culosis that characterized public health and workplace programs in the 1980s, and (3) extend additional financial and other protections to workers not provided for by voluntary tuberculosis control guidelines. On the other side is the view that (1) the rate of compliance with the tuberculosis control measures recommended by the Centers for Disease Control and Prevention (CDC) is already high; (2) even with the less than full compliance, the measures implemented have been effective; and (3) an OSHA standard would be inflexible, unnecessarily burdensome, and not easily changed to reflect revisions that might result from CDC’s recently initiated review of its 1994 guidelines for health care facilities.

The next section of this chapter examines the context in which an OSHA standard would be implemented and the conditions that would need to be met for the standard to have positive effects on tuberculosis infection, disease, or mortality. The section also reviews OSHA’s projections of the number of workplace cases of tuberculosis infection, disease, and mortality that would be prevented if the 1997 proposed rule were implemented. The final section of the chapter considers the relationship between workplace and community tuberculosis control programs. As in previous chapters, most of the available information concerns hospitals.


Changing Environment

Any assessment of the potential effects of an OSHA standard must recognize the changes in communities and workplaces since OSHA announced its rule-making process in 1994. Even though only 3 years have passed since the proposed rule was issued in 1997, much of the analysis for the rule was developed earlier and relied on 1994 or older data. The epidemiology of tuberculosis has changed substantially in recent years. In addition, health care and correctional facilities appear to have more fully adopted the kinds of tuberculosis control measures described by CDC and OSHA.

As described earlier in this report, declining tuberculosis case rates have now been confirmed for the United States for 7 straight years. After increasing by 13 percent between 1985 and 1992, tuberculosis cases rates declined by 35 percent between 1993 and 1999. The rates of multidrug-resistant tuberculosis have also decreased significantly in recent years, from 3.5 percent in 1991 to 1.2 percent in 1999. (Resistance to isoniazid dropped from 8.4 in 1993 to 7.2 in 1999.) These improvements can be attributed at least in part to better funding of community tuberculosis control programs, increased attention to AIDS patients and other groups

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