How does OSHA rule differ from CDC TB guidelines?
Risk assessments, skin testing, respirator provisions
With the 1994 Centers for Disease Control and Prevention tuberculosis guidelines widely accepted in the infection control community, much of the upcoming debate about the TB standard proposed by the Occupational Safety and Health Administration will be about where the two federal agencies differ. 1,2
The areas where OSHA took a different approach from the CDC include the following, summarized from the proposed rule:
• Risk assessment.
CDC recommends all facilities assess the risk of transmission of TB using information such as the profile of TB in the community, the number of suspected and confirmed cases of TB among patients and health care workers, and health care worker skin test conversion rates. The risk assessment is then used to determine infection control elements such as the frequency of skin testing. OSHA is not requiring employers to conduct such a risk assessment. Rather, employers are required to conduct an exposure assessment to determine which employees have occupational exposure, i.e., reasonably anticipated contact with an individual with suspected or confirmed infectious TB or air that may contain aerosolized TB. The standard then specifies the provisions applicable for the employees whom the employer has identified as having occupational exposure.
Medical surveillance: OSHA requires baseline skin testing for all employees whom the employer identifies as having occupational exposure. CDC recommends baseline skin testing for all employees with potential exposure except those who work in facilities that fall into CDC’s "minimal risk’’ category.
However, CDC notes that even for employees in "minimal risk’’ facilities, it may be advisable to perform baseline skin testing so that if unexpected exposures do occur, conversions can be distinguished from positive skin test results caused by previous exposures. Relative to periodic skin testing, OSHA requires periodic re-testing for all employees identified as having occupational exposure who have negative skin tests except for the employees of those employers who have no TB in the community and who have not encountered any individuals with confirmed infectious TB in their work settings within the past year. CDC recommends re-testing for employees in the "low’’, "intermediate’’, and "high’’ risk categories.
Another difference between CDC and OSHA is the frequency of the re-testing. This is primarily because OSHA’s required frequencies are based on the type of work that employees do that result in exposures, whereas CDC’s recommendations are based more on evidence of conversions.
For example, OSHA requires re-testing every six months for all employees who enter AFB isolation rooms or areas, perform high-hazard procedures, transport individuals with suspected or confirmed infectious TB in an enclosed vehicle, or work in intake areas where early identification procedures are performed (e.g., emergency departments, admitting areas) in facilities where six or more individuals with confirmed infectious TB have been encountered in the past 12 months. For all other employees with occupational exposure, re-testing is required every 12 months. In comparison, CDC recommends re-testing every year for employees in "low" risk categories, every 6-12 months for employees in "intermediate" risk categories, and every 3 months for employees in "high’’ risk categories. Under CDC recommendations, employees in "low’’ risk categories who enter AFB isolation rooms or areas or employees who transport individuals with suspected or confirmed infectious TB in an enclosed vehicle would be re-tested every 12 months. However, under OSHA requirements, those same employees would be required to be re-tested every six months.
With regard to two-step testing, both OSHA and CDC require or recommend two-step testing at the time baseline skin testing is administered. Also, both agencies add that two-step testing is not necessary if the employee has had a documented negative skin test within the last 12 months. CDC is different from OSHA in that its guidelines imply that two-step testing can be discontinued if there is evidence of a low frequency of boosting in the facility. OSHA’s proposed standard does not allow such an exemption, i.e., for each employee who must have a baseline skin test at the time of the initial medical examination, the skin test must include a two-step test unless the employee has a documented negative test within the last 12 months, regardless of the frequency of boosting in the facility.
Respiratory Protection: OSHA adopted CDC’s performance criteria for respirators appropriate for use for TB. However, OSHA also requires that respirators be worn when employees are transporting individuals with suspected or confirmed infectious TB within the facility if those individuals are not masked (e.g., a surgical mask or a valveless respirator). In addition, OSHA requires that respirators be worn when employees work in an area where an unmasked individual with suspected or confirmed infectious TB has been segregated or otherwise confined. For example, this provision would cover employees such as those who work in admitting areas and must attend to unmasked individuals with suspected or confirmed infectious TB while those individuals are awaiting transfer.
OSHA cannot require employers to mask clients or patients in a facility and must therefore include provisions for respirator use to protect potentially exposed employees. However, consistent with CDC, OSHA proposes not to require respirators where the employers elect, as a part of their own administrative policies, to mask individuals with suspected or confirmed infectious TB. Thus, when individuals with suspected or confirmed infectious TB are masked while they are awaiting transfer to another facility or while they are being transported within the facility, employees would not be required by the standard to wear a respirator.
References
1. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities, 1994. MMWR 1994; 43:(No. RR-13)1-133.
2. Department of Labor. Occupational Safety and Health Administration. Occupational exposure to tuberculosis; proposed rule. 62 Fed Reg 54,160-54,307 (Oct. 17, 1997).
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content