Public Health Department Policy & Procedure Manual Example

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Pepin County Health Department will require all persons with suspect or confirmed infectious or high-risk tuberculosis to exercise all reasonable airborne precautions to prevent the spread of infection to others. Pepin County Health Department will ensure that airborne precautions and isolation are provided for persons who have suspect or confirmed infectious or high-risk tuberculosis if the Health Officer decides these measures are necessary to protect others from becoming infected. If persons can be safely maintained in their own environments without being a danger to the health of the public, this will be encouraged and supported.

Pepin County Health Department will work closely with the Wisconsin Division of Public Health Tuberculosis Program to determine the need for airborne precautions and isolation of persons with suspect or confirmed infectious or high-risk tuberculosis. The health department will work collaboratively with local medical providers, hospitals, nursing homes and others to ensure appropriate precautions and potential placement of individuals who cannot be maintained at home, in order to prevent transmission of tuberculosis to uninfected persons and to protect the health of the public.


  1. Evaluate the risk of tuberculosis transmission immediately upon receiving the verbal or written notification that an individual has been identified as having suspect or confirmed infectious tuberculosis or high-risk tuberculosis. This evaluation will be conducted using the Tuberculosis Transmission Risk Assessment Form (appendix A).

  1. Public Health staff who will have contact with the individual will have been

trained and will be competent in using protective measures.

  1. Assess the individual’s environment for factors that increase the risk of tuberculosis transmission to susceptible persons.

  1. Determine if the individual lives in a congregate setting with others that share the same air. The following types of settings are considered high risk for transmission of tuberculosis:

  • Correctional institutions

  • Hospitals

  • Nursing homes

  • Mental institutions

  • Drug treatment centers

  • Homeless shelters

  • Living accommodations, including apartment and/or single room occupancy hotels, if air is shared in common areas through the building ventilation system.

  1. If the individual lives in a congregate setting, assess for engineering controls such as isolation rooms with negative pressure. An isolation room for airborne precautions must vent directly to the outside air and have a minimum of six to twelve air exchanges per hour of non-recirculated or HEPA-filtered air. The ventilation system that includes the isolation room should be designated and maintained by a professional with expertise in engineering or by consultation with a person with such expertise.
  2. Determine if the individual lives with or has other close contact with persons at greater risk for TB disease, i.e. children under 4 years of age or immuno-suppressed persons (see Conducting Comprehensive Contact and Source Case Investigations Policy/Procedure).

  3. Determine if the individual provides services to members of high-risk groups.

  1. Assess for individual factors that influence the person’s ability to establish adherence to isolation/airborne precautions, such as:

  1. Substance abuse.

  2. Mental or emotional problems.

  3. Chronic medical conditions that will increase the risk of transmission of tuberculosis, such as the need for dialysis, medical follow-up appointments, etc.

  4. Limited insight, understanding or acceptance of having tuberculosis disease, especially their understanding of the ability to transmit TB to others.

  5. Previous treatment failures for tuberculosis, either for active TB disease or latent TB infection, increase the risk of repeated failures.

  6. Informal supports are essential to assist the individual to maintain airborne precautions and to remain in isolation while getting their basic physiological and emotional needs met whether they will be in isolation at home or in an institution (grocery shopping, laundry, bill paying, medical or other appointments, obtaining medication, maintaining relationships, etc.).

  7. Other priorities that the person is accustomed to may impact their ability or willingness to adhere to airborne precautions and/or medication therapy, such as having to maintain a strict diabetic or renal diet. Other issues include drug interactions such as the effect of Rifampin, which diminishes the effectiveness of multiple important medications (anticonvulsants, analgesics, theophylline, digitalis, oral contraceptives and others).

  1. Determine the appropriateness of the living situation for this individual based on your assessment and by using the Tuberculosis Transmission Risk Assessment Form.

  1. Upon completion of the risk assessment, discuss findings with public health administration/Health Officer regarding necessary action.

  2. In the event the current living situation is not appropriate (e.g. congregate living site, or site where there is shared air through the building ventilation system or where infants and young children also reside), Public Health will assist with arrangements and referrals necessary to secure an alternative living environment.

  3. Consult with the Wisconsin Tuberculosis Program for any questions regarding placement/housing of individuals when questions arise about transmission risk. This may help prevent transmission issues or it may help prevent the implementation of any unnecessary isolation/airborne precautions.

  1. Assess knowledge and provide information on tuberculosis disease and the need for isolation to the individual and any other relevant persons. Ensure sufficient early understanding to ascertain that they will maintain isolation/airborne precautions. Expand details of teaching and care as case management proceeds.

  1. Provide basic education about tuberculosis, including the following information:

  • The disease process as relevant to the person with a new initial diagnosis adjusting to isolation (give more details later as the person adjusts).

  • The airborne nature of transmission and the risk to others with close, prolonged contact, including visitors coming in or if the person goes out where there are other people.

  • The importance of covering mouth and nose when coughing and sneezing. A mask worn by someone with tuberculosis does not protect others.

  • Review with the individual facts on M. tuberculosis giving appropriate written materials in the person’s own language and/or with use of a good interpreter.
  • Give sufficient time for the person, family and other involved people to ask all questions.

  1. Individualize and review the plan for care until it is safe, yet workable for the individual and he/she demonstrates satisfactory recall and/or verbalizes the intent to adhere to the plan. If there are any issues with the medical treatment plan, consult the physician and problem-solve to meet both the necessary medical treatment goals and the needs of the individual. A verbal or written contract for adherence to the required behaviors and actions may help the person and the family to understand what is expected and may help public health staff as well. See appendix B, Voluntary Isolation Contract.

  • Review and instruct the person regarding the medication regimen using ample feedback and questions to evaluate understanding.

  • Liberally use directly observed therapy, pill minders, visits, etc.

  • Stress the importance of taking all the medications.

  • Provide information about changes in signs and symptoms to report.

  • Provide at least one contact name and phone number for the person to call.

  • Obtain one or two contact names and phone numbers from the person in case you find them gone from home (someone who would know if they went to the hospital unexpectedly).

  • Stress the individual’s role in adhering to the medical regimen and isolation plan.

  1. Inform the person and family about the control measures to prevent transmission and determine which ones are needed for this person in this environment. Listen to their concerns and priorities so you can support them and enable all of them to adhere to the necessary restrictions and still “have a life.”

  2. Stress the importance of staying at home or at another agreed upon location. Continually assess and evaluate the individual’s knowledge about the meaning and importance of isolation.

  3. Place emphasis on the importance of excluding previously unexposed persons until non-infectious.

  4. Identify personal and service needs required to support the individual in isolation (grocery shopping, laundry, mail, medical or other appointments, obtaining medication, etc.). Provide case management as necessary to meet these needs as well as psychosocial, emotional and spiritual needs.

  5. Discuss activities that the individual can safely do without exposing unexposed people (such as walking outside if it presents no risk) and help them to cope with issues related to isolation and airborne precautions. Help them determine with whom contact is acceptable and instruct them in how to safely accept limited visitors who are approved by the Health Officer. Work with the individual to determine other ways to maintain contact with significant others who cannot visit until the infectious period is over.

  6. Use all available means, including incentives and enablers, to promote cooperation and enhance the quality of life, as well as adherence. Discuss incentives and enablers with the individual to identify those that will promote cooperation (e.g. food, personal items, books, videotapes, toys).

  1. Assure that the individual maintains isolation/airborne precautions.

  1. The Health Officer or her designee shall visit the individual as often as necessary to monitor the clinical condition, evaluate for medication side effects, ensure medication adherence, and to monitor individuals for adherence with isolation [HFS 145.09(9)]. This may include unannounced visits to assess adherence to isolation. The individuals shall be visited at least every seven days.
  2. Re-evaluate the care plan and the medical treatment plan, consulting the physician for any medical issues, to ensure that it is least disruptive to the individual’s life and still supports the goals of individual treatment and protection of the community.

  1. Evaluate the need for the Health Officer to issue an isolation or confinement order if the person does not voluntarily maintain isolation/airborne precautions. Refer to the TB – Confinement policy/procedure if necessary.

  1. Confirm and document date and circumstances of incidents indicating non-adherence such as: individual does not voluntarily remain isolated and/or allows unauthorized outside visitors.

  2. Notify the Health Officer promptly of the individual’s non-adherence to the isolation plan, discuss and problem-solve regarding the circumstances surrounding the non-adherent activity and evaluate the risk of transmission that may have occurred.

  1. Re-evaluate the appropriateness of the current living situation.

  2. Evaluate the benefits of issuing a written Health Officer isolation order and evaluate the need to progress to the legal actions of Health Officer or court-ordered confinement.

  3. Explain that further non-adherence will lead to further legal action to protect the health of others. It may be a good time to check lab findings to see if the individual is still infectious.

  4. The local Health Officer should consult with legal counsel regarding possible legal action and move forward with 72-hour Health Officer confinement and subsequent court-ordered confinement if indicated. The Health Officer may also proceed directly with a request for court-ordered confinement if appropriate. This step can always be used if the person presents a risk to the health of the public, even though they may not be infectious.
  1. Consult with the Wisconsin Tuberculosis Program regarding the need for isolation/confinement whenever necessary. There is a communicable disease epidemiologist in the Division of Public Health available after hours to receive emergency calls at (608) 258-0099. Non-emergency calls, including calls to report a case of active tuberculosis, are taken during regular business hours, 7:45 AM to 4:30 PM, Monday through Friday, except holidays, at (608) 267-3733.

  1. Assess the costs associated with implementing isolation/airborne precautions and determine sources of payment per Wisconsin Statute 252.06(10) and 252.07 (10).

  1. If the person is placed in the jurisdiction of another health department, the original health department retains responsibility for services and costs.

  2. Determine third party payers that may be appropriate for the individual.

  3. Discuss with Social Services whether the person may be eligible for the Medical Assistance TB Benefit.

  4. Provide other personnel who may become involved with the case information about infection control/airborne precautions.

  5. Expenses for necessary medical care, food and other articles needed for the care of the infected person shall be charged against the person or whoever is liable for the person’s support [Wisconsin Statute 252.06(10)].

  6. The county in which a person with a communicable disease resides is liable for the following costs accruing under this section, unless the costs are payable through 3rd party liability or through any benefit system:

  • The expense of employing guards [Wisconsin Statute 252.06(5)].

  • The expense of enforcing isolation in the confinement area [Wisconsin Statute 252,06(10)(b)].

  • The expense of conducting examinations under the direction of the Health Officer [Wisconsin Statute 252.06(10)(b)].
  1. For inpatient care of isolated pulmonary tuberculosis patients and inpatient care exceeding 30 days for other pulmonary tuberculosis patients, that is not covered by Medicare, Medical Assistance or private insurance, reimbursement may be requested from the Department of Health and Family Services. Details must be worked out with the Wisconsin Tuberculosis Program.

  1. The local Health Officer shall issue an Isolation Order whenever indicated.

  1. Write the isolation order to fit the individual circumstances, keeping the treating physician involved and well informed. See appendix C, Sample Isolation Order. The isolation order must specify:

  • Current disease status and basis.

  • Statutory authority for isolation order and required control measures.

  • Expectations and conditions of isolation.

  • Statutory basis and legal steps to be taken if the patient fails to comply with the isolation order.

  1. Specify, in writing, who can remain in the home or visit while the individual is under the isolation order.

  2. Have the order reviewed by legal counsel.

  3. The Health Officer or her designee will serve the isolation order.

  • Create two originals, with the Health Officer signing both.

  • Serve the isolation order.

  • Obtain the individual’s signature (parent/guardian for minors) and a signature of an adult witness on both forms.

  • Provide the individual with an original signed order and keep the other original signed order for the record.

  1. Assure that the individual maintains the Isolation Order by follow-up visits and rapport building as well as unannounced visits to ensure adherence to isolation.

  1. Release from isolation.

  1. In accordance with HFS 145.10, ALL of the following conditions must be met:

  1. An adequate course of chemotherapy has been administered for a minimum of two weeks, and

  2. There is clinical evidence of improvement, and
  3. Sputum or bronchial secretions are free of acid-fast bacilli, and

  4. Specific arrangements have been made for post-isolation care, and

  5. The individual is considered by the Health Officer not to be a threat to the general public and likely to comply with the remaining treatment regimen.

  1. Exceptions to the above conditions for the release of the individual from isolation must be discussed with the Wisconsin Tuberculosis Program.

  2. For individuals who are under an isolation order, provide notification and a release from isolation order when no longer infectious (see appendix D, Sample Release from Isolation Order).

  • Write the release from isolation order to fit individual circumstances.

  • Involve legal counsel for this process.

  • Create two originals of the release order; the Health Officer must sign both.

  • Take both to the individual for signatures.

  • Provide an original to the individual and keep one for the record.

  1. Continue case management and follow-up care until prescribed therapy is completed and continue to work closely with the Wisconsin Tuberculosis Program for regular case reviews.

Annual review of implementation of policy and procedure to assess the need for modifications to improve quality or efficiency of program.


The local Health Officer may require isolation if it is suspected or confirmed that someone has a communicable disease [Wis. Stats. 252.06]. The Health Officer has statutory responsibility to investigate and enforce any rules promulgated by the Department of Health and Family Services to prevent or control the transmission of M. tuberculosis [HFS 145]. Under Wisconsin Statute Chapter 252.07(5) the Health Officer is to investigate, make and enforce the necessary orders for any person with suspected or known infectious or high-risk tuberculosis. If any person does not voluntarily comply with an isolation order issued by the Health Officer, the Health Officer will take further legal actions to confine the person. See “TB – Confinement” policy and procedure.

POLICY TITLE: TB – Sputum Testing



AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director

  1. To ensure that specimens for tuberculosis, particularly sputum specimens, are collected and tested promptly and accurately for all persons who are in the jurisdiction of the health department.

  2. To ensure that persons with confirmed or suspected tuberculosis receive proper care and services and that the health of the public is protected.

The Pepin County Health Department will ensure that specimens for tuberculosis (TB) testing for persons who are within the jurisdiction of the health department are collected, tested and reported promptly and accurately. The collection, submission and testing are to be done according to standard protocols established by the Centers for Disease Control and Prevention (CDC), the Wisconsin TB Program and the Wisconsin State Lab of Hygiene.

Specimen collection will be provided or arranged for by the health department as indicated for a person’s individualized TB case management. Consultation and technical assistance will be provided by the Wisconsin TB Program.

If a person who is suspected of active TB disease refuses to comply with the collection of specimens that are necessary for the evaluation of suspect or active TB disease, the person may be subject to isolation or confinement pursuant to s. 252.07(8) and (9), Wisconsin Statutes., or to other and additional sanctions as the Court may determine. The health department will follow the statutes, codes, policies, procedures and practices for isolation or confinement as indicated to protect the health of the public.


  1. Follow established protocols and the direction of the WI TB Program for the collection of sputum specimens. See "Frequently Asked Questions about Sputum Specimens" found here: S:\PUBLIC HEALTH\Updated Policies and Procedures 2012\Communicable Disease\TB\TB Sputum Testing\freqently asked questions about sputum collections.doc

  1. Collaborate with the individual's physician for orders for sputum specimen testing. Collect the specimen promptly, when the person is able to produce sputum, while working within health department standing orders or with the individual's physician for the documentation of orders for testing. Use the health department's fee exempt number.

Sputum specimens for TB control and surveillance authorized by the Wisconsin TB Program are tested at the WI State Lab of Hygiene under the authority of the Division of Public Health

Chief Medical Officer and State Epidemiologist for Communicable Diseases.

  1. Obtain information on sputum specimen kits, lab requisitions, transportation, timing and criteria for submission from the Accessing Services and Resources Guideline in Section C., Accessing Wisconsin State Laboratory of Hygiene (WSLH) Services.

  2. Follow the directions for packaging, labeling and handling provided by the laboratory receiving the specimen and/or the manufacturer of the transportation materials. Wisconsin State Lab of Hygiene (WSLH) manual “Packaging Clinical Laboratory Samples for Domestic Transport” February 2010 provides guidelines for samples sent to WSLH.

  1. Regulations effective October 01, 2002 (for implementation in February & April 2003) for ground and mail transport of diagnostic specimens are in the Federal Register dated August 14, 2002. [Code of Federal Regulations (CFR) at 49 CFR Part 171.101, Part 173.134 and Part 173.199.]

  2. Follow the key points outlined in the Appendix entitled "Sender's Responsibility for Labeling and Transportation of Diagnostic Specimens". These instructions are based on the regulations effective 2002 that were implemented in 2003. Check with the laboratory to which the specimen will be sent about their submission and transportation criteria and keep up-to-date with any future regulation changes for transportation of biological specimens.

  1. Follow infection control precautions and use personal protective equipment (PPE) as indicated by the clinical condition of the person. The minimum standard for respiratory protection for tuberculosis or suspected tuberculosis is an N-95 or higher, fit-tested respirator.

  2. Collect early morning sputum specimens on three consecutive days, preferably Monday, Tuesday and Wednesday.

  3. Collect specimens before eating, drinking or smoking so that sputum from the lung fields can be obtained. Saliva and mucus from the nose and throat are not acceptable. Inhaling steam (hot shower or boiling water) may help sputum production.

  1. Rinsing the mouth with water is advisable to minimize the resident flora in the mouth. However, if tap water in your area has abundant mycobacteria, such as M. gordonae or M. avium, sterile water is indicated. (If necessary, this can be carried out in the home by boiling water along with a heatproof glass container for ten minutes, then cooling before use.)

  2. Teeth brushing with water is OK, but avoid an antiseptic solution such as mouthwash. Also consider potential water contamination as above and adjust accordingly.

  1. Provide supervised sputum collection for at least the first sputum specimen, until the person demonstrates the ability to properly collect the specimen.

  1. Persons who are suspected or confirmed as having TB can be so fearful of sputum specimen results that they will suppress a cough or even have another individual provide the specimen.

  2. W
    Unsupervised patients are seldom successful in providing an adequate specimen, especially the first time. The amount of coaching required on later visits will depend on individual patient needs.” Core Curriculum on Tuberculosis, 4th Edition, 2000, p. 42
    hen results do not fit the clinical picture, supervision of specimen collection should be done to ensure that the health of the public is protected.

  1. Refrigerate specimen if it is not immediately mailed or picked up by the courier.

  2. Individualize the need for submission of sputum specimens according to clinical need. In general, sputum specimens that are indicated for patient care and monitoring are outlined in the DPH document “Frequently Asked Questions about Sputum Specimens”, included in the appendix. Additional questions can be answered by the Wisconsin TB Program at 608-266-9692.

Annual review of implementation of policy and procedure to assess the need for modifications to improve quality or efficiency of program.

  • Wisconsin Statute 252.07(8)

  • Wisconsin Statute 252.07(9)

  • Wisconsin Administrative Code DHS 145.05(1)

POLICY TITLE: Response to Public Health Emergencies



AUTHORIZED BY: Heidi Stewart, BSN, Health Officer /Director
To increase the use and development of interventions known to prevent human illness from chemical, biological, radiological agents, and naturally occurring health threats. To decrease the time needed to identify health events that could result from terrorism or naturally occurring events in partnership with other agencies. To decrease the time to identify causes, risk factors, and appropriate interventions for those affected by threats to the public’s health. To decrease time needed to provide countermeasures and health guidance to those affected by threats to the public’s health. To decrease the time needed to issue guidance to the public after an event.
The Pepin County Health Department will respond to all matters of urgent public health consequence utilizing the Public Health Emergency Plan (PHEP) and other emergency response plans currently in place.


  1. During regular Health Department business hours, calls regarding matters of urgent public health consequences and communicable disease reporting will be forwarded to the Health Officer (HO) or another Public Health Nurse (PHN) in the absence of the Health Officer.

  2. The clerical staff receiving the call must take name and telephone number in the event a call is lost during transfer.

  3. Clerical staff is to immediately notify the HO or available PHN via telephone or page. No voicemails will be left.

  4. After business hours, the Pepin County Sheriff’s Department Dispatch personnel shall contact a member of the Health Department utilizing the 24/7 call information.
  5. The public health professional must initiate an epidemiologic investigation to begin with initiation of the Communicable Disease 4151 Form (see EpiNet). Surveillance worksheets will be completed as appropriate to the incident.

  6. The Public Health Emergency Plan (PHEP) will be used to guide activities for the emergency situation.

  7. The HO will be notified, at the discretion of the public health professional, if a Category I reportable disease, food or waterborne outbreak, or any case of fever and respiratory symptoms with a positive history of recent travel outside of the U.S. is the incident reported.

  8. The state and regional Divisions of Public Health (DPH) must be notified by the LHD of such an emergency.

  9. The local HO may determine the need to issue a health alert to key response partners via Command Caller or satellite phone system.

  10. If the situation requires activation of the agency Emergency Operations Center (EOC), all primary staff with public health Incident Command System (ICS) functional responsibilities will be notified of activation. Primary staff of ICS will report to the agency EOC as soon as possible after activation.

  11. A critical health message to the public about an event that may be of urgent public health consequence will be made. The Public Information Officer (PIO) or HO, and Incident Commander will design and issue message.

  12. Isolation and/or quarantine order will be issued by the HO or designee as per the Pepin County Isolation and Quarantine Policy.

  13. Guidance will be issued to public regarding recovery after an event.



POLICY TITLE: Personal Protective Equipment (PPE)

EFFECTIVE DATE: 01/18/2007


AUTHORIZED BY: Jen Rombalski, Health Officer

  1. To ensure Public Health staff understands the need for PPE to protect against infectious agents and chemical agents in the event of bioterrorism, other infectious disease outbreaks, and other public health threats and emergencies.

  2. To educate Public Health staff about how to use PPE (i.e., proper removal)

  3. To educate Public Health staff about how to test certain PPE

  4. To ensure PPE is stored and disposed of properly

Public Health Nurse

Registered Nurse

WIC Staff

Health Officer


  1. Types and Use of PPE

  1. Gloves

    • Per OSHA standards, use gloves for fingersticks, smallpox vaccinations (not so much due to blood exposure but because of live virus contamination potential), and when handling specimens. Use gloves when your hands or nails may touch someone else’s body fluids (such as blood, respiratory secretions, vomit, urine or feces) or certain hazardous drugs.

      • Wash your hands before putting on sterile gloves.

      • Be certain gloves are of a comfortable size.

      • Remove gloves between clients and wash hands thoroughly with soap and water or alcohol-based hand sanitizer.

Note: FDA requires manufacturers to identify on the package labeling the materials used to make the gloves. If you or your clients are/may be allergic to natural rubber latex, you should choose gloves made from other synthetic materials (such as polyvinyl chloride: “PVC”, nitrile, or polyurethane).

      • Be aware that sharp objects can puncture medical gloves.

      • Always change your gloves if they rip or tear.

      • Never reuse medical gloves.

      • Never wash or disinfect medical gloves.

      • Never share medical gloves with other users.

  1. Gowns
    • Use to protect skin and prevent soiling of clothing. Use when cleaning spills of body fluids. Do not reuse disposable gowns. Wash hands after removing. (Gowns are not routinely used in Public Health Unit functions).

      1. Surgical gowns

  • Usually packaged as sterile products or designed to be sterilized

  • Some are disposable and others are made of fabric that is labeled as washable for multiple use

  • Come in various sizes, including one-size-fits-all

  • Made of fluid-resistant materials to reduce the transfer of body fluids
      1. Isolation gowns

  • Not sold as sterile products

  • Usually intended to protect the wearer from the transfer of

microorganisms and only small amounts of body fluids


  • If blood or body fluids soak through a surgical gown, remove it promptly with any soiled clothing underneath and immediately wash the skin.

  • Never wash, disinfect, or reuse disposable surgical gowns.

  • Never share surgical gowns with other users.

  1. Overshirts

  • Use to protect clothing from small bloodstains in environments such as STD clinics and HIV testing sites where clients may be sensitive to the “clinical” look of customary medical settings. When visibly soiled, remove immediately and place in a plastic bag in storage until professionally cleaned. Wash hands after removal.

  1. Disposable Lab Coats

  • Use for smallpox vaccination clinics. When visibly soiled, remove immediately and place in a plastic bag in storage until professionally cleaned. Wash hands after removal.

  1. Surgical Masks
  • Disposable devices that cover the mucous membranes of the mouth and nose during medical procedures. They help protect the caregiver and patient against microorganisms, body fluids, and particles in the air.

  • Include masks labeled as surgical, laser, isolation, dental, or medical procedure masks

  • Protect against microorganisms, body fluids, and particles in the air

  • Designed to cover the mouth and nose loosely; not sized for individual fit

  • Protect patients from exposure to the wearer’s saliva and respiratory secretions

  • Made of soft materials and comfortable to wear

  • Usually packaged in boxes of single-use masks

  • What you should know before using surgical masks:

    • Surgical masks are not fit-tested to your face and may leave unprotected gaps between the mask and your face.

    • Wear goggles or glasses with side shields if your surgical masks do not

    • include eye protection.

    • Be aware that masks lose their protective properties and must be changed when they become wet from saliva or respiratory secretions.

    • Surgical masks are not tested against specific microorganisms and should not claim to prevent specific diseases.

    • See CDC recommendations for using surgical masks in the care of patients needing isolation precautions ((

    • Never wash, disinfect, or reuse surgical masks.

    • Never share surgical masks with others.

  1. N-95 Masks
  • Disposable devices that cover the mouth and nose during medical procedures. They help protect the caregiver and patient against microorganisms, body fluids, and small particles in the air. N-95 respirators are regulated by the FDA and also regulated and certified by NIOSH. When a mask is both cleared by FDA as a surgical mask and certified by NIOSH as an N-95 respirator mask, FDA calls it a "surgical N-95 respirator." Use N-95 respirators to cover your mouth and nose when you may be splattered by or exposed to someone else’s body fluids (such as blood, respiratory secretions, vomit, urine or feces).

      1. Surgical N-95 respirators

  • Surgical masks that are designed to protect against small droplets of respiratory fluids and other airborne particles in addition to the protection of surgical masks

  • Closely fit to form a tight seal over the mouth and nose

  • Must be fit-tested and adjusted to your face

  • May be uncomfortable due to tight fit

  • Usually packaged as single devices or in boxes of single-use devices

      1. Non-medical N-95 respirators

  • There are N-95 respirators and other similar respirators available for various occupational exposures that do not make medical claims and are not regulated by FDA. These respirators are available from many sources including hardware stores and online. They are rated based on the size of the particles they can filter in industrial settings. Many of these respirators are intended to filter out particles of dust and mist from wood, metal, and masonry work.

  1. Removal of PPE

  • The following method is one suggestion for removing PPE while minimizing risk of contamination of clothing, skin, and mucous membranes. It is based on the use of disposable PPE, and utilizes the principle of removing PPE from the facial area with clean hands.

  • Before leaving the area of contamination, remove the disposable gown by grasping it at the shoulders, pulling down, and rolling inside out. Keep the contaminated outside of the gown away from the body.

  • Remove gloves with the clean side of the gown while rolling it down. Keep hands on the clean side of the gown.
  • Gown and gloves may be disposed of in regular trash unless grossly soiled with blood or other body fluids.

  • Wash hands with soap and water or sanitize with alcohol-based gel.

  • Remove PPE from face (face shield, goggles) while inside the area of contamination, except for the N-95 respirator.

  • Immediately after leaving the area of contamination, remove

  • N-95 respirator, touching only straps at back of head and dispose of in regular trash.

  1. Testing of PPE

  • Fit testing of N-95 masks should be done every year. In addition, a medical evaluation (form) should be completed/updated every 2 years.

  1. Storage and Rotation of PPE

  • PPE will be stored in quantity per WI Division of Public Health recommendations for staff operations and mass clinic responders. PPE will be dated for replacement/rotation and will be stored in an area designated by the Health Officer. At present, storage is in the nursing closet in DHHS. The Health Officer or delegate will be responsible to annually replace or rotate depleted or dated items.


TB Respiratory Protection Standard (1910.139)

Respiratory Protection Standard (1910.134)

National Institute of Occupation Safety and Health

POLICY TITLE: Respiratory Protection Program

EFFECTIVE DATE: 03/26/2008


AUTHORIZED BY: Jen Rombalski, Health Officer

It is the policy of the Buffalo County Health Department to provide its employees with a safe and healthful work environment. This program is designed to help reduce employee’s exposure against bioterrorism agents and emerging infectious disease hazards. When it is not possible to remove or prevent these hazards with engineering controls, it may be necessary to use respiratory protection.

It is the intent of this policy that, as necessary, the Buffalo County Health Department shall:

  • Evaluate tasks and workplaces to determine if respiratory protection is needed

  • Evaluate employees’ medical status before issuing respirators (and if necessary, to accommodate those employees who cannot wear respiratory protection for medical reasons)

  • Provide training on the proper selection, use, care, and limitations of respirators

  • Provide properly fitted respirators to any employees who may need them

  • Perform any other tasks necessary to comply with OSHA’s 29 CFR 1910.134, Respiratory Protection, and 29 CFR 1910.139, Respiratory Protection for M. tuberculosis

No employee may be fitted for, issued, or required to use a respirator of any sort without complying fully with policies outlined in this document.




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