Tuberculosis in the Workplace (2001) / Chapter Skim
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Appendix C The Occupational Tuberculosis Risk of Health Care Workers
Appendix C The Occupational Tuberculosis Risk of Health Care Workers
Pages 189-229
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From page 189... ...
In those health care facilities where modern infection control measures are in place, it now approaches the level of risk incurred by health care workers in the communities in which they reside. That it has declined and continues to Professor Emeritus of Medicine and International Health, Case Western Reserve University, Cleveland, Ohio.
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From page 190... ...
The risk of tuberculous infection varies greatly with socioeconomic status, most of the infection risk being incurred by those who are less affluent. For health care workers, these variations in population tuberculosis incidence have two important consequences.
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From page 191... ...
Charge to the Reviewer This paper reviews the published medical literature relevant to the occupational tuberculosis risks of American health care workers. It was commissioned by the Institute of Medicine Committee on Regulating Occupational Exposure to Tuberculosis.
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From page 192... ...
Published Literature Reviews There have been a number of well-done literature reviews of the occupational tuberculosis risk to health care workers published during the past decade (2-9~. In general, these reviews emphasize the risk of tuberculous infection and do not deal with the subsequent risk of disease.
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From page 193... ...
Calculated Annual Risk of Infection If one accepts the development of tuberculin hypersensitivity as a reliable index of primary tuberculous infection, then it is a straightforward task to calculate the ARI with M tuberculosis expressed as percent per year from serial skin testing data.
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From page 194... ...
RISK OF TUBERCULOUS INFECTION Risk in the U.S. General Population If one is to examine the occupational risk of tuberculous infection among health care workers in relation to the communities in which they reside, then it is first important to try to determine the annual risk of infection in the general American public.
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From page 195... ...
A reasonable estimate for the current date for Americans of all ages might be 5 to 10 percent, and perhaps 10 percent in adults. Tuberculous infection is not uniformly distributed among Americans, and it is important to stratify any assessment of the general population risk so that infection in health care workers can be compared with that in the appropriate reference community.
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From page 196... ...
PPD, 5 TU 0.45 * Tuberculins used for skin testing have included old tuberculin (OT)
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From page 197... ...
and 1973 (16) Racial/Ethnic Group Calculated ARI, Calculated ARI, as Characterized by 1962 (20)
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From page 198... ...
. Summary of Risk of Tuberculous Infection in the General U.S.
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From page 199... ...
Risk in Hospital-Based Health Care Workers Until the 1950s, when effective chemotherapy heralded the closing of most tuberculosis sanatoria and categorical tuberculosis hospital services, the occupational risk of tuberculous infection was generally accepted by all health care workers. Indeed, primary tuberculous infection was welcomed by many because of the immunity to subsequent infection that accompanied it.
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From page 200... ...
These observations led to the conclusion that the source of tuberculous infection for most of the employees who converted their tuberculin skin tests was in the communities in which they resided rather than in the hospital. Aitken, Anderson, and Albert conducted a prospective study of tuberculin skin test conversions among employees at all 114 hospitals in the TABLE C-7.
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From page 201... ...
In this survey 124,869 skin tests were completed and 110 skin test conversions were documented (excluding 19 additional converters identified by health department contact investigations)
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From page 202... ...
. During the same time period, tuberculin skin test information was available for 1,303 employees, 711 of whom were initially tuberculin skin test negative.
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From page 203... ...
Conversion rates are number of skin test conversions/number of employees tested (percent)
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From page 204... ...
During the latter period, the conversion rate was not related to job status but was positively correlated with black race and low economic status. Subsequently, Blumberg and associates studied tuberculin skin test conversions among house staff in the Emory University Affiliated Hospitals Training Program (35~.
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From page 205... ...
Boudreau and others studied the occupational tuberculosis infection risk at Jackson Memorial Hospital in Miami, Florida (39~. They compared infection rates for 248 initially tuberculin skin test negative employees who worked exclusively on hospital divisions from which the laboratory had received respiratory specimens positive for M
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From page 206... ...
A total of 11.3 percent of employees were initially skin test positive. During the study period 0.93 percent of the initially tuberculin skin test negative employees converted to positivity, for an calculated annual risk of infection of 0.37 percent.
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From page 207... ...
In a survey of 17 Minnesota hospitals, the tuberculin reactor rate among employees was 0.3 percent in 1989-1991 (43~. Managan and coworkers compared tuberculin skin test conversion rates by questionnaire survey in two groups of hospitals: 38 hospitals admitting patients with Pneumocystis carinii pneumonia (PCP)
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From page 208... ...
In both of these outbreaks, the diagnosis of the index case was not suspected for a substantial period of time. In 1987 Price and Rutala published the results of a questionnaire survey of 12 long-term-care facilities in North Carolina; 101 skin test conversions occurred among 9,545 (1.1 percent)
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From page 209... ...
Transmission of tuberculous infection from inmates to correctional facility personnel has been documented in several published reports from California penal systems. Two of 11 prison infirmary employees converted their tuberculin skin test after contact with an infected prisoner in 1990-1991 (54~.
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From page 210... ...
Two studies of tuberculosis in prisons are of particular interest because they give some insights into the risk of tuberculous infection in relation to that in the community. In a study of 28 contact investigations in New York City correctional facilities, Tohnsen noted that the tuberculin conversion rate among inmates exposed to sputum smear-positive prisoners with tuberculosis was 6.6 percent (59~.
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From page 211... ...
Tuberculin skin test conversions were documented in two of eight previously tuberculin-negative staff members. Perhaps reflective of much of the generally transient nature of shelter staffs, 52 additional staff members who may have been exposed were not available for skin testing.
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From page 212... ...
Fourteen tuberculin skin test conversions were noted, but neither the time interval nor the number of persons at risk were given, so that no conclusions can be drawn from this report. Transmission of tuberculous infection from cadavers is well known, and autonsv rooms have been considered esneciallv hazardous.
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From page 213... ...
Risk Assessment by the Occupational Safety and Health Administration OSHA has proposed a rule to enforce infection control measures on all facilities employing health care workers (45~. As part of its proposal OSHA TABLE Cell.
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From page 214... ...
They are also notable because they all included initial two-step tuberculin skin testing to minimize confounding booster effects. Some of them have not yet been published, but abstracts were kindly made available to me by their authors, who gave me permission to cite them.
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From page 215... ...
TABLE C-12. Calculated Annual Risks of Infection Derived from Tuberculin Skin Test Conversion Data for Selected Groups of Health Care Workers (E.
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From page 216... ...
In considering these risks, it is important to distinguish between those in immunocompetent persons and those in immunocompromised individuals. Risk for Immunocompetent Health Care Workers Longitudinal Surveillance of Tuberculin Skin Test Reactors Not Treated for Latent Infection J
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From page 217... ...
It is possible that this rate is low because of the short period of follow-up of recent reactors. Myers and colleagues used tuberculin skin testing techniques with high doses of old tuberculin.
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From page 218... ...
In general, this information is excellent because the tuberculin skin testing was usually done by skilled, specifically trained individuals, the studies were done prospectively, and great effort was put into data management. For the purposes of this review, many of them have the disadvantage of having been conducted in children with follow-up through the adolescent and postpubertal years.
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From page 219... ...
Thirty-eight pecent of the cases developed during the first 5 years of observation. Perhaps the most useful data on the occurrence of tuberculosis in tuberculin skin test reactors excluded from BCG vaccination trials comes from the report of Comstock, Livesay, and Woolpert that includes data from the Puerto Rican trial (92~.
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From page 220... ...
In an editorial dealing with the use of isoniazid for the treatment of latent tuberculous infections in young adults, George Comstock and Phyllis Edwards used published and unpublished data from both BCG trials and isoniazid chemotherapy trials to estimate the lifetime risk of tuberculosis among tuberculin skin test reactors (93~. They noted that the risk declined with passing years.
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From page 221... ...
Isoniazid treatment of latent tuberculous infection was offered to all tuberculin-positive addicts, but the rate of compliance was low. In a second study in 1987-1990, Selwyn and collaborators documented patient compliance with isoniazid treatment and also used a battery of delayed hypersensitivity antigens to assess skin test energy (95~.
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From page 222... ...
Six percent of patients are inmates of correctional facilities; 6 percent are homeless; and 3 percent are residents of long-term-care facilities. Reduced access to health care among the homeless and the unemployed can be presumed to increase their risk of being diagnosed and treated late or not at all and, in turn, their risk of death from untreated tuberculosis.
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From page 223... ...
tuberculosis-Infected Health Care Workers In the surveillance studies cited above the methods of tuberculin skin testing, the completeness of follow-up, and the definitions of tuberculin positivity and of tuberculosis varied, and the rigor of examination for tuberculosis may also be open to challenge. Yet certain generalizations seem justified.
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From page 224... ...
Tuberculin skin test reaction among adults 25-74 years, 1971-1972. DHEW publication no.
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From page 225... ...
Dramatic decrease in tuberculin skin test conversion rate among employees at a hospital in New York City. American Journal of Infection Control 1995; 23:352-356.
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From page 226... ...
Aziz D Incidence of tuberculous infection among New York State prison employees.
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From page 227... ...
Descriptive profile of tuberculin skin testing programs and laboratory-acquired tuberculous infections in public health laboratories. Journal of Clinical Microbiology 1997; 35:1847-1851.
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From page 228... ...
Tuberculin skin testing surveillance of health-care workers (HCWS) (abstract)
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From page 229... ...
An outbreak of tuberculosis with accelerated progression among persons infected with the human immunodeficiency virus. New England Journal of Medicine 1992; 326: 231-235.
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