December 15, 2020

Brian M. DeLoach, M.D.
Medical Director, Student Health Services
Georgia Southern University
Post Office Box 8043
Statesboro, GA 30460

Dear Dr. DeLoach:

Thank you for your letter to the Occupational Safety and Health Administration's (OSHA) Directorate of Enforcement Programs regarding the Centers for Disease Control and Prevention's (CDC) updated Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019,¹ and its applicability to OSHA's Compliance Instruction, CPL 02-02-078, Eriforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis.² This letter constitutes OSHA's interpretation only of the requirements discussed and may not be applicable to any questions not delineated within your original correspondence. The following are your paraphrased questions and our responses.

Question 1: Is it reasonable and prudent to modify or discontinue the requirement for annual tuberculosis testing set forth in the 2005 CDC guidelines and to adopt the new recommendations set forth in the updated 2019 CDC guidelines?

Response: OSHA has no specific standard for tuberculosis (TB). OSHA protects workers from TB by enforcing the provisions set by Section 5(a)(l) of the Occupational Safety and Health (OSH) Act, the general duty clause. This clause requires that each employer furnish to each of his or her employees a place of employment that is free from recognized hazards that cause or are likely to cause death or serious physical harm. lt is OSHA's longstanding policy that an employer's adherence to the recommendations of the most recent CDC guidelines on TB would meet the provisions ofthe general duty clause.

In addition, some generally applicable OSHA standards provide protection from TB. OSHA's Respiratory Protection standard, 29 CFR § 1910.134, requires employers to provide protection to workers exposed to airborne hazards, and 29 CFR § 1910.145, Specifications for Accident Prevention Signs and Tags, requires accident prevention tags to warn of biological hazards. As you are aware, in 2015 OSHA updated its enforcement directive for TB, CPL 02-02-078, Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis.³ This continues to be the current directive and references the 2005 CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings.⁴ The directive states, "[t]he [CDC] Guidelines also contain widely accepted standards of practice employers can follow in carrying out their responsibilities under the OSH Act." ⁵

OSHA is reviewing CPL 02-02-078 and will incorporate new CDC recommendations as appropriate in future updates to the directive. Until those updates are published, an employer may discontinue the requirement for annual tuberculosis testing set forth in the 2005 CDC guidelines provided that the employer follows all of the elements in the most recent CDC guidelines as well as state and local requirements.

Additional information regarding TB can be found on OSHA's TB Safety and Health Topics Page at www.osha.gov/SLTC/tuberculosis, which includes a link to the CDC's webpage on TB at www.cdc.gov/tb with their updated recommendations.

Question 2: What is OSHA's current interpretation with regard to CDC's new recommendation to no longer conduct serial annual tuberculosis testing of healthcare personnel without known latent tuberculosis infection (LTBl), including those working in facilities not classified as low risk?

Response: According to the CDC webpage at www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm?s_cid=mm6819a3_w, the new guidelines replace only the sections related to TB testing, screening, and treatment of health care workers. The remainder of the 2005 CDC guidelines appear to be unchanged. It is our understanding that the determination of risk classifications is still necessary for guiding infection control policies and procedures; however, risk categories are no longer used for determining serial screening. Serial screening is not recommended unless there is known exposure or evidence of ongoing TB transmission. In addition, the CDC states that health care facilities might consider using serial TB screening of certain groups who might be at increased occupational risk for TB exposure based on individual factors.

As stated in OSHA's directive, CPL 02-02-078, "[t]he CDC recommends that employers conduct initial and ongoing evaluations of the risk for TB transmission regardless of whether patients with suspected or confirmed TB disease are expected to be encountered in the setting. See 2005 CDC Guidelines, [Section - TB Risk Assessment], p. 9."⁶ Since this section of the 2005 CDC guidelines has not changed, OSHA maintains that it is the employer's responsibility to evaluate exposure risk and determine those employees with known or ongoing TB exposure. OSHA also expects the employer to make such exposure determinations and provide appropriate protections, including annual screening where warranted of certain groups based on individual factors as listed by the CDC (i.e., the number of patients with infectious pulmonary TB who are examined in these areas, whether delays in initiating airborne isolation occurred, or whether prior annual testing has revealed ongoing transmission).

For additional clarification, please contact the CDC:

The Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov, Web: www.cdc.gov/nchhstp

Thank you for your interest in occupational safety and health. We hope you find this information helpful. OSHA's requirements are set by statute, standards, and regulations. Our letters of interpretation do not create new or additional requirements but rather explain these requirements and how they apply to particular circumstances. This letter constitutes OSHA's interpretation of the requirements discussed. From time to time, letters are affected when the agency updates a standard, a legal decision impacts a standard, or changes in technology affect the interpretation. To ensure that you are using the correct information and guidance, please consult OSHA's website at www.osha.gov. If you have additional questions, please contact the Office of Health Enforcement at (202) 693-2190.

Sincerely,

Patrick J. Kapust, Acting Director
Directorate of Enforcement Programs

[1] Sosa LE, Njie GJ, Lobato MN, et al. Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019. MMWR Morb Mortal Wkly Rep 2019; 68: 439-443. DOI: dx.doi.org/10.15585/mmwr.mm6819a3.

[2] Please note, your letter references OSHA CPL 02-00-106, which was replaced with CPL 02-02-078 in 2015 at www.osha.gov/enforcement/directives/cpl-02-02-078 to reflect the CDC's 2005 recommendations.

[3] See www.osha.gov/enforcement/directives/cpl-02-02-078.

[4] Jensen PA, Lambert LA, et al. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.MMWR Morb Mortal Wkly Rep 2005; 54 (RR17):1-141. DOI: www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm?s_cid=rr5417a1_e.

[5] CPL 02-02-078, p. 11, supra note 3.

[6] CPL 02-02-078, p. 12, supra note 3.