April 9, 2004
John L. Henshaw, Assistant Secretary of Labor
Occupational Safety and Health Administration
Washington, DC
Dear Assistant Secretary Henshaw:
The American Association of Occupational Health Nurses, Inc. (AAOHN) is committed to the safety and health of all employees, including health care employees, and the prevention and control of exposure to health hazards.
In September 2003, the Association provided comments to OSHA on the Respiratory Protection Standard (29 CFR Part 1910). In those comments, we addressed the threat of emerging, and increasingly virulent strains of infectious diseases and the potential hazards they pose to employee safety and health. To address the needs of employees in health care environments, AAOHN recommended a proactive approach for protection from all infectious diseases, including M. tuberculosis (TB), by promulgating a separate airborne infectious disease standard modeled after 1910.139 "Respiratory Protection for M. tuberculosis." Those comments were made prior to OSHA's decision to rescind the Respiratory Protection for M. tuberculosis (29 CFR 1910.139) in favor of applying the General Industry Respiratory Protection Standard for Fit Testing Procedures (29CFR 1910.134 App. A).
While AAOHN stands by its positions that a separate respirator standard for airborne infectious diseases is an effective approach, we do support OSHA's efforts to protect health care employees from exposure to airborne infectious diseases including TB. The Association will develop strategies to assist member compliance with the respirator standard. However, we recommend that the next step to facilitate compliance with 29 CFR 1910.134 is for the Agency to clarify the following:
- Revise Directives CPL 02-00-106 - CPL 2.106 - Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis dated February 9, 1996.
- Offer clarity to the term "reasonably anticipated" in terms fit testing health care employees who have been exposed or have the potential for exposure to TB.
Specific Comments:
- Revise Directives CPL 02-00-106 - CPL 2.106
It is apparent the experts agree respiratory protection (N95, etc.) is mandatory for health care employees in contact with clients with TB or other infectious airborne diseases. According to the Center for Disease Control and Prevention (CDC), the National Institute for Occupational Safety and Health (NIOSH) approved powered air purifying respirators (PAPR) or particulate filter respirators (N-95) will improve the protection of health care employees at high-risk or potential exposure to tuberculosis. As consistent with all components of a respiratory protection program, initial and periodic TB training must be performed and must include respirator fit testing.
The CPL 02-00-106 - CPL 2.106 - Enforcement procedures and scheduling for
occupational exposure to tuberculosis (1996) offers procedures and guidelines for health care facilities to follow, but it is out dated. AAOHN recommends updating these directives to coincide with OSHA's current respirator fit testing mandate. Reference material should also be updated as some date back twenty years (1985).
Page 8-10, Respiratory Protection of the CPL (1996): These specific guidelines for the respiratory protection of health care employees list (page 9, 2nd paragraph, #2) "the ability to be qualitatively or quantitatively fit tested in a reliable way to obtain a face-seal leakage of less than or equal to 10 percent." This supports the importance of the respirator and coincides with OSHA's current mandate. But, directive, page 9, 10th paragraph, NOTE, lessens the importance of the respirator by giving permission for health care employees to reuse disposable respirators. Based on these discrepancies, AAOHN reemphasizes the need for a CPL revision and/or update.
- Clarify term "reasonably anticipated" for fit testing
What is not clear is, "how do employers know if they are properly identifying those employees 'at risk' as it relates to the potential for TB exposure?" A review of the CPL (1996) shows that it does not provide clear guidance for identifying those employees who have the potential for exposure. The Guidelines for Preventing the Transmission of
M. tuberculosis in Health-Care Facilities (CDC, 1994) state, "health care facilities should conduct a risk assessment to determine employees 'at risk for occupational exposure' to M. tuberculosis and provide risk guidance to employers by including a table that describes the elements of a risk assessment for TB in health-care facilities." This is compared to OSHA's Bloodborne Pathogen (BBP) Standard (29 CFR 1910.1030) that states, the standard covers "all employees with the potential for exposure to blood or potentially infectious materials in the course of their normal job duties." To facilitate employer(s) and employee(s) compliance with OSHA's current fit testing mandate, AAOHN recommends OSHA clarify the meaning of "reasonably anticipated" or "at risk" as it relates to TB exposure and requirement for respirator fit testing. By providing clarification, those employees "at risk" should be identified by conducting organizational and community environmental risk assessments.
In conclusion, reports indicate a decline in TB rates in the United States, but there has been an emergence of other airborne diseases, such as SARS, with which we should also be concerned. CDC reports that TB is the leading cause of death in the world. With continued globalization and the increase in multi-drug resistance strains, the potential for a resurgence of TB should not be overlooked. Therefore, AAOHN, as an advocate for employee safety and health, believes our recommendations to facilitate compliance to OSHA's mandate is consistent with the association's values to promote healthful and safe work and community environments, as well as the association's mission to provide resources and tools for occupational and environmental health nurses in delivering health programs and services.
Sincerely,
Susan A. Randolph, MSN, RN, COHN-S, FAAOHN
President
