New TB guidelines dance the two-step
Some physicians may balk at donning respirators
Health care facilities are being urged to perform a risk analysis and to formulate a written TB infection control program based on those findings in newly published guidelines from The American College of Occupational and Environmental Medicine (ACOEM). (For ordering information, see note at end of story.)
Such a program might include any or all of the following action steps:
o two-step skin-testing of new hires;
o skin-testing every three to 12 months for employees who come into contact with TB patients;
o periodic training of health care workers to enhance awareness of TB risks;
o appropriate management of patients likely to have undiagnosed TB (emergency room patients, for example);
o implementation of engineering controls;
o respiratory protection, accompanied by respirator fit-testing and by training in the proper care and use of respirators.
Consensus about some of the guidelines followed only after considerable debate, explains Lawrence W. Raymond, MD, ScM, chief author of the guidelines and a member of ACOEM’s lung disorders committee. Raymond also is director of the department of occupational and environmental medicine at the Carolinas Medical Center in Charlotte, NC.
One example was the recommendation for two-step testing. The lung disorders committee decided in its favor because of convincing evidence, Raymond says: "We found that many larger institutions in the state cut their so-called workplace conversion rate by a factor of 10 or more simply by going to the two-step. It’s an example of one way institutions can save themselves a lot of anxiety, not to mention sparing employees from having to undergo an unnecessary course of prophylaxis."
In addition, Raymond anticipates that some physicians will bridle at the exhortation to don respirators and to be fit-tested for them. "But having seen my share of physicians and other health care workers suffering from TB, I think it’s a good idea to play by the rules," he says. As for the recommendation to skin-test employees every three to 12 months, "every 12 months is probably going to be reasonable in most institutions caring for TB patients," he says.
The ACOEM guidelines are based on those promulgated by the Centers for Disease Control and Prevention and the National Institute of Occupa tional Safety and Health and on regulations proposed by the federal Occupational Safety and Health Administration. That’s not to say they’re redundant, Raymond says, since ACOEM is an international organization whose members may not have access to American guidelines and regulations. "We’re a convenient funnel, as it were, for all sorts of job-related information," he says. Publish ing the guidelines "is a good way to communicate awareness of TB in the workplace."
The premise that work affects health
A society of 7,000 occupational and environmental physicians, ACOEM focuses on work-related health issues "ranging from something as simple as workplace falls to subjects as technically complex as dimethyl mercury poisoning to everything in between," Raymond says.
Environmental physicians are employed variously by multispecialty clinics, hospitals, industrial companies, and, in some instances, the government. The organization’s founding father was Bernardino Ramazzini, a 17th century physician who believed that knowing what kind of work his patients performed was critical to understanding their illnesses.
When counseling health care workers with positive Mantoux skin tests who resist the offer of isoniazid prophylaxis, Raymond is reminded of a comment he once heard from TB expert John Sbarbaro. "In general, we say that if I convert my skin test today, the chances for reactivation over a lifetime are somewhere around 10%," he recalls Sbarbaro saying. But for health care workers, Raymond says, Sbarbaro pegs the odds much higher — at 30%.
"I always use that figure when I’m talking with someone who’s [over age 35] and doesn’t want to take the INH," Raymond says. "I ask them, Do you really want to take this chance of 30% that you’ll reactivate?’"
Guidelines are available from ACOEM, 55 W. Seeg ars Road, Arlington Heights, IL 60005. Web: http:// www.acoem.org. Fax-on-demand: (800) 226-3626.
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