OSHA exempts most doctors' offices from TB inspections

Homeless shelters, long-term care, drug treatment facilities must comply

Clarifying a gray area in its regulations, the Occupational Safety and Health Administration in Washington, DC, has largely exempted dental and physician offices from tuberculosis control measures required of other health care and clinical facilities.

In a recent compliance update to OSHA inspectors, the agency clarifies that dental health care personnel are covered by the directive only if they treat suspected or active TB patients in a hospital or correctional facility.1 That means a TB control plan need not be developed for free-standing dental offices, nor would dentists need to stock respiratory protection equipment and regularly skin-test employees, an OSHA compliance officer explained.

"That was a gray area before, and now we are clarifying it," says Rich Fairfax, MA, CIH, industrial hygienist in OSHA's national office of health compliance. "Bear in mind, though, if a dentist in a dental office was treating active TB patients and we got a complaint from an employee -- say one of the dental hygienists -- we would go in and look at it. We could address it, we just might not address it specifically under this directive."

The action also means that OSHA inspectors visiting a dental office for another occupational health concern will not routinely assess TB control efforts -- a prerogative they can exercise in other facilities covered by the directive.

"The [OSHA directive] is consistent with what Centers for Disease Control and Prevention and the science has said about TB," says Chris Martin, spokesman for the American Dental Association in Chicago. "Dentists need to refer active TB patients to their physicians, get the TB under control, and then have the patient come back for dental treatment."

Likewise, free-standing physician offices must comply with control measures only for personnel who perform procedures considered high-hazard for the transmission of TB infection. As previously identified in guidelines by the CDC -- which form the basis for the OSHA directive -- high-hazard procedures include sputum induction and administration of aerosolized pentamidine.2 Lobbying for the change, the American Medical Association in Chicago had requested that OSHA differentiate physician offices from higher-risk settings if such procedures are not performed on site. While it has been somewhat unclear whether OSHA would target free-standing offices, infection control consultants to dental and medical settings have advised practitioners to be aware of basic TB symptoms and control measures in order to assess incoming cases and ease employee concerns that could trigger an inspection. (See Infection Control Consultant, April 1994, pp. 51-53.)

Another major development in the new compliance directive is that OSHA has identified non-hospital settings that must have the essential elements of a TB program in place. Non-hospital facilities covered under the new compliance directive include correctional institutions, long-term care facilities for the elderly, homeless shelters, and drug treatment centers.

"I think what they are doing is focusing on the high-risk settings," says Gina Pugliese, RN, MS, vice president of health consulting at Sullivan, Kelly & Associates in Chicago. "Before, they just said health care facilities and never really defined them, so OSHA is taking a step forward in defining what they mean for the purpose of their inspections."

In the aforementioned facilities -- particularly homeless shelters where TB control may be difficult -- a protocol must be in place for rapid identification of TB patients. That must be followed by immediate transfer of suspect cases to facilities with control measures in place. In essence, facilities that treat or house known or suspected TB patients on site must have controls in place that would include the use of TB isolation rooms, Fairfax says.

Even if they routinely identify and transfer patients, the covered facilities must have a TB protection plan for employees that addresses the infection control program, respiratory protection, and skin testing. Employee interviews and site observations will be used by OSHA inspectors to determine compliance. As outlined in the compliance directive, however, the inspector may not review the TB program if it can be determined the facility has had no suspected or confirmed TB patients in the previous six months.

"They need to have some sort of protocol in place so that the first contact employee knows how to evaluate for TB -- what questions to ask, what to look for," Fairfax says. "If the person is suspect for TB infection, then there should be a protocol in place to transfer that person to a hospital or some setting where they could be evaluated. We don't want to have a homeless shelter take someone in and find out two or three weeks later it was a confirmed TB case and they have exposed not only workers, but other homeless people, as well."

Typical initial TB assessment questions cited by the CDC and infection control professionals include the following:

* persistent cough of three weeks or longer;

* signs or symptoms of blood sputum;

* night sweats or fever;

* weight loss or anorexia.


1. U.S. Department of Labor: Occupational Safety and Health Administration. OSHA instruction CPL. 2.106. Enforcement procedures and scheduling for occupational exposure to tuberculosis. Washington, DC; Feb. 9, 1996.

2. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities, 1994. MMWR 1994; 43(No. RR-13): 1-133. *