Will OSHA still cite on TB skin tests, fit tests?

With no new standard, CDC guidelines reign

It’s official: The tuberculosis standard is dead. The Occupational Safety and Health Administration (OSHA) withdrew the TB standard from its regulatory agenda, citing the decline in tuberculosis cases in the United States. The action had been expected; earlier this year, OSHA placed the TB rule in the "long-term action" category of the semiannual unified regulatory agenda and called future activities "undetermined."

What does OSHA expect now? Will inspectors still cite hospitals on issues related to tuberculosis?

Tuberculosis is a recognized workplace hazard that could bring enforcement action under the agency’s "general duty" clause, says Amber Hogan, MPH, OSHA senior industrial hygienist. A 1996 compliance directive incorporated the TB guidelines of the Centers for Disease Control and Prevention (CDC) in Atlanta. So essentially, OSHA will enforce the CDC guidelines, she says. "What OSHA expects is what CDC recommends. That’s the benefit of not having a standard, but having a directive. If the CDC changes their recommendation for skin testing, we can do that, too."

For example, the CDC calls for hospitals to conduct a risk assessment, which would place them in one of five categories, ranging from minimal risk to high risk. A "minimal risk" facility, which does not admit TB patients and is located in a community that has not reported any TB cases in the previous year, would not need to conduct annual skin testing. Low-risk facilities would conduct skin tests every year, those at intermediate risk would provide skin tests every six to 12 months, and high-risk facilities would perform the tests quarterly.

Positive skin tests must be recorded on the OSHA log unless there is proof that the employee got it from a different source. "In a lot of situations, it is recordable just because it’s nearly impossible to show they got it someplace else," says Hogan.

With no new TB standard, hospitals must continue to comply with the current respiratory protection standard that specifically addresses tuberculosis, 1910.139. That does not include a requirement for annual fit-testing, although it requires initial fit-testing.

Employees must be properly trained on how to wear the respirator and how to determine if it fits properly. A fit test must be repeated if any facial changes occur that could affect fit — such as weight loss, cosmetic surgery, or a change in the size or make of the respirator.

If the respirator is used for any other substance, including any other airborne pathogen, hospitals must comply with OSHA’s revised respiratory protection standard (1910.134), which requires fit-testing "at least annually."

"It is strongly recommended that employers follow this same frequency for protection against tuberculosis," says OSHA spokesman Bill Wright.

A 1999 Administrator’s Guide, published by the National Institute for Occupational Safety and Health, details how to conduct a fit test and states that "[f]it tests should be completed at regular, periodic intervals (e.g., annually) to ensure continued adequate fit."

Greater awareness and early detection of TB has led to a decline in cases nationwide, notes Hogan. Lower risk meant less justification for a new tuberculosis standard and few citations.

"Almost all TB [enforcement] cases are based on a complaint or [occur] if there’s an outbreak," says Hogan. However, TB has been included as an inspection item in the national emphasis program that targets nursing homes with high injury rates, she notes.

(For a copy of the Administrator’s Guide, go to: www.cdc.gov/niosh/pdfs/99-143.pdf.)