Tuberculosis in the Workplace (2001) / Chapter Skim
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6 Implementation and Effects of CDC Guidelines
6 Implementation and Effects of CDC Guidelines
Pages 108-136
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From page 108... ...
announced efforts to enforce the adoption of tuberculosis control measures under the agency's general-duty clause and its 1987 respiratory protection standard. The next year it issued a notice of proposed rulemaking on 108
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From page 109... ...
to recommended practices such as using personal respiratory protection devices. The literature review in Appendix D includes additional details, and Appendixes B and F also provide relevant information on two specific control measures: tuberculin skin testing and personal respiratory protections.
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From page 110... ...
Surveys of Organizational Implementation of Tuberculosis Control Measures Mailed surveys are a relatively inexpensive way of collecting information about a large number of geographically dispersed institutions. When the surveyed institutions are familiar with both the surveying organization and the kinds of questions asked and when the topic is viewed as important, voluntary questionnaires can generate respectable response rates of 70 percent or more.
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From page 111... ...
(%) Engineering Controls Isolation rooms meeting CDC criteria Routine check of negative air pressure Monthly check of negative air pressures Respiratory Protection Nonfitted surgical mask Soft mask, molded or fitted Particulate respirator N95 Tuberculin Skin Testing Program Testing by Worker Category 59/92 (64)
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From page 112... ...
129~. Another analysis focused on tuberculosis control measures in emergency departments in a randomly selected sample of the hospitals responding to the 1992 CDC survey described above (Moran et al., 1995~.
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From page 113... ...
Other Surveys of Health Care Facilities As background for continuing efforts to develop tuberculosis control policies, researchers in Minnesota surveyed a voluntary sample of 18 hospitals to determine hospital practices and analyze tuberculin skin test results for the period from 1989 to 1991. Although the survey documented variable compliance with recommended practices of the time, the researchers concluded that practices were "reasonably consistent with the critical elements in the 1990 CDC guidelines" (Van Drunen et al., 1996~.
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From page 114... ...
The first two surveys predated the official publication of CDC guidelines for correctional facilities (CDC, 1996b) , although earlier agency and other guidelines covered high-risk populations and tuberculosis control measures applicable to facilities treating or housing people with tuberculosis (ATS, 1992; NCCHC, 1992; CDC, l990b, 1994b)
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From page 115... ...
Eleven percent of the workers reported that they had not been offered tuberculin skin testing in the previous 12 months, which is in conflict with stated institutional policy. Almost a fifth of respondents reported that they had a positive skin test history, and roughly half of this group said that they had received some type of follow-up care.
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From page 116... ...
First, institutional departures from recommended tuberculosis control policies and procedures were common, if not the norm, in the late 1980s and early 1990s. Second, institutions at least hospitals and correctional facilities were taking tuberculosis control measures more seriously and reporting substantially higher rates of implementation of recommended measures in later years.
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From page 117... ...
It was best, overall, for administrative controls. For example, annual tuberculin skin testing was reported for better than three-quarters of hospitals, prisons, shelters, and nursing homes.
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From page 118... ...
1ney also Cllrectly observed and evaluated isolation rooms and isolation practices. From 1992 to 1994, they found that hospitals made substantial progress in correcting deficits in tuberculosis control measures.
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From page 119... ...
For engineering controls, implementation is likely better for the installation of isolation rooms than for their day-to-day operation in accordance with guidelines. Implementation Lapses Mentioned in Outbreak and Other Case Reports Rather than systematically describing the implementation of tuberculosis control measures, outbreak reports typically focus on factors that might have contributed to the outbreak, including the failure to implement specific controls.
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From page 120... ...
In addition, the review authors noted other reports describing low levels of health care worker compliance with treatment for tuberculosis infection, which reduces the benefits of tuberculin skin testing programs. Dooley and Tapper (1997)
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. Worker Adherence to Tuberculosis Control Measures Several studies suggest that health care workers including physicians and other professionals vary greatly in their level of adherence to recommended measures for preventing the transmission of tuberculosis.
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knew that masks should be used in the rooms of patients with tuberculosis, but a third also thought that gowns were needed. EFFECTS OF IMPLEMENTING TUBERCULOSIS CONTROL MEASURES Ideally, the 1994 CDC guidelines would have been based on rigorous, prospective, controlled studies demonstrating the effectiveness of each
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From page 123... ...
tuberculosis.4 Instead, evidence of the effectiveness of tuberculosis control measures comes primarily from case reports, analyses of survey responses, and a few studies of specific precautions. For the most part, the case for the CDC recommendations and the proposed OSHA rule rests on these sources supplemented by logic, biologic plausibility, theoretical arguments, animal studies, laboratory simulations, and mathematical modeling.
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From page 124... ...
Some of the studies reviewed below note that new hiring partially refreshed the pool of tuberculin skin test negative workers, and some report that facilities continued to admit substantial numbers of patients with active tuberculosis. Summaries of Reports In their review of outbreak reports, Dooley and Tapper (1997)
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From page 125... ...
In June 1992, masks with submicron filters were adopted for personal respiratory protection. In July 1992, the hospital began requiring skin testing of nonemployee health care workers including attending physicians, house staff, and medical students.
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From page 126... ...
After reviewing their infection control policies and work practices, hospital managers implemented a series of more stringent tuberculosis control measures (Wenger et al., 1995~. The first control measures, which were implemented in March 1990, included a four-drug initial treatment regimen and more rigorous isolation policies on the ward (i.e., stricter isolation criteria for HIV infected patients, stricter criteria for discontinuing isolation; stricter enforcement of policies that infectious patients stay in their rooms unless medically necessary and wear surgical mask when out of their rooms, and restriction of sputum induction procedures to isolation rooms)
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From page 127... ...
Another report following an outbreak of multidrug-resistant tuberculosis tracked the sequential adoption of tuberculosis control measures from June through October 1991 (Maloney et al., 1995~. The control measures included stricter isolation criteria and use of molded surgical masks for employees (June)
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355~. A third study at Columbia-Presbyterian Medical Center of the sequential adoption of stricter tuberculosis control measures examined skin test conversions for medical house staff from tune 1992 to tune 1994 (Bangsberg et al., 1997~.
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From page 129... ...
report on an emergency department that adopted improved engineering controls while leaving isolation and respiratory pro5Appendix D reviews several surveys that asked questions about the implementation of tuberculosis control measures and about results of worker skin testing programs. Analyses of the association between control measures and conversion rates produced inconsistent results.
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(The two groups did not differ significantly in age, ethnicity, foreign birth, county of residence, BCG vaccination status, or initial tuberculin skin test status.) The department implemented tuberculosis control measures at the end of the first year for which conversion rates were compared.
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From page 131... ...
COMMITTEE CONCLUSIONS When the resurgence of tuberculosis began in the mid-1980s in the United States, communities and workplaces were generally not prepared. After years of effective treatment and declining tuberculosis case rates, tuberculosis control measures including those recommended by CDC in 1983 were not priorities for either public or occupational health programs.
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From page 132... ...
Nonetheless, after reviewing the literature (including theoretical arguments and mathematical models) , considering discussions during the committee's public meetings, and drawing on its members' experiences and judgments, the committee reached several conclusions about, first, the implementation and, second, the probable effects of workplace tuberculosis control measures.
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From page 133... ...
The hospitals experiencing outbreaks in the early 1990s clearly had a stimulus to implement control measures earlier. For other institutions, increased implementation likely reflects the impacts of further and more complete reports on workplace outbreaks of tuberculosis, the CDC's increased effort to educate health care managers and clinicians about tuberculosis and tuberculosis control measures, the pressure for action exerted by unions on both employers and public agencies, and the initiation by OSHA of enforcement procedures and rulemaking processes for occupational tuberculosis.
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From page 134... ...
Although outbreak studies suggest that most of the benefit of control measures comes from administrative and engineering controls, modeling exercises support the tailoring of personal respiratory protections to the level of risk faced by workers that is, more stringent protection for those in high-risk situations and less stringent measures for others.
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From page 135... ...
In communities with little or no tuberculosis, the effectiveness of control measures is necessarily limited. If success in community control of tuberculosis continues, more communities can be expected to join this low-prevalence group.
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That hierarchy stresses administrative controls (in particular, rigorous application of protocols to promptly identify and isolate people with signs and symptoms suspicious for infectious tuberculosis) , followed by engineering controls and, finally, by personal respiratory protections.
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