APIC battle plan against OSHA TB rule taking shape

Marshaling a collective, critical response from ICPs

Battle lines are being sharply drawn between infection control professionals and the Occupational Safety and Health Administration as a series of national hearings on OSHA’s controversial tuberculosis standard begins in April.

Strong opposition to the rule can be expected in testimony and comments from the Association for Professionals in Infection Control and Epidemio logy, which recently urged its members to fight the regulation. While APIC’s official comments to OSHA were not available at press time, the Washington, DC-based association has distributed an "action alert" strategy document to its chapter presidents and legislative representatives from Julie Sellers, RN, chair of the APIC government affairs committee. Urging every ICP to respond in a "collective voice," the talking points paper maps out the key areas APIC is seeking to revise or eliminate from the proposal before it is enacted into law. Key points of the paper are summarized as follows:

• APIC’s overall contention is that TB exposure control needs to be scientifically valid. That common theme runs through the various points highlighted, beginning with a statement regarding whether or not there is an actual need for this standard at all, in light of the availability and effectiveness of the CDC’s TB control guidelines.

• A very basic assumption that OSHA maintains is that this standard will contribute significantly to protecting health care workers from exposure to TB. Yet in the standard itself, on page 54,182, the agency acknowledges that undiagnosed TB cases have been the "primary factor" in the transmission of infection. All the control measures in the world will not protect against transmission of TB if they are not implemented, which would be the case with undiagnosed or unsuspected patients.

• OSHA requests information on the different kinds of masks currently in use. For those people in facilities using protection less stringent than a HEPA (high efficiency particulate air) or N-95 mask, this would be an excellent opportunity to make the argument that these higher levels of respiratory protection may not be necessary. Key questions include: How many employees have experienced skin-test conversions related to the use of a mask that is lower in protection than the HEPA or N-95? The answer is probably zero, because if you had identified conversions in employees wearing lower levels of respiratory protection, then you would have likely made recommended changes to a higher level of protection, such as the HEPA or N-95.

• Acknowledge that exposure controls have been implemented based upon current CDC recommendations, as appropriate for each facility. Then provide your rate of occupational exposure skin-test conversion for the period of time the controls have been in place. Remember to exclude conversions related to exposures to undiagnosed cases, because in those situations, exposure controls were not applicable. APIC hopes to demonstrate the efficacy of current exposure controls and that additional regulation from OSHA is unnecessary.

Employers to bear cost of non-work-related TB

• Express concern about OSHA’s requirements for medical removal protection, which would make employers responsible for maintaining, for up to 18 months, the full salary and benefits of employees with suspected or confirmed TB, regardless of whether infection is proved to be work-related. Challenge OSHA’s authority to supersede state worker’s compensation programs. OSHA only mentions concerns about the costs of this requirement as it relates to small businesses, but all employers would have concerns about these potential costs, and those concerns should also be conveyed, particularly from areas with high rates of skin test-positive employees. Facilities also have expressed the concern that this requirement could lead to discrimination against hiring a skin test-positive employee. If that employee’s condition progresses to active TB disease (even though it would be totally unrelated to occupational exposure), the employer would still have to absorb the inordinate costs associated with meeting this requirement.

• APIC will continue to object to any requirement for respirator fit-testing, based upon available references.1-5 Members are encouraged to cite their facilities’ costs associated with implementing a fit-testing program. Cite numbers of staff hours, employees’ time away from patient care, costs of supplies, labor costs for administration of the program, etc. Juxtapose any facility-specific data reflecting the burden of this requirement against the undocumented need for it.

• OSHA’s proposal to increase frequency of skin testing above and beyond annual testing merely because an employee enters a TB isolation room is neither scientifically justified nor fiscally responsible. In addition, the likelihood that the patient is a confirmed case varies widely in the literature, with reports of ratios of suspected to confirmed cases from 3.5 suspect:1 confirmed6 to 92 suspect:1 confirmed.7

• APIC also plans to comment on the decreasing predictive value of positive PPD tests in populations with low prevalence of actual TB.8 Utilizing the PPD test in low-prevalence areas or in the absence of true exposures to confirmed TB cases will lead to false-positive skin test conversions, inappropriate INH preventive therapy (with the associated risks of chemoprophylaxis), and unnecessary, costly, and time-consuming investigations to identify a potential source.

OSHA has scheduled three informal public hearings on the standard. The hearings will begin April 7 in the auditorium of the Department of Labor (Frances Perkins Building), 200 Constitution Ave. NW, beginning at 10 a.m. Hearings will begin at 9 a.m. on the next two days at the same location.

Hearings in three additional cities have been added, beginning May 5 in Los Angeles, May 19 in New York City, and June 2 in Chicago.

References

1. Adal KA, et al. The use of high efficiency particulate air-filter respirators to protect health care workers from tuberculosis. A cost-effectiveness analysis. N Engl J Med 1994; 331:169-173.

2. American Thoracic Society. Control of tuberculosis in the United States. Am Rev Respir Dis 1992; 146:1,623-1,633.

3. Blumberg HM, Watkins DL, et al. Preventing the nosocomial transmission of tuberculosis. Ann Intern Med 1995; 122:658-663.

4. Maloney SA, Pearson ML, et al. Efficacy of control measures in preventing nosocomial transmission of multidrug-resistant tuberculosis to patients and health care workers. Ann Intern Med 1995; 122:90-95.

5. Nettleman MD, et al. Tuberculosis control strategies: the cost of particulate respirators. Ann Intern Med 1994; 121:37-40.

6. El-Solh A, Mylotte J, Sherif S, et al. Validity of a decision tree for predicting active pulmonary tuberculosis. Am J Respir Crit Care Med 1997; 155:1,711-1,716.

7. Scott B, Schmid M, Nettleman MD. Early identification and isolation of inpatients at high risk for TB. Arch Intern Med 1994; 154(3):326-330.

8. Huebner RE, Schein MF, Bass JB. The tuberculin skin test. Clin Infect Dis 1993; 17:968-975.