in Chapter 7, in the absence of the final standard, the committee focused on the conditions that a standard would need to meet to be effective.

The rest of this chapter briefly reviews responses to resurgent tuberculosis and proposed strategies for the elimination of tuberculosis in the United States and worldwide. Chapter 2 provides a basic review of tuberculosis transmission, infection, and disease. Chapter 3 discusses the proposed OSHA rule in the larger context of regulatory and other strategies used to protect worker health and safety. It also examines the statutory, judicial, and administrative frameworks within which the rule was developed. Chapter 4 summarizes the 1994 CDC guidelines and describes how the 1997 proposed OSHA rule differs from the guidelines. Chapter 5, 6, and 7 are organized around the three questions posed to the committee: the extent of occupational exposure to tuberculosis, the effects of the CDC guidelines, and the likely effects of an OSHA rule, respectively.

Appendix A describes the committee’s activities in more detail. Appendix B discusses the strengths and limitations of the tuberculin skin test, Appendix C reviews the literature on the occupational risk of tuberculosis, and Appendix D reviews the literature on the effects of workplace tuberculosis control measures. Appendix E discusses OSHA from a legal perspective. Appendix F reviews issues related to the use of personal respiratory protection devices and programs in health care and other settings. Appendix G lists the recommendations of another recent IOM report on strategies for the elimination of tuberculosis in the United States, and Appendix H includes brief biographies for members of the committee.

RESPONSES TO RESURGENT TUBERCULOSIS

Responses to Tuberculosis in the Community

The increase in tuberculosis case rates in the mid-1980s and early 1990s prompted public health authorities to revive and adapt traditional strategies to prevent and control tuberculosis in the community. Specific federal funding for tuberculosis control programs, which had virtually disappeared in the 1970s, resumed in the 1980s and increased substantially in the 1990s, as shown in Figure 1-2 (IOM, 2000). States and some cities and counties began to rebuild programs that had been neglected or dismantled in the 1970s and early 1980s.

A particular focus of federal, state, and community efforts was drug-resistant disease, particularly that related to inappropriate or incomplete treatment. One measure, directly observed therapy, targeted the failure of many with active tuberculosis to complete their full, several-month treatment regimen (Addington, 1979; Chaulk et al., 1995; ATS/CDC, 2000a). Physician failure to prescribe the appropriate drugs at the appropriate level and frequency for the appropriate period of time is another problem (Rao



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