Strongly divided views emerge in TB comments

TST training, fit-testing create concerns

The draft tuberculosis guidelines of the Centers for Disease Control and Prevention (CDC) sparked widely ranging comments with divergent opinions — from those who think N95 filtering facepiece respirators are inadequate, to those who think they are unnecessary. Here are some highlights from major organizations representing employee health, infection control, and health care workers:

Training to read tuberculin skin tests

The training requirements are onerous, employee health professionals say:

"We find this area burdensome, costly, and beyond what is needed to ensure that health care workers who administer and read the TST are competent. There is a large concern for who will train the TST trainers and how they are to remain competent on an annual basis. . . . We believe that the number of hours for lecture, demonstration, practical work, and coaching for both the placement and reading of the TST is far beyond that necessary to administer such testing." —Association of Occupational Health Professionals in Healthcare (AOHP)

Type of respirators used

Union leaders argued that the N95 filtering facepiece respirator is not adequate to protect health care workers from TB exposure:

"We see no scientific justification put forward by CDC in support of its selection of a filtering facepiece over that of an elastomeric half-mask as the facepiece style for the minimum recommended respirator for health care workers exposed to TB. We have serious concerns about the adequacy of worker protection afforded by filtering facepiece respirators compared to elastomeric half-masks. Filtering facepieces do not fit wearers as well as elastomeric half-masks do, and filtering facepieces cannot be easily and reliably seal checked’ by the wearer as can elastomeric facepieces. . . . Because exposure to only a small amount of TB bacterium is necessary to cause infection and no safe level of TB bacilli exposure has been established, it also seems logical to conclude that all particulate filtering respirators selected for use ought to be equipped with the highest efficiency filter available, meaning P100s." — the Coalition to Fight TB in the Workplace, a coalition of 13 labor unions including Service Employees International Union, the American Nurses Association, and AFL-CIO

IC professionals contended that N95 filtering facepiece respirators are not necessary:

"Epidemiologic evidence has clearly demonstrated that TB and MDRTB outbreaks could be controlled with the use of administrative and environmental control measures using submicron surgical masks. The evidence for N95 or other industrial respirators has not been established in clinical settings." — APIC

The American Hospital Association (AHA) also requested CDC endorsement of surgical masks rather than N95 respirators:

"In the absence of evidence-based information supporting the need for respirators, the AHA and ASHE [American Society for Healthcare Engineering] recommend that the CDC correct the current draft and recommend the use of submicron masks in conjunction with administrative and environmental controls." — AHA/ASHE

Frequency of fit-tests

Union leaders criticized CDC for recommending "periodic" rather than annual fit-testing:

"The CDC guidelines absolutely must follow the respirator requirements contained within OSHA’s respiratory protection standard. The CDC should not make any recommendations that do not, at a minimum, comply with the requirements established by law, and upheld under legal challenge by the federal courts." — the Coalition to Fight TB in the Workplace

Infection control professionals argued that OSHA fit-testing regulations should not be mentioned in the CDC guidelines:

"OSHA requirements do not necessarily apply to all facilities covered by the CDC guidelines (e.g., public facilities). CDC guidance should be evidence-based and not based upon regulatory requirements imposed by OSHA that were designed and developed for industrial settings."— Association for Professionals in Infection Control and Epidemiology.

Employee health professionals also questioned the scientific basis for annual fit-testing and noted that the guidelines are confusing:

"We believe there are other ways to ensure the health and safety of health care workers with more periodic fit testing (i.e. every two to five years) with annual education and user seal-checking. [We] also request clarification on what the definition is of "periodic fit testing." This document refers to both annual and periodic fit-testing. It needs to be clearer what is being advised." — AOHP

They also asked for consistency between CDC and OSHA:

"The association suggests the two agencies collaborate and agree on appropriate standards and guidelines that would provide for the health and safety of [health care workers] and clients, for whom they provide care, satisfying the purpose of each agency (protecting the health and safety of people)." — American Association of Occupational Health Nurses