OSHA seeks unique TB standard for U.S. shelters
Hearings convince agency revisions are needed
The nation’s approximately 10,000 homeless shelters may get a break from the Occupational Safety and Health Administration (OSHA) as the federal agency goes back to the drawing board for its proposed TB standard.
"It looks like what we proposed isn’t going to work, given the constraints and the situations which most shelters face," says Mandy Edens, MPH, OSHA’s project officer for the proposed TB standard. "Shelters pose a unique problem, one that will probably take a unique solution."
Most likely, the solution will not take the form of a separate standard for shelters — the solution one advocacy shelter group had hoped for — but of a carve-out within the existing standard, according to which shelter service providers would be held to less stringent standards than other employers, says Edens. "It may come down to what can you reasonably expect [shelters] to do, not what you would like [them] to do," she says.
That’s not to say shelters will get off scot-free, even if they won’t be asked to abide by the same rules as others named in the TB standard — including hospitals, drug-treatment centers, correctional centers, home care agencies, and facilities which provide long-term care for the elderly. Some examples of simple but effective measures, which are still hypothetical at this point, Edens explains, that OSHA might ask shelters to implement include: getting guests to cover their cough with a tissue; or, as a way to separate a TB suspect, putting someone temporarily into a small room equipped with an exhaust fan.
Somewhere on middle ground
The final version of the TB standard will "probably wind up somewhere in the midground" between what OSHA had first proposed and what shelter advocates would like to see happen, Edens says.
What helped convince OSHA staff to revisit the shelter portion of the TB standard were the arguments presented by various advocacy groups and service providers during four all-day hearings, which OSHA held in different cities around the nation, Edens says. Half of the sessions examined the standard’s potential impact on homeless shelters. "We learned a lot about what some communities are trying to do about TB in the shelters," she says. "We found that in other communities, they’re just trying to get people in off the streets, and they don’t have the resources to do much more than that."
Shelter advocates attacked the proposed standard on a variety of grounds, saying it groups too many kinds of facilities and services under the broad term of homeless shelter, makes providers responsible for getting guests to do things they won’t want to do, asks lay people to make complicated medical judgments, and will effectively put more homeless people on the streets with no resulting decrease in TB transmission.
"We hear what people are saying," Edens says. "They’ve given us lots to think about. Now we have to go back and figure out what’s the best tack to take."
One thing the final version of the standard will still have to do is provide for some means of surveillance, Edens says. Without a way to monitor skin-test conversions, "you’ll never know if you have a problem."
That strikes many shelter advocacy groups as reasonable, according to Robert Reeg, MPA, policy analyst for the National Coalition for the Homeless, a Washington, DC-based agency which represents about 2,000 coalitions of homeless shelter service providers. "We have some concerns about how shelters would pay for skin testing," he says. "We’d expect local health departments and hospitals to pick up some of the responsibility."
"Maybe there will be some way to hook [shelters] up with the local health departments so they can get skin tested and get some kind of rudimentary training program," Edens replies.
Shelter advocates also have objected to the OSHA requirement that they screen arriving guests for signs and symptoms of TB. To be effective, such screenings would be too complicated for intake workers without clinical expertise and too time-consuming besides, shelter advocates protest.
Emergency departments overwhelmed?
Not screening guests at all isn’t the answer either, says Edens. "The consequences would be too great for staff and even more for other guests whose immune status may be compromised by poor nutrition, HIV infection, or other factors.
"Unfortunately, most shelters don’t have access to clinical people, such as you would expect to find in other settings," she adds. "We asked a lot of people what kind of [screening] system they used, and the answers varied all across the board. Some do have an entry point where they can ask questions, but the people doing the intake don’t have the expertise to distinguish suspects." Plus, she adds, echoing a widespread criticism of the current proposal, "in the flu season, everyone may look suspicious. They’ve got a cough, they’re underweight because they’re malnourished, and they have night sweats because they sleep in all their clothes.
"The result would be either that emergency departments would be overwhelmed, or guests would realize that to gain admittance, they need to answer no’ to questions about symptoms," Edens adds.
OSHA has acknowledged another problem in the current standard — the "isolate-or-transport" requirement. That is, if it proves impossible for a shelter to see that a TB suspect is transported to a clinic or emergency department within five hours’ time, the guest must be isolated.
"Our concern is both how this would impact people who use the shelters and how the shelters would implement it," says Reeg. Shelters that admit guests in the evening, at night, or on weekends may find it tough to transport someone during off-hours, he says. Rural shelters might not have ready access to a suitable facility at all. And ambulance services may balk at the idea of picking up a nonemergency case identified as a TB suspect.
Nor will homeless people take to the idea of being hauled off to a hospital, Reeg adds. "There are civil rights aspects," he says. "A shelter isn’t in control of a person’s life. They can’t force someone to go to the hospital. And even though they’re not supposed to simply turn someone out onto the streets, that may be what happens."
Despite the problems, that doesn’t mean shelters shouldn’t try, Edens says. Not isolating someone who’s infectious will endanger staff and guests alike. "It poses the greatest danger to guests since many may be immunocompromised due to poor nutrition or having HIV or other factors," she says. As for the isolation part of the clause, "we never envisioned that shelters, with their limited resources, would be able to provide a conventional isolation facility," Edens adds.
Since most shelters don’t have access to a medical professional equipped to decide whether someone should be isolated, one question for OSHA to answer is how long it makes sense to let someone wait for evaluation, Edens says.
Defining the term shelter’
Another concern for OSHA representatives is how they will define the scope of shelters to which the standard will apply. "People have asked us whether we mean battered women’s shelters, or places that serve street kids, or soup kitchens, or units that function as single-family homes," Edens says. "Obviously, the riskiest setting is the big, congregate-style shelter [that] people are trying to move away from." In fact, it is only for that type of shelter that the National Health Care for the Homeless Council would like the standard to apply.
The deadline for comments on the standard was Oct. 5. An earlier deadline, Sept. 4, marked the last time stakeholders could submit new data for consideration. As the Oct. 5 deadline drew near, OSHA officials weren’t expecting any new issues to surface. "The basic issues are already out on the table," says Edens.
Most of the dispute has centered around whether or not a legitimate need exists for more federal regulations, and if most facilities are already abiding by recommendations issued by the Centers for Disease Control and Prevention. Unions, by and large, would like to see more regulations; groups representing health care professionals and health care facilities tend to be divided.
Unions, for example, would like the new standard to cover some groups more broadly than what’s currently proposed. In the case of social workers and law-enforcement officers, the proposal extends not to every setting possible but only to situations where someone must enter a setting where there is already a known or suspected TB case, Edens says.
Departure from other OSHA standards
The new standard departs from traditional OSHA standards in the way it explicitly names a variety of workplaces, she explains. "This is different from the tack we took with the bloodborne pathogens standard. Typically, we don’t [list settings] with our substance-specific regulations. For example, we say occupational exposure to cadmium,’ not cadmium smelters and cadmium batteries,’ and so forth." With TB, OSHA made an exception, because so many settings involved seem to pose an especially high risk to workers, she says. "We tried to pick settings where [risk for TB exposure] is higher than in the general population," she says.
Along with shelters, settings include drug-abuse treatment centers and home health care agencies. The proposal to include drug-treatment centers has evoked little protest, perhaps because unlike many shelters, most drug-treatment centers already maintain close ties to the health care establishment, Edens says.
Bringing the home health care industry under the TB standard poses another set of problems, industry advocates say. Most of the nation’s approximately 12,000 home health care agencies are already under the gun thanks to a new interim system of payments which effectively curtails the number of patient visits for which an agency can collect reimbursement, says Mara Benner, a spokeswoman for Home Health Services and Staffing Associations, an Alexandria, VA-based advocacy group that represents 2,000 agencies across the nation. With many agencies already financially stressed, the prospect of shouldering more demands is evoking protests.
"We don’t normally see TB cases anyway," she adds. "They’ve already been treated by the time they reach us, and they’re no longer infectious." But the extra paperwork it will take to document baseline and periodic skin testing will seem onerous, says Benner.
More troubling is a stipulation requiring home care agencies to pay employees who contract TB on the job up to 18 months’ salary and benefits. "That’s really a concern for us," Benner says. "We’ll work with OSHA on the rest of it, as long as the requirements aren’t so dramatic."
Yet most employees won’t need more than a few weeks’ therapy before they’re noninfectious and can come back to work, says Edens. "It’s an incentive for employees to report possible symptoms instead of walking around sick, scared they’ll lose pay," she says. "Plus, workers’ compensation doesn’t necessarily cover full pay."
Other home care providers have bridled at the requirement that employees wear their respirators when entering the home of a suspect or known TB case. "Employers say since they’re not there, they can’t ensure that," says Edens. "But we say they can ensure other rules are enforced, so they must have some way to monitor their employees."
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