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Study Origins and Activities

In November 1999, the U.S. Congress directed the Secretary of Health and Human Services to contract with the National Academy of Sciences (NAS) for a study of the Occupational Safety and Health Administration’s (OSHA’s) rule making related to occupational exposure to tuberculosis (P.L. 106–113, Conference Report 196–749). The report was requested within 14 months of the legislation. The study was neither to delay issuing of the final rule nor to be delayed pending the rule’s publication. (OSHA released the standard after the committee completed its work.)

The agreement between the U.S. Department of Health and Human Services (DHHS) and the Institute of Medicine (IOM; the health policy arm of NAS) allowed the study to began officially on April 1, 2000. To undertake the requested study, the IOM appointed an 11-member committee of experts that met in April, August, and September 2000.

The legislative conference language listed three sets of questions. First, are health care workers at a greater risk of infection, disease, and mortality due to tuberculosis than individuals in the general community within which they reside? If so, what is the excess risk due to occupational exposure? Second, can the occupationally acquired risk be quantified for different work environments, different job classifications, etc., as a result of implementation of the 1994 guidelines of the Centers for Disease Control and Prevention (CDC) for the prevention of tuberculosis transmission at the work site or the implementation of specific parts of the CDC guidelines? Third, what effect will the implementation of OSHA’s proposed tuberculosis standard have on minimizing or eliminating the risk of infection, disease, and mortality due to tuberculosis?



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Tuberculosis in the Workplace A Study Origins and Activities In November 1999, the U.S. Congress directed the Secretary of Health and Human Services to contract with the National Academy of Sciences (NAS) for a study of the Occupational Safety and Health Administration’s (OSHA’s) rule making related to occupational exposure to tuberculosis (P.L. 106–113, Conference Report 196–749). The report was requested within 14 months of the legislation. The study was neither to delay issuing of the final rule nor to be delayed pending the rule’s publication. (OSHA released the standard after the committee completed its work.) The agreement between the U.S. Department of Health and Human Services (DHHS) and the Institute of Medicine (IOM; the health policy arm of NAS) allowed the study to began officially on April 1, 2000. To undertake the requested study, the IOM appointed an 11-member committee of experts that met in April, August, and September 2000. The legislative conference language listed three sets of questions. First, are health care workers at a greater risk of infection, disease, and mortality due to tuberculosis than individuals in the general community within which they reside? If so, what is the excess risk due to occupational exposure? Second, can the occupationally acquired risk be quantified for different work environments, different job classifications, etc., as a result of implementation of the 1994 guidelines of the Centers for Disease Control and Prevention (CDC) for the prevention of tuberculosis transmission at the work site or the implementation of specific parts of the CDC guidelines? Third, what effect will the implementation of OSHA’s proposed tuberculosis standard have on minimizing or eliminating the risk of infection, disease, and mortality due to tuberculosis?

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Tuberculosis in the Workplace For clarity in presenting its analysis, the committee slightly edited the questions as follows. (1) Are health care and selected other categories of workers at greater risk of infection, disease, and mortality due to tuberculosis than others in the community within which they reside? If so, what is the excess risk due to occupational exposure? Can the risk be quantified for different work environments and different job classifications? (2) What is known about the implementation and effects of CDC guidelines to control worker exposure to tuberculosis in hospitals, correctional facilities, and other work settings? (3) Given what is known about the CDC guidelines, what will be the likely effects on tuberculosis infection, disease, or mortality of an OSHA rule to protect workers from occupational exposure to tuberculosis? Although the revised questions broadened the scope of the committee’s work beyond health care workers, most of the information identified by the committee focused on health care workers, mainly hospital employees. The committee arranged for five background papers that appear as Appendixes B, C, D, E, and G in this report. It also conducted a 1-day workshop and a half-day public meeting to solicit oral and written statements from interested organizations. Both these meetings were open to the public. The agendas are listed below. INSTITUTE OF MEDICINE COMMITTEE ON REGULATING OCCUPATIONAL EXPOSURE TO TUBERCULOSIS Public Meeting Lecture Room, National Academy of Sciences 2101 Constitution Avenue NW, Washington, DC. Monday, August 7, 2000 AGENDA 1:00 pm Welcome and Overview of Meeting Walter Hierholzer, M.D., Committee Chair 1:10 Panel 1 Service Employees International Union, AFL-CIO William Borwegen, M.P.H. Occupational Health and Safety Director American Federation of State, County, and Municipal Employees James August, M.P.H. Assistant Director for Research and Health Services

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Tuberculosis in the Workplace   American Nurses Association Karen A.Worthington, M.S., R.N., COHN-S Senior Occupational Safety and Health Nurse Specialist New York State Public Employees Federation Jonathan Rosen, M.S., C.I.H. Director, Occupational Safety and Health Department 2:00 Panel 2 American Hospital Association Roslyne D.W.Schulman, M.H.A., M.B.A. Senior Associate Director, Policy Development Gina Pugliese, R.N., M.S. Director, Premier Safety Institute American Association of Homes and Services for the Aged Linda Bunning, R.N., N.H.A. Director of Residential Services, Presbyterian Homes, Inc. American Academy of Pediatrics Jeffrey R.Starke, M.D. Member, AAP Committee on Infectious Diseases Baylor College of Medicine American Public Health Association Occupational Health and Safety Section Melissa A.Mc Diarmid, M.D., M.P.H. Professor of Medicine Director, Occupational Health Project, University of Maryland 3:00 Break 3:20 Panel 3 National Tuberculosis Controllers Association Betty L.Gore, R.N., M.S.N., C.I.C. Nurse Consultant, Tuberculosis Control Program South Carolina Department of Health and Environment California Department of Health Robert Harrison, M.D. California Department of Health Services Chief, Occupational Health Surveillance and Evaluation Program American Society for Microbiology Mary Gilchrist, Ph.D. Director, University Hygienic Laboratory, University of Iowa Cook County Department of Corrections James McAuley, M.D. Medical Director, Cermak Health Services

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Tuberculosis in the Workplace 4:10 Panel 4 Veterans Administration Gary Roselle, M.D. National Program Director for Infectious Diseases Chief, Medical Services, Cincinnati VA Medical Center American College of Occupational Medicine John Balbus, M.D. Center for Risk Science and Public Health, George Washington University Medical Center American Thoracic Society Edward Nardell, M.D. Associate Professor of Medicine, Harvard Medical School Tuberculosis Control Officer, Massachusetts Department of Health Society for Healthcare Epidemiology of America Patrick Brennan, M.D. Hospital Epidemiologist, University of Pennsylvania Association for Professionals in Infection Control Rachel Stricof, M.T., M.P.H. Epidemiologist, New York State Department of Health 5:10 Public Comment Period Adjourn INSTITUTE OF MEDICINE WORKSHOP ON REGULATING OCCUPATIONAL EXPOSURE TO TUBERCULOSIS Lecture Room, National Academy of Sciences 2101 Constitution Avenue NW, Washington, DC. Tuesday, August 8, 2000 AGENDA 8:30 am Welcome, Workshop Objectives Walter Hierholzer, M.D., Committee Chair Professor Emeritus of Internal Medicine, Infectious Diseases and Epidemiology, Yale University 8:40–9:40 Occupational Exposure to Tuberculosis: Evidence Review Thomas Daniel, M.D. Professor Emeritus of Medicine and International Health Case Western Reserve University Discussant: George Comstock, M.D., Dr. P.H. Professor of Epidemiology Johns Hopkins University

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Tuberculosis in the Workplace 9:40–10:40 Strengths and Limitations of Tuberculin Skin Testing: Evidence Review John Bass, Jr., M.D. Chair, Department of Medicine University of South Alabama Discussant: C.Fordham von Reyn Professor of Medicine Section Chief, Infectious Disease Section Dartmouth, Hitchcock Medical Center 10:40–11:00 Break 11:00–12:15 Personal Respirators and Tuberculosis Control: Evidence Review Phillip Harber, M.D. Professor, Department of Family Medicine Chief, Occupational and Environmental Medicine University of California, Los Angeles Discussants: Lisa Brosseau, Ph.D. Associate Professor, Division of Environmental & Occupational Health, University of Minnesota Barry Farr, M.D. Professor of Internal Medicine, University of Virginia 12:15pm Lunch in Refectory (tickets in meeting folder) 1:30–3:30 1994 CDC Guidelines: Preventing Transmission of Tuberculosis in Health-Care Facilities Effects of the CDC Guidelines: Evidence Review Keith Woeltje, M.D., Ph.D. Assistant Professor, Section of Infectious Diseases, Department of Medicine, Medical College of Georgia Lessons Learned at the CDC Amy Curtis, Ph.D. Epidemiologist, CDC Division of TB Elimination and Lisa Panlilio, M.D. Medical Epidemiologist, CDC Hospital Infections Program Discussants: Gina Pugliese, R.N. Director, Premier Safety Institute, Premier Health System James August, M.P.H. Assistant Director for Research and Health American Federation of State, County, and Municipal Employees

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Tuberculosis in the Workplace 3:30–3:50 Break 3:50–4:30 Ethical Issues in Regulating Workplace Exposure to TB Ronald Bayer, Ph.D. Professor of Public Health, Columbia University 4:30 Public Comment and Continued Discussion 5:00 Adjourn