Guidelines for prevention of occupationally-acquired tuberculosis developed by the CDC in the 1990s onwards established the primary prevention triad of administrative, environmental and personal protective practices, augmented by secondary prevention measures such as screening for and treatment of latent tuberculosis infection and active disease in health care workers. More recently, a refocusing on the administrative level as ‘Find (patient) cases Actively, Separate temporarily and Treat effectively’ (FAST) has been advocated. The difficulty of applying all of these measures in low resource high tuberculosis burden settings, where most cases of occupational tuberculosis occur, was recognised by the WHO in the late 1990s. WHO modified its guidelines to apply to settings characterised by undiagnosed tuberculosis in all parts of the health system, HIV-TB co-occurrence, limitations on staff and other resources for triage, isolation, environmental controls and respirators, delays in diagnosis and in treatment of patients and shortage of drug sensitivity testing. Secondary prevention is similarly limited by shortage of skills, particularly in occupational health, and constrained by staff fears regarding lack of confidentiality and job security. Competition for management attention and resources, with attendant fragmentation of effort, add to the problem. Health care workers activists have recently called for advocacy pressure on governments and health authorities to take seriously the need to prevent transmission of tuberculosis in health care facilities, particularly in the face of rising drug resistant tuberculosis and co-occurrent HIV. This includes an occupational health approach capable of encompassing the whole spectrum of prevention. It would give weight to primary prevention appropriate to low resource settings, but also include surveillance of occupational tuberculosis, co-management of HIV and TB, protection of students, provision of effective treatment, strengthening of worker rights in the form of income, leave and job protection, stigma reduction while promoting self-disclosure, and compensation for those permanently affected.