The conclusions below relate only to the implementation of tuberculosis control measures; the following section considers their effects.

Institutional departures from recommended tuberculosis control policies and procedures were common, if not the norm, in the late 1980s and the early 1990s. In large measure, the neglect that characterized community tuberculosis control programs (IOM, 2000) appears to have been duplicated in hospitals, correctional facilities, and, probably, but with less documentation, other facilities that serve people at increased risk of the disease. Even after public health authorities and newspapers were describing the resurgence of tuberculosis in the latter half of the 1980s, surveys in the early 1990s suggested that hospitals and prisons were neglecting recommended surveillance, isolation, and other measures that had been reinforced in 1990 CDC guidelines. Reports of tuberculosis outbreaks in hospitals also document lapses in infection control measures.

Hospitals and correctional facilities reported increased implementation of tuberculosis control measures by the mid-1990s. By 1996, for hospitals and correctional facilities, responses to national surveys and some other studies were showing much more complete and consistent reported compliance with recommended tuberculosis control measures. The hospitals experiencing outbreaks in the early 1990s clearly had a stimulus to implement control measures earlier. For other institutions, increased implementation likely reflects the impacts of further and more complete reports on workplace outbreaks of tuberculosis, the CDC’s increased effort to educate health care managers and clinicians about tuberculosis and tuberculosis control measures, the pressure for action exerted by unions on both employers and public agencies, and the initiation by OSHA of enforcement procedures and rulemaking processes for occupational tuberculosis. Data do not allow the committee to draw conclusions about trends for other settings.

Implementation appears to be most complete for administrative controls including respiratory isolation policies. For engineering controls, the installation of negative-pressure isolation rooms has increased, but ventilation performance and performance monitoring may still fall short of recommendations. Information about organizational implementation of the various elements of personal respiratory protection programs is limited. Most studies suggest that most employers have been providing some kind of protection (surgical masks or respirators) and that they have changed the devices provided as new options, such as N95 respirators, have been certified.

Written policies have not necessarily been translated into routine practice. High levels of compliance with control measures, as reported in surveys, may not be matched by high compliance on a day-to-day basis. Although on-site reviews that match hospital policies to actual practices are limited,