APIC wins round in battle to block TB standard

Proposed OSHA reg may be reviewed for need

The Association for Professionals in Infection Control and Epidemiology’s (APIC) effort to derail the proposed federal tuberculosis standard gained political momentum recently, as legislation has been introduced that includes funding for a one-year study to formally review the need for the regulation.

While several political hurdles remain, the move could delay or kill finalization of the controversial TB standard proposed by the Occupational Safety and Health Administration. Washington, DC-based APIC has strenuously opposed the standard, and successfully lobbied for inclusion of the $450,000 review in legislation recently approved by the U.S. House Appropriations Subcommittee on Labor, Education, and Human Services. If the initiative survives subsequent political deliberations — and a possible presidential veto — an independent scientific group like the Institute of Medicine in Washington, DC, may ultimately weigh in on the need for the TB standard. "[The study] is going to determine whether there is a need for the rule and whether its proposals would be effective," says Jennifer Thomas, governmental affairs liaison for APIC.

Moreover, the subcommittee proposed cutting OSHA’s budget by 5%, a $17 million reduction that raises questions about how the agency could enforce the standard even if it’s finalized. "That just sort of fell on the heels of our work," Thomas says. "It would be hard to implement [the TB standard] when they are getting cuts."

Secretary of Labor Alexis M. Herman blasted the proposed budget cuts, saying "they would severely damage our ability to protect workers’ safety." But at least on the TB issue, prevailing trends suggest OSHA’s case for a standard may be a tough political sell. Since 1992, the number of reported TB cases in the United States has decreased each year, reaching a record low of 18,361 in 1998, according to the Centers for Disease Control and Prevention.1

"My guess is that any scientific body — it doesn’t even have to be someone as sophisticated as the IOM — that looks at this [standard] will find no need for it," says Eddie Hedrick, MT (ASCP), CIC, a key APIC representative on TB issues and manager of infection control at the University of Missouri Hospital and Clinics in Columbia. "The incidence of TB is at an all-time low in American-born citizens, including health care workers. We’ve been fighting this for a long time, but not because we are opposed to protecting people. My job is to protect health care workers, so for me to go against a regulation like this really requires something. But we are trying to base our preventive approach on science."

The CDC attributed the reduction in disease to more effective TB control programs that emphasize prompt identification of cases, rapid initiation of appropriate therapy, and sustained efforts to ensure therapy is completed. The subsequent 31% decrease in annual TB cases during 1992-1998 is a "notable public health achievement," the CDC concluded.

"Much of that occurred prior to any initiative on OSHA’s part," Hedrick reminds. "The problem is not really one that we need legislation to solve. The health care community rallied right away, and all of those [early] outbreaks were brought under control without respirators and expensive programs."

Still, Hedrick concedes that participating in the OSHA hearing process revealed that some hospitals have not been doing enough to protect workers. In those cases, he is hopeful that OSHA can bring its general duty standards to bear, even though a specific regulation is easier for the agency to enforce. The most appropriate role for OSHA would be to enforce CDC guidelines, which will change to meet the shifting nature of the epidemic, he notes.

"This is not a static issue," he says. "It sort of undulates depending on populations entering the country and a variety of different medical issues." Indeed, even in hailing the success of recent years, the CDC reminded that approximately 18,000 new TB infections occur annually in the United States, and approximately 15 million people have latent TB infection with the attendant risk for future disease. Costly TB outbreaks continue to occur, and multidrug-resistant (MDR) TB continues to spread. Despite the overall progress, 43 states and the District of Columbia reported at least one MDR TB case during 1993-1997, the CDC reported.

The recent success in TB control in the United States is also tempered by the burden of TB among foreign-born people residing in the country. The proportion of U.S. cases occurring in foreign-born people has increased steadily since the mid-1980s, reaching 42% in 1998. Worldwide, approximately eight million cases and two million deaths were attributed to TB in 1998. "TB cases among foreign-born persons residing in the United States could soon outnumber cases among U.S.-born persons," the CDC concluded. "Thus, TB elimination in the United States will not be possible without a substantial reduction in the global TB burden."

Reference

1. Centers for Disease Control and Prevention. Tuberculosis elimination revisited: obstacles, opportunities, and a renewed commitment. Advisory Council for the Elimination of Tuberculosis (ACET). MMWR 1999; 48(No. RR-9):1-12.