Long-awaited TB standard closely follows CDC rules
A key difference: It has the force of law
You might say the Occupational Safety and Health Administration’s new proposed standard governing employee exposure to tuberculosis has a bridal motif something old, something new, something borrowed, and it could make you blue.
The 149-page standard, unveiled in the Oct. 17 Federal Register, closely tracks the updated TB prevention and control guidelines issued by the Centers for Disease Control and Prevention (CDC) in 1994. But unlike the voluntary CDC guidelines, the OSHA standard is mandatory and enforceable, and failure to comply could result in fines.
That could be a bitter pill for hospitals that are not complying with the existing CDC guidelines. In fact, OSHA estimates that only about half of all hospitals voluntarily comply with the CDC’s current guidelines, and even fewer facilities in other occupational settings follow the existing recommendations.
If you are in compliance, the adjustment would be easier. Overall, OSHA has incorporated the basic elements of the CDC recommendations: written exposure control plans, procedures for early identification of suspected cases, procedures for investigating employee skin test conversion, and employee education and training.
"It seems that they do follow the CDC more than I thought they would," says Lee Reichman, MD, MPH, director of the National Tuberculosis Center in Newark, NJ, and spokesman for the American Lung Association in New York. "It shows they are responding to the fact that these standards should be scientifically, rather than politically, based."
As with the CDC guidelines, the OSHA standard would require hospitals and other employers to develop written exposure control plans and either to identify and isolate people with TB or to transfer them to facilities with isolation capabilities. In addition, the standard requires engineering controls, including negative pressure isolation rooms in high-risk facilities, tuberculin skin testing, hazard communication, training and record keeping.
OSHA allows reusable respirators
In keeping with CDC recommendations, the OSHA standard allows facilities to use the new N-95 respirators approved by the National Institute of Occupational Safety and Health. It also requires both respirator fit testing and fit checking.
"The proposed standard would allow the use of low-cost respirators that can be used multiple times," says Greg Watchman, OSHA’s acting assistant secretary. "We believe that, in combination with other controls, respirators are effective in preventing TB transmission."
Generally, the OSHA standard adopts CDC guidelines on respirator use, but it adds two new situations where they are required:
• When a person with suspected or confirmed TB is transported without wearing a mask (such as a combative patient), the transporter must wear a respirator.
• Employees who work in areas where a confirmed or suspected TB patient who isn’t wearing a mask is segregated must wear respirators.
Other requirements include:
• Respirators must be used by personnel who maintain air circulation systems that could contain aerosolized M. tuberculosis.
• Employers would be responsible for ensuring that hospice or home health workers wear respirators when dealing with confirmed or suspected TB patients.
The standard also would extend significant job protection to employees unable to wear a respirator. It would require that they be transferred to a position that does not require one, be retrained for up to six months for a new position, or otherwise kept on the payroll at their previous pay rate for up to 18 months.
The medical surveillance requirements of the new standard would require hospitals to:
• follow the most current CDC requirements;
• follow detailed procedures for conducting medical histories, physician examinations, face-to-face skin testing, and fit testing;
• use physicians or licensed health care professionals to conduct all exams;
• perform skin tests every six months for employees who enter isolation rooms or are present during high-hazard procedures on suspected TB patients, who transport those patients, or who are in enclosed vehicles with them;
• perform skin testing of employees within 30 days prior to termination of employment.
The standard also requires that employees suspected or confirmed to have contracted TB be removed from the work setting, but remain on the payroll at their previous pay level.
While the proposed standard follows much of the CDC guideline, it expands its reach, covering not only hospitals, correctional facilities, homeless shelters, and long-term care facilities for the elderly, but also emergency medical services, hospice facilities, home health care, home-based hospice care, drug treatment centers, and high-hazard laboratories.
The standard also would cover occupational exposures to workers involved in social work, social welfare services, teaching, law enforcement, or legal work if those services are provided in those settings or in residences where people are being segregated or confined for suspected or confirmed infectious TB.
Employers in facilities located in counties at low risk of TB infection would be exempt from some of the requirements. While those facilities would be required to prepare a written exposure control plan, provide baseline skin tests, and be able to manage an exposure incident, they would not have to undertake periodic medical surveillance and respiratory protection.
A more limited program would apply to facilities that meet the following criteria, similar to the CDC guidelines:
• doesn’t admit or provide medical services to people with suspected or confirmed TB;
• has had no case of confirmed infectious TB in the past 12 months;
• is located in a county that, in the past two years, had reported no cases of confirmed infectious TB in one year and fewer than six cases of confirmed TB reported in the other year.
The OSHA standard differs from the CDC guidelines in several other areas. It requires employers to conduct an exposure assessment, rather than a site-specific risk assessment. The CDC guidelines recommend that local TB control programs take into account TB prevalence at their facilities as well as in their counties, whereas the OSHA standard requires assessment for the county alone. Also, the standard’s medical surveillance requirements requires six-month skin testing in some instances, compared with the annual skin-testing requirement by the CDC.
Having already received widespread, and sometimes critical, input from stakeholder group meetings, OSHA officials expect broad participation in a series of public hearings on the standard scheduled to begin in February 1998.
Several infection control organizations have opposed the standard, arguing that its cost in dollars and time is unwarranted, considering TB rates in the United States are lower now than any time since the CDC began gathering detailed rates in 1953.
"The success of that document [the 1994 CDC guidelines] is amazing, so why do we need additional things?" asks Eddie Hedrick, MT, CIC, chairman of the TB committee for the Associ ation for Professionals in Infection Control and Epide miology (APIC). "The data OSHA presents in their press release is very dramatic, that it will prevent 130 deaths. But I’m not sure that is accurate. In all my years I can’t think of a [HIV-negative] health care worker dying of TB."
Fit checking vs. fit testing
APIC questions the need for several of the standard’s proposals, such as the need for annual fit-testing of respirators, says Hedrick. "APIC’s not sure we need a respiratory protection program with fit-testing for these kinds of respirators [N-95]," he elaborates. "We think fit checking makes more sense than fit testing. . . . Taking 2,000 people and fit-testing them is extremely expensive."
Although the final draft appears nearly identical to one OSHA presented to stakeholders nearly three years ago, Hedrick still is optimistic that a groundswell of public opinion could result in substantial changes in the document.
"Because OSHA was petitioned to do this, they feel they have to go forward," he says, "but many of us would have liked them to have simply taken the CDC document and enforced it."
Indeed, Bill Borwegen, health and safety director of the Services Employee International Union in Washington, DC, which helped lobby for the standard, argues that health care providers will benefit from having an enforced standard just as they have with OSHA’s bloodborne pathogen standard, which evoked strong criticism at first.
"Whether they understand it or not, they would benefit from this standard, just as with the bloodborne pathogen standard, which gave them resources to deal with that problem," he adds.
(Editor’s note: In coming issues, Hospital Employee Health will present detailed information on the proposed TB standard, and on the changes critics will be trying to make to it.)
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