Question 2: What is known about the implementation and effects of the 1994 CDC guidelines for the prevention of tuberculosis in health care facilities?

Conclusions about the implementation and effect of the CDC guidelines must be read within the larger context of the social response to resurgent tuberculosis. The actions recommended in the CDC guidelines are consistent with general standards of good infection control, and the 1994 guidelines were built on a series of earlier government and professional recommendations. In addition, by the mid-1990s, OSHA and some state agencies were also requiring many of the same basic measures.

Implementation

Data from surveys, facility inspections, and other sources indicate that institutional departures from recommended tuberculosis control policies and procedures were common, if not the norm, in the late 1980s and the early 1990s. By the mid-1990s, hospitals, and, less clearly, other health care organizations and correctional facilities began to take tuberculosis control measures more seriously. The adoption of written tuberculosis control policies does not, however, always translate into consistent day-to-day practice.

Implementation is probably most complete for administrative controls including procedures for promptly identifying, isolating, diagnosing, and adequately treating people with active tuberculosis. For engineering controls, available data suggest that the rate of installation of negative-pressure isolation rooms has increased, but not all in-use rooms are assessed on a daily basis to ensure that they remain under negative pressure. Information about personal respiratory protection programs is very limited. It suggests that most hospitals have been providing some kind of protection and have been updating the equipment provided as new options, such as the N95 respirator, have been developed and certified by the National Institute for Occupational Safety and Health.

Effects

Overall, the measures recommended by CDC in 1994 and earlier to prevent the transmission of tuberculosis in health care facilities have contributed to ending hospital outbreaks of tuberculosis and preventing new ones. Studies of outbreaks as well as logic and biologic plausibility support CDC’s stress on administrative controls, particularly the rigorous application of protocols for the prompt identification and isolation of people with signs and symptoms suspicious for infectious tuberculosis. Studies of outbreaks and modeling exercises suggest that engineering controls also make a contribution in limiting the transmission of tubercu-



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