OSHA TB Standard: R.I.P. -- Public Health System Approaching Breakdown?

As I noted last week, OSHA has finally decided to withdraw the tuberculosis standard, dumping over ten years of work into the trash can largely due to pressure from the health care industry. Ditching the TB standard could probably have not come at a worse time with a public health system approaching the breaking point between new demands placed upon it by preparations for SARS, new homeland security requirements, gigantic state budget problems and the Bush tax cuts eating up any chance of significant federal assistance.The TB standard could have been an important measure to help prepare this country not just to prevent a possible future increase in TB infections, but to also confront assaults from other air-borne diseases like SARS.

AFSCME, SEIU and a number of other unions petitioned OSHA for a Tuberculosis standard in 1993 in response to a nationwide outbreak of tuberculosis -- including multiple drug resistant TB -- that was exposing and killing health care and corrections workers. The standard was on the verge of being issued at the end of the Clinton administration, but because of OSHA's total focus on ergonomics, the curtain fell before the standard was finalized.

To what do we owe the demise of an almost completed health standard designed to protect health care, corrections and others from the second-leading infectious cause of death worldwide? An estimated 2 billion people -- one-third of the world's population -- are infected with the bacteria that cause TB, and about 2 million people die each year from the disease, according to the CDC. In the United States, minorities are affected disproportionately by TB: 54 percent of active TB cases in 1999 were among African-American and Hispanic people, with an additional 20 percent found in Asians.

One factor is Republicans like Mississippi Congressman Roger Wicker, a member of the Appropriations subcommittee on Labor, Health and Human Services and Education, who has been a staunch foe of the TB standard and a major recipient of campaign contributions from the health care industry. Wicker had been putting pressure on OSHA for years to withdraw the standard.

Assistant Secretary of Labor for OSHA, John Henshaw justified his action by arguing that TB rates have fallen 43 percent since 1993, the (unenforceable) Centers for Disease Control guidelines "are working as far as reducing tuberculosis to the highest risk group -- health care workers," and OSHA has other priorities.

OK, let's look at this.

First, yes, the number of TB cases in this country has dropped sharply since the mid-1990's. But as AFSCME President Gerald W. McEntee said in a recent letter to Henshaw petitioning OSHA for issuance of the standard,

Although total cases in the United States have declined each year since 1992, the number of new cases only decreased by about two percent from 2000 to 2001....The number of cases actually increased in 20 states during this same period.....Fourteen states and the District of Columbia had tuberculosis rates that were higher than the 2001 national rate of 5.6 cases per 100,000 population."

Lee Erdmann, the city manager of Hartford, CT, certainly doesn't think the TB problem is going away. In a column opposing a bill that would create a new presumption that emergency medical personnel and public safety workers who are stricken by hepatitis, meningitis, or tuberculosis contracted the disease through their work and entitle them to automatic workers' compensation benefits, Erdman argued that the bill would:

impose a new and costly unfunded state mandate. The Office of Fiscal Analysis says there are "potential significant" fiscal implications for municipalities and has identified the bill as a costly "State Mandate." Noting that the number of cases of tuberculosis and meningitis are increasing, the Office of Fiscal Analysis says one case could cost $750,000 to $1.5 million.

Another recent article noted that "Tuberculosis cases in the United States fell to an all-time low last year, but they went up in Virginia. The Virginia Department of Health said Monday that the state had 315 cases last year, nine more than in 2001 for a 2.9 percent increase." And there have been recent outbreaks in Colorado, Maryland and elsewhere.

So is an OSHA standard really needed? This is the question that Congressional opponents of the standard, led by Wicker, asked the Institute of Medicine (IOM) to study. (Republicans used a similar tactic with ergonomics, asking the National Academy of Sciences to conduct two almost identical reviews of the scientific evidence undergirding OSHA's ergonomics standard.)

The IOM issued its report in 2001, finding that "Overall, the committee concludes that tuberculosis remains a threat to some health care, correctional facility, and other workers in the United States. Although the risk has been decreasing in recent years, vigilance is still needed within hospitals, prison, and similar workplaces, as well as in the community at large."

The IOM study also concluded that an OSHA standard was necessary to protect workers because an OSHA standard would help to sustain or increase adherence to effective workplace tuberculosis control measures. The IOM also found that an OSHA standard (unlike CDC recommendations) would increase compliance with tuberculosis control measures because workers will be in a stronger position to know what protections should be in place and to challenge employers who did not implement adequate prevention programs.

Sounds like the IOM gave Congress and OSHA a pretty clear message. So how do we explain this explanation for OSHA's action in the regulatory agenda? The IOM report

concluded that OSHA should move forward with a standard modeled after the CDC guidelines and tailored to the extent of TB risk present in the community. The IOM study concluded that an OSHA standard was needed to maintain national TB rates among health care and other employees at their current levels and to prevent future outbreaks of multidrug resistant and other forms of TB among these workers. OSHA reopened the record to obtain comment on the IOM study, the draft final risk assessment and the peer reviewers¡¯ comment on the risk assessment. The Agency has decided to withdraw the proposal.(emphasis added)

Well, that's perfectly clear.

Ditching the TB standard probably could not have come at a worse time. The United States faced a near epidemic of multiple drug resistant TB in the mid-1980's and early 1990s because the public health system in this country let down its guard. According to the IOM:

Complacency led to neglect of basic public health measures including surveillance, contact tracing, outbreak investigations, and case management services to ensure that individuals completed treatments for latent infection and active disease. This neglect helped set the stage for the resurgence of tuberculosis when new circumstances emerged—including the HIV/AIDS epidemic, the increase in multidrug-resistant disease (largely due to incomplete treatment), and expanded immigration from regions of the world with high rates of tuberculosis.

In hospitals across the country complacency translated into inadequate isolation rooms, ventilation systems that were not maintained, isolation room doors left open, infectious patients left to wander the halls and no training to recognize symptoms in waiting rooms. In correctional institutions the level of knowledge and control measures was virtually non-existent.

Now we may be faced with a new complacency fueled by an "all-clear" message from OSHA, falling national TB rates, and a public health system stressed to the breaking point by new homeland security demands, huge state budget problems and the Bush tax cuts eating up any chance of significant federal assistance.

Serious problems are already evident in the U.S. public health system

Keeping SARS from spreading in the United States is straining the already besieged public health system, and it's partly a matter of luck that this newest killer so far has been contained here.

The question is how long that luck will hold - and at what price. Health departments that already were struggling to deal with bioterrorism and West Nile virus say their ability to protect against more common threats today is compromised.

What if the anticipated summer resurgence of West Nile virus occurs at the same time as some other outbreak, perhaps food poisoning, and SARS is still around? Could CDC possibly handle it all, wonders Barry Bloom, dean of Harvard's School of Public Health.

APHA Executive Director Georges Benjamin testifying before Congress warned that

We are at a critical juncture in public health. For many years, experts have been warning us that our nation's public health infrastructure is in disarray. We lack adequate personnel and training, laboratory capacity and communications networks. There are serious gaps in our disease surveillance systems.

In fiscal year 2002, Congress appropriated $7.7 billion for CDC. In 2003, Congress appropriated $7.1 billion for CDC. The President's proposed budget for the agency in 2004 is $6.6 billion-an 8.5 percent cut over last year. We are moving in the wrong direction

This year, the budget for the National Institute for Occupational Safety and Health is slated for a 10 percent cut. CDC's NIOSH is the only federal agency responsible for conducting research and making recommendations for the prevention of work-related injuries.

Problems are already being felt on the local level.

Dr. Alonzo Plough, public health director for Seattle-King County, Washington says it's like an undermanned fire department having to choose which burning building to save: Between SARS, smallpox vaccination, West Nile preparation and a major tuberculosis outbreak, he's almost $2 million over budget already. His swamped infection specialists have a backlog of hepatitis cases to investigate, and they can forget any work soon to fight some rapidly increasing sexually transmitted diseases.

One of the main problems facing public health officials is the lack of infrastructure needed to protect workers and other patients from airborne diseases like TB and SARS.

Funding problems have prevented Seattle hospitals from providing enough rooms to contain infectious patients, said Plough.

"We're talking about major shortfalls in negative pressure (isolation room) capacity and hospitals' epidemiological capacity," Plough said. Keeping SARS from spreading in the United States is straining the already besieged public health system, and it's partly a matter of luck that this newest killer so far has been contained here.

OSHA seems intentionally oblivious to the connection between precautions for TB and similar precautions for SARS. As I wrote last month after AFSCME petitioned OSHA for issuance of the TB standard,

What's most interesting about this saga is that OSHA just posted a SARS Web Page. And although there are tons of references to OSHA's Bloodborne Pathogens Standard and references on its SARS webpage, there's not a single reference to tuberculosis, despite the fact that OSHA has an extensive TB webpage describing the same precautions that are needed to protect health care workers and others against SARS. Is the agency embarrassed that it [was about to repeal] the standard when it's clear now that it was needed?

Should SARS come calling in the U.S. as it has in parts of Canada, health care workers will be the first victims. SARS will be just another hazard added to the plague health care workers in the U.S. and Canada face daily. In Toronto,

SARS opened many people's eyes to the health risks nurses face on the job, but it is not surprising that most nurses shrugged it off as just another in a long time of hazards. More than 40 per cent of ward nurses suffer chronic back problems due to a combination of 12-hour shifts on their feet and lots of heavy lifting (100-pound nurses routinely have to move and restrain 200-pound patients). Emergency room nurses are victims of assault (drunks are the biggest problem, but increasingly, patients and family members frustrated by long waiting times also lash out).

Public health nurses are routinely exposed to tuberculosis, and jabs with needles; oncology and surgical nurses are exposed to noxious chemicals that leave them with higher cancer rates. Even shift work is a health hazard: It has been associated with higher rates of breast cancer and sleep disorders.

As AFL-CIO John Sweeney said in a statement following OSHA's announcement,

While Big Business in health care has pushed to block these safeguards, the Administration should value people over profit and provide workers the regulations they desperately need to protect themselves and patients from a serious health hazard.

Stay tuned for coming attractions: A standard that would have required employers to pay for workers' personal protective equipment was also on the verge of being issued at the end of the Clinton Administration. OSHA was rumored to be on the verge of withdrawing that standard as well until the United Food and Commercial Workers and National Hispanic Caucus petitioned the agency to release the standard. Might be a good time to call your Senators and representative.