Tuberculosis screening in low-risk healthcare settings

June 23, 2009

Ms. Virginia Bren, MPH, RN, CIC

Infection Control Coordinator

Altru Health System

[Recipient address omitted]

Dear Ms. Bren:

Thank you for your letter of April 20, 2009, to the Occupational Safety and Health Administration's (OSHA) Directorate of Enforcement Programs (DEP). You specifically ask whether it is reasonable and prudent to modify or discontinue the requirement for annual employee tuberculosis (TB) skin testing for health care workers (HCWs) in low risk facilities as detailed in the Centers for Disease Control and Prevention (CDC) Guidelines for the Prevention of Transmission of Mycobacterium Tuberculosis in Health- Care Settings, 2005 (MMWR December 30, 2005; Vol. 54, No. RR-17). This letter constitutes OSHA's interpretation only of the requirements herein, and may not be applicable to any questions not delineated within your original correspondence.

Scenario: Your letter acknowledges that OSHA's current policy (see CPL 02-00-106, Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis) requires annual TB skin testing for low risk personnel which was based on the CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities, 1994 (MMWR October 26, 1994; Vol. 43, No. RR-13). Since that time, the CDC updated their guidelines in December 2005, which modified TB screening procedures for settings (or HCWs) classified as low risk.

Question: What is OSHA's current interpretation of CPL 02-00-106 now that CDC updated their guidelines in 2005 which no longer requires annual testing for HCWs whose duties do not include contact with patients or TB specimens in settings classified as low risk?

Reply: OSHA's current compliance directive (CPL 02-00-106) references the 1994 CDC guidelines which, as you know, recommended TB skin testing to be conducted at least annually for all healthcare settings. The Agency's current means of enforcement of worker protection from TB in large part falls under the provisions set by Section 5(a)(l) of the Occupational Safety and Health (OSH) Act, the general duty clause. Under the general duty clause, an employer could be cited if he/she did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees exposed to the hazard of being infected with Mycobacterium Tuberculosis. An employer's adherence with the recommendations of the most recent CDC guidelines would be considered to meet the provisions of the general duty clause.

Please know that employers are recommended to make determinations of risk categories only after performing a thorough workplace hazard assessment for TB (including, but not limited to making a determination of the admission of persons with unrecognized TB disease; performing an evaluation of the community profile, in consultation with the local or state TB-control program etc.). Periodic reassessment (at least annual) is also needed to assure continued employee protection.

Thank you for your interest in occupational safety and health. We hope you find this information helpful. OSHA requirements are set by statute, standards, and regulations. Our interpretation letters explain these requirements and how they apply to particular circumstances, but they cannot create additional employer obligations. This letter constitutes OSHA's interpretation of the requirements discussed. Note that our enforcement guidance may be affected by changes to OSHA rules. Also, from time to time we update our guidance in response to new information. To keep apprised of such developments, you can consult the OSHA website at http://www.osha.gov. If you have any further questions, please feel free to contact the Office of Health Enforcement at (202) 693-2190.

Sincerely,

Richard E. Fairfax, Director

Directorate of Enforcement Programs