Condition 3. Will an OSHA standard allow reasonable adaptation of control measures to fit different organizational situations or changing environmental circumstances?

In general, regulations tend to reduce organizational flexibility. Revisions in regulations may also lag behind important changes in the environment or in the problem that gave rise to the regulation in the first place. Although much of the controversy about the flexibility of an OSHA tuberculosis standard focuses on costs or cost-effectiveness, some criticisms—mainly those relating to tuberculin skin testing requirements— involve the potential for inflexible requirements to harm workers’ health. (As discussed earlier and below, CDC is reexamining its recommendations on tuberculosis control in health care facilities, including its statements about baseline and periodic tuberculin skin testing.)

The voluntary character of the CDC guidelines ultimately gives employers at any risk level the discretion to tailor their responses to the particular risks faced by their workers. Although some provisions of the 1994 guidelines are described as requirements, CDC has no enforcement power. Also, many statements are not phrased as “shoulds” (much less “musts”) but, rather, are presented as suggestions for organizations to consider.

The following discussion compares the flexibility offered by the 1994 CDC guidelines and the 1997 proposed OSHA rule in three areas. The first and most important area involves the provisions of each for assessing the workplace risk of tuberculosis transmission, categorizing workplaces by the level of risk facing workers, and matching tuberculosis control measures to the level of risk. The other two areas involve tuberculin skin testing programs and respiratory protection programs.

Matching Requirements to Risk Level: Facility Risk Assessment

Chapters 1 and 5 make clear that the incidence of tuberculosis varies substantially among communities and that the risk of acquiring infection with M. tuberculosis has varied among hospitals and other workplaces. As described in Chapter 4, the 1997 proposed OSHA rule provides some very limited risk-related flexibility by distinguishing two categories of organizations, one of which would face fewer regulatory requirements. To quality for the “lower risk” category (a label not used in the proposed rule), an organization would have to (1) neither admit nor provide medical services to individuals with suspected or confirmed tuberculosis, (2) have had no confirmed cases of infectious tuberculosis during the previous 12 months, and (3) be located in counties that have had no confirmed cases of infectious tuberculosis during 1 of the previous 2 years and fewer than six cases during the other year. Any facility that did not meet all of these



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