Epidemiologic Notes and Reports
Tuberculosis in a Nursing Care Facility -- Washington
In November 1980, a 95-year-old female nursing home resident
was
found to have sputum smears positive for acid-fast bacilli. She
died
in December 1980, less than a week after beginning multiple drug
therapy for tuberculosis. Sputum culture results confirmed the
diagnosis of tuberculosis; the organisms were sensitive to all
antituberculosis drugs. Subsequently, 11 other individuals were
found
to have bacteriologically proven tuberculosis.
The index patient had been a resident of the nursing home since
November 1969. In 1975, she was examined as a contact of two
patients
with tuberculosis in the facility. She had a significant skin test
reaction and a normal chest radiograph. Preventive therapy with
isoniazid (INH) was not given. During the year before death, she
lost
52 pounds and was seen by a physician several times because of a
recurrent cough and "flu-like" symptoms. However, sputum
examination
for tuberculosis was not performed until November 1980.
The index patient lived in a 156-bed skilled nursing care
facility, which housed 139 other residents and had 118 employees.
Since 1975, skin testing recommended by state regulation had
identified 48 residents and 29 employees with significant skin-test
reactions. None of the residents was given INH preventive therapy.
Repeat skin testing of the other residents and employees in
December
1980 and January 1981 identified 59 (65%) of 91 residents and 38
(44%)
of 87 employees as newly infected. All those with new infections
were
started on preventive therapy with INH. Regular visitors to the
nursing home were not examined as contacts except those who
requested
testing in February 1981 after reports of the outbreak appeared in
a
local newspaper.
Chest radiographs were performed on all persons, including
visitors requesting examination, who had significant skin test
reactions. Eleven individuals who had suspicious films were found
to
have current pulmonary tuberculosis, all with sputum cultures
positive
for Mycobacterium tuberculosis. Seven of these patients were
residents of the facility, one was an employee, and three were
visitors of the facility. None of the seven residents shared
sleeping
quarters with each other or the index patient, but they did share
common hallway, activity center, and dining area space. The air
circulation system drew air from the residents' rooms, the activity
center, and dining areas, and expelled it through two vents at each
end of the hallway.
M. tuberculosis isolates from the index patient and the 11
other
patients were phage-typed at CDC. The index case had been
excreting
phage type 2. The same phage type was found in the sputum of five
other residents, the one employee, and one visitor. For the
preceding
year, this visitor had spent 2-3 hours per day in the room of one
of
the residents with phage type 2. Two other visitors, a husband and
wife, had phage type 5. The remaining two residents were infected
with phage type 7.
Reported by R Munger, MD, Chelan-Douglas Health District, K
Anderson,
R Leahy, MD, J Allard, PhD, JM Kobayashi, MD, State Epidemiologist,
Washington State Dept of Social and Health Svcs; Mycobacteriology
Section, Div of Bacterial Diseases, Center for Infectious Diseases,
Div of Tuberculosis Control, Center for Prevention Svcs, CDC.
Editorial Note
Editorial Note: This episode illustrates several aspects of
tuberculosis control. First, health workers, particularly those
serving high risk populations, such as those in nursing homes and
prisons, must consider a diagnosis of tuberculosis in a person with
chronic weight loss and respiratory symptoms (1,2). Early
diagnosis
of the index patient might have prevented some additional cases and
new infections. Second, existence of a skin-testing program for
nursing home employees and residents did not prevent the outbreak.
Infected persons at high risk of developing disease who are
identified
in screening programs must be given INH treatment to prevent
development of disease (3,4). Third, thorough and careful
investigation of close contacts should be performed whenever
exposure
to infectious tuberculosis occurs, and treatment or preventive
therapy
should be given when indicated (5). Investigation of contacts in
this
outbreak identified 11 additional tuberculosis cases and a large
number of newly infected persons, all of whom required treatment.
This report demonstrates the epidemiologic usefulness of phage
typing in tuberculosis outbreaks (6). In an outbreak of
drug-resistant tuberculosis in rural Mississippi, phage types
corresponded well with the history of contact between patients (7).
In this nursing home outbreak, the same phage type tubercle
bacillus
caused disease in the index case, five other residents, one
employee,
and a visitor, suggesting a common source for these infections.
The
other two visitors and two residents appear to have acquired
infection
from other sources. Phage typing of M. tuberculosis can be
performed
at CDC when circumstances suggest it may be useful in investigating
a
tuberculosis outbreak.
References
Stead WW. Tuberculosis among elderly persons: an outbreak in a
nursing home. Ann Intern Med 1981;94:606-10.
Stead WW. Undetected tuberculosis in prison. Source of
infection
for community at large. JAMA 1978;240:2544-7.
Kent DC, Atkinson ML, Eckmann BH, Hilman BC, McDonald RJ.
Screening for pulmonary tuberculosis in institutions. Am Rev
Respir Dis 1977;115:901-6.
Barlow PB, Black M, Brummer DL, et al. Preventive therapy of
tuberculous infection. Am Rev Respir Dis 1974;110:371-4.
Iseman MD, Bentz RR, Fraser RI, Locks MO, Ostrow JH, Sewell EM.
Guidelines for the investigation and management of tuberculosis
contacts. Am Rev Respir Dis 1976;114:459-63.
Jones WD Jr, Good RC, Thompson NJ, Kelly GD. Bacteriophage
types
of Mycobacterium tuberculosis in the United States. Am Rev
Respir
Dis 1982;125:640-3.
Reves R, Blakey D, Snider DE Jr, Farer LS. Transmission of
multiple drug-resistant tuberculosis: report of a school and
community outbreak. Am J Epidemiol 1981;113:423-35.
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