criteria would have to meet all of the proposed rule’s requirements applicable to its type of work environment.

In contrast, the 1994 CDC guidelines provide for a more complex risk assessment process for health care facilities. That process incorporates more information and differentiates facility risk level and related control measures more finely.1 The guidelines specify that a health care facility or an area within a facility may be assigned to one of five risk categories: minimal, very low, low, intermediate, and high. For the facilities in the two lowest risk categories, the guidelines recommend considerably fewer control measures.2

Even if a facility had admitted no tuberculosis patients, had no tuberculosis cases in its community, and had a policy of referring those with diagnosed or suspected tuberculosis, that facility could not qualify for OSHA’s “low risk” category if the surrounding county had reported one case of tuberculosis in each of the preceding 2 years. As discussed in Chapter 4, a facility’s service area may not match county boundaries and may have a much different incidence of tuberculosis.

Reasonable flexibility in adoption of tuberculosis control measures does not imply lack of attention to the risk of tuberculosis in low risk facilities. Both the CDC guidelines and the proposed OSHA rule specify that all facilities—even those that have not recently encountered someone with active tuberculosis—should have protocols and trained individuals in place to identify the unexpected infectious individual and then transfer or otherwise manage the person in ways that minimize risks to workers and others. The issue is the degree to which control measures can be matched to tuberculosis risk in the community and in the facility, taking into account the facility’s experience in preventing transmission of tuberculosis. The risk assessment criteria described in the CDC guidelines allow for a more sensitive match between control measures and tuberculosis risk than do the criteria in the proposed OSHA rule.

Overall, the committee concludes that if an OSHA standard follows the 1997 proposed rule it may not offer sufficient flexibility for organizations to adopt control measures appropriate for the level of risk facing workers. To the extent that an OSHA standard inflexibly extends requirements to institu


As described in Chapter 4, the CDC risk assessment process includes a review of the community tuberculosis profile, the numbers of patients with tuberculosis examined or treated in different areas of the facility, the tuberculin skin test conversion rates for workers in different areas of the facility or in different job categories, and evidence of person-to-person transmission of M. tuberculosis resulting in active disease. The process also includes review of medical records to identify possible delays or deficiencies in identifying or treating individuals with infectious tuberculosis. In some cases, it calls for observation of infection control practices.


For the three higher-risk categories, the CDC recommendations differ primarily in whether they call for certain steps to be taken yearly or more frequently.

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