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  • ACOEM Responds to OSHA Call for Comments on Exposure to Infectious Diseases in Health Care Settings

    August 4, 2010

    OSHA Docket Office
    Docket No. OSHA -2010-0003
    U.S. Department of Labor
    Room N-2625
    200 Constitution Avenue, NW
    Washington DC 20210 

    Docket No. OSHA-2010-0003

    To Whom It May Concern:

    The American College of Occupational and Environmental Medicine (ACOEM) welcomes the opportunity to respond to a request from the Occupational Safety and Health Administration (OSHA) for information and comment on occupational exposure to infectious agents in settings where health care is provided.

    Protection of health care workers is an essential goal of both OSHA and the ACOEM membership. Health care workers are at substantial risk for several adverse outcomes. Injury rates from assaults and musculoskeletal disorders, primarily from manual handling of patients, contribute to several occupations in health care having the highest injury rates of any working groups. In addition, exposures to bloodborne pathogens continue to pose the threat of devastating illness to workers. ACOEM has strongly supported OSHA efforts in the past to address issues of ergonomics, violence prevention, and bloodborne pathogen exposure, and OSHA activities around those issues have resulted in enhancements of health care worker safety. Nevertheless, ACOEM has concerns regarding the effort to establish an OSHA standard addressing infectious disease exposures.

    Those concerns are based primarily on: 1) the presence already of a substantial infection control infrastructure in health care institutions to protect both patients and healthcare workers; 2) a renewed and assertive national focus on prevention of infectious transmissions in health care institutions; 3) a broad range of extant and highly scrutinized activities to protect health care workers overseen by hospital-based occupational medicine practitioners in close cooperation with infection control specialists; 4) the expectation that over time, important microbiological changes among organisms of which we are currently aware, as well as the emergence of novel organisms, will require rapid adaptation of national guidance to ensure the protection of health care workers; and 5) that advancements in our scientific understanding of microbiology and microbial disease transmission also will require rapid adaptations of national guidance to keep pace with scientific advances.

    The fact that incidences among health care workers of a range of infectious diseases have not been shown to exceed population rates speaks to the effectiveness of hospital-based infection control and occupational medicine infrastructures. Those infrastructures are in place to ensure compliance with hand washing and the implementation of contact, droplet, and airborne precautions, all measures which are protective of both health care workers and the patients they treat. In addition, when health care workers have unprotected exposures to agents such as tuberculosis, pertussis, or varicella zoster, they are identified and evaluated for appropriate follow-up and/or prophylactic therapy through those same infrastructures. (It is worth noting here that the majority of unprotected exposures of health care workers to infectious agents, other than to the bloodborne pathogens, occur not due to a failure of implemented transmission-based precautions, but due to delays in the diagnosis of conditions that require precautions.)

    In recent years, a renewed emphasis on prevention of infectious diseases in hospitals has resulted from public reporting initiatives and the broader public recognition of infectious hazards in hospitals. Hospitals are closely scrutinized by their State health departments, by the Centers for Medicare and Medicaid Services (CMS) and by the Joint Commission around practices, which, while protective of patients, also directly enhance healthcare workers safety from infectious diseases. The experience of our membership is that hospital administrators have become extremely attuned to adherence on the part of health care workers to transmission-based precautions, handwashing, and annual training around transmission of agents by the droplet, contact, and airborne route.

    From the first day of employment in a healthcare setting, workers’ risks to infectious agents are overseen by hospital-based occupational medicine practitioners working closely with infection control staff. In the hospitals in which our members have experience, health care workers’ immunization status with respect to measles, mumps, rubella, varicella, diphtheria, tetanus, pertussis, and hepatitis B are assessed at time of employment, and vaccines are provided free of charge to those lacking immunity. Healthcare workers also are screened for latent and active tuberculosis and are fit tested for N95 respirators. In addition they receive initial and annual training addressing bloodborne pathogens, airborne pathogens, and infectious agents transmitted by other routes. On an annual basis, healthcare workers also receive education around influenza, are offered influenza vaccine at no charge, and undergo screening for tuberculosis when indicated, in accordance with CDC guidelines.

    The recent past has provided important examples of emerging infectious diseases. The SARS epidemic of 2003 and the Novel H1N1 influenza pandemic of 2009 demonstrated not only that healthcare workers will find themselves on the front line when new diseases emerge, but also that the public health and hospital-based responses to such events require the rapid development of guidance to respond to issues presented on a daily basis by such emergences. The public health infrastructure must respond immediately as characteristics of a novel agent are revealed, and the guidance issued must, in timely fashion, influence medical center-based practices around protection of workers. The SARS epidemic of 2003 provides a particularly rich example of voluminous production of guidance by the U.S. Centers for Disease Control and Prevention (CDC) to respond within days to issues as they arose in the public health and hospital-based management of the disease.

    In similar fashion, as our scientific understanding of microbiological agents, their complex interactions with the human host, and the complexities of disease transmission develop in the years to come, we must have guidance that responds to the scientific conclusions which are reached.

    ACOEM is concerned that an OSHA standard addressing the broad range of infectious agents other than bloodborne pathogens will take years to develop and finalize, that the knowledge base on which some of its components will be based will be outdated by the time the standard is passed, and that it will not be possible for OSHA to further develop its guidance to respond to novel infectious threats or advancements in our understanding of infectious disease transmission.

    U.S. Public Health Service guidance can be adapted much more quickly to protect health care workers from specific infectious disease threats as they emerge. It can also respond more quickly to advances in our scientific understanding of infectious diseases. ACOEM would submit that OSHA’s enforcing such guidance on issues that impact the safety of health care workplaces from infectious disease hazards, assuring that health care workers are provided appropriate PPE, training, and any recommended testing or post-exposure prophylaxis at no charge, is a better approach than the promulgation by OSHA of a new standard. This would imply increased reliance on the General Duty Clause to enforce safety within the workplace, citing current CDC guidance as the basis for proper precautions around infectious agents. There is already precedent for the enforcement of health care worker protection from tuberculosis under the General Duty Clause. There is also precedent for an analogous approach in the Bloodborne Pathogen Standard, which cites currently applicable U.S. Public Health Service guidance as a basis for prophylactic therapy of health care workers exposed to HIV.

    We encourage OSHA to address the issue of health care worker protections by promulgating a generic safety standard for health care settings. That approach would require hospitals to identify hazards, explicitly address risks, enforce CDC guidance and implement solutions. The presence of written programs, required under such a standard, would address OSHA’s concerns around transparency and evaluation. The presence of the hazard assessment elements could also address the changing epidemiology and ecology of infectious agents. Constructing infectious disease protection in a “generic” fashion would support health care workers in their expectations of formal program development

    ACOEM appreciates the opportunity to provide input on this important set of issues.

    Sincerely,

    Natalie Hartenbaum, MD, MPH, FACOEM
    President
    American College of Occupational and Environmental Medicine

    Mark Russi, MD, MPH, FACOEM
    Chair, Medical Center Occupational Health Section
    American College of Occupational and Environmental Medicine