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Balanced’ report dishes out helpful criticism
The proposed new federal TB rule may help protect health care workers and others in some settings, but it needs to be more flexible, concludes a new Institute of Medicine report on the subject.
The 350-page document, commissioned with a grant from Congress by partisans seeking to stop the U.S. Occupational Safety and Health Administration (OSHA) from going forward with the new standard, is titled "Tuberculosis in the Workplace" and was released Jan. 16.
"It is a consensus document, one in which we don’t specifically address the case for or against a new OSHA standard," says IOM project officer Marilyn Field, MD. "That’s not what we were asked to do; and considering that we weren’t, and given the very limited amount of time available, we stuck pretty closely to our charge."
That charge was to assess the occupational risk for TB; to determine how closely employers are abiding by the Centers for Disease Control and Prevention’s standards; and to weigh the likely impact of a new OSHA standard.
The IOM committee decided the risk of TB infection remains a problem for certain workers and in certain places, Field says. "Though occupational risk is declining, we found that vigilance is still needed in workplaces and communities," she says. At the same time, the report faults the proposed OSHA standard for not being flexible enough, she adds.
The committee found three areas in which the rule should be more flexible, she says:
• the way a risk setting is categorized;
• the way the OSHA document approaches the issue of skin-testing;
• the way the need for respiratory protection is assessed and determined.
In the area of categorizing risk, the OSHA proposal lacks the requisite subtlety to deal with the variety of situations that exist. "The CDC has five categories of risk, ranging from high to minimal, but OSHA essentially recognizes only two," Field says. By that reckoning, an institution that falls into the "low-risk" category needs to do very little to protect its workers from TB; on the other hand, institutions that fall into the so-called "high-risk" category must do quite a lot, Field notes. A more appropriate scheme would take a more flexible approach, depending on where institutions fall along a spectrum of risk.
When it comes to skin-testing, Field says the committee readily acknowledged that old CDC guidelines reflect concerns of a bygone era and were formulated in the wake of several TB outbreaks. The biggest concern with skin-testing now is that testing too much may elicit false-positive reactions, she adds. "We concluded that even though skin-testing is not something the OSHA standard can’t deal with, we were still worried about [the standard’s lack of] flexibility."
Finally, OSHA also needs to revisit its recommendations for respiratory protection, Field says the committee concluded. On one hand, she says, the committee felt the OSHA standard should have been more explicit when it came to certain high-risk occupations, such as those that require performance of autopsies and bronchoscopies, and that the standard ought to insist on high levels of protection in those settings.
On the other hand, she adds, hospitals or other facilities in which there is only an occasional case may be adversely affected by the burden of having to implement respiratory protection programs, because such programs can "divert resources" from areas of greater need, says Field.
The report cites new data that suggest some brands of respiratory protective devices on the market cannot be properly fitted and provide inadequate protection, Field says.
Most of the available data pertaining to the effectiveness of respiratory protection come from animal studies or laboratory modeling, she adds. What data there are do offer support for the CDC concept that administrative controls take precedence over engineering controls, which in turn should take priority over respiratory measures.
One of the most interesting parts of the report may be the piece that examines new evidence from tests of various respiratory protective devices. Some manufacturers’ equipment has been found not to seal effectively, Field says. "For some of these models, people couldn’t get a good fit so the equipment did not leak unacceptable amounts of air," she says. "We felt [government agencies] should be attending more closely to the manufacturing process."
To order or view the report, readers may call the IOM at (800) 624-6249, or they can visit the National Academies of Science Web site at www. nap/edu/catalog/10045.html. The report should be available as a hardcover document by early spring. The cost is $49, and the report is offered at a 20% discount to those who order on-line.