During a one-year period, the researchers identified seven HCWs in a New York institution with reactivated TB, who were being treated by their private physicians, said Sheldon Landesman, MD, at the 36th Annual Meeting of the Infectious Diseases Society of America.
All but one of the patients were foreign-born, and the American-born patient had recently visited India. All the foreign patients were born in TB-endemic areas, and had visited these areas within one year prior to the diagnosis. Five of seven had pulmonary disease and three had extrapulmonary disease, according to Landesman of State University of New York Health Sciences Center in Brooklyn, N.Y.
In each case, the physician, the laboratory and the HCW failed to report the condition to the department of health, employee health service or the infection control department of the facility, Landesman said.
"The identification and reporting of an active case of TB in a HCW may be unknown to their health care facility because the primary physician doesn't report it to the health care facility, the patients don't tell the truth because they don't want anyone to know within their health care facility and health departments now, with the exception of New York City, do not, as a matter of policy, report these cases back to the health care facility [employing] the person who has the case," explained Landesman.
The cases were identified by a retrospective examination of pathology and lab-based surveillance of culture results that were sent by physicians who were treating the patients. Laboratory tests determined that all the cases were reactivation of TB and not nosocomially acquired disease, Landesman added.
Seven of seven were PPD positive. Six of seven had received BCG (bacille Calmette-Guérin) vaccine. "Our concerns, based upon this cluster of cases, were ones that, far and wide, health care workers may believe that positive PPD in the presence of acquired BCG is not indicative of TB infection," Landesman said. "Many of the physicians, whom they go to see for care, come from the same country and have the same belief."
This may lead to a decreased willingness to take isoniazid (INH) therapy. In addition, the physician may not offer rifampin to a foreign-born person with a positive PPD; four patients either refused treatment or were not offered treatment, Landesman said.
The PPD test also affected contact-tracing efforts. "Approximately 75% of the HCW contacts in the hospital were previously PPD positive and many were also foreign-born, and therefore, contact tracing yielded little additional information in the hospital about transmission in hospital personnel," said Landesman. There was one PPD conversion among the residents and three among family members of these patients.
Landesman made several recommendations to improve reporting:
For your information:
- Landesman S, Jendresky L, Stricof R, et al. Occurrence of tuberculosis (TB) among health care workers (HCWs): Is TB hiding in your facility? Abstract #19. Presented at the 36th Annual Meeting of the Infectious Diseases Society of America. Nov. 12-15. Denver.