The rule proposed by OSHA would cover individuals providing services not only in hospitals but also in other situations including nursing homes, correctional facilities, immigration detainment facilities, law enforcement facilities, hospices, substance abuse treatment centers, homeless shelters, medical examiners’ offices, home heath care providers, emergency medical services personnel, research and clinical laboratories culturing tubercle bacilli and processing infectious specimens, ventilation system workers serving buildings housing tuberculous patients, social service workers, personnel service agencies providing workers to covered facilities, and attorneys visiting known or suspected infectious tuberculous patients (45). While it is logical to believe that contact of uninfected persons with infectious tuberculosis patients may occur in these situations, published data that support this hypothesis are lacking in many and sparse in others of these cases. Much of what has been reported is in the form of descriptions of outbreaks for which no denominator exists, so that the risk cannot be quantified.
In 1995, about 1.5 million Americans, 89 percent of them age 65 or older, about 5 percent of the elderly population, resided in nursing homes, and they contributed 7.7 percent of the tuberculosis cases nationally in individuals older than 64 years (46, 47, 48). The age-specific case rate for these persons is 1.8 times that for older persons not in nursing homes.
Stead reported an outbreak of tuberculosis in an Arkansas nursing home in 1978, with the index case being an elderly man thought to have bronchogenic carcinoma whose disease had not been adequately investigated (49). He was a gregarious individual who had many contacts throughout the home. Among 138 previously tuberculin-negative employees, 21 (15 percent) converted their skin tests and one developed active tuberculosis. In 1980 an outbreak of tuberculosis occurred in a Washington State nursing home after an elderly long-time resident was found to have sputum smear-positive tuberculosis (50). Upon investigation, 11 other cases of active tuberculosis were identified in the same facility. A skin testing survey found that 38 of 87 employees (44 percent) had newly positive tuberculin reactions. The air in this facility moved from patient rooms through dining and activity areas into two exhaust vents in the corridor. In both of these outbreaks, the diagnosis of the index case was not suspected for a substantial period of time.
In 1987 Price and Rutala published the results of a questionnaire survey of 12 long-term-care facilities in North Carolina; 101 skin test conversions occurred among 9,545 (1.1 percent) employees during the years