Food-service industry focus of Denver debate
Should license be linked to PPD?
Some TB experts in Denver want to implement a program of mandatory TB screening that targets foreign-born workers in the food-service industry by making them complete a skin test before they go to work.
If that sounds a bit draconian, consider the experts’ reasoning: TB cases in Denver are up from 63 cases in 2000 to 91 cases last year, with most of the increase among the foreign-born. In Denver, as elsewhere in the country, many of the food-service workers who staff the kitchens of the city’s restaurant industry are foreign-born, and many are medically underserved, local TB experts say. Federal guidelines, in fact, single out food-service workers, saying that group may be an occupational sector where TB screening is important.1
Until a few years ago, Denver did have such a program. In its final version, the program was set up so that only high-risk workers were pulled for TB testing. Latency rates among that selected subpopulation were over 30% tuberculin skin-test positive, showing that the program was needed, its boosters say. More important, they add, the program snagged a handful of active cases among food-service workers that otherwise may have gone undetected for much longer.2
"With a rising incidence of TB in Colorado, anything you can do to identify those at high risk for TB is something you should do," says John Sbarbaro, MD, professor of medicine at the University of Colorado Health Sciences Center in Denver. Sure, Sbarbaro adds, there are high concentrations of foreign-born workers in other industries as well, such as migrant farm workers, roofers, and landscapers, but they’re simply not as accessible. "It would great to screen migrant farm workers too, but there’s no central place to do it," he argues. "Here in metro Denver, the TB clinic is right in the middle of town, a bus ride away from most restaurants. You get your card, and away you go."
Once upon a time, a great program
It was Sbarbaro, in fact, who inaugurated the original screening program in the early 1970’s when he served as Denver’s director of public health. During its genesis, the program screened as many as 12,000 food-service workers a year. Over the years, however, it became clear that most of the pertinent epidemiology was increasingly concentrated among foreign-born workers, so the program was refined by inserting a questionnaire that flagged applicants if they met any of several high-risk categories.
That whittled the pool of people who had to be skin-tested down to only about 2,500 food-service applicants a year, the vast majority of whom were foreign-born, and about one-third of whom turned out to be skin-test positive. Then — for reasons that Sbarbaro and others assert have more to do with politics than good policy — the program was shut down.
It’s important to know that one reason the original program functioned so smoothly was because workers already had to trek to the health department to take a food-handler test. That involved watching a movie about food handling and taking a test on the contents. Because job applicants already had to make the trip to see the movie, it wasn’t much trouble to require them to take a TB skin test while they were there.
But at a certain point, the food handler test requirement was dropped. Then the restaurant trade association claimed that forcing food-service workers to make a trip to the health department solely for a TB skin test was an inconvenience. Further, they argued that it was unfair because they were the only industry in town so burdened.
At that point, according to one version of the story, the situation became politicized. First, the regulatory and enforcement arm of the city’s public health department was severed from the medical arm as the unintended consequence of a procedure aimed at giving more financial security to the city’s indigent care hospital.
With little public health expertise, this side of the story goes, the then-director of the agency where enforcement power now resided — by that time re-christened the Board of Environmental Health — caved in to pressure from the food-service industry.
At the meeting where it was decided to shut down the program, public health experts weren’t even invited to speak, says Frank Judson, MD, director of the Denver Department of Public Health. "We went on our own, but my testimony was interrupted after only two minutes," recalls Judson.
That’s not what happened at all, retorts Bob Conrad, acting manager of the Board of Environmental Health. Conrad, who was not in office at the time the screening program was axed, says the city’s lawyers had strong misgivings about a program that singled out one industry. "There was pressure from the restaurant association, but that had nothing to do with our decision," Conrad says. "Few, if any, health departments around the country do such focused screening. I’m not a doctor, and I’m no expert, but why single out TB? Why not hepatitis or another communicable disease?"
Ned Calonge, MD, Colorado’s chief medical officer (and not a member of Conrad’s department), sides with Conrad. It wasn’t fair to make only food-service workers come to the health department, Calonge says. "They didn’t single out other industries where the foreign-born worked, so the effect was to place differential pressure on the food-service industry," he says. Far more important, to Calonge’s thinking, is getting the governor’s signature on a bill that would update the state’s TB statute.
But to Judson, the program didn’t "discriminate" against the food-service industry; it provided an important service (albeit one the food workers didn’t have the right to turn down) that certain other industries should be getting as well.
"The fact that you can’t reach everyone who’d benefit from screening — the roofers, the construction workers, the cab drivers — is not a good reason not to do something," Judson says. Programs that targeted other industries where foreign-born workers are also concentrated simply wouldn’t be feasible, he adds. "I don’t know who’s out there doing weekend roofing, or running an unregistered lawn and garden service," he points out. "We have no way to reach these other industries."
Nor does it trouble Judson that no other jurisdiction in the country, evidently, has a program targeting food-service workers. "The mere fact that you’re creative and innovative enough to come up with a program others haven’t done yet is a good reason to do this," he says. Las Vegas actually had such a program until recently, but with fewer foreign-born workers than Denver, the program was eventually cancelled because it was deemed to be too low-yield to justify its continued existence.
Whatever its merits, almost everyone in Denver agrees the prospects for starting the program back up are not especially promising. "It would be harder to do, since we no longer have the food-handler test," says Randall Reves, MD, medical director of the city’s TB control program. More likely, there will be some sort of move to start voluntary outreach programs, he adds. That means finding money, of course, and the state of Colorado doesn’t provide money for targeted testing.
Looking at cabbies and bus drivers
At the same time, Reves concedes he’s intrigued by the prospect of using a licensing procedure to access particular industries dominated by foreign-born workers. Last year, for example, three active cases of TB were reported among taxi and bus drivers, a number that suggests the case rate is even higher among cabbies and bus drivers than in the food-service industry, because it’s a smaller job sector. As it happens, there’s already a licensing procedure in place for cabbies and bus drivers, so in that industry, a mandatory screening program "might actually make sense," he says.
What Reves seems to hanker for most, though, is a sort of paradigm shift. "To me, the question is whether people should be thinking about TB risk assessment as a part of pre-employment screening," he says. "The point is to find ways to do it that are effective but impose the least aggravation."
After all, he says, no one disputes the requirement that children starting school have to provide proof they’ve gotten their immunizations. "It doesn’t really make sense for kids to wait until they hit the first grade to get immunized," he adds. "It’s just that first grade is a logical place to do it, since that’s where everybody goes."
Some employment sectors such as the meat processing industry have been hard-hit by TB outbreaks and have reacted by implementing TB screening for job applicants. By inserting a simple risk assessment for TB into the application process, just like the food-handlers’ test was doing before it was scrapped, employers could easily spot candidates for TB skin testing and offer the test when indicated.
1. Screening for tuberculosis and tuberculosis infection in high-risk populations: Recommendations of the Advisory Committee for the Elimination of Tuberculosis. MMWR May 18, 1990/39(RR-8); 1-7.
2. Judson FN, Sbarbaro JA, Tapy JM, et al. Tuberculosis screening: Evaluation of a food-handlers’ program. Chest 1983; 83:879-882.