tives evident in later guidelines (Nardell, 1997). The 1994 revision of the guidelines was a specific response to disease outbreaks in health care facilities and the contributing factors identified during investigations of the outbreaks. In 1995, the National Institute for Occupational Safety and Health, which is part of the CDC, certified a new class of respirator for use in preventing transmission of tuberculosis.

One problem faced by CDC in 1990 and then again in 1994 was the lack of rigorous, prospective, controlled studies documenting the effectiveness of individual protective measures in preventing workplace transmission of tuberculosis. Both the lack of research and the expected cost of tuberculosis control measures contributed to the controversy over the revised guidelines for health care facilities that CDC issued in draft form in 1993 and final form in 1994 (Sepkowitz, 1995).

In 1993, the Congressional Office of Technology Assessment observed that none of the measures described in CDC’s 1990 guidelines for health care facilities were thought to have been widely adopted (OTA, 1993, p. 6). Survey data supported these suspicions (see Chapter 6).

Groups representing health care and other workers created the Labor Coalition to Fight TB in the Workplace. In 1992, the coalition petitioned OSHA to issue an “advisory notice” with enforcement guidelines designed to protect workers from occupational exposure to tuberculosis. In 1993, it asked OSHA to issue a permanent standard (Labor Coalition, 1993).3 In addition to citing the 1990 CDC guidelines, the coalition cited enforcement guidelines issued by Region II of the Occupational Safety and Health Administration and by the state of California’s occupational safety and health agency. The Secretary of Labor announced in 1994 that OSHA would initiate a rulemaking process to establish formal standards to prevent workplace transmission of the disease. The U.S. Department of Labor, however, declined to issue the emergency temporary standard sought by labor groups, which had argued that the 1990 CDC guidelines were not being adequately implemented.

In 1993 and 1996, OSHA issued statements that emphasized the statutory obligations of employers to provide a safe workplace, described the applicability of certain existing regulations, and outlined procedures for investigating worker complaints and inspecting workplaces identified by CDC as having a higher incidence of tuberculosis than the general population (OSHA, Fact Sheet No. OSHA 93–43, 1993; OSHA directive CPL 2.106, February 9, 1996). Consistent with those statements, OSHA has cited or fined employers for failure to protect


Unions signing the petition included the Service Employees International Union, the American Federation of State, County, and Municipal Employees, and the American Federation of Teachers.

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