in the rate of multidrug-resistant disease (largely due to incomplete treatment), and expanded immigration from areas 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 neglect in the late 1980s and early 1990s contributed to workplace outbreaks of tuberculosis. Surveys, investigations of outbreaks, and facility inspections all point to institutionalized lapses in tuberculosis control including inattention to signs and symptoms of infectious tuberculosis, delays in initiating appropriate evaluations and treatments, and improper ventilation of isolation rooms and areas. Outbreaks were, however, concentrated in a relatively small number of states that account for a large proportion of people with HIV infection, immigrants from high-prevalence countries, and cases of multidrug-resistant disease.

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 and reduce the potential for new ones. For example, public health efforts to ensure completed treatment of active tuberculosis can be credited with reducing the number and proportion of people appearing in hospitals and other workplaces with highly lethal, multidrug-resistant disease. This has reduced the risk to workers in these settings. At the same time, the implementation in hospitals of better tuberculosis control measures as recommended by CDC has almost certainly reduced the rates of transmission of drug-sensitive and multidrug-resistant tuberculosis not only within hospitals but also in the broader community into which patients are discharged.

The challenge now is to understand and adapt to the decreasing incidence of tuberculosis without re-creating the conditions that will make institutions and workers vulnerable to new and possibly more deadly outbreaks of the disease. Maintaining expertise and vigilance will not be easy assuming that tuberculosis case rates continue to decrease.

Ending Neglect set out a strategy for maintaining long-term vigilance and moving toward the elimination of tuberculosis in the United States. (The report’s recommendations are listed in Appendix G.) This strategy stresses (1) better methods for identifying people with recently acquired tuberculosis infection, (2) stronger efforts to effectively treat those who could benefit from treatment of infection, (3) research to develop effective vaccines, (4) more active product development initiatives focused on diagnostic and treatment technologies, and (5) research to tackle the problem of patient and provider failure to follow treatment recommendations.

Many of the recommendations from the earlier report would, if implemented, benefit workplace- as well as community-based tuberculosis control programs. One recommendation calls for research to de-

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