Tuberculosis Control
The OSHA regulations on occupational exposure to tuberculosis are less well known than the bloodborne pathogen rules but they affect a much broader set of businesses. [Proposed Rules Department of Labor Occupational Safety and Health Administration. 29 C.F.R. part 1910, Occupational Exposure to Tuberculosis, Friday, October 17, 1997, 62 Fed. Reg. 54160–01 (1997).] The following is a list of the groups, industries, and work settings that are covered by the standard. Basically, this includes all types of medical care, social work, and law enforcement agencies and personnel:
nursing homes
correctional facilities
immigration detainment facilities
law enforcement facilities
substance abuse treatment centers
homeless shelters
medical examiners’ offices
home medical care providers
emergency medical services
research and clinical laboratories handling TB
Contract work on ventilation systems or areas of buildings that may contain aerosolized M. tuberculosis
physicians performing certain high-hazard procedures
social service workers providing services to individuals identified as having suspected or confirmed infectious TB
personnel service agencies when providing workers to covered facilities
attorneys visiting known or suspected infectious TB patients
The CDC guidelines on TB control recommend that a facility does risk assessment to determine the level of TB exposure risk for the facility as a whole and for specific work areas and occupational groups. The CDC defines five levels of risk based on the number of clients with active TB, the rate and pattern of PPD skin test conversions, and whether there is evidence of person- to-person transmission of TB. OSHA has chosen a simpler approach. Employers are required to determine which employees have occupational exposure to TB. OSHA then specifies that measures must be taken to protect these exposed employees
Institutions that have no internal TB exposure and that are in communities with little or no active TB are exempt from some of the OSHA requirements. However, some actions are required of all covered institutions:
There must be a written exposure control plan.
Baseline PPD skin testing and medical history must be obtained on all employees who are identified as having occupational exposure.
Medical management and follow-up must be provided after exposure incidents.
Infectious employees must be removed from the workplace until noninfectious.
There must be acceptable employee training and recordkeeping.
The OSHA regulations require PPD retesting every three to twelve months depending on the level of risk and exposure history of a given employee. Employees with a low risk of exposure may be retested yearly. Those with higher risk must be retested every six months. The latter include those who (1) enter AFB isolation rooms, (2) perform high- hazard procedures, (3) transport TB patients in an enclosed vehicle, or (4) work in intake areas in an institution with a high number of TB patients (6 in 12 months). If there has been a direct exposure, the employee must be retested immediately and again in three months.
The OSHA regulations do allow for the limitations of the PPD skin test as a screening test. Anyone who has not had a TB skin test in the last 12 months, must have a two- step baseline test. This involves doing the test and then repeating it in two weeks if it is negative or equivocal. This allows them to distinguish true conversions from the booster effect. A true conversion occurs when the patient becomes infected with TB between two tests. The booster effect occurs when a patient has been infected in the past but does not have high levels of antibody. The first test boosts the antibody levels so that the repeat in two weeks will give a true reading. Contrary to popular myth, you cannot develop a positive PPD skin test by having too many tests.
If the employee already has a documented positive PPD skin test, then it does not have to be repeated. The employer may rely on careful history and chest X ray when indicated to follow these employees. Routine chest X rays are not required or recommended. In addition to regular screening of individual employees, regulated establishments must watch for clusters of disease or skin test conversion. These may indicate areas where active TB has gone unnoticed or where administrative or engineering controls have broken down.
When an employee has become infected with TB, whether they have active disease or silent infection detected on skin testing, the employer must provide medical care and follow-up. Some states recognize such infection as a compensable injury under workers’ compensation. Other do not. However, under OSHA regulation, proper care and treatment must be provided.
An employee who is found to have infectious TB must be put on medical exclusion from work until they are no longer infectious and do not pose a risk to others. This means that a medical care professional cannot practice until they are noncontagious. The nurse who is on medical exclusion from the hospital may not do immunization clinics or home health visits.
An important consideration about TB control in the work environment is that it must fit with the control of this disease in the larger community. The OSHA regulations and recordkeeping do not negate the state public health laws. TB is a reportable disease in every state and territory of the United States. There is a large federal TB control program administered at the local health department level. In addition, charity hospitals, homeless shelters, and jails have a large number of clients in common. Patients receive better care and workers have a safer work environment when there is coordination of TB control efforts by local public health officials.