more organizational adherence to control measures than can be achieved by voluntary guidelines. A standard is also likely to be clearer, more hazard specific, and easier to use than the other legal strategies available to OSHA. In addition, by providing a firmer basis for OSHA enforcement actions, a standard should put workers on stronger ground in identifying and challenging an employer’s inadequate implementation of mandated tuberculosis control measures.

The committee is concerned, however, that if an OSHA standard follows the 1997 proposed rule, it may not meet the third condition of allowing organizations reasonable flexibility to adopt tuberculosis control measures appropriate to the level of risk facing workers. The 1997 proposed rule defines a category of employers that would be excused from some of the rule’s requirements, but the criteria defined are very narrow and would likely subject too many low-risk organizations to the rule’s full scope. In addition, as an indicator of tuberculosis risk in the community, the proposed rule would require use of county-level data to assess community risk, even though a facility’s service area might be quite different and have a much different incidence of tuberculosis. To the extent that an OSHA standard inflexibly extends requirements to institutions that are at negligible risk of occupational transmission of M. tuberculosis, the standard is unlikely to benefit workers at the same time that it would impose significant costs and administrative burdens on covered organizations and absorb institutional resources that could be applied to other, potentially more beneficial uses.

The committee also concludes that OSHA’s 1997 estimates overstated the number of infections, cases of disease, and deaths due to tuberculosis that would be averted by adoption of the 1997 proposed rule. (The committee did not have access to OSHA’s recently revised estimates.) Tuberculosis case rates are down substantially from 1994 and the earlier years used for the estimates, and implementation of community and workplace tuberculosis control measures appears to be considerably improved. Recent data on tuberculosis infection are limited but indicate low levels of tuberculosis infection in health care facilities and suggest that exposure in the community is a significant factor in health care worker infections. In addition, the agency’s estimates relied on assumptions about the progression of tuberculosis from infection to active disease and from disease to death that are widely used but inconsistent with available data and are unlikely to fit employed workers with reasonably good access to health care.

PUBLIC POLICY AND THE CHANGING EPIDEMIOLOGY OF TUBERCULOSIS

Unlike typical workplace health problems such as those involving exposure to hazardous chemicals or dust, the likelihood of occupational



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