TUBERCULOSIS IN THE WORKPLACE

Marilyn J.Field, Editor

Committee on Regulating Occupational Exposure to Tuberculosis

Division of Health Promotion and Disease Prevention

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.



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Tuberculosis in the Workplace TUBERCULOSIS IN THE WORKPLACE Marilyn J.Field, Editor Committee on Regulating Occupational Exposure to Tuberculosis Division of Health Promotion and Disease Prevention INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C.

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Tuberculosis in the Workplace NATIONAL ACADEMY PRESS 2101 Constitution Avenue, NW Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the U.S. Department of Health and Human Services (Contract HHS-100–00–0008). The views presented are those of the Institute of Medicine Committee on Regulating Occupational Exposure to Tuberculosis and are not necessarily those of the funding organization. Library of Congress Cataloging-in-Publication Data Tuberculosis in the workplace/Marilyn J.Field, editor; Committee on Regulating Occupational Exposure to Tuberculosis, Division of Health Promotion and Disease Prevention, Institute of Medicine. p. cm. Includes bibliographical references. ISBN 0-309-07330-8 1. Tuberculosis—United States. 2. Medical personnel—Health risk assessment—United States. 3. Tuberculosis—Prevention—Government policy—United States. I. Field, Marilyn J, (Marilyn Jane) II. Institute of Medicine (U.S.). Committee on Regulating Occupational Exposure to Tuberculosis. RC313.A2 .T83 2001 614.5′42′0973–dc21 2001030369 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, N.W. Box 285 Washington, DC 20055 Call (800) 624–6242 or (202) 334–3313 (in the Washington metropolitan area) Internet: www.nap.edu Copyright 2001 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Cover image: Mycobacterium tuberculosis. Copyright Dennis Kunkel Microscopy, Inc.

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Tuberculosis in the Workplace “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE Shaping the Future for Health

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Tuberculosis in the Workplace THE NATIONAL ACADEMIES National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M.Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A.Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I.Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M.Alberts and Dr. William A.Wulf are chairman and vice chairman, respectively, of the National Research Council.

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Tuberculosis in the Workplace COMMITTEE ON REGULATING OCCUPATIONAL EXPOSURE TO TUBERCULOSIS Walter Hierholzer (Chair), Professor Emeritus of Internal Medicine, Infectious Diseases and Epidemiology, Yale University Scott Barnhart, Medical Director, Harborview Medical Center, and Associate Dean, School of Medicine, University of Washington Henry M.Blumberg, Associate Professor, Department of Mediine, Division of Infectious Diseases, Emory University and Hospital Epidemiologist, Grady Memorial Hospital Scott Burris, Professor of Law, Temple University School of Law Robyn Gershon, Assistant Professor, Division of Sociomedical Sciences, Mailman School of Public Health at Columbia University Douglas Hornick, Associate Professor, Division of Pulmonary Diseases and Critical Care Medicine, Department of Internal Medicine, University of Iowa Pamela Kellner, Director, Program Development Unit, Bureau of Tuberculosis Control, New York City Department of Health James Melius, Executive Director, New York State Laborers’ Health and Safety Trust Fund Stephen G.Pauker, Sara Murray Jordan Professor of Medicine and Vice Chair, Clinical Affairs, Department of Medicine, Tufts/New England Medical Center Robert C.Spear, Professor, Environmental Health Sciences, University of California, Berkeley Lester N.Wright, Deputy Commissioner and Chief Medical Officer, New York Department of Correctional Services Committee Consultants and Liaison John J.Bass, Jr., Chair, Department of Medicine, University of South Alabama Thomas M.Daniel, Professor Emeritus of Medicine and International Health, Case Western Reserve University Lawrence Geiter, Director of Clinical Programs, Sequella Foundation, Maryland Phillip Harber, Professor of Family Medicine and Chief, Occupational and Environmental Medicine, University of California, Los Angeles Michael L.Tapper, Hospital Epidemiologist, Lennox Hill Hospital, New York City Keith F.Woeltje, Assistant Professor of Medicine, Section of Infectious Diseases, Medical College of Georgia M.Donald Whorton, Liaison, Board on Health Promotion and Disease Prevention, Institute of Medicine

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Tuberculosis in the Workplace Institute of Medicine Staff Marilyn J.Field, Study Director Elizabeth Epstein, Project Assistant (through July 2000) Cara N.Christie, Project Assistant Rose Marie Martinez, Director, Division of Health Promotion and Disease Prevention

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Tuberculosis in the Workplace Acknowledgments In developing this report, the committee and staff benefited from the expertise and experience of many individuals. In particular, we learned much from the presenters and participants in the workshop and public hearing held in August, 2000. At the committee’s request following the workshop, Ronald Bayer further developed his presentation about ethical issues, and Lisa Brousseau, Rachel Stricof, and Barry Farr also provided additional information or other assistance. Appendix A lists the workshop participants, presenters, and agendas. The authors of the commissioned background papers presented in Appendixes B (John J.Bass, Jr.), C (Thomas M.Daniel), D (Keith F. Woeltje), E (Scott Burris and Jamie Crabtree), and F (Phillip Harber, Scott Barnhart, Douglas Hornick, and Robert Spear) made essential contributions to this report through their evidence reviews, and their extensive discussions with committee members and staff. Their ability to develop the evidence reviews on a tight schedule for discussion at the workshop was especially appreciated. Dr. Daniel also patiently allowed us to draw on his deep expertise and decades of experience in research on tuberculosis. Consultants Michael Tapper and Lawrence Geiter provided expert advice and information about many issues. M.Donald Whorton, the liaison to the committee from the IOM’s Board on Health Promotion and Disease Prevention, likewise provided useful insights about the committee’s deliberations and analyses. The project officer at the National Institute for Occupational Safety and Health (NIOSH), Greg Wagner, always responded promptly to ques-

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Tuberculosis in the Workplace tions. Others at the agency who provided information and explanations about NIOSH research and statements included Paul Jensen and Christopher Coffey. At the Division of Tuberculosis Elimination (which is also part of the Centers for Disease Control and Prevention [CDC]), Renee Ridzon and Amy Curtis patiently answered many questions about CDC data, guidelines, and procedures. The weekly summary of news about tuberculosis developed by John Seggerson was an invaluable resource. At the Occupational Safety and Health Administration (OSHA), Amanda Edens was unfailingly helpful in answering questions about the proposed rule. She and Claudia Thurber helped clarify aspects of OSHA’s legislative, administrative, and judicial framework and differences between the language of the 1997 proposed rule and the 1994 CDC guidelines. Others at OSHA who provided useful information or explanations included Susan Sherman for her review of legal matters, Steven Bayard, Marthe Kent, and John Rainwater. At the Institute of Medicine, study staff appreciate the assistance of Sue Barron, Claudia Carl, Mike Edington, Pat Spaulding, Rita Gaskins, Karen Autrey, and Melissa Goodwin among others. Michael Hayes helped in copy editing the report.

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Tuberculosis in the Workplace REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: James August, American Federation of Labor and Congress of Industrial Organizations Alfred Franzblau, M.D., School of Public Health, University of Michigan Victoria Fraser, M.D., Washington University School of Medicine Alan Hinman, M.D., M.P.H., Task Force for Child Survival and Development Richard Menzies, M.D., Respiratory Epidemiology Unit, McGill University, Montreal Chest Institute Mary L.Powell, Ph.D., University of Kentucky, Lexington Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Robert Lawrence, M.D., School of Hygiene and Public Health, Johns Hopkins University, appointed by the Institute of Medicine and Elaine L.Larson, R.N., Ph.D., Columbia University School of Nursing, appointed by the NRC’s Report Review Committee, who were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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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

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Tuberculosis in the Workplace     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

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Tuberculosis in the Workplace 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

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Tuberculosis in the Workplace 4.3   Summary of Engineering Controls Recommended by CDC forFacilities 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

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Tuberculosis in the Workplace TUBERCULOSIS IN THE WORKPLACE

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