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Low risk’ criteria called too stiff
Opponents of the TB standard proposed by the Occupational Safety and Health Administration (OSHA) say they are pleased with a recently released report from the Institute of Medicine (IOM) that eyes the impact of implementing the new OSHA rule.
"The findings of the IOM are consistent with what we’ve been presenting to OSHA and to the IOM," says Rachel Stricof, MPH, an epidemiologist at the New York State Department of Health in Albany and a member of a task force for the Washington, DC-based Association for Professionals in Infection Control and Epidemiology (APIC). APIC has lobbied hard to convince Congress that plugging in the proposed standard would drive up costs without substantially benefiting employees in health care facilities — a complaint echoed in the IOM report.
"To the extent that an OSHA standard inflexibly extends requirements to institutions that are at negligible risk for occupational transmission of TB, the standard is unlikely to benefit workers. At the same time it would impose significant costs and administrative burdens on covered organizations, and absorb institutional resources that could be applied to other, potentially more beneficial uses," the report says.
Specifically, the report takes the proposed standard to task on three counts:
• It raises questions about data the federal agency used in its projections of cases that implementing the standard would avert.
• It questions the usefulness of OSHA’s narrowly defined standard of what constitutes a "low risk" facility.
• It tackles issues related to use of respirators and fit testing, arguing that not enough data exist to make a call for or against their use.
Low-risk definition said too strict
The report questions OSHA’s claim that between 1,477 and 1,744 cases of TB could be prevented among health care workers each year by plugging in the TB rule. "In its surveillance report, CDC lists a total of 551 cases of [TB] among health care workers, and 16 cases among correctional facility workers," the IOM panel writes. "This figure is less than two-thirds the number of cases that OSHA predicted would be prevented. Moreover, of the reported cases of active disease, some proportion will have been the result of community rather than workplace exposure."
The OSHA definition for a "low risk" facility is also overly stringent, the report suggests. Under the proposed criteria, to qualify as low-risk, a facility must have had no confirmed cases of infectious TB during the previous 12 months and must be located within a county that has had no confirmed cases of infectious TB during one of the previous two years and less than six cases during the other year.
"Even if a facility had admitted no tuberculosis patients in the preceding 12 months, had no cases in its service area, and had a policy of referring those with diagnosed or suspected TB, this facility could not qualify for this lower risk’ category if the surrounding county had reported one case of TB in each of the two preceding years," the report notes.
A better way to assess risk might be to take into account a hospital’s service area, says Marilyn Field, MD, the IOM report’s project officer.
Finally, a paucity of data makes it difficult to lay down standards governing the use of respirators and fit-testing, the report cautions. The committee said it found no epidemiologic studies, either initially or annually, that have evaluated either qualitative or quantitative studies of N95 fit-testing.
"Administrative and environmental controls have clearly been shown to be effective," adds Stricof. "What has not been shown to be effective are respirators and fit-testing programs."