In addition, during the late 1980s and early 1990s, several U.S. hospitals experienced outbreaks of tuberculosis that affected both patients and employees. Some outbreaks involved a particularly lethal combination of multidrug-resistant disease and people with suppressed immune systems, most often related to HIV infection. Outbreaks also occurred in prisons and other workplaces serving people at increased risk of tuberculosis.

Lack of Preparation

In general, public health departments, health care facilities, prisons, and similar organizations were not prepared to cope with the resurgence of tuberculosis in the mid-1980s. After years of effective treatment and declining case rates, tuberculosis control measures were not a priority in either the community or the workplace. The HIV/AIDS epidemic and its interaction with tuberculosis were not well documented or understood. Similarly, the threat of multidrug-resistant tuberculosis resulting from incomplete treatment of the disease had yet to be clearly appreciated. Workplace outbreaks of tuberculosis were often associated with lapses in infection control measures.

Rebuilding Capacity

The resurgence of tuberculosis in communities and the outbreaks of the disease in workplaces prompted a range of public and private responses. Congress revived federal funding for tuberculosis control programs, which had virtually disappeared in the 1970s. States and some cities and counties also began to rebuild programs that had been neglected or dismantled. These programs focused on groups at increased risk of tuberculosis such as people with HIV infection or AIDS, and they emphasized directly observed therapy for individuals with active tuberculosis. Hospitals, prisons, and perhaps other institutions, especially those affected by outbreaks and those located in high-risk areas, improved their infection control programs.

Guidelines and Regulations

In 1990, CDC issued new guidelines for tuberculosis control measures in health care facilities. In 1993, in response to calls from health care and other workers, OSHA began to enforce some tuberculosis control measures under its general powers to protect worker safety and under other regulations related to airborne hazards. In 1994, the agency began a formal rulemaking process to develop specific regulations on occupational tuberculosis. Also in 1994, CDC issued a major revision of its 1990



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