CDC considers risk-based guidelines in update on TB
January 1, 2001 3 minutes read
CDC considers risk-based guidelines in update on TB
New guidelines likely to come after OSHA standard
The Centers for Disease Control and Prevention is reviewing its tuberculosis guidelines with a focus on how recommendations for skin-testing and protective equipment should apply to hospitals in areas with a very low prevalence of TB.
This fall, a CDC working group began reviewing the existing guidelines, which were issued in 1994. CDC officials estimated it would take two years to complete a final version of new TB guidelines, including publication in the Federal Register and collection of comments on a draft copy.
"An important goal we have is to simplify and clarify the guidelines," said Adelisa Panlilio, MD, MPH, medical epidemiologist in the Hospital Infections Program, at a meeting of the Healthcare Infection Control Practices Advisory Committee (HICAC) in Atlanta. "As in 1994, the issues are complex and [a final version] will need to consider diverse interests."
The guideline revision comes amid controversy over a proposed Occupational Safety and Health Administration (OSHA) tuberculosis standard. The OSHA standard has drawn intense criticism from the Association of Professionals in Infection Control (APIC) and the American Hospital Association, among others, for provisions that would require skin-testing and respirator fit-testing at least yearly.
A final OSHA standard is expected sometime in 2001. Meanwhile, an Institute of Medicine report on key questions about TB skin-testing and protective equipment likely will be released by early January.
Members of the hospital infections committee, an expert panel that serves an advisory function to CDC, reacted favorably to the news that CDC is drafting new TB guidelines.
"The fact that CDC is willing to open the 1994 guidelines is helpful because at least it sends the message that they need revision," said Alfred DeMaria, MD, state epidemiologist with the Massachusetts Department of Public Health and liaison member to the Advisory Committee for the Elimination of Tuberculosis.
The current CDC guideline calls for hospitals to assess TB risk at least annually and identifies five risk categories, from high to minimal. All employees should have a baseline TB skin test, and the frequency of follow-up tests depends on the risk level, the guidelines state.
For example, in a "minimal risk" facility — one that doesn’t admit TB patients to inpatient or outpatient areas and is located in a community with no TB cases in the past year — periodic skin testing of health care workers is not necessary, according to a decision chart in the guideline.
Revised guidelines are likely to clarify which risk levels can rely on baseline and exposure-based testing only, with no routine follow-up, said Denise Cardo, MD, chief of CDC’s HIV infections branch.
National consequences?
Such a clarification would resolve the predicament of Robert J. Sharbaugh, PhD, CIC, international director of infection control for Hill-Rom in Charleston, SC, and HICAC member. Sharbaugh noted that he had calculated "very low" risk levels for home health agencies affiliated with Hill-Rom, but the Joint Commission on Accreditation of Healthcare Organizations informed him that OSHA doesn’t recognize the "very low" and "minimal" risk levels.
When he pressed the issue with OSHA, he received notification that his question "may have national consequences" and would be sent to the Washington, DC, headquarters for an answer. None was immediately forthcoming.
"My main concern is with the [proposed OSHA] standard [and the] necessity for routine, periodic skin-testing," says Sharbaugh, who is chairman of the guidelines committee for APIC.
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