The 1994 guidelines, which followed CDC statements issued in 1982 and 1990 (1,6,7), presented recommendations for TB infection control based on a risk assessment process.
Despite the general decline in TB rates in recent years, a marked geographic variation in TB case rates persists, which means that HCWs in different areas face different risks (10). The risk assessment process includes the assessment of additional aspects of infection control. The 1994 CDC guidelines were aimed primarily at hospital-based facilities, which frequently refer to a physical building or set of buildings.
Outpatient settings include TB treatment facilities, medical offices, ambulatory-care settings, dialysis units, and dental-care settings.
In addition to close contacts, the following persons are also at higher risk for exposure to and infection with M. Populations at high risk who are defined locally as having an increased incidence of TB disease.
Persons who use tobacco or alcohol (40,41), illegal drugs, including injection drugs and crack cocaine (42–47), might also be at increased risk for infection and disease.
HIV infection is the greatest risk factor for progression from LTBI to TB disease (22,39,48,49).
All HCWs should be informed regarding the risk for developing TB disease after being infected with M. Vaccination with BCG probably does not affect the risk for infection after exposure, but it might decrease the risk for progression from infection with M. The first and most important level of TB controls is the use of administrative measures to reduce the risk for exposure to persons who might have TB disease. Collaborate with the local or state health department to develop administrative controls consisting of the risk assessment, the written TB infection-control plan, management of patients with suspected or confirmed TB disease, training and education of HCWs, screening and evaluation of HCWs, problem evaluation, and coordination.
Collaborate with the local or state health department to develop administrative controls consisting of the risk assessment and the written TB infection-control plan. Every health-care setting should conduct initial and ongoing evaluations of the risk for transmission of M.
Consult the local or state TB-control program to obtain epidemiologic surveillance data necessary to conduct a TB risk assessment for the health-care setting. Determine which HCWs need to be included in a TB screening program and the frequency of screening (based on risk classification) (Appendix C). Identify areas in the setting with an increased risk for health-care–associated transmission of M.
Risk classification should be used as part of the risk assessment to determine the need for a TB screening program for HCWs and the frequency of screening (Appendix C). The three TB screening risk classifications are low risk, medium risk, and potential ongoing transmission.
The classification of medium risk should be applied to settings in which the risk assessment has determined that HCWs will or will possibly be exposed to persons with TB disease or to clinical specimens that might contain M. If uncertainty exists regarding whether to classify a setting as low risk or medium risk, the setting typically should be classified as medium risk.
The following hypothetical situations illustrate how assessment data are used to assign a risk classification. Evaluation of HCWs for LTBI should include information from a serial testing program, but this information must be interpreted as only one part of a full assessment. Environmental control design specifications should be compared with guidelines from the American Institute of Architects (AIA) and other ventilation guidelines (117,118) (see Risk Classification Examples) and the installed system performance. Environmental data should be used to assist building managers and engineers in evaluating the performance of the installed system. The number of AII rooms should be suitable for the setting based on AIA Guidelines and the setting risk assessment. Rationale for infection-control measures and documentation evaluating the effect of these measures in reducing occupational TB risk exposure and M. Importance of completing therapy for LTBI or TB disease to protect the HCW's health and to reduce the risk to others. Success of adherence to infection-control practices in decreasing the risk for transmission of M.
Available tests and counseling and referrals for persons with HIV infection, diabetes, and other immunocompromising conditions associated with an increased risk for progression to TB disease. The primary TB risk to HCWs is the undiagnosed or unsuspected patient with infectious TB disease. The classification of the risk assessment of the health-care setting is used to determine how many AII rooms each setting needs, depending on the number of TB patients examined.
To do a risk assessment, you need to understand what, in your business, might cause harm to people and decide whether you are doing enough to prevent that harm.
This is not the only way to do risk assessment as there are no fixed rules about how a risk assessment should be carried out. Your risk assessment should include consideration of what in your business might cause harm and how and, the people who might be affected.
Any paperwork that is produced should help with communicating and managing the risks in your business. You should carry out an assessment before you do work which presents a risk of injury or ill health.
We have produced Microsoft Word and Open Document Format templates to help you record your assessment. The template can also be used to record your health and safety policy. Remember that any paperwork that is produced should help with communicating and managing the risks in your business. Remember that you only need to record your risk assessment if you employ five or more people and any paperwork that is produced should help with communicating and managing the risks in your business. This means balancing the level of risk against the measures needed to control the real risk in terms of money, time or trouble. Personal protective clothes and equipment - Only after all the previous measures have been tried and found ineffective in controlling risks to a reasonably practicable level, must personal protective equipment (PPE) be used. You need to make sure that, based on the findings of the assessment, you take adequate and appropriate fire safety measures to minimise the risk of injury or loss of life in the event of a fire.
Remember, the greater the risk the more robust and reliable the control measures will need to be. Significant risks are those that are not trivial in nature and are capable of creating a real risk to health and safety which any reasonable person would appreciate and would take steps to guard against.

You will need to review your risk assessment to check whether you need to make any changes in the measures you take to control risk. This is particularly important when, for example, people return to work following surgery etc, as new or expectant mothers or if an employee develops a disability. There is no set amount of time that you need to keep your records relating to general risk assessment. Risk is the chance, high or low, of somebody being harmed by the hazard, and how serious the harm could be.
A risk assessment is simply a careful examination of what, in your work, could cause harm to people, so that you can weigh up whether you have enough precautions or whether you should do more.
As an employer or self-employed person, you must do a risk assessment but you only need to record it if you employee five or more people. Whether safety method statements are used or not, it is essential to make sure that risks are controlled. Within the context of their general obligations, employers have to take the necessary measures for the safety and health protection of workers, including prevention of occupational risks. For preventing occupational accidents and ill health, employers must perform risk assessment regarding safety and health at work, and decide on protective measures to take and, if necessary, on protective equipment to use. Risk assessment, as referred before, is a legal obligation in Europe but it is also a good practice that contributes to keep companies competitive and effective.
Risk is the combination of the likelihood of an occurrence of a hazardous event or exposure and the severity of injury or ill health that can be caused by the event or exposure[1]. From a psychosocial perspective risk is defined as the likelihood that psychosocial factors have a hazardous influence on employees’ health through their perceptions and experience and the severity of ill health that can be caused by exposure to them.
It is important that employers know where the risks are in their organizations and control them to avoid putting in risk employees, customers and the organization itself. As referred, according to EU legislation employers are responsible for performing risk assessment regarding safety and health at work. Workers participation in the process of occupational safety and health risk management is fundamental, since workers are the actors that best know the OSH problems and the resources involved in their tasks. Risk assessment is the process of evaluation of the risks arising from a hazard, taking into account the adequacy of any existing controls and deciding whether or not the risks is acceptable[1]. Risk evaluation involves the determination of a quantitative or qualitative value for the risk. Qualitative risk evaluation is more common and usually adopts a methodology based on a matrix, for instance the matrix proposed in British Standard 8800[4]. Based on the risk values obtained during the risk evaluation phase, risks should be sorted and ranked according to their severity.
A decision whether or not a risk is acceptable result from the comparison of the obtained risk value with reference values defined in legislation. In this decision process it is advisable to take into account the individuals’ total exposure to risk, allowing for the fact that they could be exposed to risks associated with a number of different hazards[4]. It should be highlighted that a particularly careful assessment of individual risk exposure should be performed to workers of special groups (for example, vulnerable groups such as new or inexperienced workers), or to those most directly involved in the highest risk activities] (i.e.
This risk classification is the baseline for selecting safety actions to be implemented and when defining the timescale, i.e.
As an example, table 2 depicts a simple risk categorization and the respective guidance to the application of corrective safety measures proposed by[4]. To have a consistent base for all risk assessments the company should first establish the acceptability criteria. Risk control is the stage where the actions to identify and implement safety measures to control risks are performed having in mind the protection of workers’ health and safety, as well as their monitoring over time. It is very important to take account of the number of individuals exposed to the risk when setting priorities and timescales to the implementation of safety control measures. The first step of risk control is the design of the safety control measures to eliminate risks.
The risk management process should be reviewed and updated regularly, for instance every year, to ensure that the safety measures implemented are adequate and effective.
The review of the risk management process should consider a variety of types of information and draw them from a number of relevant perspectives (e.g.
For instance, Last Minute Risk Assessment (LMRA) is a new tool, adequate to be used in companies where (acute) safety risks are relevant.
In this process, health-care facilities were classified according to categories of TB risk,with a corresponding series of environmental and respiratory-protection control measures. However, because of multiple other potential risk factors that commonly occur among such persons, use of these substances has been difficult to identify as separate risk factors.
Therefore, voluntary HIV counseling, testing, and referral should be routinely offered to all persons at risk for LTBI (1,50,51).
Give the supervisor or supervisory body the support and authority to conduct a TB risk assessment, implement and enforce TB infection-control policies, and ensure recommended training and education of HCWs. The risk classification for the setting should help to make this determination, depending on the number of TB patients examined. The classification of low risk should be applied to settings in which persons with TB disease are not expected to be encountered, and, therefore, exposure to M. If greater than or equal to six TB patients for the preceding year, classify as medium risk. If greater than or equal to three TB patients for the preceding year, classify as medium risk. The risk classifications are for settings in which patients with suspected or confirmed infectious TB disease are expected to be encountered. Infection-control plans should address HCWs who transfer from one health-care setting to another and consider that the transferring HCWs might be at an equivalent or higher risk for exposure in different settings.
Data from the case reviews and observations in the annual risk assessment should be used to determine the need to modify 1) protocols for identifying and initiating prompt airborne precautions for patients with suspected or confirmed infectious TB disease, 2) protocols for patient management, 3) laboratory procedures, or 4) TB training and education programs for HCWs.
These are quick and easy tools for low-risk environments (eg offices, shops and classrooms). See Interactive tools.
However, we believe that the controlling the risks in the workplace guidance provides the most straightforward way for most businesses. You do not need to include risks from everyday life unless your work activities increase the risk.
For example, where you cannot eliminate the risk of a fall, use work equipment or other measures to minimise the distance and consequences of a fall (should one occur). It is a legal requirement for every employer and self-employed person to make an assessment of the health and safety risks arising out of their work.

The fire safety assessment can be carried out either as a separate exercise or as part of a single risk assessment covering other health and safety risks. They will have useful information about how work is done which will help you understand the actual risks. When you take on work or go to a new site, cover any new or different risks with a specific assessment.
However, they can be used to help you work out the level of risk associated with a particular issue. It describes in a logical sequence exactly how a job is to be carried out in a safe manner and without risks to health. This could be achieved through a risk management process, which involves risk analysis, risk assessment and risk control practices. It is advisable that risk assessment should be done at least every year or every time a change is introduced in the workplace, for instance due to the introduction of new work equipment or procedure, or the use of a new chemical substance or preparation.
Risk assessment is a dynamic process that allows companies and organizations to put in place a proactive policy for managing occupational risks. According to the BS OHSAS 18001 an acceptable risk is a risk that has been reduced to a level that can be tolerated by the organization having regard to its legal obligations and its own OSH policy[1]. The main goal of risk management is to eliminate or at least to reduce the risks according to the ALARP (as low as reasonably practicable) principle. Therefore, the overall responsibility for identifying, assessing and controlling risks at the workplace lies with the employer, who must guarantee that the occupational safety and health (OSH) risk management activities are properly executed. Several methods to perform risk assessment are available ranging from expert to participatory methodologies and from simple to complex methods.
Quantitative risk evaluation requires calculations of the two components of the risk: the probability that the risk will occur, and the severity of the potential consequences. The safety measures implemented should be the ones that best protect everyone exposed to the risk.
The risks that cannot be avoided or eliminated should be reduced to an acceptable level, i.e.
Another reason is that new knowledge regarding risks can emerge; either leading to the need of an intervention or offering new ways of controlling the risk. The European Safety and Health Agency (OSHA) have developed a risk assessment tools database with tools from all over Europe. Every time, before the work is started, workers confirm that there are no acute risks and that normal preventive measures are in place. The 1994 guidelines, which followed statements issued in 1982 and 1990, presented recommendations for TB-infection control based on a risk assessment process that classified health-care facilities according to categories of TB risk, with a corresponding series of administrative, environmental, and respiratory-protection control measures. The risk for progression of LTBI to TB disease is highest during the first several years after infection (36–38).
Although HIV infection increases the likelihood of progression from LTBI to TB disease (39,49), whether HIV infection increases the risk for becoming infected if exposed to M. The magnitude of the risk varies by setting, occupational group, prevalence of TB in the community, patient population, and effectiveness of TB infection-control measures. These control levels also reduce, but do not eliminate, the risk for exposure in the limited areas in which exposure can still occur. The TB risk assessment determines the types of administrative, environmental, and respiratory-protection controls needed for a setting and serves as an ongoing evaluation tool of the quality of TB infection control and for the identification of needed improvements in infection-control measures. After a determination that ongoing transmission has ceased, the setting should be reclassified as medium risk. Infection-control plans might need to be customized to balance the assessed risks and the efficacy of the plan based on consideration of various logistical factors.
The purpose of the assessment is to identify what needs to be done to control health and safety risks.
It includes all the risks identified in the risk assessment and the measures needed to control those risks. In order to carry out an effective risk management process, it is necessary to have a clear understanding of the legal context, concepts, risk analysis, assessment and control processes and the role played by all involved in the process. Therefore, risk assessment constitutes the basis for implementation of appropriate preventive measures and, according to the Directive; it must be the starting point of any Occupational Safety and Health (OSH) Management system. Risks are estimated according to their likelihood and potential severity of harm, combining the severity and likelihood categories, as shown on table 1. Documentation should provide an overview of the identified hazards, respective risks and subsequent safety control measures implemented.
Part of the risk assessment is similar to a program review that is conducted by the local TB-control program (42).
Examples of assigning risk classifications have been provided (see Risk Classification Examples).
The review should be based on the factors listed on the TB Risk Assessment Worksheet (Appendix B). Carrying out risk management implies performing several steps (whose activities will be detailed in the next sub-sections).
This means employers must perform a cost-benefit analysis to balance the cost (include money, time, trouble and effort) they could have to reduce a risk against the degree of risk presented[5].
The closer the proximity and the longer the duration of exposure, the higher the risk is for being infected. The TB Risk Assessment Worksheet (Appendix B) can be used as a guide for conducting a risk assessment.
Risk classification: medium risk (Correctional facilities should be classified as at least medium risk). It should be demonstrated that the cost involved in reducing the risk further would be grossly disproportionate to the benefit gained.
Use of respiratory protection can further reduce risk for exposure of HCWs to infectious droplet nuclei that have been expelled into the air from a patient with infectious TB disease (see Respiratory Protection). Risk classification: medium risk (with close ongoing surveillance for episodes of transmission from unrecognized cases of TB disease, test conversions for M.
Risk classification: low risk (because HCWs might be from populations at higher risk for LTBI and subsequent progression to TB disease because of foreign birth and recent immigration or HIV-infected clients might be overrepresented, medium risk could be considered).

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