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News Release USDL: 97-366
Thursday, October 16, 1997
Contact: Bill Wright (202)219-8151

More than 130 lives would be saved annually under a proposed new Occupational Safety and Health Administration (OSHA) standard to protect workers exposed to tuberculosis, Secretary of Labor Alexis M. Herman announced today.

The proposed standard helps protect an estimated 5.3 million workers in more than 100,000 hospitals, homeless shelters, long-term care facilities for the elderly, detention facilities, certain laboratories and other work settings with a high risk of TB infection. Implementation of the proposed standard would prevent 70-90 percent of work-related tuberculosis (TB) infections.

"The battle against TB is far from over," said Herman. "While the rate of active TB in the general population has declined overall during the past 40 years, the risk for the workers who care for clients and patients infected with TB continues to be high, and in some areas is growing.

"Of even greater worry now," she said, "is the emergence of a new and deadly form of the disease that is resistant to current treatment. Infection with these multidrug-resistant strains can lead to severe lung damage and is often fatal. One of my top priorities is to ensure a safe and healthful workplace. We must do all in our power to protect workers against this deadly disease."

OSHA estimates that the proposed standard would prevent between 21,000 and 25,000 infections per year and save from $89 million to $116 million in medical costs for treatment of tuberculosis and lost production caused by employee absence from work and disabilities associated with active cases of TB.

Tuberculosis is a contagious disease caused by inhaling airborne particles containing the bacterium Mycobacterium tuberculosis. Generally, these particles are generated when an infected person coughs, speaks or sneezes. The disease most commonly affects the lungs although it can affect several organs of the body, including the brain, kidneys and bones. Left untreated, the infection multiplies and destroys the affected tissues, leading to serious illness or death.

The proposed standard comes on the heels of nationwide enforcement procedures issued by OSHA during February 1996, which reflected revised guidelines by the Centers for Disease Control (CDC) to prevent transmission of TB, including drug-resistant strains of the disease. CDC and OSHA rely on identifying individuals with suspected infectious TB and isolating them.

OSHA's proposal has incorporated the basic elements of the revised CDC recommendations for health care facilities, such as written exposure control plans, procedures for early identification of individuals with suspected or confirmed infectious TB, procedures for investigating employee skin test conversions and employee education and training. The major difference between OSHA's proposal and the CDC's guidelines is that a final OSHA standard would be enforceable. Additionally, there are differences in the areas of risk assessment, medical surveillance and respiratory protection.

"We want to give employers clearly defined steps to protect their workers while, at the same time, assuring workers that steps will be taken to help protect them against this deadly disease," said Greg Watchman, OSHA's acting assistant secretary. "This proposed rule represents OSHA's best ideas for preventing workplace transmission of TB. However, we are seeking broad public participation through a series of hearings to ensure that the final rule is refined and tailored to address the many different types of workplaces it would cover."

The proposal incorporates basic infection control provisions designed to reduce occupational risks for exposed workers. It would require employers to develop a written exposure control plan and identify and isolate individuals with suspected or confirmed infectious TB or transfer them to facilities with isolation capabilities. The proposed standard would also require the installation of engineering controls in some facilities, such as negative pressure isolation rooms or areas that would reduce or eliminate exposures to employees. Other provisions in the proposed standard include tuberculin skin testing, hazard communication and training and recordkeeping.

Respiratory protection would also be required by the proposal under specific conditions. Respirators selected for use must be approved by the National Institute for Occupational Safety and Health (NIOSH). "The proposed standard, following CDC recommendations, would allow the use of low-cost respirators that can be used multiple times," Watchman said. "We believe that, in combination with other controls, respirators are effective in preventing TB transmission."

More than five million workers in approximately 100,000 establishments would be covered by this standard, including: hospitals, long-term care facilities for the elderly, correctional facilities and other facilities that house inmates or detainees, hospice facilities, shelters for the homeless, facilities that offer treatment for drug abuse, facilities where high-hazard procedures are performed and laboratories that handle TB specimens or process or maintain the resulting cultures.

The proposed standard would also cover occupational exposure to workers involved in social work, social welfare services, teaching, law enforcement or legal services. However, the proposal would only cover those services if provided in any of the settings previously mentioned, or in residences, to individuals who are isolated, segregated or confined due to suspected or confirmed infectious TB. Finally, the standard would also apply to workers providing emergency medical services, home health care or home-based hospice care.

Tuberculosis is a national concern, occurring in every state among people in every age group, and among both low-wage and high-wage workers. However, employers with facilities that are located in counties where the risk of TB infection is low would be subject to fewer requirements. The proposal would permit an employer to implement a more limited program if the facility (1) doesn't admit or provide medical services to persons with suspected or confirmed infectious TB, (2) has had no cases of confirmed infectious TB in the past 12 months, and (3) is located in a county that, in the past two years, had reported no case of confirmed infectious TB in one year and fewer than six cases of confirmed infectious TB reported in the other year.

These employers would be responsible only for preparing a written exposure control plan, providing baseline skin tests and making medical management available after an exposure incident. They would also need to provide medical removal protection if necessary, and give information and training to employees with potential occupational exposure, while complying with pertinent recordkeeping requirements. Periodic medical surveillance and respiratory protection would not be required.

Annual costs for implementing the standard are estimated to be $245 million, or about $2,400 per establishment. Because the standard would have a significant impact on small businesses (averaging approximately $1,600 per small entity or establishment), it underwent a joint review involving OSHA, the Small Business Administration and the Office of Management and Budget. OSHA also has held a series of meetings to discuss development of the proposal with 33 stakeholder groups representing labor unions, professional organizations, trade associations, governmental agencies and employer representatives.

OSHA will continue to work with representatives of drug treatment facilities and homeless shelters to ensure that a final standard, and its subsequent enforcement, would not impose unreasonable burdens on these facilities. Public hearings will also provide time for discussion of homeless shelter issues. Finally, OSHA has contracted for a special study regarding implementation of the proposed standard in homeless shelters.

OSHA was first petitioned for a permanent standard for occupational exposure to TB in August 1993 by a coalition of labor unions in light of a resurgence in the number of reported active TB cases nationwide. (The 7-year period ending in 1992 showed a 20 percent increase in the number of TB cases in the United States). The petitioners included the Service Employees International Union, American Federation of State, County and Municipal Employees, Local 1199 National Health and Human Services Employees Union, American Federation of Teachers and the American Federation of Government Employees. The petitioners contended that TB guidelines issued by CDC in 1990 were not being fully implemented in relevant work settings.

As an interim measure, OSHA issued nationwide enforcement procedures in October 1993 (revised in February 1996) for certain limited work settings. On Jan. 26, 1994, the agency announced its plan to develop a proposed rule. In developing the proposal, OSHA staff have visited affected industries, met with stakeholders and sought peer review of the risk assessment.

Public comment periods and public hearings are scheduled to provide an opportunity for interested parties to submit their comments and concerns on the provisions of the proposed standard. Public hearings are scheduled to begin in Washington, D.C., on Feb. 3, 1998, (beginning at 10 a.m. on the first day, and 9 a.m. each succeeding day). Hearings will be held in the auditorium of the Department of Labor (Frances Perkins Building), 200 Constitution Avenue, NW, Washington, D.C. Subsequent additional public hearings will be held in other U.S. locations. A Federal Register notice will be issued upon determination of the locations and dates of those hearings.

Comments on the proposed standard, as well as notices of intent to appear at hearings, testimony and documentary evidence should be submitted in quadruplicate to the Docket Officer, Docket No. H-371, Room N-2625, U.S. Department of Labor, 200 Constitution Ave., N.W., Washington, D.C. 20210. Comments of 10 pages or less may be transmitted by fax to (202) 219-5046.

The tuberculosis proposed standard is scheduled for publication in the Oct. 17, 1997, Federal Register.

Highlights of OSHA's Proposed Tuberculosis Standard

Tuberculosis is a contagious disease caused by inhalation of airborne particles containing the bacterium Mycobacterium tuberculosis. OSHA estimates that as many as 13 million adults in the United States are currently infected with TB, and about five million workers are exposed at work. The proposed standard would cover those workers in more than 100,000 establishments, averting between 21,000-25,000 infections annually and between 138-190 deaths. Costs for the standard are $245 million annually, or $2,400 per establishment ($1,600 per small business establishment).

SCOPE -- Covers occupational exposure in the following establishments:
(1) hospitals; (2) long-term care facilities for the elderly; (3) correctional facilities and other facilities that house inmates or detainees; (4) hospice facilities; (5) shelters for the homeless; (6) facilities that offer treatment for drug abuse; (7) facilities where high-hazard procedures are performed; (8) laboratories that handle specimens that may contain M. tuberculosis or process or maintain the resulting cultures or perform related activity that may result in the aerosolization of M. tuberculosis; (9) during the provision of social work, social welfare services, teaching, law enforcement or legal services if the services are provided in any of the work settings listed in (1) through (8), or in residences, to individuals who are in isolation or are segregated or otherwise confined due to having suspected or confirmed infectious TB; and (10) during the provision of emergency medical services, home health care or home-based hospice care.

Where the risk of TB infection is low, OSHA proposes an exemption from certain provisions of the standard. The standard includes less stringent requirements for facilities that: (1) do not admit or provide medical services to individuals with suspected or confirmed infectious TB; (2) have had no cases of confirmed infectious TB in the past 12 months; and (3) are located in a county that, in the past two years, had no cases of confirmed infectious TB reported in one year and fewer than six cases of confirmed infectious TB reported in the other year.

Employers in those work settings would need to prepare a written exposure control plan, provide baseline skin tests, make medical management available after an exposure incident, provide medical removal protection if necessary and provide information and training to employees with exposure potential and complying with record keeping requirements. Periodic medical surveillance and respiratory protection would not be required.

Exposure Control -- Calls for employers to identify employees who have occupational exposure to TB at their work setting. That determination would include a list of job classifications in which all employees have occupational exposure and a list of job classifications in which some employees have occupational exposure, including a list of tasks and procedures performed by these employees that involve occupational exposure. Employers would develop a written exposure control plan, which would be accessible to employees. The plan needs to be reviewed at least annually and updated whenever necessary to reflect new or modified tasks, procedures or engineering controls that affect occupational exposure, in addition to new or revised employee classifications with occupational exposure. The plan for all employers must include:

• The exposure determination;

• Procedures for providing employees with information about individuals with suspected or confirmed infectious TB, or about ventilation systems that could be anticipated to contain aerosolized M. tuberculosis; and

• Procedures for reporting an exposure incident.

Additional elements are required for employers who transfer individuals with suspected or confirmed infectious TB; employers who admit those individuals or provide medical services to them; employers operating a laboratory; and employers who provide home health care or home-based hospice care.

Work Practices and Engineering Controls -- Requires employers to identify individuals with suspected or confirmed infectious TB and, except in settings where home health and home-based hospice care is being provided: (1) mask or segregate such individuals until transfer (to a facility that has isolation capabilities) or placement in an isolation room can be accomplished; (2) if transfer or placement can't be accomplished within five hours from the time of identification, then such individuals must be temporarily placed in isolation until placement or transfer can be accomplished. Negative pressure in isolation rooms must be maintained to reduce or eliminate exposures to employees. Ventilate isolation rooms or areas after they have been vacated by an individual with suspected or confirmed infectious TB for an appropriate period before allowing employees to enter without respiratory protection. Air should be exhausted from isolation rooms to the outside where it is safe to do so; otherwise, employers must use an HEPA filtration system before discharge or recirculation. Employers must also provide information about the hazard to any contractor who provides temporary or contract employees who may incur occupational exposure.

Respiratory Protection -- Mandates provision of respirators to employees who: (1) enter an isolation room in use for TB isolation; (2) are present during the performance of procedures or services for individuals with suspected or confirmed infectious TB who are not masked; (3) transport individuals with suspected or confirmed infectious TB in an enclosed vehicle or transports such an individual within the facility if the individual is not masked; (4)work on air systems or equipment that may reasonably be anticipated to contain aerosolized M. tuberculosis; (5) work in an area where an unmasked individual with suspected or confirmed infectious TB has been segregated or otherwise confined (e.g. awaiting transfer); or (6) work in a residence where an individual with suspected or confirmed infectious TB is known to be present.

The proposal also contains respirator provisions regarding approval by the National Institute for Occupational Safety and Health, filtering efficiency, fit testing, and fit checking.

Medical Surveillance -- Requires medical surveillance for all employees who have occupational exposure to TB. This includes medical evaluations and post-exposure follow-up as well as periodic tuberculin skin testing. Surveillance would take place:

1. Before assignment to a job with occupational exposure, or within 60 days of the effective date of this standard, and then annually thereafter (includes medical history, TB skin test and physical examination, (if indicated).

2. When an employee has signs or symptoms of TB (medical history, physical examination, TB skin test and medical management and follow-up).

3. When an employee experiences an exposure incident (medical history, TB skin test - if negative, a second test three months later, medical management and follow-up, and a physical examination, if indicated).

4. When an employee has a skin test conversion (medical history, physical examination, and medical management and follow-up).

5. Within 30 days of termination of employment (TB skin test)

6. At any other time a physician or licensed health care professional deems it necessary.

Hazard Communication and Training -- Calls for employers to label exhaust systems that may reasonably be anticipated to contain aerosolized M. tuberculosis, stating that contaminated air is present and that respiratory protection is required. Signs would be posted at entrances to isolation rooms or areas where procedures or services are being performed on individuals with suspected or confirmed infectious TB, indicating no admittance without an appropriate respirator. In addition, signs would be posted at the entrance to clinical and research labs where M. tuberculosis is present.

Employers would ensure each employee with occupational exposure participates in a training program, at no cost to the employee and at a reasonable time and place. Training would be provided: (a) before initial assignment to tasks where occupational exposure may occur; (b) within 60 days after the effective date of the standard; and (c) at least annually thereafter. Annual retraining is required unless the employer can demonstrate that the employee has the specific knowledge and skills required by the proposal. Retraining would need to be provided in any topic(s) where such specific knowledge and skills could not be demonstrated. The training program would include information such as an explanation of the contents of this standard, the general epidemiology of TB, signs and symptoms of TB, personal health conditions that increase an employee's risk of developing the disease, the employer's exposure control plan, respiratory protection and medical surveillance programs, procedures to follow if exposure incidents occur, and procedures to follow should an employee develop signs or symptoms of the disease.

Recordkeeping -- Specifies the following records: medical, OSHA illness and injury, training, and engineering control maintenance and monitoring. Medical records would be kept confidential and maintained for the duration of employment, plus 30 years. Medical records of employees who have worked for less than one year need not be retained, provided they are returned to the employee upon employment termination. Training records and engineering control maintenance and monitoring records would be maintained for three years.