Abstract
To investigate a cluster of newly identified tuberculosis infections. A field study was conducted including interviews; medical record reviews; checking of bills and invoices, pharmacy records, and drug manufacturer information; and clinical retesting. Community residential facilities providing comprehensive services to retarded adults. Twenty residential facility staff (not previously known to be purified protein derivative [PPD] positive). Staff had been tested with 250 TU of PPD, and 9 of 20 were tuberculin positive. Retesting with 5 TU yielded no reaction. Reactions were attributable to testing with a product not recommended for routine PPD screening. Healthcare workers planting PPD Mantoux tests always should check the vials to ensure that the appropriate strength solution is being used.
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