Tuberculosis control in New York City hospitals.

OBJECTIVES: To assess the implementation of tuberculosis (TB) control measures in New York City hospitals in 1992 and determine trends during the subsequent 2 years. METHODS: The 22 acute care facilities with the largest number of hospitalized TB patients in 1991 were selected for inclusion in the study. Medical and laboratory records of the 10 most recent acid fast bacilli (AFB) smear-positive patients in each of the selected facilities in 1992, 1993, and 1994 were reviewed by using a standardized questionnaire to determine risk factors for TB, previous history of TB, clinical signs and symptoms, AFB laboratory turnaround times, emergency department contact, timing of isolation, timing of treatment, case reporting, and status on discharge. The patients' rooms were evaluated for TB environmental control measures if the patient was still on respiratory isolation precautions. RESULTS: More than one third of patients were admitted with a previous history of TB, 31% were admitted with a cavitary lesion on chest x-ray examination, and 48% were known to have HIV infection. Eighty-five percent were admitted from the emergency department where they stayed for up to 116 hours (mean stay: 17 hours). The proportion of patients placed in AFB isolation on admission to the floor increased from 75% in 1992 to 84% in 1994. The proportion of patients given a minimum of four anti-TB drugs increased from 88% in 1992 to 94% in 1994. Patients "on isolation" were sharing rooms with up to nine other patients in 1992, whereas no patients were sharing rooms in the 1994 survey. In 1992, 51% of the rooms were under negative air flow with respect to the corridor. During the 1994 survey, 80% of rooms were under negative air flow. Between 1992 and 1994, the proportion of AFB isolation rooms with dust/mist respirators increased from 28% to 76% (p < 0.00001). Approximately 25% of discharged patients left against medical advice (no trend over time). The proportion of medically discharged patients with three negative AFB smears before discharge increased from 26% to 48% (p = 0.03) and the proportion referred for directly observed therapy increased from 15% to 53% (p = 0.00001). CONCLUSION: TB control efforts in New York City hospitals improved dramatically between 1992 and 1994. The ultimate control of TB will continue to depend on the coordinated efforts within and between health care facilities, providers, and the community.

A death associated with therapy for nosocomially acquired multidrug-resistant tuberculosis.

Treatment of multidrug-resistant tuberculosis is difficult and has been associated rarely with severe side effects. We report the nosocomial transmission of multidrug-resistant tuberculosis to a health-care worker who was seronegative for HIV infection. She died because of liver failure associated with treatment for active multidrug-resistant tuberculosis.

False positive tuberculosis skin test results.

The re-emergence of tuberculosis as a significant public health threat has led to greatly renewed activity in tuberculin skin testing to identify infected persons. However, even use of the preferred skin test technique (intradermal injection of purified protein derivative via the Mantoux method) can lead to either false positive or false negative results. Interpretation of a Mantoux test can be influenced by cross reactions with other mycobacteria, intertester variation, host-response variation, and product related problems. At least 25 apparent false positive purified protein derivative skin test reactions in New York State in 1992 appeared to be associated with lots of the derivative produced by one manufacturer. These unexpected skin test results led to examination of a product with an altered appearance that may have caused the unanticipated responses. After announcement of these false positive results to the press, the company removed the product from the market. Food and Drug Administration analysis later revealed particulate matter in vials of the suspected lots of purified protein derivative.

Nosocomial tuberculosis: an outbreak of a strain resistant to seven drugs.

OBJECTIVE: To evaluate nosocomial transmission of multidrug-resistant (MDR) tuberculosis (TB). DESIGN: Outbreak investigation: review of infection control practices and skin test results of healthcare workers (HCWs); medical records of hospitalized TB patients and mycobacteriology reports; submission of specimens for restriction fragment length polymorphism (RFLP) typing; and an assessment of the air-handling system. SETTING: A teaching hospital in upstate New York. RESULTS: Skin-test conversions occurred among 46 (6.6%) of 696 HCWs tested from August through October 1991. Rates were highest on two units (29% and 20%); HCWs primarily assigned to these units had a higher risk for conversion compared with HCWs tested following previous incidents of exposure to TB (relative risk [RR] = 53.4, 95% confidence interval [CI95] = 6.9 to 411.1; and RR = 37.4, CI95 = 5.0 to 277.3, respectively). The likely source patient was the only TB patient hospitalized on both units during the probable exposure period. This patient appeared clinically infectious, was associated with a higher risk of conversion among HCWs providing direct care (RR = 2.37; CI95 = 1.05 to 5.34), and was a prison inmate with TB resistant to seven antituberculosis agents. The MDR-TB strain isolated from this patient also was isolated from other inmate and noninmate patients, and a prison correctional officer exposed in the hospital. Mycobacterium tuberculosis isolates from all of these patients had matching RFLP patterns. Infection control practices closely followed established guidelines; however, several rooms housing TB patients had marginal negative pressure with variable numbers of air changes per hour, and directional airflow was disrupted easily. CONCLUSIONS: These data strongly suggest nosocomial transmission of MDR-TB to HCWs, patients, and a prison correctional officer working in the hospital. Factors contributing to transmission apparently included prolonged infectiousness of the likely source patient and inadequate environmental controls. Continued urgent attention to TB infection control is needed.

Transmission of multidrug-resistant Mycobacterium tuberculosis among persons exposed in a medical examiner's office, New York.

OBJECTIVE: To determine the prevalence of and risk factors for having a positive tuberculin skin test (TST) result among employees at a medical examiner's office (MEO). DESIGN: Cohort study, environmental investigation. SETTING: Several employees at a medical examiner's office were found to have positive TST results after autopsies were performed on persons with multidrug-resistant tuberculosis (MDR-TB). PARTICIPANTS: Employees of the MEO. RESULTS: Of 18 MEO employees, 5 (28%) had a positive TST result; 2 of these 5 had TST conversions. We observed a trend between TST conversion and participation in autopsies on persons with MDR-TB (2 of 2 converters versus 3 of 13 employees with negative TST; relative risk = 4.3; 95% confidence interval 1.61 to 11.69; P = 0.10). The environmental investigation revealed that the autopsy room was at positive pressure relative to the rest of the MEO and that air from the autopsy room mixed throughout the facility. CONCLUSIONS: A systematic approach to preventing transmission of Mycobacterium tuberculosis in autopsy suites should include effective environmental controls and routine tuberculin skin testing of employees.

Multidrug-resistant tuberculosis in the New York State prison system, 1990-1991.

Three epidemiologically linked multidrug-resistant (MDR) tuberculosis (TB) outbreaks in 1990-1991 involving New York State (NYS) inmates suggested MDR-TB was widespread in NYS prisons. Inmate lists were linked to 1990-1992 TB registries, medical records were reviewed, and movement histories for inmates with MDR-TB were examined within and between prisons and hospitals. In 1990-1991, 171 inmates were diagnosed with TB. This rate (156.2/100,000) was significantly higher than the 1990-1991 US rate (10.4/100,000) and the 1986 rate among NYS inmates (105.5/100,000). Of 171 cases, 155 were cultured-confirmed; 37 (32%) of 116 with drug susceptibilities determined had MDR-TB. Two other inmates with TB before 1990 were diagnosed with MDR-TB in 1990-1991. Of 39 inmates with MDR-TB, 38 (97%) were infected with the human immunodeficiency virus and 34 (87%) have died. These 39 lived in 23 of the 68 NYS prisons while potentially infectious; 12 were transferred through 20 prisons while ill with MDR-TB. Policies of correctional systems on infection control and inmate transfers need to be reevaluated to prevent spread of TB.

Tuberculosis in a correctional facility.

BACKGROUND: After the identification of five suspected cases of tuberculosis (TB) in a Nassau County (New York) jail during a 3-week period, an epidemiologic investigation was begun to document the number of cases of TB infection and disease associated with the jail, the characteristics of current or former inmates with TB disease, and the factors contributing to TB transmission in the jail. METHODS: The county TB register was matched against the inmate files of the jail. Medical records from hospitals, the health department, and the jail were then reviewed. All inmates in the jail were skin tested during a mass screening. RESULTS: From January 1, 1988, through March 16, 1990, of 205 TB cases in the county, 49 (24%) were associated with the jail. Forty of the cases occurred among current or former inmates, one in a corrections officer, and eight among community contacts of inmates. The 40 inmates with TB were predominantly nonwhite (75%), unmarried (80%) men (90%), with a median age of 32 years. Twenty-three (58%) had a history of injecting drug use, and 14 (35%) were known to be seropositive for the human immunodeficiency virus. Thirty (75%) of the inmates had culture-confirmed pulmonary TB. Five (29%) of 17 Mycobacterium tuberculosis isolates had the same phage type and DNA fingerprint, which was consistent with transmission of infection within the jail. The mass screening revealed that 374 (20%) of 1855 inmates were tuberculin positive. CONCLUSIONS: Without an effective program of TB control, jails can act as reservoirs of disease for inmates and staff, and for the community into which the inmates are released.

An evaluation of the use of the Statewide Planning and Research Cooperative System of New York State as a resource planning tool for HIV infection.

Hospital discharge records of patients with Pneumocystis carinii pneumonia (PCP) in New York State were studied to determine whether cases of human immunodeficiency virus (HIV) infection were identified. We estimate that as many as 13 percent of hospitalizations of patients with PCP in 1987 and 10 percent of those in 1988 were not appropriately identified as HIV related. Identification of PCP as HIV related was a function of a hospital's volume of PCP admissions.

Assessment of AIDS knowledge in selected New York State sexually transmitted disease clinics.

A 1988 survey regarding the level of knowledge about acquired immunodeficiency syndrome (AIDS) among 505 clients of sexually transmitted disease (STD) clinics demonstrated 80% correct responses. However, 13% thought AIDS could be transmitted via sharing utensils, and 51% were unaware that acquiring another STD could increase one's risk of human immunodeficiency virus (HIV) infection. In addition, only 10% always used condoms. An average 69% of patients obtained their AIDS information from newspapers, magazines, television, or radio; and 30% acquired information from medical or clinic staffs. In response to this survey, a videotape on AIDS was developed to show to patients of STD clinics while they are waiting to see a physician.

Increasing incidence of tuberculosis in a prison inmate population. Association with HIV infection.

The incidence of tuberculosis (TB) among inmates of the New York State prison system increased from 15.4 per 100,000 in 1976 through 1978 to 105.5 per 100,000 in 1986. Matching of TB and acquired immunodeficiency syndrome registries indicated that the majority (56%) of inmates with TB reported in 1985 and 1986 had acquired immunodeficiency syndrome or human immunodeficiency virus infection; none were known to be human immunodeficiency virus seronegative. A case-control study examined 59 inmates with TB reported from 1984 through 1986 and 59 matched control inmates without TB. Inmates who reported street drug use were more likely to develop TB: odds ratio, 9.7; 95% confidence interval, 2.8 to 33.6 and odds ratio, 7.3; 95% confidence interval, 0.9 to 59.3 by unconditional and conditional logistic regression analyses, respectively. Although the majority of cases are thought to be due to reactivation of latent infection, phage typing of 16 Mycobacterium tuberculosis cultures suggested the possibility of inmate-to-inmate transmission in at least one cluster of three cases. It is of crucial importance that TB control measures be reinforced in the prison setting to counter the increased risk created by human immunodeficiency virus infection.

Evaluation of isolated cases of salmonellosis by plasmid profile analysis: introduction and transmission of a bacterial clone by precooked roast beef.

In July-August 1981, the number of isolated cases of salmonellosis in New Jersey and Pennsylvania markedly increased. Concurrently, two outbreaks in these states caused by the same Salmonella serotypes were traced to a single brand of precooked roast beef. Plasmid profiles of outbreak and isolated strains were examined, and Salmonella newport isolates from the implicated meat and from cases in the two outbreaks were identified with a unique profile, present in 45% of reported strains from isolated cases in this area during the same period. Review of the food exposure histories in isolated cases demonstrated association between this plasmid profile and consumption of precooked roast beef (P = 0.003). Examination of S newport strains from other regions and intervals indicated that this strain was introduced into these two states sometime after March 1981. Thus, plasmid profile analysis was useful in studying the epidemiology of isolated cases of salmonellosis due to a sensitive common serotype.