Tuberculosis (TB) morbidity and mortality have increased substantially since the mid-1980s in areas with a high prevalence of medically underserved populations, human immunodeficiency virus, foreign-born persons, residents of long-term care facilities and crowded correctional institutions, and alcoholics and intravenous-drug abusers. The occupational risk has likewise increased for those exposed to these high-risk people in the course of their work. The magnitude of the occupational hazard is present unclear, although implications are disturbing. We used available data bases containing occupational exposure information, and telephone surveys, in an attempt to elucidate the magnitude of risk of occupationally acquired TB. We obtained up-to-date employee conversion rates at high-risk institutions, identified changing rates of TB infection and disease over time, documented high conversion rates following accidental exposures, and revealed a relative lack of reported TB disease and deaths. Numerous barriers to worker protection against TB are identified and recommendations are made to reduce the risk of occupationally acquired tuberculosis.