100,000 population in Vermont and Wyoming to more than 10 per 100,000 population in California (10.9), New York (11.0), and Hawaii (15.5) (CDC, 2000b). Some metropolitan statistical areas have even higher rates. For example, in 1999, case rates per 100,000 population were 17.7 for New York City and 18.2 for San Francisco. In 1998, the case rate in central Harlem was 63.7 per 100,000 population, which is similar to rates seen in developing countries such as Brazil (75 per 100,000 population) although it is far lower than the rates in the most severely affected countries, such as Zimbabwe (540 per 100,000) (Dye et al., 1999).

More than 40 percent of the tuberculosis cases reported in the United States in 1999 involved people born in other countries (IOM, 2000; CDC, 2000b). Individuals from Mexico, the Philippines, and Vietnam accounted for nearly half (45 percent) of these cases, with 151 other countries accounting for the remainder.

RISKS TO HEALTH CARE AND OTHER WORKERS

The resurgence of tuberculosis in the mid-1980s and early 1990s also affected health care workers and others employed in settings that served patients, inmates, or clients with tuberculosis. A number of high-profile outbreaks of tuberculosis—including cases of multidrug-resistant disease—were documented in hospitals, nursing homes, prisons, homeless shelters, and other settings (see, e.g., CDC [1994a], Dooley and Tapper [1997], and Garrett et al. [1999]). Most such outbreaks have been linked to lapses in infection control practices, delays in diagnosis and treatment of infectious individuals, and the presence of high-risk populations including people with HIV infection or AIDS and recent immigrants from countries with high rates of tuberculosis.

In 1999, of the 16,223 cases of tuberculosis for which occupational data were reported (92.5 percent of all reported cases), unemployed individuals accounted for nearly 60 percent of reported tuberculosis cases (CDC, 2000b). Such individuals accounted for less than 5 percent of the total workforce (BLS 2000a, 2000b). Health care workers accounted for about 2.6 percent or 422 of the cases in 1999. In 1998, health care workers accounted for about 9 percent of employed persons and 8 percent of tuberculosis cases among employed persons (Amy Curtis, CDC, 2000, personal communication) and about 5 percent of the total workforce. As discussed in Chapter 5, it can be difficult to determine whether tuberculosis in health care and other employed workers is due to workplace or community exposure.

Several health care and correctional workers have died of tuberculosis following documented work-related exposure to the disease (Dooley and Tapper, 1997), but no comprehensive mortality figures are available. Most of these workers as well as patients or inmates who died suffered



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