In April 1994, one of the most important laws protecting emergency response employees (EREs) who were exposed to communicable diseases went into effect. The Ryan White Comprehensive AIDS Resources Emergency Act, Public Law 101-381, required inclusion of all emergency response employees—firefighters, emergency medical technicians, paramedics, law enforcement officers and volunteers—in the post-exposure medical notification process in the event of an exposure to a bloodborne or airborne transmissible disease. This law was necessary because medical facilities often only focused on their employees' post-exposure and not on emergency response personnel's. After we had this dual standard of care for many years, this law essentially forced medical facilities to have source patients tested if an exposure occurred in the field and enabled EREs to receive source patient test results in a timely fashion.
The Ryan White law was a comprehensive HIV funding bill that required reauthorization every five years. There was no problem until the last reauthorization in late December 2006, when the emergency response provisions were deleted from the law. These provisions have been of great assistance in getting EREs important information when exposures occur and have been a great help when medical facilities were not cooperative in testing or revealing source patient results. We need to get it back, but it will take some time.
Why do we need this law? Because OSHA's bloodborne pathogen regulation does not give us the coverage the Ryan White notification law encompassed. Let's look at what has been lost and why OSHA's regulation does not meet our needs:
- The Ryan White notification law specifically included volunteers. OSHA does not cover volunteers unless a specific state has granted them coverage, which leaves out a large number of persons on a nationwide basis.
- State and municipal employees are not covered by OSHA unless states have their own OSHA plans and inspectors. Without a state plan, there is no coverage for EREs, unless a separate law has been passed providing such coverage.
- The Ryan White law stated that each employer of EREs must have a designated officer to act on their behalf to ensure source patient testing and proper medical follow-up and testing. This helped ensure proper care for exposed employees and in turn lowered liability risks for the employer. OSHA only requires the employer "to ensure proper care and counseling" post-exposure.
- Under the Ryan White law, the designated officer makes the first determination of whether an exposure occurred. Having a designated officer trained to do this saves the ED time and the employer money. Simply sending an ERE to the ED without an initial screening generates two costs: one to sign in and one to be seen by a physician. If there was not an exposure, the department may have generated a cost of $1,000 or more. Check the fees at your medical facilities.
- If an exposure did occur, there is a step-by-step process in the Ryan White law that clearly lists the responsibilities of the employer and the medical facility. The OSHA regulation does not give a step-by-step process, but simply states that compliance is "performance-based." You have to figure out the process and get the medical facilities to cooperate. Even with the law there have been problems across the country. Some facilities say they are not responsible for testing source patients for ERE exposures because they are not their employees.
- The Ryan White law states that medical facilities must get source patient test results back to the designated officer as soon as possible, but no longer than 48 hours. OSHA does not give a timeframe, but refers to the Centers for Disease Control & Prevention (CDC) guidelines. Many facilities are either not familiar with timeframes or just ignore them.
- If a designated officer determines that an exposure occurred and the medical facility disagrees, the Ryan White notification law contains an administrative process to assist the designated officer. The public health officer or someone at the CDC/NIOSH is assigned to intervene. This is not addressed in the OSHA regulation.
- With regard to a patient death and exposure to that patient, the Ryan White notification law states clearly that the person who determines cause of death is responsible for obtaining testing on the source patient. This is not addressed in the OSHA regulation.
- The Ryan White notification law lists coverage for more diseases than OSHA. It covers HIV, HBV, TB, meningitis, hemorrhagic fevers, plague and rabies, but does not list hepatitis C, which is covered under OSHA regulation.
- The Ryan White notification law states that medical facilities have a responsibility to notify the designated officer for the EREs who transported a patient suspected for or diagnosed with an airborne transmissible disease. Again, this must be within the ASAP timeframe and no longer than 48 hours.