APIC: TB standard would do more harm than good

IOM testimony continues epic debate

Rather than increasing protection of health care workers, a proposed federal tuberculosis standard would undermine patient care, lead to false-positive TB tests and unnecessary treatment of workers, and spur substantial expenditures for a disease in steep decline in the nation, the Association for Professionals in Infection Control and Epidemiology (APIC) argues.

"[The Occupational Safety and Health Administration] proposes minimizing employ-ee exposures by combining tasks and limiting the number of employees entering an isolated patient’s room," said Rachel Stricof, MT(ASCP), MPH, who testified for APIC recently before a panel of the Institute of Medicine (IOM) in Washington, DC. "This proposal is in direct conflict with the mission to care for patients. The risks to health care workers have clearly been demonstrated to be associated with the unidentified, unisolated, and untreated case, not with patients placed in appropriate AFB isolation. In addition, the majority of patients in isolation are suspect cases that are ultimately found to have another etiology for their symptoms."

Would rule protect or harm?

Proposed in 1997, the OSHA TB rule is aimed at protecting health care workers through requirements for TB screening and engineering controls that include respirators. (See Hospital Infection Control, December 1997, pp. 177-184.) Congress ordered the IOM panel to review the need for the standard.

"Frequent tuberculin skin tests in low-prevalence areas will result in more false positives than true positives resulting in unnecessary treatment and follow-up," Stricof testified. As a result, health care workers with false-positive TB tests — without known exposure — may be targeted inappropriately for treatment of latent TB, she said. The toxicity of some TB drugs can contribute to hepatitis, she cautioned the IOM panel. Moreover, the number of TB cases in the United States has gone down from 25,287 reported cases in 1993 to 17,528 in 1999, a 31% decline. "This is the lowest incidence reported since national reporting began in 1953," she said.

Likewise, the number of patients requiring hospitalization has declined due to the decreasing incidence and the provision of diagnostic, treatment, and follow-up services in the community. Fewer TB cases are being readmitted due to treatment failure. The provision of directly observed or closely monitored therapy by public health agencies has resulted in fewer treatment failures, admissions, and readmissions. There also are fewer multidrug-resistant TB (MDR-TB) cases.

"In New York City, the number of MDR-TB cases declined from 441 in 1992 to 34 in 1999, a 92% reduction," Stricof said. "In the rest of New York state, only one MDR-TB case was reported in 1999."

Continuing to call for the standard was Bill Borwegen, occupational health and safety director of the Service Employees International Union (SEIU), AFL-CIO. The SEIU, which represents some 600,000 health care workers, lobbied to get the standard proposed and has continued to call for its finalization.

"I have also heard from many members of SEIU who are infection control practitioners — as well as APIC members — firmly supporting the need for an OSHA TB rule," he testified. "The ultimate question seems to be should we require employers to implement the CDC guidelines by way of an OSHA standard, or shouldn’t we? The problem really boils down to do we need a requirement for employers to act? If employers were voluntarily implementing the guidelines, then we wouldn’t need to be here today."

While there have been modest improvements in compliance with CDC TB guidelines, there are still far too many institutions that have chosen not to act voluntarily, Borwegen said. "We wish we didn’t have to be here fighting for these protections for our members," he said. "Frankly, however, we are tired of the age-old refrains from some elements within the health care community which voice their ideological opposition to government regulations, rules which are now necessary because they have failed to do their job to adequately protect their own employees."