Employee health pushes OSHA for standard on biologic hazards

Conflict causes confusion with SARS, TB

The struggle with severe acute respiratory syndrome (SARS) and confusion over how to adequately protect health care workers has led some employee health professionals to call for a new U.S. Occupational Safety and Health Administration (OSHA) standard on biological hazards.

Currently, only tuberculosis warrants special attention from OSHA. Although the agency abandoned its efforts to create a TB standard, it still has a respiratory standard that specifically addresses tuberculosis. All other infectious diseases fall under a respiratory protection standard that was designed for industrial exposures.

"We’re dealing with something very different from asbestos or one known [chemical] hazard," says MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM, executive president of the Association of Occupational Health Professionals in Healthcare (AOHP) in Warrendale, PA, and employee health coordinator at Western Pennsylvania Hospital in Pittsburgh.

"There are multiple hazards that are transmitted in [a similar] way," she says. "I think it needs to be a broad standard that covers those hazards. Maybe they can use the TB standard as a model."

In fact, a House Appropriations Committee report in July specifically urged OSHA to "consider an airborne disease standard" to protect health care workers. "With our country confronting these new airborne biological threats, we have asked our health care professionals to do more to protect all of us. These workers have responded," the report stated. "The committee believes that Congress now owes a debt of gratitude and has a responsibility to protect these same health care workers from the occupational hazards they face, so that they can focus on doing the best job possible in caring for and treating their patients."

Although the statement carries no force of law, it represents a first effort to push OSHA to address biological hazards, says Bill Borwegen, MPH, occupational safety and health director for the Service Employees International Union (SEIU) in Washington, DC. "I think this is a recognition that OSHA’s not doing what it needs to be doing in this area," he says.

Fit test every year — or only once?

For employee health professionals, consistency is a key concern. Although some hospitals routinely conduct annual fit tests on employees who provide care to TB patients, many rely on baseline testing and employee fit checks. If the employee has experienced significant weight change or has concerns that the mask no longer fits properly, a new fit test would be conducted.

However, employees who wear respirators to prevent exposure to any other infectious disease must have annual fit tests, OSHA says.

AOHP and the American Association of Occupa-tional Health Nurses (AAOHN) in Atlanta are asking OSHA to consider a respiratory protection standard for all airborne infectious diseases. This could possible mean the revision of the tuberculosis respiratory protection standard (1910.139). This approach ultimately might eliminate the need for annual fit testing, which would be a significant undertaking for short-staffed employee health services, Gruden says.

"We’d have to come up with a whole new process to fit test people because our office couldn’t handle it," she says. "The departments would have to be responsible for their own fit testing. We’d have to train [staff on the units], and they’d have to do it. Most employee health offices would be in the same situation."

If annual fit testing is necessary to adequately protect workers, Gruden says she would support it but would need guidance and assistance.

"I want to do what’s right for the employee," she says. "If it means testing everybody every year, we need to know it’s based on science, then we need to figure out how we’re going to implement it."

Health care needs its own respiratory protection standard, not one based on an industrial model, says Lori Schaumleffel, RN, COHN-S, ARM, coordinator of employee health services at Mercy Hospital of Folsom (CA) and Mountain Western regional director of AAOHN.

"Instead of labeling that [respiratory protection] exception tuberculosis,’ let’s label it biological hazards,’ so that diseases spread by the same mechanism can be lumped together," she says.

"We all have the same goal in terms of making health care workers safe," Schaumleffel points out. "We don’t want to create a standard that is not safe; but health care workers have been utilizing this program for many years, where they are not fit tested annually, and they have done very well."

Protection against biologic hazards is often related to risk assessment. For example, the Centers for Disease Control and Prevention’s (CDC) TB guidelines offer different approaches based on the risk of TB in the community and the hospital’s patient population. But with SARS, many questions remain unanswered about the route of transmission and level of exposure that leads to infection.

It is not possible, as in industry, to set an exposure limit and measure the exposure levels in the air, notes respiratory protection expert Roy McKay, PhD, director of the occupational pulmonology services program at the University of Cincinnati College of Medicine. Health care workers will not know from a toxic odor whether something is breaching the protective equipment.

That underscores the need for proper fit testing that occurs on an annual basis, he says. McKay would favor eliminating the exception for tuberculosis. "As it stands now, TB is the only agent that has respiratory protection practices different from every other chemical and biological agent. That really makes very little sense," he says.

Not everyone agrees. The Association of Professionals in Infection Control and Epidemiology (APIC), also in Washington, DC, spent years arguing against the need for annual fit testing and a TB standard. The problem, says Jennifer Thomas, APIC director of governmental affairs, is that a one-size-fits-all approach doesn’t work for hospitals that face different risk profiles and patient populations.

"OSHA is not an agency that should be regulating a biological agent, period," she says. "You can’t have a static regulatory standard protecting workers against something biological because it doesn’t allow for proper and timely modification."

Meanwhile, employee health professionals are faced with different rules and guidelines for different diseases and confusion about how to best protect health care workers.

"We’re all kind of on our own," says Geoff Kelafant, MD, MSPH, FACOEM, medical director of the occupational health department at the Sarah Bush Lincoln Health Center in Mattoon, IL. "You hope you do the right thing. My fear would be that you’re going to throw an N95 on someone when that level of protection is just not enough. Or conversely, [with] something you don’t need to worry about, you’re going to spend a lot of time and money on something you don’t need to do."