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Is TB hiding in your health facility?

Medical facilities may not be told if health care workers have a reactivation of tuberculosis.

[Confidentiality issues]

[Your turn]

January 1999

DENVER - Employers may not know when health care workers (HCWs) have active cases of tuberculosis (TB), if a new study presented here is any indication of TB surveillance in the United States.

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.

Confidentiality issues

One reason physicians do not report the cases is a concern about confidentiality, which Landesman called a legitimate concern. "They feel their primary loyalty and responsibility is to the patient," he said. Also, physicians often think the laboratories will report the cases, and the laboratories think the physicians will report them.

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:

• Policies need to address the issues of private physician reporting. They must deal with issues, such as patient confidentiality and job security. Landesman said these two issues are "in conflict" with public health.
• Policies must look at the role of the PPD test in foreign-born patients. It can no longer be assumed that a positive PPD is the result of BCG, instead of an indication of reactivation of disease. "It is clear that we have moved out of the era where there are a lot of nosocomial tuberculosis because of HIV cases and have now moved back into a more traditional area where much of the cases of TB in health care workers actually represents reactivation disease," Landesman explained.
• ISONIAZID (INH) therapy should be strongly encouraged in health care workers from foreign countries with positive PPDs.
• Finally, health departments should inform health facilities when a worker at that facility has been identified with tuberculosis.

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.

Your turn

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Copyright 2000, SLACK Incorporated. Revised 15 September 2000.