Fit-test frequency is left up to hospitals
Fit-test frequency is left up to hospitals
CDC sticks to periodic, but OSHA calls for annual
"Periodic," not annual, fit-testing will continue to be the watchword in the tuberculosis guidelines that currently are being finalized by the Centers for Disease Control and Prevention (CDC). The CDC has declined to define "periodic," leaving the decision to individual health care facilities.
"It doesn’t make it easy for the user, but it allows for flexibility in deciding on periodicity," acknowledged CDC’s Chief Science Officer Dixie Snider, MD, MPH, who explained the TB decision to the Hospital Infection Control Practices Advisory Committee (HICPAC), a federal advisory panel.
Respiratory protection has been an area of conflict within CDC, and the controversy delayed the release of the draft version of updated TB guidelines. The U.S. Occupational Safety and Health Administration (OSHA) requires annual fit-testing of filtering facepiece respirators as part of its respiratory protection standard — although Congress prohibited OSHA from spending money to enforce that provision for FY 2005. That language was incorporated in the 2006 appropriations bill that is under consideration.
Representatives of the Division of Health Care Quality Promotion (DHQP), the Division of Tuberculosis Elimination, and the National Institute for Occupational Safety and Health (NIOSH) — all part of CDC — tried to reach a consensus on fit-testing, Snider said.
They agreed there is insufficient evidence-based data to determine the appropriate periodicity of fit-testing. Without such evidence, NIOSH supported annual fit-testing, while other representatives did not.
"From our perspective, this is the best we could do to come to one decision within CDC," Snider noted. "We’d like to have definitive answers to a lot of unanswered questions. We hope through further research, we can make more definitive recommendations and feel comfortable we have a strong evidence base in some areas where the evidence is either lacking or inconclusive at this time."
Many employee health professionals may welcome the vague wording, as they question the need for annual fit-testing and worry about expending significant resources on those efforts. The flexibility allows them to take into account the transmissibility of the organism and a risk assessment of the facility.
Some hospitals halted their annual fit-testing programs when Congress froze OSHA enforcement. By recommending periodic fit-testing, the CDC guidelines enable hospitals to decide when employees may need the update. OSHA requirements for medical evaluation, annual training, and record keeping remain in force.
However, the congressional action only affects federal funding, and state-plan states still can spend state money to enforce annual fit-testing. Twenty-six states and territories have state-run and OSHA-approved occupational safety and health programs. Further, annual fit-testing still is required when respirators are used for protection against respiratory diseases other than TB, such as severe acute respiratory syndrome (SARS) or monkeypox.
How do you decide whether to fit-test? JoAnn Shea, MSN, ARNP, director of employee health and wellness at Tampa (FL) General Hospital takes a cost-benefit approach to fit-testing. She tracks TB conversions and exposures monthly. In 2004, the hospital had five conversions among employees, none of which were linked to known hospital-based exposures. The hospital treated 14 patients with TB, and five employees were exposed before TB was diagnosed. None of them seroconverted.
The hospital also is very strict about annual TB screening, requiring employees to have the screening before they can receive their annual raise, Shea adds.
"I feel we would not be putting any employee at risk [by not performing annual fit-tests]," she says. "There’s a lot more we can do for employees with those resources."
But Shea notes that the hospital would comply with an enforceable OSHA standard on fit-testing.
Baystate Health System in Springfield, MA, fit-tested about 2,800 employees and now is repeating those fit-tests, says James Garb, MD, director of occupational health and safety. Although he, too, has concerns about the allocation of resources, Garb notes, "If you’re going to use N95 respirators, you really should be doing annual fit-testing." The fit-testing incorporates education, which helps ensure employees are using the respirators correctly, he says.
Meanwhile, the annual fit-testing issue continues to garner political attention. U.S. Rep. Roger Wicker (D-MS) who sponsored the congressional language halting enforcement of the rule, asked OSHA to revert to the old respiratory protection standard for tuberculosis, which did not require annual fit-testing. When OSHA halted work on a proposed TB-specific standard in 2003, the agency also eliminated the respiratory protection rule that had applied to TB during the rulemaking.
In a letter for Wicker, OSHA said it would have to initiate rulemaking to create a special respiratory protection standard for TB, and it did not have a scientific basis to make a different requirement for TB than for other aerosolized particles.
In fact, OSHA said it concurred with CDC’s recommendation for periodic fit-testing — with a period of one year. Yet some health and safety experts worry that the respiratory protection debate reflects an underlying flaw in the way CDC views health care worker protections.
CDC does not have a strong enough voice from the occupational medicine community on its advisory panels, contends Bill Borwegen, MPH, health and safety director of the Service Employees International Union in Washington, DC. "This is the result of the domination of the infection control community within CDC," he says. "When you’re dealing with worker health and safety, it’s been a perennial problem."
The problem is of particular concern when it relates to emerging infectious diseases, says Bill Charney, DOH, a national occupational health consultant based in Seattle. When little is known about the transmission of a new disease, such as SARS, CDC should be advocating a higher level of protection for health care workers, he explains.
Even a perfectly fitting N95 filtering facepiece respirator has an inherent leakage factor of 15% — 5% through the filter and 10% around the face seal.
"If you don’t know what you’re being exposed to, the dose-response relationship, or the toxicities, then you recommend the highest level of protection and you work your way down as the science becomes more available," Charney points out. "You don’t offer the least amount of protection. That was totally backward."
Hospitals should have access to powered air purifying respirators for newly emerging diseases and bioterrorism agents, particularly when health care workers perform aerosolizing procedures such as bronchoscopies, he says.
The CDC should defer to occupational health and industrial hygiene authorities, Charney adds. "They’ve got no business being involved in this technology. This is an OSHA jurisdiction, and people should follow the simple rules of OSHA."
Periodic, not annual, fit-testing will continue to be the watchword in the tuberculosis guidelines that currently are being finalized by the Centers for Disease Control and Prevention (CDC). The CDC has declined to define periodic, leaving the decision to individual health care facilities.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.