A survey on the onset of tuberculosis in nursing homes

PURPOSE: To obtain the informations how to promote early detection and prevention of nosocomial infection of tuberculosis in nursing homes for the elderly. SUBJECT: Fifteen elderly patients who developed tuberculosis from 1998 to 2002 at nursing homes within a certain health center jurisdiction area which has a total of 23 nursing homes were investigated. METHOD: We collected informations on these 15 patients concerning the clinical conditions, details of contact examinations and status of chemoprophylaxis by using TB registration card in the health center and interviewing with the members of staff of the nursing homes and hospitals, and case conferences conducted at the health center. RESULTS: Four patients died within 10 days after the diagnosis due to the delay in referring them to doctors. The most common symptoms leading to the detection was fever, followed by cough. DISCUSSION: Early diagnosis is the key to prevent early death and nosocomial infection of tuberculosis in nursing homes. A similar study will be useful at each health center or region to improve the tuberculosis control in nursing homes. CONCLUSION: Tuberculosis control programs in nursing homes should be strengthened. The staff of nursing homes should be trained for closer observations of the elderly about their health conditions such as fever and cough, and their early reference to physicians when such symptoms were observed. Two step tuberculin skin tests to the staff is also important for the contact investigations.     

Special problems in tuberculosis. Tuberculosis in the elderly and in residents of nursing homes, correctional facilities, long-term care hospitals, mental hospitals, shelters for the homeless, and jails

Now that tuberculosis is well controlled in most segments of our society, it is all too often forgotten as a disease that still plagues its less fortunate members. Thus, it may break out wherever persons are housed together for extended periods: for example, naval vessels (not discussed herein), nursing homes, prisons, jails, mental hospitals, chronic disease hospitals, juvenile detention facilities, and shelters for the homeless. It is the responsibility of the authorities operating any such facility to take the necessary precautions to prevent spread of tuberculous infection. This requires more than just keeping the facility clean; it requires the use of some technology--in this instance, in the form of performing tuberculin testing, taking chest radiographs of those who react positively, and treating appropriately those who are infected, whether they are already diseased or merely infected. It should not be forgotten that tuberculosis in any segment of the population endangers all citizens. If this disease is to be eliminated in America, special attention must be given to the segments of society in which both prevalence of infection and incidence of tuberculosis are still high. Probably the most efficient way to stop the spread of infection is through better control of the infection in institutions such as those described in this article.     

The risk of tuberculosis in transplant candidates and recipients: a TBNET consensus statement

Tuberculosis (TB) is a possible complication of solid organ and hematopoietic stem cell transplantation. The identification of candidates for preventive chemotherapy is an effective intervention to protect transplant recipients with latent infection with Mycobacterium tuberculosis from progressing to active disease. The best available proxy for diagnosing latent infection with M. tuberculosis is the identification of an adaptive immune response by the tuberculin skin test or an interferon-γ based ex vivo assay. Risk assessment in transplant recipients for the development of TB depends on, among other factors, the locally expected underlying prevalence of infection with M. tuberculosis in the target population. In areas of high prevalence, preventive chemotherapy for all transplant recipients may be justified without immunodiagnostic testing while in areas of medium and low prevalence, preventive chemotherapy should only be offered to candidates with positive M. tuberculosis-specific immune responses. The diagnosis of TB in transplant recipients can be challenging. Treatment of TB is often difficult due to substantial interactions between anti-TB drugs and immunosuppressive medications. This management guideline summarises current knowledge on the prevention, diagnosis and treatment of TB related to solid organ and hematopoietic stem cell transplantation and provides an expert consensus on questions where scientific evidence is still lacking.     

Infections and infection control among residents of eight rural Wisconsin nursing homes

During 1984 and 1985, an initial prevalence survey and six consecutive months of comprehensive prospective surveillance were conducted in eight rural Wisconsin nonproprietary nursing homes managed by eight nonprofit hospitals in the same communities. Our purpose was to define the infections in the residents and the infection control programs in the nursing homes. The initial prevalence survey analyzed the records of all 403 residents of the eight nursing homes. The average resident was 83.4 years old and had 3.4 chronic diseases noted on the chart. During this initial survey, 52 (12.9%) of the residents were found to have 56 active infections of all types. During six consecutive months of comprehensive surveillance in the eight nursing homes, 265 episodes of acute infection were found for an overall incidence of 10.7 infections per 100 resident months. Clusters of infection by site, pathogen, or month of onset were quite uncommon throughout the study. Susceptibility testing of organisms recovered from infections failed to reveal any clinically important resistance patterns. Because nursing homes are different in many respects from hospitals, appropriately modified definitions and infection control strategies are required for nursing homes and their residents.     

Meticillin-resistant Staphylococcus aureus among US prisoners and military personnel: review and recommendations for future studies

We reviewed published work examining the prevalence and risk factors for meticillin-resistant Staphylococcus aureus (MRSA) infection in two high-risk groups: prisoners and military enlistees. Significant risk factors for infection included prison occupation, gender, comorbidities, prior skin infection, and previous antibiotic use. Although characteristics such as hygiene, physical contact, and crowding were postulated as risk factors for MRSA infection, there were few epidemiological studies supporting these factors. Most studies identified were retrospective in design and only one study used prospective surveillance for MRSA colonisation among all individuals residing within a single military setting. Our results suggest that there is a high incidence of MRSA infection among individuals in prisons and military settings, but surveys that quantify the prevalence of MRSA colonisation among individuals living within these specialised settings are needed. A thorough examination of MRSA acquisition and transmission patterns in prisons and military settings could help elucidate preventive strategies in other crowded and closed settings.     

Prevalence of tuberculous infection and active tuberculosis in old age homes in Hong Kong

OBJECTIVES: To assess the prevalence of tuberculous infection and active tuberculosis (TB) in old age homes in Hong Kong and to determine whether there is institutional transmission in these homes. DESIGN: Cross-sectional. SETTING: Old age homes. PARTICIPANTS: Total of 2,243 residents, representing 84.6% of all residents in 15 old age homes; 1,698 were women, and 545 were men, with an average age of 82. MEASUREMENTS: All residents had a questionnaire-based interview, medical record review, two-stage tuberculin testing using two units purified protein derivative-RT23, and a chest x-ray. Those with radiological abnormalities had sputum examined for acid-fast bacilli. RESULTS: The estimated prevalence rate of active TB in this population was 669 per 100,000, significantly higher in men than in women (1,101 per 100,000 vs 530 per 100,000). The proportion with positive tuberculin reactivity (> or =10 mm induration) after two-stage testing was 68.6%, significantly higher in men than in women. There was no evidence of active transmission of disease in these old age homes, with restriction fragment length polymorphism (RFLP) analysis performed on five cases of active pulmonary TB in the home with the highest rate of TB showing unique RFLP patterns. CONCLUSION: The rate of active TB and TB infection in old age homes in Hong Kong is still high. Because treatment for latent TB carries a high risk for liver dysfunction in this population, clinicians and other healthcare workers need a high index of suspicion and to diagnose and treat this disease as early as possible to prevent transmission.     

Factors influencing health care workers' adherence to work site tuberculosis screening and treatment policies

BACKGROUND: Despite the known risk of tuberculosis (TB) to health care workers (HCWs), research suggests that many are not fully adherent with local TB infection control policies. The objective of this exploratory study was to identify factors influencing HCWs' adherence to policies for routine tuberculin skin tests (TSTs) and treatment of latent TB infection (LTBI). METHODS: Sixteen focus groups were conducted with clinical and nonclinical staff at 2 hospitals and 2 health departments. Participants were segmented by adherence to TST or LTBI treatment policies. In-depth, qualitative analysis was conducted to identify facilitators and barriers to adherence. RESULTS: Among all focus groups, common themes included the perception that the TST was mandatory, the belief that conducting TSTs at the work site facilitated adherence, and a general misunderstanding about TB epidemiology and pathogenesis. Adherent groups more commonly mentioned facilitators, such as the perception that periodic tuberculin skin testing was protective and the employee health (EH) provision of support services. Barriers, such as the logistic difficulty in obtaining the TST, the perception that LTBI treatment was harmful, and a distrust of EH, emerged consistently in nonadherent groups. CONCLUSIONS: This information may be used to develop more effective interventions for promoting HCW adherence to TB prevention policies. Informed efforts can be implemented in coordination with reevaluations of infection control and EH programs that may be prompted by the publication of the revised TB infection control guidelines issued by the Centers for Disease Control and Prevention in 2005.     

Tuberculosis and multidrug resistance in Zambian prisons, 2000-2001.

BACKGROUND: Data on prevalence of tuberculosis (TB) and multidrug-resistant tuberculosis (MDR-TB) in Zambian prisons are lacking. METHODS: Between January 2000 and July 2001, a case-finding study was performed in 13 Zambian prisons for pulmonary TB. Prisoners were administered a questionnaire to obtain demographic information. Information regarding housing density and diet was also collected. Three consecutive first morning sputum specimens were cultured for Mycobacterium tuberculosis. Antimicrobial resistance testing was performed by the resistance ratio method. RESULTS: A total of 1080 prisoners were recruited: 1055 were males and 25 females. Sputum from 245 (22.7%) prisoners yielded M. tuberculosis, including 168 (15.6%) with smear-positive disease. Based on a total prison population of 6118, the minimal prevalence of TB was 4.0%. There was a linear relationship between the proportion of prisoners evaluated and the prevalence of TB (R(2) = 0.9366) across facilities, suggesting that the true prevalence of TB may approach 15-20%. Resistance to at least one anti-tuberculosis drug was detected for 40 (23.8%) isolates, while MDR-TB was identified for 16 (9.5%) isolates. CONCLUSION: There is a high rate of pulmonary TB in Zambian prisons, with significant rates of drug resistance and MDR-TB, highlighting the need for active surveillance and treatment programs.     

非活动性肺结核人群的流行病学特征和预防干预

Houben博士等利用高斯过程回归模型估算我国约有3.5亿人感染结核分枝杆菌(MTB),是世界上MTB感染负担最重的国家之一。2020年,世界卫生组织发布的《结核病综合指南:预防性治疗》中提出“有既往结核病史或者非活动性肺结核病灶者因有更高的发病风险也应该成为暴露后干预的目标人群”。美国和加拿大等国家均将提示有既往肺结核病史的肺部纤维化病灶人群作为潜伏性结核感染检测和治疗的目标人群。目前,我国暂未对有非活动性肺结核人群进行系统干预。考虑到结核病高负担国家和地区可能同样存在较重的非活动性肺结核负担,针对这一高危人群开展活动性结核病的常规监测和早诊早治,并对潜伏性结核感染者开展预防性干预将可能对降低社区发病率做出重要贡献。     

Epidemiology and preventive intervention of inactive tuberculosis

Houben博士等利用高斯过程回归模型估算我国约有3.5亿人感染结核分枝杆菌(MTB),是世界上MTB感染负担最重的国家之一。2020年,世界卫生组织发布的《结核病综合指南:预防性治疗》中提出“有既往结核病史或者非活动性肺结核病灶者因有更高的发病风险也应该成为暴露后干预的目标人群”。美国和加拿大等国家均将提示有既往肺结核病史的肺部纤维化病灶人群作为潜伏性结核感染检测和治疗的目标人群。目前,我国暂未对有非活动性肺结核人群进行系统干预。考虑到结核病高负担国家和地区可能同样存在较重的非活动性肺结核负担,针对这一高危人群开展活动性结核病的常规监测和早诊早治,并对潜伏性结核感染者开展预防性干预将可能对降低社区发病率做出重要贡献。     

An outbreak of Severe Acute Respiratory Syndrome in a nursing home: Lessons to learn

Hong Kong experienced an epidemic of Severe Acute Respiratory Syndrome (SARS) from March to June 2003. Nursing homes were a potential area of cross-infection because of the crowded living space, substandard environmental hygiene, inadequate ventilation, low working staff to resident ratio, and staff who lacked knowledge of infection control. The mortality in elderly SARS patients was high because of their atypical presentations, their multiple comorbidities, and that they are more susceptible to the side-effects of treatment. The community geriatric assessment team need to work closely with the hospitals and the primary health care system to provide surveillance of the disease, infection control, and management of sub-acute clinical problems, in order to reduce unnecessary hospital admissions in nursing home residents during an epidemic outbreak.     

The association between environmental factors and tuberculosis infection among household contacts

A cross-sectional study was conducted to determine the association between environmental factors and tuberculosis infection among household contacts aged less than 15 years in Bangkok, Thailand, between May and December 2003. During the study period, 480 household contacts aged under 15 years were identified. The prevalence of tuberculosis infection among household contacts was 47.08% (95% CI = 42.60-51.56). A generalized estimating equation (GEE) indicated that the risk of positive tuberculin skin testing in household contacst was found to increase with household crowding. Children living in a crowded household were five times more likely to have tuberculosis infection (OR = 5.19, 95% CI = 2.65-8.69). The association between environmental factors and tuberculosis infection assists community tuberculosis staff in understanding the risks for tuberculosis infection in the community and planning appropriate preventive actions based on this risk.     

Tuberculosis in patients with human immunodeficiency virus infection

Tuberculosis (TB) is the major opportunistic infection of human immunodeficiency virus (HIV)-infected persons worldwide. Human immunodeficiency virus infection is the most potent known risk factor for reactivation of latent Mycobacterium tuberculosis infection, and TB disease appears to increase the rate of HIV progression. Pulmonary disease is seen in most patients, including a large proportion of those with extrapulmonary disease. Failure to suspect TB and to order the appropriate diagnostic tests is the most common reason for diagnostic delays. With advancing HIV infection, tuberculin skin test reactivity decreases along with reactivity to nonspecific antigens such as mumps, tetanus toxoid, and Candida; anergy testing need not be a routine component of tuberculosis screening of HIV-infected persons. The diagnosis depends on identifying the organism on smears or cultures; direct amplification tests may facilitate rapid identification of M. tuberculosis, but the relatively low sensitivity in smear-negative specimens limits their use. Also, these tests must be used in conjunction with the clinical assessment, and they must always be performed in conjunction with microscopy and standard culture. Shorter courses of combination preventive therapy of patients with latent tuberculous infection are effective, but the potential advantages of improved adherence and reduced costs of shorter courses should be balanced with an increased risk secondary to ongoing TB exposure in areas with a high TB prevalence. Six months of treatment for active tuberculosis is recommended, unless the response of a particular patient is slow or otherwise suboptimal. The use of highly active antiretroviral therapy (HAART) made a remarkable impact on the course or HIV disease, but raises several issues with respect to HIV-related TB. Drug interactions necessitate either a non-rifamycin-based regimen or a rifabutin-based regimen in patients on HAART treated for TB.     

Nosocomial infection of scabies in national hospitals and sanatoria in Japan

The aim of this study was to investigate cases of nosocomial infection of scabies in the national hospitals in Japan. Questionnaires sent to 183 hospitals and sanatoria were returned by 93. Fifty-three cases in 24 institutions of nosocomial infection were reported in the past 5 years. No nosocomial infection was reported from 7 sanatoria for Hansen's diseases where the patients were relatively older and had higher ADL scores. It took 7.5 weeks on the average to eliminate nosocomial infection and more than 8 weeks were required to control them in the hospitals where more than 10 cases had occurred. Benzyl benzoate, gamma benzene hexachloride, and Pyrethroids, which were not approved as drugs for the treatment of scabies in Japan, were used in the all institutions where nosocomial infection occurred except for one institution. Problems to be solved were as follows; (1) delay of diagnosis and treatment, (2) lack of nursing staff, (3) difficulties of complete isolation due to lack of spaces, inability of patients to understand the need for isolation and also the psychological instability of the isolated patients, (4) recurrence due to the use of ineffective drugs, (5) insufficient information about the prevalence of scabies in the previous institutions, (6) misdiagnosis of non-scabies patients with itchy skin rash as the scabies, (7) inconsisitent care due to poor evaluation of skin lesions.     

Tuberculosis in travellers

Tuberculosis (TB) incidence is increasing in many countries which are popular with international travellers. The development of active TB is a two-stage process; the risk of acquiring new TB infection depends primarily on the risk of contact with an individual with infectious TB, and the risk of disease on the immune status of the newly infected person. The risk of TB infection is low for most holiday-makers, but among long-term travellers to countries with high TB incidence, the risk may be similar to that experienced by the local population (0.5-2.5% per year); the risk to people working in health care is particularly high. Effective pre-travel advice involves assessing the traveller's risk of TB infection and disease. Recommendations on the prevention of TB in travellers vary between countries. Possible strategies include avoidance of exposure; BCG vaccination; and tuberculin skin testing before and after travel, with preventive therapy for those whose post-travel skin tests indicate recent infection. For those at highest risk of progression to disease, there may be value in preventive therapy during travel to reduce the risk of new TB infection. Further information on the contribution of recent travel to incident TB in industrialised countries would be valuable.     

Tuberculosis vaccination versus isoniazid preventive therapy: a decision analysis to determine the preferred strategy of tuberculosis prevention in HIV-infected adults in the developing world.

SETTING: The developing world. OBJECTIVE: To compare the strategy of TB vaccination with that of tuberculin skin-testing in conjunction with isoniazid (INH) in preventing tuberculosis in HIV-infected persons. For any clinical scenarios in which immunization would be more effective than INH preventive therapy, to determine the minimum necessary vaccine safety and effectiveness required. DESIGN: Decision analysis. A hypothetical cohort of 10000 HIV-infected persons, 65% of whom were tuberculin positive, living in the developing world, was studied. Probability estimates were based on BCG vaccine for the baseline analysis, and it was assumed that the vaccine cannot protect if given after infection. RESULTS: Under the probability estimates and assumptions of the analysis, tuberculin skin testing/INH preventive therapy would prevent 458 more cases of TB and 45 more deaths due to TB than TB vaccination. One- and two-way sensitivity analyses revealed no thresholds at which TB vaccination would be the preferred strategy. Vaccine safety did not impact the outcome of the analysis. Three-way sensitivity analysis revealed that if the prevalence of anergy were 35% and the risk of progression to active TB among anergic persons 12.2 cases per 100 person-years, a vaccine would have to be at least 87% effective to be preferred over INH preventive therapy. CONCLUSIONS: Under the conditions of the analysis, which did not account for cost or logistics, tuberculin skin testing/INH preventive therapy would be more effective than TB vaccination in preventing TB among HIV-infected persons. The hypothesized TB vaccine would prevent more TB than INH preventive therapy only in areas where the prevalence of anergy and risk of active TB if anergic were high, and vaccine effectiveness exceeded 87%.     

Investigation on preventive measures of tuberculosis infection and onset of tuberculosis in nursing homes for the aged

The need to strength on preventive measures of tuberculosis infection in Japanese medical institutions (include nursing homes) has been discussed in recent several years. The actual performance of measures to prevent the spread of tuberculosis infection among employees in hospitals has gradually become clearer, and various trials to improve the performance have simultaneously been made. However, actual performance of these preventive measures has not yet become clear in nursing homes for the aged. Therefore, we assessed actual status of preventive measures of infection and the incidence of tuberculosis among employees and residents in nursing homes for the aged where there are many elderly persons who are almost bed ridden, and we intended to solve problems in preventive measures for tuberculosis in welfare facilities for the aged. Measures to prevent infection were well considered in a few facilities, but these measures were in general not sufficient. The incidence of tuberculosis among employees and residents were lower compared with these in the age-matched general population, however, it could be possible that there was no responses from the welfare facilities where outbreak of tuberculosis was present. We outlined the essential points for concrete measures to prevent tuberculosis infection in nursing homes for the aged.     

Provider-initiated diagnostic HIV counselling and testing in tuberculosis clinics in Thailand

SETTINGS: Twelve large public hospitals geographically distributed in Thailand. OBJECTIVES: To assess the uptake of diagnostic human immunodeficiency virus (HIV) counselling and testing (DCT), HIV prevalence in tuberculosis (TB) patients and HIV services provided to newly diagnosed HIV-infected TB patients. METHOD: We provided DCT in TB clinics to newly registered TB patients. Post-test counselling was provided at TB clinics for non-HIV-infected patients and at HIV voluntary counselling and testing centres for HIV-infected patients. HIV-infected patients were referred for HIV-related care during TB treatment. RESULTS: From July to October 2006, 8% of 1086 new TB patients were known to be HIV-infected at the time of TB diagnosis. Of 1000 patients with unknown HIV status, 93% were tested: HIV infection was diagnosed in 11%. Including patients with previously diagnosed HIV infection, 17% of all TB patients were HIV-infected. Of 99 newly diagnosed HIV patients, 36% received cotrimoxazole prophylaxis. Of 41 with CD4 < 200 cells/microl, 42% began antiretroviral treatment during TB treatment. CONCLUSION: The acceptance of DCT was high, but the provision of HIV services was disappointingly low. Increased staff capacity building, stronger coordination with the acquired immune-deficiency syndrome programme and better field supervision are needed to achieve universal access to care for HIV-infected TB patients.     

Risk factors for and knowledge of Mycobacterium tuberculosis infection among drug users in substance abuse treatment

Objective. To determine the prevalence, incidence and risk factors for Mycobacterium tuberculosis infection, as well as to assess TB knowledge and attitudes, among a group of known drug users in a city with low TB incidence (11.3 per 100 000 in 1995). Methods. Patients of an urban drug treatment facility enrolled in opioid substitution, opioid antagonist and other drug treatment programs were screened for TB, including tuberculin skin testing and standardized data collection on TB risk factors. A subsample of clients was interviewed about TB knowledge and attitudes. Results. Between 1 June 1995 and 31 May 1996, 1055 individuals were screened. The prevalence of infection was 15.7% (CI: 13.2-18.2%). PPD positivity was associated with older age (per annum, OR = 1.08, CI: 1.05-1.11), non-white race (OR = 2.81, CI: 1.72-4.60), foreign birth (OR = 4.24, CI: 2.35-7.62) and a history of injecting drug use (OR = 1.89, CI: 1.14,3.12). The incidence of infection was 2.9 per 100 person-years (CI:1.8-4.7). Thirty-two per cent of 79 drug users interviewed about TB knowledge and attitudes thought TB could be prevented by bleaching or not sharing needles/syringes. Fifty-one per cent thought anyone with a positive TB skin test was contagious. Conclusion. M. tuberculosis infection was common in this population and associated with injecting drugs and several demographic factors. The incidence of new infection was relatively low. In this non-endemic environment, the detection and treatment of latent infection are important aspects of TB control. Misconceptions about TB transmission were also widespread in this population. Drug treatment programs can play a key role by undertaking screening programs that educate about TB and identify infected subjects who would benefit from preventive therapy.     

Prevalence and characteristics of nursing home-acquired infections in the aged.

OBJECTIVES: This study provides estimates of the prevalence of infections in all patients from a representative sample of 53 Maryland nursing homes; identifies risk factors for these infections; and describes diagnostic procedures carried out. METHODS: The records of 4,259 patients in a stratified random sample of 53 Maryland nursing homes were reviewed for diagnostic procedures, medical, functional, and behavioral status. Infections were identified by signs, symptoms, and laboratory findings. RESULTS: Study patients were characteristic of aged patients in US nursing homes. The prevalence of infections actually acquired in the nursing home (80% of all infections) was 4.4%. Multivariate analysis revealed that skin infections (35% of nursing home-acquired infections) were associated with skin ulcers and inversely with urine incontinence. Fevers of uncertain source (13%) were associated with bladder catheters. Symptomatic urinary infections (12%) and lower respiratory infections (12%) were associated with bedfast status, and the latter with tracheostomy and lung disease. Skin ulcers, urethral catheters, and bedfast status were markers for nursing home-acquired infection. The prevalence of infection in patients with all three markers was 32%; in patients with none, 2%. Fewer than a quarter of the four most common nursing home-acquired infections received an evaluation which met minimal diagnostic criteria established by a panel of infectious disease specialists and geriatricians. Patients with dementia, those in large homes (greater than 150 beds), and those in urban homes were less likely to be evaluated in a manner meeting these criteria. CONCLUSIONS: Use of three characteristics (ie skin ulcers, urethral catheters, bedfast status) to identify patients at risk for nursing home-acquired infections may allow targeted infection surveillance and prevention programs. In addition, nursing home-acquired infections are not evaluated uniformly across patients and facilities, suggesting the need to establish, through further study, guidelines for such evaluations.