Tuberculosis in the Workplace

Contents Summary 1 1 Introduction 13 Risks to Health Care and Other Workers, 15 Overview of Report, 16 Responses to Resurgent Tuberculosis, 17 The Broader Public Health Context: Eliminating Tuberculosis in the United States and Worldwide, 21 Conclusion, 23 2 Basics of Tuberculosis 24 Transmission and Development of Latent Tuberculosis Infection and Active Tuberculosis, 25 Detection and Treatment of Latent Tuberculosis Infection, 28 Diagnosis and Treatment of Active Tuberculosis, 37 Conclusion, 41 3 Occupational Safety and Health Regulation in Context 43 Strategies for Reducing Workplace Hazards, 43 The Occupational Safety and Health Act of 1970 and Its Administration, 45 Conclusion, 55 4 Comparison of CDC Guidelines and Proposed OSHA Rule 56 CDC Guidelines on Preventing Transmission of Tuberculosis in Health Care Facilities, 57 xii CONTENTS xii Proposed OSHA Rule on Occupational Exposure to Tuberculosis, 59 Comparison of Guidelines and Proposed Rule: Administrative Controls, 63 Comparison of Guidelines and Proposed Rule: Engineering Controls, 74 Comparison of Guidelines and Proposed Rule: Personal Respiratory Protections, 76 Conclusion, 80 5 Occupational Risk of Tuberculosis 81 Concepts and Definitions, 82 Historical Perspectives on the Occupational Risk of Tuberculosis, 85 More Recent Information on the Community and Occupational Risk of Tuberculosis, 86 Committee Conclusions, 104 Summary, 107 6 Implementation and Effects of CDC Guidelines 108 Implementation of Tuberculosis Control Guidelines, 109 Effects of Implementing Tuberculosis Control Measures, 122 Committee Conclusions, 131 Summary, 135 7 Regulation and the Future of Tuberculosis in the Workplace 137 Potential Effects of an OSHA Standard on Occupational Tuberculosis, 138 The Workplace and the Community, 154 References 157 Appendixes A Study Origins and Activities 173 B The Tuberculin Skin Test 179 C The Occupational Tuberculosis Risk of Health Care Workers 189 D Effects of CDC Guidelines on Tuberculosis Control in Health Care Facilities 230 E OSHA in a Health Care Context 271 F Respiratory Protection and Control of Tuberculosis in Health Care and Other Facilities 293 CONTENTS xiii G Recommendations of the Institute of Medicine Committee on Eliminating Tuberculosis in the United States 309 H Committee Biographies 314 Index 319 BOXES, FIGURES AND TABLES Boxes 1.1 Regulating Occupational Exposure to Tuberculosis: Selective Chronology of Events, 19 3.1 Key Terms Relevant to Justification of OSHA Standards as Used by the Agency, 49 Figures 1.1 Reported cases of tuberculosis, 1978–1998, 14 1.2 Trends in tuberculosis funding and numbers of tuberculosis cases in the United States, 18 4.1 Protocol for conducting a tuberculosis risk assessment in a health care facility, 67 5.1 Tuberculosis incidence rates per 100,000 population by year and reported employment status within preceding 24 months, 90 Tables 2.1 Differences Between Latent Tuberculosis Infection and Active Pulmonary Tuberculosis, 25 2.2 CDC Recommendations for Interpreting Reactions to the Tuberculin Skin Test, 30 2.3 Positive Predictive Value of a Positive Tuberculin Skin Test Assuming 95 Percent Sensitivity, 31 2.4 Importance of Disease or Condition Prevalence, Bayesian Probability Analysis, 32 3.1 Worker Strategies to Control Workplace Hazards, 44 4.1 Summary of Administrative Controls (other than diagnosis and treatment) Recommended by CDC for Health Care Facilities, with Notes (in italics) on How Proposed OSHA Rule Differs, 64 4.2 Summary of Patient Management Recommendations by CDC, with Notes (in italics) on How Proposed OSHA Rule Differs, 73 xiii xiv CONTENTS 4.3 Summary of Engineering Controls Recommended by CDC for Facilities That Serve People with Tuberculosis, with Notes (in italics) on How Proposed OSHA Rule Differs, 75 4.4 Summary of Personal Respiratory Protections Recommended by CDC, with Notes (in italics) on How Proposed OSHA Rule Differs, 78 5.1 Tuberculosis Case Rates per 100,000 Population, United States, 1989–1999, 87 6.1 Comparison of Tuberculosis Control Measures for 103 Hospitals That Reported More than Six Admissions of Patients with Tuberculosis in 1992 CDC Survey and That Also Responded to 1996 CDC Survey, 111 6.2 Results of Interventions at Grady Memorial Hospital, 125