Few children with tuberculosis (TB) have communicable disease, and most do not require isolation within the hospital. However, parents or adult visitors with unrecognized pulmonary TB may be a threat to hospital staff and other patients. We prospectively evaluated adults accompanying children hospitalized for suspected TB at a children's hospital to determine the frequency of undiagnosed, potentially contagious disease.

From 1992 to 1998, chest radiographs were obtained from adult caretakers accompanying 59 consecutive children admitted to Texas Children's Hospital with suspected TB. A child and his or her family were placed under Airborne Precautions only if the child or the accompanying adult exhibited characteristics of potentially contagious disease. Annual rates of tuberculin skin test conversion in hospital employees were obtained for the same period.

Of the 105 screened adults, 16 (15%) had previously undetected pulmonary TB. These adults were associated with 14 (24%) of the 59 children. In all instances in which the adult was the patient's parent, he or she was the source of infection to the child. Only 8 (13.5%) of the 59 children required isolation. Tuberculin skin test conversion from a negative to a positive reaction occurred in 127 employees (8 per 1,000 employee-years at risk). Only 4 of these 127 employees performed activities involving direct patient contact. None was in contact with families with a known potentially contagious adult or pediatric patient.

The risk of infection of healthcare workers from pediatric patients with primary TB appeared to be minimal, and most children with TB did not need isolation. Infection control efforts should be focused on accompanying adults and adult visitors. (Infect Control Hosp Epidemiol 2002;23:568-572).

We report a case of congenital tuberculosis in a neonatal intensive care unit (NICU) and the management of exposure to other neonates in the hospital. We review the literature regarding congenital tuberculosis and management of exposures in the NICU.

Case report and a survey of exposures with a 3-month follow-up.

Urban hospital.

Neonates exposed to a case of congenital tuberculosis.

Exposure to tuberculosis was treated with isoniazid. Purified protein derivative tests were placed at base-line and 3 to 4 months after exposure. Chest radiographs were performed if clinically indicated.

Congenital tuberculosis was diagnosed in our patient at 21 days of age during a prolonged hospital course. After initiation of anti-tuberculous medications, the patient gradually recovered from his illness. While he was treated in the NICU, there were 37 potentially exposed infants. Of these, 36 were administered tuberculin skin tests (average age, 1.7 months), all of which were read as 0 mm of induration. Of those 37, 35 began prophylaxis with isoniazid, and 30 were able to complete treatment with a minimum of 3 months of isoniazid therapy. Of those 30, two infants received 6 months of therapy. Additionally, 29 of the 37 infants had chest radiographs, none of which showed suspicious infiltrates or adenopathy. Finally, 30 of the 36 infants had repeat tuberculin skin tests at 3 months, all of which were read as 0 mm of induration (average age, 3.7 months).

Congenital tuberculosis is an uncommon disease that requires early diagnosis for successful therapy and vigilant follow-up of potential exposures in the NICU. (Infect Control Hosp Epidemiol 2002;23:573-579).

To identify the contamination source of a cluster of eight positive Mycobacterium tuberculosis isolates from one laboratory session.

Spoligotyping was performed on M. tuberculosis isolates processed during one laboratory session. Laboratory and sputum induction protocols and records were reviewed. Sputum induction staff were interviewed. An environmental assessment of the sputum induction booth was performed.

Spoligotyping identified a unique strain of susceptible M. tuberculosis from five induced sputa collected at Clinic A on the same day. Three specimens processed concurrently from other clinics had spoligotypes different from each other and from the cluster strain. A laboratory investigation revealed no procedural lapses. Sputum induction records from Clinic A indicated that patient 1 in the sputum induction booth had prior culture-confirmed tuberculosis. Patient 2 had a history of a drug-resistant strain. Patient 3 had completed tuberculosis treatment, with positive cultures 7 months earlier. Patients 4 and 5 were new to the clinic and had no subsequent positive M. tuberculosis specimens. The sputum induction booth was working within normal parameters. Sputum induction that day was overseen by a new employee with limited training and no supervision. A review of the sputum induction protocol identified ambiguity regarding care of the ultrasonic nebulizer between patients, which may have led to reuse of the discarded nebulizer solution from patient 1.

A break in the sputum induction protocol may have contributed to contamination of patient specimens. Sputum induction is complicated, mandating adequate staff training and supervision and patient preparation. Spoligotyping identified a potential source of M. tuberculosis contamination.(Infect Control Hosp Epidemiol 2002;23:580-583).

To determine the occupational risk of Mycobacterium tuberculosis infection among healthcare workers (HCWs) and to examine the utility of tuberculin skin testing in a developing country with a high prevalence of bacille Calmette-Guerin vaccination.

Tuberculin skin test (TST) survey.

A tertiary-care referral center and a teaching hospital in Kuala Lumpur, Malaysia.

HCWs from medical, surgical, and orthopedic wards.

Tuberculin purified protein derivative RT-23 (State Serum Institute, Copenhagen, Denmark) was used for the TST (Mantoux method).

One hundred thirty-seven (52.1%) and 69 (26.2%) of the HCWs tested had indurations of 10 mm or greater and 15 mm or greater, respectively. Medical ward HCWs were at significantly higher risk of a positive TST reaction than were surgical or orthopedic ward HCWs (odds ratio, 2.18; 95% confidence interval, 1.33 to 3.57; P = .002 for TST positivity at 10 mm or greater) (odds ratio, 2.61; 95% confidence interval, 1.44 to 4.70; P = .002 for TST positivity at 15 mm or greater). A previous TST was a significant risk factor for a positive TST reaction at either 10 mm or greater or 15 mm or greater, but a duration of employment of more than 1 year and being a nurse were only significantly associated with a positive TST reaction at a cut-off point of 15 mm or greater.

HCWs at the University of Malaya Medical Centre had an increased risk for M. tuberculosis infection that was significantly associated with the level of occupational tuberculosis exposure. A TST cut-off point of 15 mm or greater may correlate better with M. tuberculosis infection than a cut-off point of 10 mm or greater in settings with a high prevalence of bacille Calmette-Guerin vaccination (Infect Control Hosp Epidemiol 2002;23:584-590).

To describe the cumulative incidence of and risk factors for tuberculosis (TB) infection among medical students.

In 1999, a cohort study of medical students with negative results (induration < 10 mm) on tuberculin skin test (TST) was performed. Students who had undergone two-step testing in 1998 were retested.

University and teaching hospital and referral center for TB and acquired immunodeficiency syndrome, and the Health Sciences Building of the Medical School of the Federal University of Rio de Janeiro, Brazil.

A sample of 618 consecutive medical students with negative TST results who had been tested 12 months before were approached. Information about sociodemographic characteristics, bacille Calmette-Guérin vaccination history, and potential exposures to TB was obtained using a standardized questionnaire. Four hundred fourteen (67%) students completed the study. Students were at two different levels of their training programs (juniors = no contact with patients; seniors = intensive contact with patients).

Of 414 participants, 16 (3.9%; 95% confidence interval, 1.06% to 12.1%) had converted to a positive reaction after 1 year. In a multivariate logistic regression analysis, higher level of clinical training was confirmed to be an independent factor associated with TST conversion (odds ratio, 4.77; 95% confidence interval, 1.01 to 22.46; P = .048).

Senior medical students are at increased risk of Mycobacterium tuberculosis infection in this setting. Therefore, a program of routine tuberculin skin testing and specific TB infection control guidelines are needed for this population (Infect Control Hosp Epidemiol 2002;23:591-594).

Respiratory isolation for 90% of individuals with acid-fast bacillus (AFB)-smear–positive tuberculosis (TB) is a recommended performance indicator in recent Infectious Diseases Society of America and Centers for Disease Control and Prevention guidelines. However, compliance with respiratory isolation reported from multiple centers in the United States and Europe falls short of that goal.

To identify missed clues in TB patients who are not appropriately isolated.

Retrospective survey.

A 900-bed voluntary hospital.

All patients with AFB-smear–positive TB admitted between January 1995 and December 1999 who were not appropriately isolated.

There were 173 TB cases admitted, including 106 with pulmonary TB. AFB smears were positive in 82 cases; 24 (29%) of these were not appropriately isolated. During the study period, the number of TB cases declined, but the proportion of appropriately isolated patients did not change. Most isolation failure cases were men (median age, 45.5 years); 21 of these patients were black, 2 were Hispanic white, and 1 was Asian, but none was non-Hispanic white. All isolation failure cases had at least one characteristic predictive of TB that could have been elicited at admission (eg, abnormal chest radiograph findings consistent with TB, fever, weight loss, a history of TB, a positive result on tuberculin skin test, hemoptysis, and human immunodeficiency virus infection).

Consistent with experiences at other hospitals, we found that the rate of isolation failure remained unchanged despite an overall decline in TB cases. In our experience, almost all isolation failures could be avoided by careful review of the history, physical examination, and chest radiograph for characteristics classically considered predictive of TB. (Infect Control Hosp Epidemiol 2002;23:595-599).

To identify delayed prophylaxis from a preexisting database and strategies to improve performance.

A skilled nursing facility with 14 floors (4 buildings). The “outbreak unit” was a 50- to 60-bed floor.

We performed surveillance during six seasons using one protocol. Prophylaxis was started when influenza was cultured in the building and 10% of residents on the floor had a new respiratory illness within 7 days. We defined delayed prophylaxis as four or more residents on a floor with positive cultures whose specimens had been collected within 5 days before the application of prophylaxis.

We identified 14 examples of delayed prophylaxis. In three, delayed prophylaxis was related to the 3.9-day delay between culture collection and culture report. There was a high degree of commonality among building attack rates within a season. During six seasons, the first case in the last building occurred 27 to 64 days after the first case in the facility. The two seasons with the greatest activity (68 and 154 cases, respectively) began with explosive, multi-floor outbreaks in a single building. The match between the circulating strain and the vaccine was good, except in 1997-1998 when there were seven examples of delayed prophylaxis.

Influenza may involve buildings sequentially with a commonality of building attack rates. Explosive, multi-floor outbreaks early in the season could lead to a lower threshold for prophylaxis within a larger area when initial cases are encountered later in the season. This strategy could have prevented five examples of delayed prophylaxis. Rapid testing of multiple specimens while waiting for culture confirmation could have prevented three examples of delayed prophylaxis. (Infect Control Hosp Epidemiol 2002;23:600-603).

To describe compliance with and the safety and prophylactic efficacy of zanamivir among patients at risk of developing influenza-related complications after exposure to both influenza A and B viruses.

Nonrandomized trial using both historical and contemporaneous controls from ward populations within the same facility.

A 547-bed urban hospital providing complex continuing care and rehabilitation.

Fifty patients on a single ward concomitantly exposed to both influenza A and B during an influenza outbreak.

All patients were screened for symptoms of influenza and nasopharyngeal swabs were sent for viral culture prior to treatment (two oral inhalations [2 × 5 mg] twice daily for 5 days) or prophylaxis (two oral inhalations [2 × 5 mg] once daily for 14 days) with zanamivir. Patient symptoms, compliance, and drug tolerance were monitored daily. Demographic data, comorbidities, vaccination status, and functional status (Katz score) were collected for all patients.

The mean age of the patients was 70.6 years (standard deviation, ± 16.4 years). Ninety-four percent had two or more comorbidities, 71% were dependent in two or more activities of daily living, 63% had been vaccinated for influenza, and 82% had received amantadine. Zanamivir was well tolerated, with 93% of the patients completing their course. The efficacy for preventing symptomatic infection was 82% and 91% (95% confidence interval, 62% to 98%) based on historical and contemporaneous controls, respectively.

These data suggest that zanamivir can be used safely and effectively as a prophylactic agent in the management of influenza outbreaks in a complex continuing care population with multiple comorbidities. (Infect Control Hosp Epidem 2002;23:604-608).

To investigate the health behavior associated with influenza vaccination among healthcare workers (HCWs) in long-term–care facilities.

A cross-sectional, self-administered survey of HCWs, augmented with focus groups to further examine attitudes toward influenza vaccination.

Two long-term–care facilities participated in the survey. The focus groups were held at one of the two facilities.

All HCWs were invited to participate in the survey and all nonmanagerial staff members were invited to participate in the focus groups. The response rate for the survey was 58% (231 of 401).

Vaccinated HCWs had a more positive attitude toward influenza vaccination and a greater belief that the vaccine is effective. This was not accompanied by differences in vaccine knowledge or values of potential preventive outcomes. Nonvaccinated respondents were more likely to believe that other preventive measures, such as washing hands, taking vitamins and supplements, eating a nutritious diet, exercising, and taking homeopathic or naturopathic medications, were more effective than vaccination. Additional findings from the focus groups suggest that HCWs believe that the main purpose of influenza vaccination programs is to protect residents' health at the expense, potential harm, and burden of responsibility of the staff.

This study identifies challenges to and opportunities for improving vaccination rates among HCWs. A message that emphasizes the health benefits of vaccination to staff members, such as including vaccination as part of a staff “wellness” program, may improve the credibility of influenza immunization programs and coverage rates.(Infect Control Hosp Epidemiol 2002;23:609-614).

To describe a nosocomial influenza A out-break, how it was managed, what impact it had on subsequent delivery of health care, and the additional charges attributable to it.

Prospective cohort study and microbiological investigation.

One internal medicine unit in an acute care, university-affiliated hospital.

Twenty-three patients and 22 staff members from February 28 to March 6,1999.

Attack rates were 41% (9 of 22) among patients and 23% (5 of 22) among staff members, with 3 of 14 cases being classified as “certain”. The influenza virus isolates were typed as A/SYDNEY/5/97 (H3N2). The index case was a patient who shared a room with the first nosocomial case. Vaccination rates for influenza virus were 43% (10 of 23) among patients and 36% (8 of 22) among staff members. The outbreak resulted in staff members' taking 14 person-days of sick leave. Furthermore, 8 scheduled admissions were postponed and all emergency admissions were suspended for 11 days. Hospital charges attributable to the influenza outbreak totaled $34,179 and the average extra charge per infected patient was $3,798.

Nosocomial influenza outbreaks increase charges and alter the quality of care delivered in acute care settings. Strategies for their prevention need to be evaluated in acute care settings. (Infect Control Hosp Epidemiol 2002;23:615-619).