Tuberculosis in the Workplace (2001) / Chapter Skim
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5 Occupational Risk of Tuberculosis
5 Occupational Risk of Tuberculosis
Pages 81-107
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From page 81... ...
The problem is not just that such information is unavailable to outsiders but that it may also be unavailable to support internal assessments of risk and then guide appropriate responses. This scarcity of surveillance information for settings such as homeless shelters and local jails is a concern because many of these facilities serve people at increased risk of active tuberculosis including those who are unemployed, homeless, or poor; people with HIV infection or AIDS or substance abuse problems; and recent immigrants from countries with high rates of tuberculosis.
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From page 82... ...
Although these problems have not disappeared, they have been mitigated by increased funding for community tuberculosis control, intensive programs of directly observed therapy, more effective treatments for HIV infection and AIDS, and increased attention to tuberculosis control measures in the workplace. Since 1993, national tuberculosis case rates have dropped for seven successive years.
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From page 83... ...
The foundation of workplace surveillance programs has been the finding and investigating of tuberculin skin test conversions. As discussed in Chapter 2 and Appendix B
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From page 84... ...
If an investigation does not indicate workplace transmission, then the presence of skin test conversions or cases of active tuberculosis does not constitute a workplace outbreak. Sometimes community is described in social rather than geographic terms.
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From page 85... ...
summarizes studies from the 1920s through the 1950s that showed that nurses, physicians, and others working with tuberculosis patients had high rates of positive skin tests or skin test conversions compared to the rates expected in the broader community. For nursing students who were initially tuberculin skin test negative, conversion rates reported in studies in the United States and Europe ran as high as 95 to 100 percent by the time the students graduated.
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From page 86... ...
MORE RECENT INFORMATION ON THE COMMUNITY AND OCCUPATIONAL RISK OF TUBERCULOSIS U.S. Government Surveys and Databases General Population Active Tuberculosis and Mortality from Tuberculosis CDC reports annually on cases of active tuberculosis nationwide and by state and selected cities (see, e.g., CDC [2000b]
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From page 87... ...
Data from government surveys and databases as well as other sources fairly consistently show mat rates of active tuberculosis vary by race, Toxicity, age, and country of origin. Table 5-1 shows that such demographic variation persists despite the decline in case rates during recent years.
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From page 88... ...
The last effort to collect systematic information on the prevalence of tuberculosis infection nationwide dates back to the 19711972 National Health Survey. For that survey, trained personnel administered and read tuberculin skin tests for a national sample of American adults.
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From page 89... ...
As shown in Figure 5-1, for the period 1994 to 1998, the overall incidence of active tuberculosis among health care workers was similar to that for other employed workers about 5.1 per 100,000 population for the former and 5.0 per 100,000 population for the latter (Curtis et al., 1999~. Between 1994 and 1998, the tuberculosis case rate for health care workers dropped from 5.6 to 4.6 per 100,000 population, whereas the rates for other employed workers stayed relatively steady at 5.2 per 100,000 population in both 1994 and 1998.
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From page 90... ...
In the 21 occupational groups that met their criteria, two race- and sex-specific subgroups had potential workplace exposure to tuberculosis. They were white male funeral directors 6An analysis of 1985-1986 data from 29 states found that the rate of active tuberculosis was nearly four times higher for adult inmates of correctional facilities than for unincarcerated individuals of similar ages (Hutton et al., 1993~.
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From page 91... ...
Where modern infection control measures have been implemented, occupational risk approaches the level of risk in the communities in which workers reside. Overall, data for the mid-199Os do not show that health care workers as a group are at higher risk of active tuberculosis than other employed
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From page 92... ...
Although they reviewed several studies reporting rates of tuberculosis infection among health care workers, the authors cited the limitations of the studies and did not present an overall assessment of infection risk in the postantibiotic era. They did not present mortality data.
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From page 93... ...
They concluded that the conversion rates in hospitals did not differ significantly from the estimated rate for the state population overall. A study in a nonoutbreak environment found correlations between positive skin test conversions and the worker's age, the worker's race, and the poverty level in the worker's zip code of residence (Bailey et al., 1995~.
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From page 94... ...
Another study reporting higher rates of skin test conversions for respiratory therapists involved a military medical center in Maryland (Ball and Van Wey, 1997~. Annual skin test conversion rates, which ranged between 0.4 and 2.6 percent across the occupational categories identified, did not differ significantly for patient-contact and non-patient-contact categories.
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From page 95... ...
Health care staff at the jail have documented 24 known exposure episodes involving workers and have concluded that these were associated with 10 documented and 30 possible skin test conversions, none of which involved health care workers. The test results for correction officers did not differ by the area of the facility in which they worked.
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From page 96... ...
Although national CDC data show approximately 400 to 600 cases of tuberculosis in health care workers per year in recent years, case investigations of hospital or other outbreaks indicate that outbreaks reports account for only a small number of all cases of tuberculosis (Dooley and Tapper, 1997; Garrett et al., 1999, CDC, 2000b)
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From page 97... ...
A high percentage of the cases involved patients or workers who were seriously immunocompromised due to HIV infection or AIDS and who were thus at high risk of progressing quickly from tuberculosis infection to active disease. This made it easier for clinicians and others to recognize possible links to earlier hospital stays.
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From page 98... ...
In one outbreak involving an autopsy on a person with unsuspected tuberculosis, all five of those present for the 3-hour procedure including one person present for only 10 minutes subsequently had skin test conversions and two developed active tuberculosis (Templeton et al., 1995~. Two developed active tuberculosis.
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From page 99... ...
Again, the investigators documented lapses in infection control measures. At Grady Memorial Hospital in Atlanta, hospital staff tracked skin test conversion rates after an outbreak of tuberculosis and the implementation of infection control measures (Blumberg et al., 1995; Sotir et al., 1997~.7 In the first period studied, lanuary through tune 1992, 3.3 percent (annual rate, 6.49 percent)
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From page 100... ...
A report on two other outbreaks in 1995 and 1996 cited annual skin test conversion rates for previously negative employees of 2.8 percent for those exposed in one prison and 4.9 percent for those exposed in a second prison (Prendergast et al., 1999~. No employees developed active tuberculosis.
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From page 101... ...
tuberculosis isolates suggested that transmission of the disease was occurring within the jail. The jail did not screen detainees or workers for tuberculosis infection or active tuberculosis.
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From page 102... ...
Another report on a skin testing program for workers on a chronic care ward in a Veterans Administration Medical Center found evidence of "occult" transmission of endemic tuberculosis (Brennen et al., 1988~. Since 1995, New York State has required acute-care hospitals and longterm-care facilities to report clusters of tuberculin skin test conversion and evidence of nosocomial tuberculosis transmission as well as cases of active tuberculosis (Rachel L
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From page 103... ...
Although skin test conversions were documented in 2 of 8 previously tuberculin skin test negative staff members, 52 other staff members who might have been exposed were not available for skin testing. Shelter workers are often previous shelter clients.
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From page 104... ...
Many nursing homes, jails, and other facilities will not accept persons known to have active tuberculosis. A1though these policies should reduce risk, workers may still be exposed to individuals with undetected disease.
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From page 105... ...
Investigations of workplace outbreaks of tuberculosis have typically identified lapses in infection control measures as probable contributors to transmission. As discussed in Chapter 6, much of the support for the effectiveness of tuberculosis control measures comes from outbreak investigations and subsequent studies of the implementation of administrative controls and other measures.
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From page 106... ...
For these workers, in particular, the effectiveness of workplace tuberculosis control measures matters. Workers at particular risk from occupationally acquired tuberculosis infection include those with HIV infection or AIDS or other conditions associated with suppression of normal functioning of the immune system.
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From page 107... ...
In general, low-income individuals, members of racial and ethnic minorities, immigrants from developing countries, and people living in low-income neighborhoods are at higher risk of community-acquired tuberculosis infection and active tuberculosis. This does not mean that the risk of workplace transmission of tuberculosis can be disregarded for workers with these demographic risk factors.
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