OSHA TB standard may overburden public health TB clinics
OSHA TB standard may overburden public health TB clinics
Concerns raised over how programs can afford employee screening
As health care professionals prepare responses to the proposed federal tuberculosis standard, public health officials are concerned that state and local programs will have to divert resources to screen additional employees covered by the regulations. The added burden comes at a time when growth in federal funding for TB control is flat, and agencies face political pressure to reduce that support now that TB rates are declining.
Responding to the Occupational Safety and Health Administration’s (OSHA) proposed standard released in October, the National TB Controllers Association has been formulating its position as it tries to assess its possible impact, particularly for local health departments.
"We want to closely examine the implications for TB control programs for the way the new OSHA rules extend worker protections," says Bruce Davidson, MD, MPH, spokesman for the Atlanta-based association. "The negative changes might be to burden busy TB control programs with lower priority screening of municipal workers who fall under the new rules. On the positive side, extending protection to workers at risk could be a highly effective way of further reducing our TB burden and taking us toward elimination."
The proposed standard has tracked closely with guidelines issued by the Centers for Disease Control and Prevention in 1994. In the area of screening, however, OSHA would extend coverage of occupational exposures to include employees in social work, social welfare services, teaching, law enforcement, and legal work if those services are provided in settings where people are being segregated or confined for suspected or confirmed infectious TB. The responsibility of screening those additional employees would likely fall to the TB control programs of health departments.
"Suddenly, there is an enormous amount of resources needed to screen those folks, most of whom are at low risk, and at a time when you are barely keeping up with your workload," Davidson tells TB Monitor, adding that the best use of screening is on contacts.
Kathleen Gensheimer, MD, state epidemiologist and TB controller for Maine, voices another concern: Testing low-risk employees will result in more false-positive test results and unnecessary preventive therapy.
"Even if resources weren’t declining, we should still be going after the truly high-risk populations and putting all our energies and efforts into seeing that cases are rapidly identified, putting patients on appropriate directly observed therapy, and seeing that contact investigations are done in a timely fashion," she says. "That is the bottom line with TB control. Everything else is overreacting to the hysteria that resulted from some of the hospital outbreaks in the late 80s."
If resources for the additional screening are added to TB program budgets, the association’s concerns would be mollified, Davidson says. But that is unlikely, especially when TB funding has been stagnant the past two years and will be difficult to maintain at present levels.
At the CDC’s October meeting of the Advisory Council for the Elimination of TB, Helene Gayle, MD, MPH, director of the National Center for HIV, STD, and TB Prevention, noted that federal funding for TB in 1998 is not expected to increase over this year’s level.
"We will be very happy if we continue to have a stable budget for TB activities," she said. "It really means that in these years of declining cases we have to make sure that we continue to state our case for how important it is to maintain the TB infrastructure. It is very tempting for people to say, Well, since the rates are going in the right direction, why can’t we take this money and put it somewhere else?’"
Cost of additional screening
How much it will cost to screen these additional employees is debatable. OSHA put the estimated total burden of skin testing all employees at 1.02 million hours second only to the cost for performing medical histories. The total toll for implementing the standard is estimated at 7 million hours the first year and 3.6 million in subsequent years.
In addition to extending screening to other workers, the standard also would require that health care facilities provide PPD testing to employees one month after they terminate. Because PPD reactions take up to 10 weeks or more to respond, an employee could be exposed before leaving, convert, and not be detected. The post-exit screening would make facilities responsible for treating those employees. OSHA estimates this screening would impact about 76,257 people and cost an additional 100,504 hours of labor.
At a large hospital like Grady Memorial in Atlanta, which employs more than 6,000 workers, the requirement would add a considerable burden, says Patricia Parrott-Moore, RN, the hospital’s TB control coordinator. "If you have a large hospital and a high turnover, you could have to test hundreds of persons after they leave," she says. "What if they are spread out across the country?"
Another area of controversy that involves increased costs is the need for respirator fit-testing. As part of a facility’s respiratory protection program, the OSHA standard requires that every employee who comes into contact with suspected or known TB patients must be educated on and fitted for the new N-95 respirators. Employees also must fit check the respirator each time it is donned. Critics of fit-testing say the new N-95 masks are nearly identical to the old dust-mist respirators that many hospitals used in the past and because they are relatively simple to use, fit-checking should be adequate to ensure protection.
"They are really nothing more than an old dust mist mask with increased stitching," says Eddie Hedrick, MT, CIC, chairman of the TB committee for the Association for Professionals in Infection Control and Epidemiology (APIC). "Fit checking makes more sense than fit testing."
Not so, says Joan Otten, RN, director of the TB control program at Miami’s Jackson Memorial Hospital. From her experience with fit testing at the teaching hospital, she feels so strongly about the need for fit-testing, she will be testifying at the OSHA public hearing in February.
"Do you fit-test or don’t you? That has been debated across the country," she says. "I have observations that show you really need to do it. Yes, it is very time-consuming and financially costly, but it is also something I think is necessary."
Her observations after training and fit-testing hundreds of employees have convinced her that those employees who have been fit-tested are less likely to misuse the respirator than those who rely on fit-checking only. She notes there are small but important differences in the N-95 masks compared with the masks they replaced. The N-95, for example, has two bands rather than one; the two bands make breathing harder but provide a tighter fit, she says.
"It is important for people to know why you have to wear the two rubber bands," she tells TB Monitor. "The masks also have a metal piece around the nose and everyone’s nose is so very different it is important to mold the metal piece around the nose."
An added benefit of fit-testing is that it gives employees one-on-one contact with trainers and provides an opportunity to instill verbally the reasons for proper respirator fitting and how fitting can be compromised, such as by weight loss or and growth of facial hair.
Grady has fit-tested more than half of its employees during the past year, says Parrott-Moore. For new employees, the fit-testing is part of their orientation. They come onto a clinical unit knowing what size they wear and carrying paperwork showing they know how to fit themselves.
"It was a tremendous undertaking but we went ahead and bit the bullet," she says. "The biggest burden was the man-hours. It took up all my time for more than a month just training the trainers."
Moore estimates that each fit-test session takes about 30 minutes, but the added paperwork can increase the total time. When all is said and done, Otten says the process adds up to 45 minutes per employee.
Although OSHA doesn’t require annual fit-testing, facilities must track employees who may need refitting because of physical changes. That requirement presents a problem, Hedrick says, adding, "I don’t know how you do that unless you follow them all the time."
Grady resolves that problem by adding several questions to the mandatory twice- yearly physicals for employees that would alert employee health staff to an employee who has undergone changes i.e., lost or gained large amounts of weight, had teeth pulled, grown facial hair. If so, they would receive a follow-up fit-test, she adds.
The standard does allow the disposable N-95 masks, most of which cost less than 75 cents, to be worn more than once as long as they have not been compromised. At Jackson, employees can use the same mask throughout the day but must discard it at the end of their shift, says Otten. "Our policy says you can use it throughout your shift unless it becomes moist or your fit check doesn’t work right," she explains. "You can use them longer, but then you get into the need for a storage facility, and I don’t want to deal with storage. They sit in a locker and get stuff piled on them."
Declining PPD conversion rates
At both hospitals, PPD conversion rates for employees have steadily dropped since the CDC updated its TB guidelines. These lowered rates, coupled with declines in patients with TB, underscore the success of the guidelines in controlling new infections, Parrott-Moore says. Four years ago, the hospitalwide, sixth-month conversion rate was nearly 3% at Grady. Today, it’s about 0.3%, she notes.
"We attribute that to implementing the CDC guidelines across the board, and a lot of things happened at one time, so it’s hard to attribute it to one thing."
One major factor, she says, has been increased isolation of suspected TB patients.
Otten also attributes the lower conversion rate to greater vigilance in putting suspected patients in negative pressure rooms sooner and more often. At both facilities, in fact, nurses have been given the power to initiate isolation.
"We isolate a lot of patients who don’t necessarily have TB, but that has help us maintain this low conversion rate since 1995," she says. "Some [HIV-positive] patients are so atypical, they slip through, but our ability to pick them up over five years of doing this has increased tremendously. What used to be a week’s exposure is now only a 24-hour exposure because we are so attuned to atypical as well as typical presentations."
As both private and public health care organizations prepare their written response to the OSHA standard, Hedrick and others believe it is not too late to rally enough support to make substantive changes to the proposal. They will use the success of the CDC guidelines to bolster their argument that the standard is overkill. But health policy regulators and health care labor unions have ample evidence of facilities not complying with the CDC recommendations.
The Society for Healthcare Epidemiology of America published a study in the August issue of its journal, Infection Control and Hospital Epidemiology, that found that even hospitals with a history of TB outbreaks were not following all the CDC guidelines.1
"All study hospitals achieved at least partial compliance with CDC TB infection control guidelines," the authors concluded. "However, none achieved complete compliance with all recommendations during the study period."
Reference
1. Kellerman S, Tokars J, Jarvis W. The cost of selected tuberculosis control measures at hospitals with a history of mycobacterium tuberculosis outbreaks. Infect Control and Hosp Epid, 1997; 18:542-547.
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