exposure to tuberculosis has a close connection to the risk of tuberculosis in the surrounding community. Those responsible for occupational health programs cooperate with those responsible for public health programs to track and prevent the transmission of tuberculosis.

The committee draws a parallel between the circumstances facing workplace tuberculosis control programs and the circumstances described in the recent IOM report Ending Neglect: The Elimination of Tuberculosis in the United States (IOM, [2000]). That report attributed the resurgence in tuberculosis in the mid-1980s to the complacency that followed the introduction and spread of effective treatment beginning around 1950. Complacency led to neglect of basic public health measures including surveillance, contact tracing, outbreak investigations, and case management services to ensure that individuals completed treatments for latent infection and active disease. This neglect helped set the stage for the resurgence of tuberculosis when new circumstances emerged—including the HIV/AIDS epidemic, the increase in multidrug-resistant disease (largely due to incomplete treatment), and expanded immigration from regions of the world with high rates of tuberculosis.

For health care facilities, prisons, and other organizations that serve people at high risk of tuberculosis, a similar pattern of workplace complacency in the late 1980s and early 1990s—combined with an increasing incidence of tuberculosis in the community—contributed to workplace outbreaks of tuberculosis. Surveys, investigations of outbreaks, and facility inspections all pointed to institutional lapses in tuberculosis control measures including inattention to the signs and symptoms of infectious tuberculosis, delays in the initiation of appropriate evaluation and treatment, and improper ventilation of isolation rooms.

Just as community neglect interacted with workplace neglect to set the stage for workplace outbreaks of tuberculosis, it now appears that community control measures have interacted with workplace control measures to help end outbreaks of tuberculosis and reduce the potential for new ones. For example, increased government funding and public health efforts to ensure that individuals complete their treatments for active tuberculosis can be credited with reducing the number and proportion of infectious people—including those with multidrug-resistant disease—who appear in hospitals and other workplaces. At the same time, the implementation of tuberculosis control measures as recommended by CDC has almost certainly reduced the rate of transmission of drug-sensitive and multidrug-resistant tuberculosis in hospitals and in the broader community into which patients are discharged.

The challenge now is for policymakers, managers, and health professionals to understand and adapt to the decreasing incidence of tuberculosis without re-creating the conditions that would make institutions and workers vulnerable to new and possibly more deadly outbreaks of the



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