length } function GetSldNum( href ) { for(ii=3D0; ii 1 ) PopSldList(); else if( !IsFramesMode() ) { if( gLoopCont ) GoToFirst() else EndShow() } } function GoToPrevSld() { ii=3DgCurSld-1 if( ii > 0 ) { obj=3DGetHrefObj(ii) while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) ) obj=3DGetHrefObj(--ii) if( ii =3D=3D 0 ) ii=3D1 GoToSldNum(ii) } } function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) } function GoToLast() { ii=3DGetSldList().mList.length if( ii !=3D gCurSld ) GoToSld( GetHrefObj(ii).mSldHref ) } function GoToSldNum( num ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue obj =3D GetHrefObj( num ) obj.mVis=3D1 gPrevSld=3DgCurSld gCurSld =3D num; PPTSld.location.replace(MHTMLPrefix+obj.mSldHref) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function GoToSld( href ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue GetHrefObj( GetSldNum(href) ).mVis=3D1 PPTSld.location.replace(MHTMLPrefix+href) } function SldUpdated( id ) { if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return gPrevSld=3DgCurSld gCurSld=3DGetSldNum(id) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) } function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO= bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) } function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) } function CloseWindow() { if( HideMenu() ) return; =09 var event =3D PPTSld.event; if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D= =3D32 || event.type=3D=3D"click" ) ) window.close( self ); CatchNumKeys( self, event ); } function Unload() { gIsEndShow=3D0; } function SetupEndShow() { gIsEndShow=3D1; PPTSld.document.body.scroll=3D"no"; PPTSld.document.onkeypress=3DCloseWindow; PPTSld.document.onclick=3DCloseWindow; PPTSld.document.oncontextmenu=3D_CM; } function EndShow() { if( IsFramesMode() ) return if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue doc=3DPPTSld.document var dir =3D doc.body.dir if( dir !=3D "rtl" ) dir =3D "ltr"; doc.open() doc.writeln('


' + ENDSHOW_MESG + '

') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 0) { PushSldList(sldList,fEnd); gCurSld =3D 1; } else if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue } function PushSldList(arr,fEnd) { var ii =3D gSldStack.length; gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd); GoToSld( gSldStack[ii].mList[0].mSldHref ); } function PopSldList() { if (gSldStack[gSldStack.length-1].fEndShow) EndShow() else { gCurSld =3D gSldStack[gSldStack.length-1].mCurSld; gSldStack[gSldStack.length-1] =3D null; gSldStack.length--; var sldList =3D gSldStack[gSldStack.length-1]; GoToSld( sldList.mList[gCurSld - 1].mSldHref ); } } var custShowList=3Dnew Array(); /********************************************* Navigation button implementation There are 2 types of buttons: ImgBtn, TxtBtn implemented as function objects. They share a similiar interface so the event handlers can call SetActive, for example, on a button=20 object without needing to know exactly=20 what type of button it is. **********************************************/ //---------------------------------- function ImgBtn( oId,bId,w,action ) //---------------------------------- { var t=3Dthis t.Perform =3D _IBP t.SetActive =3D _IBSetA t.SetInactive=3D _IBSetI t.SetPressed =3D _IBSetP t.SetDisabled=3D _IBSetD t.Enabled =3D _IBSetE t.ChangeIcon =3D null t.UserAction =3D action t.ChgState =3D _IBUI t.mObjId =3D oId t.mBorderId=3D bId t.mWidth =3D w t.mIsOn =3D t.mCurState =3D 0 } function _IBSetA() { if( this.mIsOn ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _IBSetI() { if( this.mIsOn ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0=20 } } function _IBSetP() { if( this.mIsOn ) { obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 ) obj.style.posLeft+=3D1; obj.style.posTop+=3D1 } } function _IBSetD() { =20 obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 ) obj.style.posTop=3D0=20 } function _IBSetE( state ) { var t=3Dthis GetObj( t.mBorderId ).style.visibility=3D"visible" if( state !=3D t.mIsOn ) { t.mIsOn=3Dstate if( state ) t.SetInactive() else t.SetDisabled() } } function _IBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( t.ChangeIcon ) { obj=3DGetObj(t.mObjId) if( t.ChangeIcon() ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth else obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth } t.SetActive() } =20 } function _IBUI( clr1,clr2,nextState ) { var t=3Dthis SetBorder( GetObj( t.mBorderId ),clr1,clr2 ) obj=3DGetObj( t.mObjId ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj= .style.posTop t.mCurState=3DnextState return obj } //----------------------------------------- function TxtBtn( oId,oeId,action,chkState ) //----------------------------------------- { var t=3Dthis t.Perform =3D _TBP t.SetActive =3D _TBSetA t.SetInactive=3D _TBSetI t.SetPressed =3D _TBSetP t.SetDisabled=3D _TBSetD t.SetEnabled =3D _TBSetE t.GetState =3D chkState t.UserAction =3D action t.ChgState =3D _TBUI t.mObjId =3D oId t.m_elementsId=3D oeId t.mIsOn =3D 1 } function _TBSetA() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gHiliteClr,gShadowClr,0,0 ) } function _TBSetI() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) } function _TBSetP() { if( this.mIsOn ) this.ChgState( gShadowClr,gHiliteClr,1,1 ) } function _TBSetD() { =20 this.ChgState( gFaceClr,gFaceClr,0,0 ) this.mIsOn =3D 0 } function _TBSetE() { var t=3Dthis if( !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) else t.ChgState( gShadowClr,gHiliteClr,1,1 ) t.mIsOn =3D 1 } function _TBP() { var t=3Dthis if( t.mIsOn ) {=20 if( t.UserAction !=3D null ) t.UserAction() if( !t.GetState ) return if( t.GetState() ) t.SetPressed() else t.SetActive() } =20 } function _TBUI( clr1,clr2,lOffset,tOffset ) { SetBorder( GetObj( this.mObjId ),clr1,clr2 ) Offset( GetObj( this.m_elementsId ),lOffset,tOffset ) } function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle= ft } function SetBorder( obj, upperLeft, lowerRight ) { s=3Dobj.style; s.borderStyle =3D "solid" s.borderWidth =3D 1=20 s.borderLeftColor =3D s.borderTopColor =3D upperLeft s.borderBottomColor=3D s.borderRightColor =3D lowerRight } function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] } function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() } function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() } function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() } function BtnOnUp() { b=3DGetBtnObj() if( b !=3D null ) b.Perform() else Upd() } function GetNtsState(){ return parent.gNtsOpen } function GetOtlState(){ return parent.gOtlOpen } function GetOtlTxtState(){ return parent.gOtlTxtExp } function NtsBtnSetFlag( fVal ) { s=3Ddocument.all.item( this.m_flagId ).style s.display=3D"none" if( fVal ) s.display=3D"" else s.display=3D"none" } function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etActive() } function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etInactive() } function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etPressed() } function _BSetA_BorderImg() {=20 b =3D gBtnArr[this.mBorderId]=20 if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _BSetI_BorderImg() {=20 b =3D gBtnArr[this.mBorderId] if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"= THREEDFACE" var gBtnArr =3D new Array() gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan= e,GetOtlState ) gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt= lPane,GetOtlState ) gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN= tsPane ) gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg; gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg; gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.= ToggleNtsPane,GetNtsState ) gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To= ggleNtsPane,GetNtsState ) gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n= b_prevBorder",30,parent.GoToPrevSld ) gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n= b_nextBorder",30,parent.GoToNextSld ) gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent= .FullScreen ) gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa= rent.FullScreen,null ) gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border; gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent= .FullScreen,null ) gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border; gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice= ","nb_voiceBorder",18,parent.ToggleVNarration ) gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT= xt","nb_otlTxtBorder",23,parent.ToggleOtlText ) gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts" gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState /********************************************* Context menu implementation _CM() is the function that's hooked up to the oncontextmenu event. Once we're asked to show the menu, we first build it by creating DIVs on-the-fly. Then we position it=20 within the screen area so it doesn't get clipped. Creating the DIVs using createElement() means we don't have to write out any extra HTML into the slide HTML files. **********************************************/ var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr= row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval" function ShowMenu() { BuildMenu(); var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y= =3DPPTSld.event.clientY+doc.scrollTop m =3D PPTSld.document.all.item("ctxtmenu") m.style.pixelLeft=3Dx if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) ) m.style.pixelLeft=3Dx-m.scrollWidth m.style.pixelTop=3Dy if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) ) m.style.pixelTop=3Dy-m.scrollHeight m.style.display=3D"" } function _CM() { if( !parent.IsFullScrMode() ) return; if(!PPTSld.event.ctrlKey) { ShowMenu() return false } else HideMenu() } function BuildMenu() { if( PPTSld.document.all.item("ctxtmenu") ) return var mObj=3DCreateItem( PPTSld.document.body ) mObj.id=3D"ctxtmenu" mObj.style.visibility=3D"hidden" var s=3DmObj.style s.position=3D"absolute" s.cursor=3D"default" s.width=3D"120px" SetCMBorder(mObj,"menu","black") var iObj=3DCreateItem( mObj ) SetCMBorder( iObj, "threedhighlight","threedshadow" ) iObj.style.padding=3D2 CreateMenuItem( iObj,sNext,M_GoNextSld,M_True ) CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld ) =09 CreateSeparator( iObj ) CreateMenuItem( iObj,sEnd,M_End,M_True ) mObj.style.visibility=3D"visible" } function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa= lue=3Dfalse } function Highlight() { ChangeClr("activecaption","threedhighlight") } function Deselect() { ChangeClr("threedface","menutext") } function Perform() { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) e.Action() else PPTSld.event.cancelBubble=3Dtrue } function ChangeClr( bg,clr ) { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) { e.style.backgroundColor=3Dbg e.style.color=3Dclr } } function M_HasPrevSld() { return( parent.HasPrevSld() ) } function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() } function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();= PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() } function M_True() { return true } function M_End() { window.close( self ) } function CreateMenuItem( node,text,action,eval ) { var e=3DCreateItem( node ) e.type=3D"menuitem" e.Action=3Daction e.IsActive=3Deval e.innerHTML=3Dtext if( !e.IsActive() ) e.style.color=3D"threedshadow" e.onclick=3DPerform e.onmouseover=3DHighlight e.onmouseout=3DDeselect s=3De.style; 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charset="us-ascii" Occupational Exposure to Tuberculosis (TB) ------=_NextPart_01C51292.D12930F0 content-location: file:///C:/B0F95993/Occupational_Exposure_Tuberculosis_files/outline.htm content-transfer-encoding: quoted-printable content-type: text/html; charset="us-ascii"
 N= otes
Slide Show
Outline
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------=_NextPart_01C51292.D12930F0 content-location: file:///C:/B0F95993/Occupational_Exposure_Tuberculosis_files/filelist.xml content-transfer-encoding: quoted-printable content-type: text/xml; charset="utf-8" ------=_NextPart_01C51292.D12930F0--