Recent Updates

2013 Conference in Sacramento

Capital Steps for Occupational and Environmental Health Nursing

The Pre-Conference Day was Thursday Oct 17th Capital Steps in Legislative and Regulatory Affairs

The conference was Friday Oct 18 – Saturday Oct 19th


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Recurrent Nationwide Shortage of Tuberculin Skin Test Antigen Solutions

This is an official


Distributed via the CDC Health Alert Network

September 04, 2013, 13:00 ET (1:00 PM ET)


Recurrent Nationwide Shortage of Tuberculin Skin Test Antigen Solutions: CDC Recommendations for Patient Care and Public Health Practice

Summary: In HAN 345 (, April 2013, CDC reported that TUBERSOL, a product of Sanofi Pasteur Limited, was in shortage nationwide. Although supplies were restored in early June 2013, TUBERSOL is in shortage again until at least the middle of October 2013. At the current time, the 5 tuberculin units/0.1 mL, 5 mL (50 tests), multiple dose vials are unavailable. The 5 tuberculin units/0.1 mL, 1 mL (10 tests), multiple dose vials are in limited supply. This notice updates and supersedes the advice in HAN 345 and advises public health officials, clinicians, and workers in occupational health and infection control about how to adapt testing protocols to the recurrent shortage.

TUBERSOL is one of two purified-protein derivative (PPD) tuberculin antigen solutions that are licensed by the United States Food and Drug Administration (FDA). JHP Pharmaceuticals, LLC, manufactures APLISOL, the other PPD tuberculin product that

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is licensed by FDA. JHP Pharmaceuticals, LLC, has notified FDA that APLISOL is on allocation, meaning that historical customers have precedence for buying the product, and APLISOL is available in restricted quantity. Regional shortages of APLISOL have been reported since healthcare providers switched from TUBERSOL to APLISOL.


Two kinds of immunological methods are used for detecting Mycobacterium tuberculosis infection: tuberculin skin tests

(TSTs) and interferon-γ release assay (IGRA) blood tests. The indications for using these tests are the same for both methods, although one or the other method is preferred for certain populations (1). When setting testing priorities because of the current shortage of antigen, these preferences may be considered as factors when one of the methods is unavailable. Together, these tests are the only means for detecting latent M. tuberculosis infection, and they contribute to diagnosing tuberculosis (TB) disease. When findings such as chest radiography and mycobacterial cultures are sufficient for confirming or excluding the TB diagnosis, the results from a TST or an IGRA blood test might be unnecessary (2). Nevertheless, most TB cases in the United States are diagnosed with a set of findings including results from one of these tests. When TB disease is strongly suspected, specific treatment should be started regardless of results from TST or an IGRA blood test (1,3).

In cross-sectional controlled studies, TUBERSOL and APLISOL give similar results for most patients. The agreement between results from a TST and an IGRA blood test or between results from the two commercial IGRA blood tests is lower (1).


CDC recommends any of three general approaches for addressing the shortages of tuberculin skin test antigens:

1. Substitute IGRA blood tests for TSTs. The cost associated with using the blood tests can be greater than the cost of TST because the per-unit cost of the IGRA test materials is greater than for those of TST and, unlike TST, IGRAs entail services external to the point of care in some settings. The blood tests require phlebotomy, preparation of blood specimens, and specific laboratory services for analysis; therefore, these tests are not available in all practice settings. Clinicians who use the

IGRA blood tests should be aware that the criteria for test interpretation are different from the criteria for interpreting TSTs (1). IGRAs do not utilize the risk-stratified cut-off measurements that are used for TST. Both IGRA products that

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between positive and negative). TST does not yield indeterminate or borderline results (1).

2. Substitute APLISOL for TUBERSOL for skin testing if APLISOL is available. In studies, the two products give similar results for most patients. The fixed availability of APLISOL has created a relative shortage because of increased demand at sites where TUBERSOL is unavailable, thus limiting the feasibility of this approach.

3. Allocate TSTs to priority usages, such as TB contact investigations, as determined by public health authorities. Priorities can be set in accordance to relative TB risks (4) and local TB epidemiology. A priority strategy might require deferment of testing some persons, and it might require modification of public health rules, regulations, or policies. CDC does not recommend testing persons who are not at risk for TB (4).

Some surveillance programs for TB infection control rely on routine serial TSTs. Switching products or methods might make serial changes in test results difficult to interpret. The apparent conversions of results from negative to positive or reversions from positive to negative could be caused by inherent inter-product or inter-method discordance (1,5). In settings with a low likelihood of TB exposure, the deferment of routine serial testing should be considered in consultation with public health and occupational health authorities.

Updates about the shortages of tuberculin skin test solutions are posted by the FDACenter for Biologics Evaluation and Research at


1. CDC. Updated guidelines for using interferon gamma release assays to detect Mycobacterium tuberculosis infection — United States, 2010. MMWR 2010;59(RR-5).

2. American Thoracic Society. Diagnostic standards and classification of tuberculosis in adults and children. Am J Respir Crit Care Med 2000;161:1376–95.

3. CDC. Treatment of tuberculosis. MMWR 2003;52(RR-11).

4. CDC. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR 2000;49(RR-6).

5. CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR 2005;54(RR-17)

The Centers for Disease Control and Prevention (CDC) protects people’s health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations.


Categories of Health Alert Network messages:

Health Alert Requires immediate action or attention; highest level of importance

Health Advisory May not require immediate action; provides important information for a specific incident or situation

Health Update Unlikely to require immediate action; provides updated information regarding an incident or situation

HAN Info Service Does not require immediate action; provides general public health information

ABOHN is seeking new board members


ABOHN is seeking new board members to represent our credential holders. Representatives are needed from the Mountain-Western areas of the country. We are especially interested in recruiting representatives from the chemical industry and manufacturing areas of practice.

If you are interested in applying

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SB 491 Nurse Practitioners (Hernandez) (Support)
The NP Scope of Practice Bill has passed the Assembly and is now in the Business, Professions, and Consumer Protection Committee. Amendments to the bill are expected soon. CANP is collaborating on the amendments.

UPDATE: The bill was initially voted down by the Assembly Committee for Business, Professions, and Consumer Protection on Tuesday August 6 but was granted reconsideration again yesterday. Two more members voted Aye, thus pushing the bill through to the next hurdle, a hearing by the Assembly Appropriations Committee. Though amended to remove

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full independent practice after 3 years under physician supervision, the bill stiff faces fierce opposition from the CMA.

First Aid:
Mike Horowitz from the DWC last solicited informal comments in March 2013. We emailed Mike regarding the status and our desire for finalization. He emailed back on Jul 19 that hewill be focusing back on First Aid in the near future. We can expect another formal comment period and are ready to respond.

Cal/OSHA Globally Harmonized System (GHS) Update to Hazard Communication
Alert! Employee training on the mechanics of the revised Hazard Communication standard is due by Dec 1, 2013!
See Cal/OSHA regulatory info below.–_health.html

Fed OSHA and Cal/OSHA require employee training

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on GHS, including info on pictograms and new Safety Data Sheet (SDS) format by Dec 1, 2013. This is not widely publicized by Cal/OSHA, so see Fed/OSHA web site for comprehensive information on training requirements.

The wonderful Fed/OSHA Hazard Communication Site:
Cal/OSHA Regulatory:

SB 863 Workers’ Compensation Reform Implementation:
Emergency regulations

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are still in place as rulemaking continues. The DWC held a meeting on July 17 for the new physician fee schedule using Relative Value Resource Based System (RVRBS) that eventually will cap at 120% of Medicare. The big surprise at the hearing was that the DWC realized a math error and RAND posted a revised report on new

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conversion factors. This report had not been released before the hearing so the comments were based on the old report. It is unsure if they will have another hearing.

Anna Reilly: Attended a meeting with Maximus, the DWC’s contracted provider for Independent Medical Review (IMR) and Independent Bill Review (IBR) services. So far the number of reviews for each program is relatively low but slowly ramping up (100 Bill Reviews, 1000 IMRs with 400 in the last month). More activity is expected as the criteria for review are fully implemented.

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IMR decisions are posted on the DWC at the bottom of the IMR link on the DWC website.

See the DWC website for further information on SB 863

Other Issues of Interest
AAOHN is looking at the issue of fracking and deciding whether to make a policy statement or not. Katy participated in the literature search for the Advocacy Committee. This also potentially relates to the proposed federal silica standard as crystalline silica is one of the agents used in fracking.

A long-awaited report from the CDPH to support a lower PEL for Lead should be coming out in Sept or Oct. This could substantially lower the PEL and medical removal requirements for lead. The report is many years in the making and long-anticipated. Cal/OSHA feels the updated research is needed to establish a variance from the Fed/OSHA lead standard. Once the report is out it will need to go through a peer review process. Stay tuned!

Planning for the Active Shooter

Planning for the Active Shooter
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about, but many of us recognize the potential for having an active shooter incident at our workplace. BICEPP brings together experts from the FBI, Los Angeles County Public Health and the private sector to talk about planning and preparing for an active shooter scenario.

This workshop includes:
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World Hepatitis Day

National Viral Hepatits Roundtable

July 28th is World Hepatitis Day, providing a tremendous opportunity to highlight the impact of the global viral hepatitis epidemic and to continue spreading awareness in the United States. With one in twelve people in the world living with chronic hepatitis B or C, and over 15,000 Americans dying each year from viral hepatitis, the need for urgency among our leaders has

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never been greater. We urge everyone to recognize World Hepatitis Day by calling or emailing their elected representatives in Congress and the state and local levels and urging them to take action now to end the viral hepatitis epidemic.We also want to hear what your organizations are doing to recognize World Hepatitis Day.

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Please send us information about events or actions so that we can post on our website and highlight through social media. You can send information to

USPSTF Victory!

On June 24th, 2013, the U.S. Preventive Services Task Force released its final hepatitis C testing recommendations with the welcome news that it recommends testing all born between 1945 and 1965, as well

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USPSTF changed its original draft “C” grade to a “B” for testing Baby Boomers. Thank you to everyone who submitted public comment and helped convince the Task Force to improve its draft grade. We did this together! Read NVHR’s press release about this announcement here.

Affordable Care Act webinar

Our recent webinar on Affordable Care Act implementation provided excellent information about the challenges and opportunities we face and what viral hepatitis advocates can do now to make a difference. Many thanks to AIDS Foundation of Chicago and for hosting the webinar and to our presenters. You can view slides from this webinar here.

Member highlight: American Liver Foundation

The American Liver

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Foundation has developed a new program called “HEP C 123, Diagnosis, Treatment and Support.” The program is designed to provide patients with a “one stop shop” for hepatitis C information and includes a helpline staffed by trained information specialists. For more information go to

Copyright © 2013 NVHR,
All rights reserved.

Community Initiatives

Hazardous Materials Management Course in Austin, TX; August 20-22, 2013


Tuesday August 20, 2013 at 8:00 AM
Thursday August 22, 2013 at 5:00 PM


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HERE for directions.

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This course parallels the curriculum developed by the Alliance of Hazardous Materials Professionals’ Hazardous Materials Management Desk Reference in order to assist

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National Viral Hepatitis Webinar

National Viral Hepatitis Roundtable All Member Webinar
The Affordable Care Act & Viral Hepatitis: Opportunities and Challenges

Thursday, June 27, 2013
3 pm – 4 pm Eastern

Register now!

All are welcome to participate!

Expansion of health care coverage under the Affordable Care Act begins on January 1, 2014. Many states are well underway with developing their programs, while some states haven’t even agreed to expand Medicaid to serve low-income people. This webinar will provide an update on ACA implementation, some key things viral hepatitis advocates need to know to help ensure the ACA provides access to hepatitis B and C testing, care, and treatment services, the role of state-level advocacy, and useful ACA implementation resources.

Martha Saly, Executive Director, National Viral Hepatitis Roundtable

Malinda Ellwood, Health Law and Policy Clinical Fellow, from Center for Health Law

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Heather Lusk, Executive Director, the C.H.O.W. Project and Hep B Free Hawaii
Ryan Clary, Director of Public Policy and Programs, National Viral Hepatitis Roundtable

NVHR thanks AIDS Foundation of Chicago and

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own work in pursuit of greater knowledge and expertise.

Please read about the specific awards and their criteria listed below:


CSAOHN offers assistance to chapters to promote leadership development among its members. Stipends are available to assist with attendance at Conference of Leaders, the Annual State Conference and certain legislative events. Presidents please download the eligibility criteria and application above and submit to the awards committee by August 1st, 2013 . (Note change in submission deadline)

Hepatitis Awareness Month

NVHR NEWSLETTER – Hepatitis Awareness Month
National Viral Hepatits Roundtable
Hepatitis Awareness Month is an important time of the year for viral hepatitis education and advocacy, and this year’s second annual Hepatitis Testing Day, May 19, offers many opportunities to reach the millions of Americans who do not know they have hepatitis B or C. This special NVHR newsletter spotlights Hepatitis Awareness Month and Testing Day activities that NVHR and some of our members are organizing. If you would like to list your organization’s activity or event on our website, please send details to Please also visit the CDC’s Hepatitis Awareness Month’s website for more information about activities taking place across the country.

As always, thank you for all you do each day to fight the viral hepatitis epidemic.


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Hepatitis Testing Event

On May 23, NVHR and our partners, along with the Congressional Hepatitis Caucus, will host a Viral Hepatitis Testing and Awareness Day at the Capitol in Washington, DC. For more information about this and other hepatitis awareness month events go here for more details.

Groups Partner for Testing and Awareness Events in San Francisco, LA, and New York

San Francisco Hep B Free and AsianWeek Foundation are working in partnership with CBS HealthWatch, NVHR, and many community based organizations in San Francisco, Los Angeles, and New York City on a Viral Hepatitis testing and awareness campaign. Hepatitis B and C testing and media events, led by local organizations, will take place in New York on May 14, Los Angeles on May 17, and San Francisco on May 18. Televised CBS HealthWatch spots about Viral Hepatitis began airing on May 8 and are scheduled to run through National Hepatitis Testing Day on May 19th.

Advocates Push For Hepatitis

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C Testing in Medicare

As part of Hepatitis Awareness Month, NVHR sent a letter signed by more than 110 organizations around the country urging HHS Secretary Kathleen Sebelius to ensure Medicare provides hepatitis C testing in the Welcome to Medicare exam and the annual wellness visit.

Berkeley Free Clinic to Provide Hepatitis Testing

On Saturday,

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May 18th, the Berkeley Free Clinic will provide free hepatitis C testing and vaccinations for hepatitis A and B. Visit their website for more information.

Chicago Hepatitis Awareness Event

There will be an Asian Heritage Month Hepatitis Awareness event at Daley Plaza in Chicago on Friday, May 17th from noon to 1 pm. Go here for more information.

Asian Health Coalition Hepatitis B PSA

The Asian Health Coalition has produced a public service announcement highlighting the need for hepatitis B testing and vaccinations in the Asian American community. You can view the PSA here.

CalHEP Legislative Briefing

On Tuesday, May 14th, the California Hepatitis Alliance is hosting a viral hepatitis legislative briefing at the State Capitol in Sacramento to educate lawmakers about the need for increased leadership and funding for hepatitis B and C services. You can view the agenda for this event here.

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