Prisons Overlook TB Infection

Most of the hoopla and controversy surrounding OSHA's late-term abortion of the tuberculosis standard focuses on the hazards facing health care workers. But in many ways, hazards facing other workers -- like corrections officers, for example -- are much worse. In fact, it was the tuberculosis-related death of a New York corrections officer and the hospitalization of another (along with his young son whom he had unknowingly infected) that helped stimulate labor's petition of OSHA in 1995 for a tuberculosis standard. OSHA's withdrawal of the proposed standard was based largely on the assumption that everyone was already following voluntary CDC guidelines and doing what they were supposed to do to protect their employees.

But CDC's August 20 Morbidity and Mortality Weekly Report (MMWR) paints a far different -- and more troubling -- picture, at least in correctional institutions. A CDC investigation found that a clearly symptomatic inmate with an active TB infection "had resided in three different jails and a state prison, placing hundreds of employees and other inmates at risk for TB infection."

More than 5% of prison employees who had a previously negative TB test, and almost 13% of employees who had not received a previous TB test received diagnoses of latent TB infection. (Latent infections are not "active" or infectious, but can become active and infectious at a later date if not treated.) More upsetting is the suspicion that undiagnosed prison-related TB infections can contribute to rises in TB infection rates among the general outside population:

During 1992--2002, the TB rate in Kansas increased from 2.2 per 100,000 population to 3.3, the largest increase among all 50 states and the District of Columbia; in the majority of states, the TB rate declined. Although the contribution of correctional facilities to the TB burden in Kansas is unknown, a study in Tennessee reported that 43% of persons identified with TB in the city of Memphis had previous contact with a single urban jail and no other identified common exposure.

The CDC calls for correctional institutions to implement formal Tuberculosis Infection Control Plans (TBICPs), educate employees, continuously monitor the effectiveness of the TBICP, maintain a tracking system for inmate TB screening and treatment and to establish a mechanism for sharing this information with local and state health departments and other correctional facilities.

Of course, had the tuberculosis standard been in effect now, all of this (and more) may have been required and the exposures and infections might not have happened. On the other hand, this incident occurred in Kansas, a state that does not provide federally approved OSHA coverage for its public employees (although it does have a non-federally approved program). But that's another story.

Nurse's TB Death Raises Troubling Questions

I have reported a couple of times on the death of a Virginia nurse from an undiagnosed tuberculosis infection. (here and here). And, although I hate to say "I told you so," OSHA's decision last year to withdraw the tuberculosis standard is looking dumber and dumber as the number of TB cases in many states creep up. This article in the Virginian-Pilot raises a number of disturbing questions:

When guards drop or awareness of the disease’s threat lessens, TB can kill.

Sometimes guidelines established to thwart it don’t prove enough. Nowhere is that clearer than in the case of 52-year-old Deborah Byrd Chrysostomides, the Chesapeake General nurse who died seven weeks ago.

Questions linger about her case and whether more could have been done to prevent it –certainly, from the more than 100 patients and visitors who have since tested positive for TB, and also from those closest to her.

Tim Peluso, the fiance of the once-vibrant and compassionate nurse, questions whether the hospital could have done more to detect her illness when she displayed TB symptoms. Hospital and public-health officials wonder whether Chrysostomides ever sought medical help, as she claimed to friends and a supervisor. If so, why didn’t a doctor diagnose her sooner?

And why can’t public-health officials find the doctor who supposedly treated her?

Two questions that loom largest for the general public: How could her illness have gone undetected in a hospital, of all places, and should anything be changed to keep such cases from occurring again?

Despite weeks of investigation by state health officials, some questions may never be answered. But what the investigations have been able to determine is that three of the usual safeguards against the spread of tuberculosis broke down : One, the expectation that a health professional will seek and receive proper treatment.

Two, the assumption that supervisors would notice someone with obvious symptoms, and make sure that person seeks help or stops working. And three, the reliance on annual tuberculosis screenings for health-care employees to flag a brewing TB outbreak.

OSHA: TB Standard? What TB Standard?

American Federation of State, County and Municipal Employees President Gerald W. McEntee today petitioned Labor Secretary Elaine Chao to immediately issue its long overdue tuberculosis (TB) standard to protect American workers against exposure to TB, a standard that will also protect workers against Severe Acute Respiratory Syndrome (SARS). AFSCME was among the unions to originally petition the agency for a TB standard almost 10 years ago.

OSHA originally proposed a TB standard in 1997 and was close to issuing the standard when the Bush Administration came in and immediately shoved it to the back burner. OSHA even has a Compliance Directive enabling the agency to enforce violations of best practices for TB control. The standard was strongly opposed by such organizations as the American Hospital Assocation.Thirteen people have died of SARS in Canada and there have been 193 suspected cases in the U.S., but no deaths.

In what might be considered an understatement, James August, director of occupational safety and health for AFSCME warned that

"There is great anxiety among health-care workers that it could happen here because of international travel. And there is no reason to think it couldn't, given what happened in Toronto."

AFSCME was one of several unions to originally petition OSHA for a TB standard in 1995.

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 embarassed that it had deepsixed the standard when it's clear now that it was needed?

Actually, it's clear that a TB standard was already needed. Athough a serious outbreak several years ago was controlled, TB is still a serious problem in the United States. Drug resistant strains are especially deadly. And, as OSHA documents, in its Web Page, "TB is the leading cause of death due to an infectious agent in the world," which means it's a major problem among immigrants in the U.S.and anyone who is exposed to them.

AFSCME's petition referenced a National Academy of Sciences/Institute of Medicine (IOM) 2001 Report 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.

On the other hand, OSHA has designed an attractive SARS logo and the agency, which has basically gone out of the regulations business, has included its usual legal disclaimer on the SARS web page, assuring employers that while they can be cited under the General Duty Clause for not providing a safe workplace, the the information on its web site is not "itself is not a new standard or regulation, and it creates no new or independent legal obligations." Wouldn't actually want to cite employers for not protecting their employees.

According to a Reuters article, "Officials at OSHA declined comment." Must be busy with homeland security, and voluntary guidelines and, uh, stuff.