Where are we in tuberculosis infection control?

Abstract

This month's issue of Infection Control and Hospital Epidemiology is devoted to the subject of tuberculosis (TB) and its control in healthcare settings. Few other recent problems in hospital epidemiology have had the impact upon infection control practices and have caused the degree of concern and consternation evoked by the initial reports of nosocomial outbreaks of TB in institutions in Puerto Rico, Miami, and, most dramatically, in New York City and the New York State prison system.1-6 Most of these outbreaks have been characterized by a high attack rate involving human immunodeficiency virus (HIV)-positive patients, with alarming morbidity and mortality. In many of the institutions, the isolates of Mycobacterium tuberculosis were resistant to both isoniazid and rifampin, the two leading agents used for the treatment of TB; hence, the name multidrug-resistant (MDR)-TB. While reports of TB outbreaks in healthcare facilities have paralleled the resurgence of TB in the community, principally in urban areas where public health and community TB control efforts had been neglected, the use of molecular typing techniques has made clear that transmission within a healthcare facility of a single unique strain of TB can occur with remarkable ease. While the intrainstitutional transmission of TB is hardly new, and the risk to healthcare workers from institutional spread of TB was recognized long ago, the magnitude of these recent outbreaks and the degree to which such outbreaks could proceed unchecked, involving both patients and healthcare workers, have caused understandable alarm among patients and workers about the safety of receiving or providing health care in such institutions. Furthermore, the fact that such outbreaks could extend to healthcare workers (with reported tuberculin skin-test conversion rates in some institutions ranging from 33% to 50%) has led to charges of i difference on the part of the infection ontrol commu ity and hospital administrators to the risks f healthcare workers in caring for patients with active TB. These concerns prompted several labor unions to petition the Occupational Safety and Health Administration (OSHA) to issue a temporary emerg ncy standard to protect healthcare workers. To date, the activities of OSHA in the field of TB have been limited to the issuance of a compliance directive and memorandum to its regional offices and state programs regarding the essentials of a TB control program, operating under its general duty clause to ensu a safe work place. A more comprehensive TB and respiratory pathogen control standard (similar to that developed for bloodborne pathogens) is expected to be issued by OSHA later in 1995. To assess the status of existing TB control measures in US hospitals, Fridkin et al7'8 provide a two-part report of responses to a questionnaire developed in collaboration with SHEA, examining the status and efficacy of TB control programs between 1989 and 1992. Not surprisingly, there was a wide disparity in the degree to which institutions were in compliance with the guidelines for the control of no o omial transmission of TB promulgated by the Centers for Disease Control and Prevention (CDC) in 1990.9 Interestingly, despite the controversy and confusion over recommended means of respiratory protection, the survey indicated that by 1992 an increasing