CDC official questions need for OSHA TB rule
ICPs urged to respond by Feb. 17
The tuberculosis standard proposed by the Occupational Safety and Health Administration may prove confusing and costly at a time when the risk of nosocomial TB transmission is "very low," warns William Jarvis, MD, acting director of the Centers for Disease Control and Prevention’s hospital infections program.
"Full implementation of the CDC [TB] guideline recommendations, I think, would be the best way to go," Jarvis tells Hospital Infection Control.
"Divergence from that will just lead to confusion and possibly be more costly. We have increasing data that more and more of the hospitals in the U.S. are complying with our recommendations. We certainly have not been seeing at least brought to [CDC] attention outbreaks of nosocomial transmission of TB," Jarvis says.
The OSHA proposed rule incorporated many aspects of the 1994 CDC guidelines, but drew criticism for changes that included dropping the CDC risk assessment approach and requiring more frequent skin testing.1,2 (See HIC, December 1997, p. 177.)
"We have tried in the CDC guidelines to offer some flexibility, to allow institutions to assess their risk not just for the institution itself, but for certain areas within the institution," Jarvis says. "You have certain wards where exposure to TB patients is very common, and others where it is never going to happen at all. I think the idea that one size fits all ends up being very, very costly."
The CDC is incorporating responses from several of its branches including the division of TB elimination and the National Institute of Occupational Safety into a formal written response to the proposed OSHA rule. While Jarvis’ comments certainly indicate the OSHA rule may not draw any ringing endorsement from the CDC, the agency’s official position had not yet been received by OSHA at press time.
"We are only a part of the puzzle," Jarvis says. "TB elimination and NIOSH are also looking at the document, and actually NIOSH is the one that is coordinating the response from CDC to OSHA."
A larger unanswered question is whether opposition from the CDC in the subsequent comment and hearing process could undermine the controversial OSHA proposal, which is already under siege by the infection control community. (See related story, p. 23.) Jarvis says the CDC’s position may carry no special weight in the process, and urged individual ICPs to make their opinions known.
"It is critically important that the infection control community review these and respond individually," he says. "If APIC and SHEA respond, that’s fine, but if members of APIC and SHEA respond, that is better."
In that regard, infection control professionals have until Feb. 17, 1998, to submit comments. (See related story, p. 23.) OSHA extended the original Dec. 16, 1997, comment deadline by 60 days at the request of several medical groups and associations, including the Association for Professionals in Infection Control and Epidemiology (APIC).1 The groups sent a joint letter requesting an extension due to the complexity and far-reaching implications of the proposal.
"We are getting feedback from people all over the country and are trying to formulate a common-sense, broad response that really addresses these issues and is representative of our membership," says Eddie Hedrick, BS, MT(ASCP), CIC, chairman of the APIC TB committee.
While individual issues include respiratory requirements, skin testing frequency, and costs, perhaps the most common lament from ICPs is that the CDC guidelines have already been implemented and are proving effective, he says.
What about the CDC guidelines?
"The need for a new [OSHA] document is a constant in people’s responses," he says. "People are frustrated by the fact that they have implemented the CDC guidelines, and now after all that expense and time they are going to have to modify how that was done."
In addition, there are concerns that the TB rule goes well beyond OSHA’s bloodborne pathogen standard, addressing human resources and labor issues outside the purview of infection control departments, says Patti Grant, RN, BSN, CIC, infection control professional at RHD Memorial Medical Center and Trinity Medical Center, both in Dallas.
"This is not just going to impact infection control," she says.
For example, OSHA outlines "medical removal protection" provisions for employees who are unable to wear respiratory protection or who contract infectious tuberculosis. Medical removal protection requires that a worker receive full salaries, full benefits, and no loss of job position or seniority while the employee is unable to work, or unable to work at his or her usual position, the proposed standard states. The purpose of medical removal protection is to assure that workers provide timely and accurate information to their employers concerning their medical symptoms. In the absence of medical removal protection, workers have financial and job security incentives to avoid reporting symptoms, OSHA claims in the proposed rule.
"The reason we have medical removal protection in there is that some employees are very suspicious of their employers," says Amanda Edens, MPH, industrial hygienist in the OSHA health standards program in Washington, DC. "They may be fearful that by participating in medical surveillance, [employers] will find out some health condition and they will be fired from work."
A particular concern regarding the provision, however, is that the proposed standard stipulates that employers must provide medical removal protection if the employee develops infectious TB "even if such employee is not categorized as having occupational exposure."
That appears to blur the line between nosocomial and community-acquired TB, essentially making the health care setting responsible for any TB infections incurred by its workers, Grant argues.
"If a health care worker acquires nosocomial TB, with or without this proposal we are going to take care of them," she says. "But they are going to make the hospital responsible for the employee who gets community-acquired tuberculosis."
Edens clarified that the provision was added to provide some protection for employees who are not classified by the facility as having TB exposures (i.e., entering AFB isolation rooms), but may become occupationally infected through failure of engineering controls or other inadvertent exposure to a TB patient. Such workers, however, would not be included in the respiratory protection program or routine testing provisions, she says. Grant’s point is not without basis, she concedes, agreeing that mistaking community-acquired TB for nosocomial TB would obviously be the "downside" of the provision.
"Maybe we shouldn’t make the employer responsible, and those are the kind of issues that we hope to air out through this whole rule-making process," Edens says. "[But] what if an exposure incident did happen? You are in a shared air space. Shouldn’t the employer do something to make sure that these people do get adequate follow-up?"
References
1. Department of Labor. Occupational Safety and Health Administration. Occupational exposure to tuberculosis; proposed rule. 62 Fed Reg 54,160-54,307 (Oct. 17, 1997).
2. 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.
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