OSHA mandates 2-step tests in new TB rules

Retest new HCWs not documented negative

New tuberculosis compliance procedures developed by the Occupational Safety and Health Administration in Washington, DC, require initial two-step TB testing for some employees and identify which facilities may face OSHA TB inspections.1 (See related article in the Infection Control Consultant, p. 47.)

Replacing a 1993 OSHA directive, the new compliance document precedes the expected development of a formal TB standard by the agency sometime this year. Procedures for hospitals that treat TB patients call for TB skin testing to to be offered to all potentially exposed current employees and to all new employees prior to exposure.

"A two-step baseline shall be used for new employees who have an initially negative purified protein derivative (PPD) test result and who have not had a documented negative TB skin-test result during the preceding 12 months," the OSHA document states. "TB skin tests shall be offered at a time and location convenient to workers. Follow-up and treatment evaluations are also to be offered at no cost to the workers."

Some hospitals will see costs rise

Though essentially adopting the Centers for Disease Control and Prevention's TB guidelines, the OSHA requirement may increase costs for hospitals that have not adopted two-step testing due to perceived low risk of TB in their area, notes Gina Pugliese, RN, MS, vice president of health consulting at Sullivan, Kelly & Associates in Chicago.2

"In the CDC guidelines, that is only a recommendation to consider," she says. "In certain groups and certain areas of the country, that may not be appropriate. Two-step testing is expensive, and it may not be appropriate in all settings. It depends on your population."

The CDC guidelines clarify that the practice may be useful, recommending that the second test be performed one to three weeks later if the initial test is negative. If the second test is positive, the employee has most likely had a "booster effect" indicating previous infection. However, if the second test is negative, the worker should be classified as uninfected -- meaning any subsequent test is likely to represent new infection due to recent exposure to TB.

Two-step testing will help facilities identify recent infections for the purposes of documentation and reporting on the OSHA 200 form, says Rich Fairfax, MA, CIH, industrial hygienist in the OSHA office of health compliance in Washington, DC.

"I've had a lot of health care facilities complain about it, but it is actually in their best interest," he says.

In an additional requirement based on CDC guidelines, OSHA also specified that TB skin testing must be conducted every three months for workers in high-risk categories, every six months for workers in intermediate-risk categories, and annually for low-risk personnel. Two-step testing does not apply to periodic testing over time on the same workers, Fairfax emphasizes.

In addition to testing requirements, OSHA inspectors will assess whether appropriate signs and warnings are posted on the rooms of patients with suspected or confirmed TB. The compliance document states that some signal word must be on the sign, such as "stop," "halt," or the biological hazard symbol. Facilities that do not want to cite respiratory isolation on the sign in deference to patient confidentiality can post signs requiring visitors to report to a nursing station for instructions, Fairfax says.

"There has to be something on that door -- we're not telling them what -- that tells people not to enter without putting on a respirator or checking with the nurses' station to make sure they are properly protected," he says.

Under current OSHA plans, TB inspections will be conducted in response to employee complaints or as part of any industrial hygiene inspections on other matters. Additional highlights of the OSHA directive to inspectors include the following:

* Upon entry, the OSHA inspector shall request the presence of the infection control director and employee occupational health professional responsible for occupational health hazard control.

* The inspector shall establish whether or not the facility has had a suspected or confirmed TB case within the previous six months based upon interviews and, in a hospital, a review of infection control data.

* If the facility has had a suspected or confirmed TB case within the previous six months, the inspector shall proceed with the TB portion of the inspection, verifying implementation of the employer's plans for TB protection through employee interviews and direct observation where feasible.

* Areas of the facility that may be inspected during the walk-through include emergency departments, respiratory therapy areas, bronchoscopy suites, and the morgue. After review of the facility plans for worker TB protection, the employee interviews combined with an inspection of the facility will be used to determine compliance.

* There must be a protocol for the early identification of individuals with active TB.

* TB isolation rooms must be maintained under negative pressure. At a minimum, the employer must use nonirritating smoke trails or some other indicator to demonstrate that the direction of airflow is from the corridor into the isolation/treatment room when the door is closed.

* Air from isolation and treatment rooms must be decontaminated by a recognized process such as high-efficiency particulate air (HEPA) filtering if it is being recirculated in the room rather then exhausted directly outside. Ultraviolet radiation lamps cannot be the sole means of decontamination, though they may be used in waiting rooms, emergency departments, corridors, and other areas where patients with undiagnosed TB could potentially contaminate the air.


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. *