OSHA moves forward with ID standard

Will California or failed TB rule be the model?

As the U.S. Occupational Safety and Health Administration moves deliberatively toward an infectious diseases standard, two paradigms could spell very different fates for a proposed rule.

Is California the model, with its Aerosol Transmissible Diseases standard? Or, as some critics say, is this standard on a path similar to the tuberculosis standard, which reached the final rule stage before it was abruptly revoked?

OSHA contends that the SARS epidemic, which killed two nurses and a doctor in Ontario and sickened scores of health care workers,1 and the H1N1 pandemic, which killed a California nurse and sickened at least 81 health care workers in the first weeks of the pandemic,2 reflect the need for workplace protections against infectious diseases. By taking a broad approach — the standard will likely address airborne, droplet and contact transmission — OSHA puts the tuberculosis rule behind it.

"While the agency learned a great deal from the previously proposed tuberculosis rule, the agency is considering the current infectious disease activity in the larger context of standard and transmission-based precautions rather than on a disease-by-disease basis," agency officials said in response to a question posed by HEH in an online chat. OSHA was scheduled to hold a stakeholder meeting in late July to gather further comments.

But many in the occupational health and infection control communities say guidelines from the Centers for Disease Control and Prevention are sufficient to protect health care workers and patients alike. They note that guidelines can change as new knowledge emerges about disease transmission, and although they are not regulatory, accrediting bodies expect hospitals to follow them.

The American College of Occupational and Environmental Medicine (ACOEM) has urged OSHA to use a "generic" approach to ensure that employers provide health care workers with appropriate personal protective equipment and training. "There is already precedent for the enforcement of health care worker protection from tuberculosis under the General Duty Clause," ACOEM said in a letter to OSHA.

In written comments to OSHA, the Association of Occupational Health Professionals in Healthcare (AOHP) noted that OSHA already has tools to enforce protections related to infectious disease hazards.

"We felt that with the current OSHA standards, including the general duty clause, respiratory protection program, personal protective equipment and recordkeeping, that those adequately protected the workers," says MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM, manager of Employee Health Services at Allegheny General Hospital and the Western Pennsylvania Hospital in Pittsburgh.

Are hospitals following CDC?

But are CDC guidelines adequate to provide workplace protection for health care workers? When hospitals fail to follow recommended infection control guidelines or provide adequate protections, an outbreak may occur. In California, that failure also can lead to citations.

That extra imperative has made a difference in spurring compliance with CDC guidance, says Deborah Gold, MPH, CIH, deputy chief of health for Cal-OSHA in Oakland.

Case in point: Pertussis vaccination of health care workers. In 2006, a CDC advisory panel recommended pertussis vaccination for health care workers who care for infants. That recommendation was later expanded to include all health care workers with patient contact.

But as pertussis cases rose in California to the highest levels in 50 years, the California Department of Public Health found that vaccination was spotty. "Even though there had been a voluntary recommendation saying people should be vaccinated, [many] people weren't," says Gold. "The requirement in the standard helped move the vaccination program along."

Clear requirements in California meant greater protections as the H1N1 pandemic emerged, says Bill Borwegen, MPH, safety and health director of the Service Employees International Union (SEIU). "It was a lot easier to protect our members [with respirators] in California than it was in the rest of the country, especially when public health departments were providing conflicting advice," he says.

With the ATD standard, the requirements related to workplace protection are clearly spelled out, says Gold. "It gives everybody an understanding of what needs to be followed," she says. And if they're not, employees then have recourse to file an OSHA complaint, she says.

If employers are already in line with CDC recommendations, then they have little to worry about, she says. "A hospital or any health care facility that's doing a good job of complying with CDC guidelines is not going to find a big challenge complying with our ATD standard," she says.

What is the HCW risk?

Infection control practitioners and occupational health professionals argue that health care workers do not have higher rates of diseases than the general public — the argument that ultimately was pivotal in the scuttling of the tuberculosis standard.

"The fact that incidences among health care workers of a range of infectious diseases have not been shown to exceed population rates speaks to the effectiveness of hospital-based infection control and occupational medicine infrastructures," ACOEM said.

The Association for Professionals in Infection Control and Epidemiology (APIC) was blunt in its comments: "Because these efforts are already well-guided by other government agencies, they do not require additional monitoring by another government agency and represent a redundant and unnecessary cost burden for employers and taxpayers. "

At the Marshfield (WI) Clinic, which serves about 1.4 million patients a year, since 1994 only one employee's illness has been linked to probable transmission from a patient — a case of H1N1, says Bruce Cunha, RN, MS, COHN-S, manager of employee health and safety. "Other than that, we have not been able to document a connection between seeing a patient with a disease and an employee getting a disease," he says.

"The OSH Act [which created OSHA] says in order to develop a standard, OSHA has to show there's a specific hazard," he says. "I don't see how they can do this without having good hard evidence that health care workers have any greater risk of developing disease than the general public."

Yet a recent transmission of meningitis in California illustrates the infectious disease hazard to first responders and emergency room personnel. A police officer responded to a call and found an unconscious person in his home — but did not wear respiratory protection when he tried to clear the man's airway. The police officer ultimately was hospitalized with bacterial meningitis.

So was a respiratory therapist who subsequently assisted in an intubation of the patient in the emergency department — without wearing a mask or respirator. CDC recommends "protection of the eyes, nose and mouth" when performing aerosol-generating procedures.3 The ATD standard calls for the use of respirators during "high hazard procedures" (including intubation) for droplet and airborne diseases. (The ATD standard is available at www.dir.ca.gov/title8/5199a.html.)

"We're trying to [ensure that health care workers] take appropriate precautions at each level of interaction," says Gold.

Reference

1. Campbell, A. The SARS Commission, December 2006. Executive summary available at http://bit.ly/p4vVTy

2. Wise ME, de Perio M, Halpin J, et al. Transmission of pandemic (H1N1) 2009 influenza to healthcare personnel in the United States. Clin Infect Dis 2011; 52:S198–S204. http://bit.ly/oEOWzg

2. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Available at http://1.usa.gov/r21L9g