Tuberculosis in the Workplace (2001) / Chapter Skim
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7 Regulation and the Future of Tuberculosis in the Workplace
7 Regulation and the Future of Tuberculosis in the Workplace
Pages 137-156
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From page 137... ...
achieve more complete, consistent, and long-term compliance with recommended tuberculosis control measures, especially in nonhospital settings, (2) prevent the kind of complacency about tuber137
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From page 138... ...
The section also reviews OSHA's projections of the number of workplace cases of tuberculosis infection, disease, and mortality that would be prevented if the 1997 proposed rule were implemented. The final section of the chapter considers the relationship between workplace and community tuberculosis control programs.
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From page 139... ...
An OSHA standard must allow reasonable flexibility to adapt tuberculosis control measures to fit differences in the level of risk facing workers. Condition 1.
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From page 140... ...
Condition 2. Will an OSHA standard help sustain or increase the level of adherence to effective workplace tuberculosis control measures?
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From page 141... ...
Except to the extent that they have been incorporated as requirements by other public or private agencies, the steps recommended by CDC are voluntary. On the basis of logic and experience, the committee expects that an OSHA standard would sustain or increase the rate of compliance with mandated tuberculosis control measures.
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From page 142... ...
The following discussion compares the flexibility offered by the 1994 CDC guidelines and the 1997 proposed OSHA rule in three areas. The first and most important area involves the provisions of each for assessing the workplace risk of tuberculosis transmission, categorizing workplaces by the level of risk facing workers, and matching tuberculosis control measures to the level of risk.
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From page 143... ...
Overall, the committee concludes that if an OSHA standard follows the 1997 proposed rule it may not offer sufficient flexibility for organizations to adopt control measures appropriate for the level of risk facing workers. To the extent that an OSHA standard inflexibly extends requirements to institu~As described in Chapter 4, the CDC risk assessment process includes a review of the community tuberculosis profile, the numbers of patients with tuberculosis examined or treated in different areas of the facility, the tuberculin skin test conversion rates for workers in different areas of the facility or in different job categories, and evidence of person-toperson transmission of M
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From page 144... ...
Requirements for Baseline and Serial Tuberculin Skin Testing In addition to the broad concerns about whether an OSHA standard would allow sufficient flexibility for organizations to match tuberculosis control measures to the risk facing workers, a narrower question is whether a standard would allow organizations reasonable flexibility to adjust tuberculin skin testing programs to reflect the changing epidemiology of tuberculosis and, possibly, changing CDC recommendations. As described in Chapter 2 and Appendix B
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From page 145... ...
It then examines the requirements for fit testing of personal respirators. Requirements for Respirator Use Although the respiratory protection requirements of the 1997 proposed OSHA rule have been criticized for inflexibility, the proposed rule and the 1994 CDC guidelines mostly target the same types of workers for use of personal respirators.
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From page 146... ...
In general, both the proposed rule and the guidelines focus their respirator use provisions on the worker's reasonably anticipated risk of exposure rather than the facility's risk category. Requirements for Fit Testing As described in Chapter 4, both the 1994 CDC guidelines and the 1997 proposed OSHA rule provide for initial training and fit testing for workers who use personal respirators.
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From page 147... ...
(The 1 percent pass-fail criterion is thought to be needed to achieve no more than 10 percent respirator face-seal leakage during normal use in the work place.) A determination that qualitative fit testing is ineffective and that quantitative fit testing is required could add substantial costs to a respiratory protection program, especially one that included annual testing for large numbers of workers.
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From page 148... ...
Although the group agreed that respiratory protection is the least important of the hierarchy of tuberculosis controls, it also agreed that respirators and respiratory protection programs have a role to play when an occupational risk of tuberculosis exists. As described in Chapter 6, modeling studies suggest that the benefits of respiratory protection are directly proportional to the presence of risk.
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From page 149... ...
The committee expects that a standard will meet the first two conditions by sustaining or increasing the rate of use of tuberculosis control measures that appear to be effective. The committee is, however, concerned that if an OSHA standard follows the 1997 proposed rule, it will not meet the third condition of allowing organizations reasonable flexibility to adopt measures appropriate to the level of risk facing their workers.
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From page 150... ...
As described earlier, although treatment is not risk free and individuals offered treatment should be informed of both benefits and risks, recent data suggest that the risk of liver damage from carefully monitored treatment of latent infection using isoniazid is quite low and is less than that described in the proposed rule. Estimation of levels of tuberculosis infection and potential reductions in such infections as a result of an OSHA standard is particularly
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From page 151... ...
In the 1997 proposed rule, OSHA estimates the occupational risk of tuberculosis infection over a 4s-year working lifetime to range from 4 to 723 per 1,000 population for hospital workers With the lowest estimates based on the Washington state data and the highest based on the Jackson Memorial Hospital datay.
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From page 152... ...
likewise questions the 10 percent figure based on data analyses indicating that the rate of progression is probably half that figure or less, especially in populations more likely than average to be treated for latent infection. Most health care workers constitute such a population, although home health workers, workers in homeless shelters, and certain other groups covered by the proposed rule may have less access to health insurance and health care.
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From page 153... ...
In the 1997 proposed rule, OSHA estimated that 7.8 percent of all active tuberculosis cases among workers would end in death. It based the estimate on the 3-year average of mortality data reported by CDC for 1989 to 1991 (62 FR 201 at 54207~.
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From page 154... ...
A theme throughout this report has been the interconnection between community risk and workplace risk and the challenge of fitting workplace tuberculosis control measures to these risks and to changes in risks over time. The committee draws a parallel between the circumstances facing occupational health programs and the circumstances described in the recent report Ending Neglect: The Elimination of Tuberculosis in the United States (IOM, 2000~.
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From page 155... ...
For health care facilities, prisons, and other organizations that serve people at high risk of tuberculosis, a similar pattern of workplace neglect in the late 1980s and early 1990s contributed to workplace outbreaks of tuberculosis. Surveys, investigations of outbreaks, and facility inspections all point to institutionalized lapses in tuberculosis control including inattention to signs and symptoms of infectious tuberculosis, delays in initiating appropriate evaluations and treatments, and improper ventilation of isolation rooms and areas.
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From page 156... ...
The report also calls for the United States to increase its support for global tuberculosis control. With more than 40 percent of tuberculosis cases in the United States and among health care workers involving people born in other countries, policymakers and public health authorities cannot ignore the international problem of tuberculosis.
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