July 23, 2004

Ms. Janice Zalen
American Health Care Association
1201 L St., NW
Washington, DC 20005-4014

Dear Ms. Zalen:

Thank you for your March 29, 2004 letter to the Occupational Safety and Health Administration (OSHA), Directorate of Enforcement Programs, concerning the applicability of the respirator standard to long-term healthcare facilities. This letter constitutes OSHA's interpretation only of the requirements discussed and may not be applicable to any questions or situations not delineated within your original correspondence.

In your letter you ask if a long-term care facility that does not accept people with tuberculosis (TB) and immediately transfers a person who shows signs of tuberculosis to other facilities would fall under the general industry respiratory standard, 29 CFR 1910.134. Briefly, if any employees in a facility are required to wear a respirator for any reason, then their use would fall under the general industry respiratory protection standard.

As stated in the CDC's "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, 1994," "Personal respiratory protection should be used by: a) persons entering rooms in which patients with known or suspected infectious TB are being isolated; b) persons present during cough-inducing or aerosol-generating procedures performed on such patients; and c) persons in other settings where administrative and engineering controls are not likely to protect them from inhaling infectious airborne droplet nuclei. These other settings include transporting patients who may have infectious TB in emergency transport vehicles and providing urgent surgical or dental care to patients who may have infectious TB before a determination has been made that the patient is noninfectious."

Thus, the need for a respiratory protection program for tuberculosis will vary with the facility. TB infection control measures for each health-care facility must be based on a careful assessment of the risk for transmission of M. tuberculosis in that particular setting. Appropriate infection-control interventions can then be developed on the basis of actual risk.

The CDC guidelines divided risk into a number of categories. A "minimal-risk" facility does not admit TB patients to inpatient or outpatient areas and is not located in a community with TB (i.e., counties or communities in which TB cases have not been reported during the previous year). Thus, there should be essentially no risk for exposure to TB patients in the facility. In the example you provided us, where a long term care facility accepts only patients who have already been evaluated by the referring physician and have been shown to have a negative TB status, there also appears to be a minimal risk. If the risk assessment determines that there is no hazard, employees would have no requirement to wear a respirator and there would be no need to create a respiratory protection program.

A "very low-risk" facility is one in which a) patients with active TB are not admitted to inpatient areas but may receive initial assessment and diagnostic evaluation and b) patients who may have active TB and need inpatient care are promptly referred to a collaborating facility. In such facilities, the outpatient areas in which exposure to patients with active TB could occur should be assessed and assigned to the appropriate low-, intermediate-, or high-risk category. Categorical assignment will depend on the number of TB patients examined in the area during the preceding year and whether there is evidence of nosocomial transmission of M. tuberculosis in the area. If TB cases have been reported in the community, but no patients with active TB have been examined in the outpatient area during the preceding year, the area can be designated as very low-risk (e.g., many medical offices). The referring and receiving facilities should establish a referral agreement to prevent inappropriate management and potential loss to follow-up of patients suspected of having TB during evaluation in the triage system of a very low-risk facility.

Because very low-risk facilities do not admit patients who may have active TB to inpatient areas, health care workers (HCWs) in such facilities would not be required to wear a respirator. However, those who are involved in the initial assessment and diagnostic evaluation of patients or transport of suspect patients to other facilities could be exposed potentially to a patient who has active TB. Some of these HCWs may need to be included in a respiratory protection program.

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. 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 OSHA's website at http://www.osha.gov. If you have any further questions, please feel free to contact the Office of Office of Health Enforcement at (202) 693-2190.

Sincerely,


Richard E. Fairfax, Director
Directorate of Enforcement Programs