"Phthisiophobia": the difficult recognition of transmission of tuberculosis to health care workers.

BACKGROUND: Even if the contagious nature of tuberculosis was universally accepted during the nineteenth century, its transmission to health care workers (HCWs) was initially denied by the scientific community. Working among TB patients was not considered dangerous for healthy adults, so the potential risks for HCWs were branded as unwarranted "phthisiophobia" (fear of contracting tuberculosis). OBJECTIVES: This study aims at analyzing the problem of tuberculosis transmission among health care workers from an historical perspective, particularly highlighting the contribution made by the Italian Occupational Medicine community. METHODS: Scientific literature and historical sources on different theories regarding tuberculosis transmission were investigated, specially focusing on the period at the turn of the 19th and 20th centuries. RESULTS: At the beginning of the twentieth century, Luigi Devoto (1864-1936), an Italian pioneer in the field of Occupational Medicine, was one of the first scientists to conduct research on the transmission of tuberculosis among nurses. Since the 1920s several studies, conducted mainly on medical and nursing students, confirmed the risk for HCWs. However an international consensus on this issue was only achieved during the 1950s, when the institution of mandatory chest radiographs on admission for all patients significantly decreased the cases of tuberculosis among HCWs. CONCLUSIONS: Devoto was one of the first scholars who postulated the transmission of tuberculosis to HCWs. He also theorized that hospital personnel with active disease could also be a source of contagion to patients. Nowadays, "third party risk" and latent tuberculosis infection pose a new challenge for occupational physicians in hospitals.

Sickening nurses: fever nursing, nurses' illness, and the anatomy of blame, New Zealand 1903-1923.

In the early twentieth century, patients with infectious fevers represented a danger to the health of others including their nurses. This research describes the training New Zealand nurses received in fever nursing during the period 1903-1923, and considers how they applied hospital cross-infection principles in emergency tent fever camps in remote rural areas. It examines the reaction of nurses, hospital boards, and physicians to nurses who succumbed with their patients' fevers. It therefore reveals attitudes to nurses, prevailing ideas about responsibility for nurses' health, and elements in the emerging professional culture of nursing. Although some measures protected them against epidemic fevers, nurses were held responsible for their own health. A complex anatomy of blame is evident against those who sickened; the nature of the blame shifted, depending on the observer, disease, and practice setting. Physicians blamed nurses, especially when they sickened with typhoid fever. The country's chief nurse and other nurses blamed those who jeopardized their health through ill-spent leisure time. Sick nurses could be absolved from blame for the lax discipline evident through their failure to observe cross-infection principles if their practice setting was the fever camp. Willingness to work in difficult circumstances showed they embodied the ideal of sacrifice that, like discipline, was part of the emerging nursing culture.

When pestilence prevails...physician responsibilities in epidemics.

The threat of bioterrorism, the emergence of the SARS epidemic, and a recent focus on professionalism among physicians, present a timely opportunity for a review of, and renewed commitment to, physician obligations to care for patients during epidemics. The professional obligation to care for contagious patients is part of a larger "duty to treat," which historically became accepted when 1) a risk of nosocomial infection was perceived, 2) an organized professional body existed to promote the duty, and 3) the public came to rely on the duty. Physicians' responses to epidemics from the Hippocratic era to the present suggests an evolving acceptance of the professional duty to treat contagious patients, reaching a long-held peak between 1847 and the 1950's. There has been some professional retrenchment against this duty to treat in the last 40 years but, we argue, conditions favoring acceptance of the duty are met today. A renewed embrace of physicians' duty to treat patients during epidemics, despite conditions of personal risk, might strengthen medicine's relationship with society, improve society's capacity to prepare for threats such as bioterrorism and new epidemics, and contribute to the development of a more robust and meaningful medical professionalism.

Tuberculin skin testing and the health care worker: lessons of the Prophit Survey.

SETTING: Concern about occupationally-acquired tuberculosis continues to grow, even as control of tuberculosis in the USA has improved. Many health care workers have developed occupationally-acquired tuberculosis in recently described outbreaks and several have died. Regulatory agencies are struggling to develop a rational policy that promises both worker safety as well as cost-effectiveness. Future infection control efforts will be evaluated by results of tuberculin skin tests of employees. However, unlike many modern diagnostic tests, the tuberculin skin test is poorly understood, may be unreliable, and requires individual physician interpretation. DESIGN: Review of the British Prophit Survey, conducted from 1933-1944, which involved tuberculin testing of 10,000 young adults, with the goal of defining 'the relationship between tuberculin sensitivity and tuberculous immunity'. RESULTS: Four findings are particularly pertinent to the current debate: 1. job-specific rates of tuberculin conversion and subsequent development of disease; 2. risk of exogenous re-infection among already-tuberculin positive health care workers; 3. rates of tuberculin skin test reversion; and 4. implications of induration size. CONCLUSION: The British Prophit Survey produced a great deal of meaningful information regarding the meaning of a positive tuberculin skin test, a negative test, and a change in tuberculin status. Proper interpretation of this test requires full appreciation of its many idiosyncrasies.

Tuberculosis and the health care worker: a historical perspective.

Many hospital outbreaks of tuberculosis have occurred in recent years in the United States, resulting in tuberculosis infection and disease among health care workers and patients. Several hospital workers have died of nosocomially acquired multidrug-resistant tuberculosis. Assuring the safety of the health care worker with respect to tuberculosis has become an urgent priority. A review of the medical literature of the past 100 years reveals that our current view of tuberculosis care as an occupational hazard emerged only in the 1950s, after a fierce and extensive debate. Many authorities had felt that care of the tuberculous patient conferred a health advantage to the care provider. This paper reviews this debate and considers steps taken decades ago, before our current environmental interventions were available to ensure the safety of the health care worker.

Occupational infection in health care. The century-old lessons from syphilis.

The dangers of occupational infection (where the infectious agent was acquired during the provision or receipt of a medical service) have received renewed interest in the era of the human immunodeficiency virus. The dilemmas raised by this phenomenon, however, are far from novel and were the subject of considerable debate in the medical literature at the turn of the century with regard to syphilis. After recognition of the problem, it took time to manage syphilis effectively through technical innovation, personal prophylaxis, education, and regulation. These efforts led to the development of a strategy remarkably similar to that of the "universal precautions" approach applied to human immunodeficiency virus today.