and visitors as well as employees. Similarly, CDC’s discussion of tuberculosis control measures is generally more detailed, clinically oriented, and educational than the discussion of such measures in the proposed OSHA rule. Consistent with OSHA’s regulatory responsibilities, the proposed rule is often more specific and directive than the guidelines.

Both the CDC guidelines and the proposed OSHA rule were published during a period of change, and as discussed in Chapters 5, 6, and 7, circumstances continue to change. This chapter provides a descriptive overview and comparison of the guidelines as issued by CDC in 1994 and the rule as proposed by OSHA in 1997. Chapter 6 presents the committee’s assessment of the impact of the CDC guidelines, and Chapter 7 examines the likely impact of an OSHA standard. Complicating this latter assessment was the lack of a final published standard.


CDC has published guidelines and recommendations for controlling tuberculosis in health care facilities (CDC, 1990b, 1994b), correctional facilities (CDC, 1996b), and facilities serving homeless people (CDC, 1992a). It has also developed guidelines focusing on special populations including migrant workers (CDC, 1992b), at-risk minority groups (CDC, 1992c), foreign-born persons (CDC, 1998b), and those with human immunodeficiency virus (HIV) infection (most recently, CDC, 1998a, 2000c).1

CDC’s 1994 guidelines for health care facilities, which replaced those issued in 1990, served as the foundation for the rule proposed by OSHA in 1997. In the fall of 2000, CDC began a reexamination of the guidelines, in particular, the recommendations on tuberculin skin testing. No new recommendations are expected before 2002.

The 1994 CDC guidelines present a three-level hierarchy of measures to prevent transmission of tuberculosis in health care facilities. As explained below, the hierarchy consists of (1) administrative controls, (2) engineering controls, and (3) personal respiratory protection.2


Other organizations have also issued guidelines and recommendations on preventing the transmission of tuberculosis. The American College of Chest Physicians (ACCP) and the American Thoracic Society (ATS) issued a joint statement on institutional measures to control tuberculosis in 1995 (ACCP/ATS, 1995). The next year the ATS (1996) issued a statement on respiratory protections. (For a comparison of these and other guidelines, see Nardell, 1997.) Recent joint statements from ATS and CDC include recommendations on skin testing and treatment for latent tuberculosis infection (ATS/CDC, 2000a,b).


In occupational health, the traditional hierarchy of strategies to control workplace hazards emphasizes engineering controls first (McDiarmid et al., 1996). For example, one text states that “Engineering controls are the most desirable and reliable means for reducing workplace exposures [to toxicants]” (Cohen, 1992, p. 1401).

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