Fit-testing rule draws emotional response

Little common ground at CDC workshop

The TB doctor stood and made her plea. Annual fit-testing is a waste of time and resources, she said. She and her staff don’t even wear masks — and they don’t become infected, the doctor added.

"The only people who wear masks in our clinic are patients," said Mazae Kawamura, MD, TB controller with the California Department of Health at San Francisco General Hospital. She also is chair of the Advisory Committee on the Elimination of Tuberculosis, an advisory panel of the Centers for Disease Control and Prevention (CDC).

But the industrial hygiene expert had a plea of his own. The integrity of the face seal is a critical aspect of respiratory protection, whether the particles are infectious or inert. And the rules of respiratory protection can’t be rewritten for one industry or one disease, he said.

"What everyone here is trying to say is we don’t want half a program. If it’s needed, you need to do it correctly," said James S. Johnson, chemical and biological safety section leader at the Lawrence Livermore National Laboratory in Livermore, CA.

State-of-the-art program

"I don’t know what is needed to convince you that annual fit-testing is an important aspect of a respiratory protection program. This is the current state of the art," he said.

Sharp differences over fit-testing were highlighted at the CDC Workshop on Respiratory Protection for Airborne Infectious Agents held in Atlanta Nov. 30 and Dec. 1.

There was little common ground — although industrial hygienists did point out circumstances in which fit-testing could be curtailed or even eliminated.

The goal of the workshop was to set a research agenda. Panels discussed key questions about respiratory protection and agreed that hospitals need more information on when respirator use is necessary. They asked for more information on what exposures could lead to transmission and how to conduct risk assessments for respirator use.

"It’s important to look at the science both of how respirators work and the epidemiology [of tuberculosis transmission to health care workers] so we can identify the risk and determine how to prevent it," commented Mark Russi, MD, MPH, associate professor of medicine and public health at the Yale University School of Medicine and director of occupational health at Yale-New Haven (CT) Hospital.

"We need greater emphasis on quantitative risk assessment," agreed Roy McKay, PhD, who is director of the Occupational Pulmonology Services program at the University of Cincinnati College of Medicine.

Officials from the National Institute of Occupational Safety and Health also told the participants that new criteria requiring manufacturers to produce better-fitting respirators would be completed later this year.

Yet research will occur amid an unchanged regulatory backdrop. The General Industry Respiratory Protection Standard requires annual fit-testing. And although Congress voted to halt enforcement of that provision as it relates to tuberculosis, the rule remains in effect.

Changing it would require a lengthy process of new rule-making, noted Bill Borwegen, MPH, health and safety director of the Service Employees International Union.

"The lead industry would be asking for the same thing the next week, then the asbestos industry the week after that," he pointed out. "A rule is a rule is a rule."

Hospitals still are required to perform annual fit-tests if health care workers use the masks for infectious diseases other than tuberculosis, he continued.

As the workshop progressed, deep concerns rose to the surface about the burden vs. the benefit of annual fit-testing.

"It seems to be an emotional issue," Johnson remarked.

"It is an emotional issue," Kawamura added. "Our hospitals are broke. Our public health programs are broke."

"I want to make the plea that you look at TB as a start," Johnson responded. "Any hospital in this country is going to deal with unknown respiratory hazards."