California dreaming: New approach to biohazards

Fit-testing draws foes to look for a better rule

If you’re looking for a silver lining to requirement for annual respirator fit-testing, look to California. That trendsetting state has begun discussions on an airborne biologic hazards standard.

Both advocates and critics of fit-testing agree that it should be part of a broader approach to biologic hazards. That common ground may lead to a different regulatory approach in California — the state that also led the way in needle safety.

Kaiser Permanente, the largest health care provider in California, and Service Employees International Union (SEIU), the largest union representing about 500,000 health care workers, joined forces to ask for a task force to explore a new standard.

The task force held its first meeting July 26. The two groups also worked together to build the framework for the needle safety legislation.

"When those two get together, amazing things happen," says Len Welsh, JD, MS, acting chief of Cal-OSHA (Occupational Safety and Health Administration) in San Francisco.

An airborne biologic hazards standard could gain national support. Several organizations, including the Association of Occupational Health Professionals in Health Care and the American Association of Occupational Health Nurses, have asked federal OSHA to consider a broader approach to airborne biologic hazards.

With the emergence of avian influenza, severe acute respiratory syndrome (SARS), and bioterrorism, hospitals need to take a comprehensive view of protecting health care workers, says Jeanne Pfeiffer, RN, MPH, CIC, president of the Association of Professionals in Infection Control and Epidemiology in Washington, DC.

"I see that there’s an opportunity here to do some good work," she says. "I think we could have one approach to protection that makes a lot of sense, and that would be a great boon for the health care industry and OSHA, too."

John Mehring, health and safety educator with the SEIU Education and Support Fund in San Francisco, says he sees the momentum to put the biologic hazards issue on a fast track, perhaps with recommendations as early as the end of the year.

"Putting aside all the infighting about the TB standard, it makes sense to have an equivalent airborne disease standard," says Mehring, who is a member of the task force. "If we’re going to have a bloodborne pathogen standard, why would we not do that for airborne diseases?"

Ironically, the motivation for a new standard stems from objections to other regulations.

Infection control professionals feel that annual fit-testing is an unnecessary use of resources because it does not address the most significant cause of nosocomial spread of tuberculosis, which is exposure to an undiagnosed case. That concern came to the forefront as the California Board of Standards met and voted to adopt the federal OSHA rule that requires hospitals to comply with the General Industry Respiratory Protection Standard for tuberculosis.

"The state standard has to be at least as effective as the federal standard," Roger Richter, senior vice president of the California Healthcare Association in Sacramento. "What you can do at the state level is come up with an alternative that’s just as effective."

That generated discussion of a new, comprehensive approach to biologic hazards.

Mehring knows that some of his task force colleagues would like to create a new rule that would minimize fit-testing. He still strongly supports annual fit-testing — industrial hygienists note that fit-testing ensures the proper protective qualities of the respirator.

But Mehring is willing to listen to their ideas. "I agree that [protection] is not just about respirators. We totally agree with that feeling and that belief. On the other hand, respiratory protection is going to be an element.

"We might as well construct something that people feel will do the job and not be too onerous to any one party," he says. "Who knows? It may be the template for other states or federal OSHA."

Whatever the outcome, Welch welcomes the meeting of otherwise opposing parties.

"They see the opportunity, as do I, for some productive talk," he points out. "Whether or not we actually modify the annual fit-testing requirement, there’s certainly a lot to be gained by sitting around the table and talking about airborne infectious disease."

Thinking of risks beyond TB

A biologic hazards standard also could address some issues that are now overlooked in OSHA standards. For example, OSHA’s hazard communications standard requires employers to provide training and information related to chemical hazards but not biological ones.

In Minnesota, hospitals conduct training on the array of infectious diseases, from bloodborne pathogens to airborne hazards, says Pfeiffer, who is infection control program coordinator at Hennepin County Medical Center in Minneapolis.

"People in Minnesota didn’t feel vulnerable about TB and other [diseases] because we were educating them regularly," she says.

An airborne biologic hazards standard also could address issues that go far beyond the proposed tuberculosis standard, which OSHA formally withdrew in December 2003.

"A TB standard would have only been a proxy for an airborne infectious disease standard," says Bill Borwegen, MPH, SEIU health and safety director.

"I think we need to enlarge it and cover all these other airborne risks from SARS to avian flu to weapons of mass destruction," he adds.

Welch notes that an airborne biologic hazards standard will have constituencies beyond health care, including prisons and law enforcement.

"I think it’s very timely," he says. "I think we need a standard like this. The only question is if we can get enough [of a] consensus to make it happen."