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XDR-TB, pandemic flu revive fit-testing flap
APIC responds to SEIU charges
The emergence of extensively drug-resistant tuberculosis (XDR-TB) has joined with the aftershocks of SARS and the threat of pandemic flu to put respiratory protection issues for health care workers back on the front burner.
"Obviously, we want to prevent [health care workers] from getting this TB, particularly since it is in a form that does not seem to be treatable," says Bill Borwegen, MPH, occupational safety and health director for the Service Employees International Union (SEIU). "We are concerned that the health care system may not be as robust as it needs to be in order to prevent [XDR-TB] and other types of emerging infections such as pandemic flu."
The current lack of preparedness can be traced to the failed effort to get a national TB standard finalized by the Occupational Safety and Health Administration (OSHA), Borwegen claims. The SEIU lost a protracted battle to enact the standard, which was defeated after groups such as the Association for Professionals in Infection Control and Epidemiology (APIC) successfully argued that it was inflexible, overly burdensome and unnecessary to prevent TB transmission in hospitals.
"Individuals and [infection control] organizations undermined the final OSHA TB standard," he says. "As a result of these types of activities, we are concerned that infection control professionals and others may not have the resources necessary to mount a robust response as needed in order to protect health care workers from being exposed to these types of airborne biological threats. We are concerned that the infrastructure is not in place to deal with diseases such as this new form of TB because of this continued ideological opposition by some of the professional organizations to various standards that would protect health care workers."
Borwegen charges that APIC is working with its allies in Congress to block OSHA enforcement of an existing requirement for annual fit-testing of N95 respirators used by health care workers against TB and other airborne agents. As a result, he says, some hospitals have the false impression that fit-testing never is required for these respirators.
"As a result [of APIC's stance on fit-testing], people are going to be less prepared to deal with these threats, whether it is in the form of TB or pandemic flu," Borwegen says. "I hope that APIC will sit down and revisit this. They have had a positive response to a lot of other occupational health and safety threats that health care workers face, but I don't understand their evidence-based reasoning [on] fit-testing. When manufacturers tell you that the only safe way to use the product is to fit-test at least initially and annually, who are they to contradict the people that sell the product?"
Hospital Infection Control asked APIC to respond to these charges and received a written response signed by Sue Sebazco, RN, 2007 APIC Public Policy Chair; and Denise Graham, APIC vice president of public policy. The response is summarized as follows:
"We believe it should go without saying that APIC shares the common goals of achieving worker protection as well as patient safety. That being said, we further believe our rationale for opposing annual fit-testing comes from a foundation of solid information, not unsubstantiated anecdotes. APIC's concerns center around the fact that mandating practices such as annual fit-testing are not evidence-based but are instead extremely resource-dependent and have not demonstrated that they provide additional benefit or protection to workers. Therefore, we believe OSHA's General Industry Respiratory Protection Standard (GIRPS) to be unsubstantiated when applied to a biological agent. There is a substantial body of evidence documenting prevention and control strategies to be effective in controlling occupational exposure to TB, influenza, and other infectious agents.
"TB cases have been consistently decreasing since the early 1950s, without annual fit-testing. The TB outbreaks of the late 1980s and early 1990s were controlled without the use of respirators, much less annual fit-testing of those respirators. Health care workers controlled those outbreaks using surgical masks, which continue to be effective: TB is at its lowest level in U.S. recorded history. This being the case, the burden of proof lies not on APIC's scientifically sound stance but on that of our opponents to come up with evidence to support their case.
"OSHA's GIRPS were not developed, designed, or evaluated for health care workers with potential occupational exposure to patients with potentially communicable conditions. Instead, scientific data, including studies conducted by NIOSH, strongly suggest that inherent fit characteristics of well-designed respirators may be more important than fit-testing in predicting consistent results with various fit-testing methods and presumably, adequate worker protection. In short, we believe the need for routine, annual fit-testing has never been substantiated and that the key to controlling transmission lies in the prompt identification, isolation and appropriate treatment of patients with potentially communicable conditions. The unrecognized case poses the most significant risk of transmission in health care settings, not the lack of an OSHA-directed medical evaluation and routine, annual fit testing."