are likely to have poor access to health care and, thus, to experience serious delays in diagnosis and treatment or to go untreated altogether. Even if all cases of tuberculosis among health care workers were due to occupational acquisition, which is clearly not the case, OSHA’s estimates translate into an unrealistic 20 to 25 percent rate of tuberculosis-related mortality based on the number of cases of disease reported by CDC for health care and correctional workers in recent years.

For people with drug-sensitive disease who are diagnosed early and treated fully, the risk of death is very low (Cohn et al., 1990; Combs et al., 1990; Appendix C). Those who have both suppressed immune systems and multidrug-resistant disease, however, run a very high risk of death (Garrett et al., 1999, Appendix C). Fortunately, levels of multidrug-resistant disease are low in the United States and have been declining in recent years.

Unlike unemployed individuals, many workers covered by the proposed OSHA rule tend to have good access to health care and to spend their working day among health care professionals. In general, they should be more likely to be diagnosed relatively early and to be offered prompt, appropriate treatment. The financial protections for workers provided for in the 1997 proposed rule also should encourage workers to seek evaluation and treatment if they suspect they have contracted tuberculosis.

THE WORKPLACE AND THE COMMUNITY

Unlike typical occupational health problems such as those involving hazardous chemicals or dust exposures, the occupational risk of tuberculosis has a close connection to the risk of tuberculosis in the surrounding community. A theme throughout this report has been the interconnection between community risk and workplace risk and the challenge of fitting workplace tuberculosis control measures to these risks and to changes in risks over time.

The committee draws a parallel between the circumstances facing occupational health programs and the circumstances described in the recent report Ending Neglect: The Elimination of Tuberculosis in the United States (IOM, 2000). That report attributed the resurgence in tuberculosis in the 1980s to complacency resulting from the striking reduction in disease resulting from effective treatments introduced after World War II. Complacency led to disinterest in the goal of tuberculosis elimination and to the dismantling of tuberculosis control programs. Basic public health measures were neglected, including surveillance activities, contact tracing, outbreak investigations, and case management services to ensure completed treatment of latent infection and active disease. This helped set the stage for the resurgence of tuberculosis in the 1980s when new circumstances emerged—including the HIV and AIDS epidemic, the increase



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