A cautionary tale: Why you should ‘think TB’
Hospital occupational health program misses signs in screening
An employee health nightmare unfolded in El Paso, TX, last year when a patient care technician with active tuberculosis spent months bathing and caring for newborns before she discovered the source of her cough and fatigue. Some 853 babies needed to be tested. At least two developed latent TB infection related to the exposure.
The incident underscores the importance of annual screening of employees with latent TB infection — and of detecting symptoms between those annual screenings, says Lisa Y. Armitige, MD, PhD, medical consultant with the Heartland National TB Center in San Antonio, TX, who provided assistance in the El Paso case.
The bottom line: “Any employee who has a cough for more than three weeks should be evaluated in occupational health,” Armitige says.
Paradoxically, detecting TB becomes a greater challenge as the number of U.S. cases declines, notes Rachel Stricof, MPH, a consultant with the Council for State and Territorial Epidemiologists.
“We only are concerned when we start seeing transmission. Then [when TB spread subsides], we go into complacency,” says Stricof, who previously oversaw TB control at the New York State Department of Health. “And it inevitably resurfaces. We really cannot stop thinking [of] TB when we see that cadre of symptoms.”
According to the Centers for Disease Control and Prevention, symptoms of active TB include a bad cough lasting three weeks or more; pain in the chest; coughing up blood or sputum from deep in the chest; weakness or fatigue; lack of appetite; weight loss; fever and night sweats.
‘No definitive diagnosis’ — and no chest X-ray
The patient care tech, who worked in the post-partum unit of Providence Memorial Hospital in El Paso, began having symptoms in December 2013. She felt fatigued and had a “productive” cough, but although she’d had a positive TB test more than 10 years earlier, no one suspected tuberculosis, according to findings of the Texas Department of State Health Services.
On July 2, the employee came to Occupational Health for her annual tuberculosis screening. She told the occupational health nurse that she was being seen by a private physician for her cough and fatigue, but “no definitive diagnosis had been determined,” according to the report. She apparently received no chest X-ray nor follow-up by the employee health department.
The chief nursing officer later told public health authorities that she had met with the employee and never observed her coughing and that the symptoms were attributed to allergies.
On August 21, a test at her physician’s office was positive for TB; the patient care tech had last worked on August 16. She notified her supervisor, and the hospital began working with local public health authorities on an exposure investigation. None of the employee’s coworkers developed TB infection.
An unresolved cough of any origin should be addressed with further follow-up, says Armitige. She also notes that a cough from allergies would be non-productive — a dry cough from post-nasal drip. “If I had a patient with a cough for more than three weeks and even one of those [other TB] symptoms, that’s a red flag,” she says.
There are other reasons why health care workers sometimes minimize the significance of a cough. In one case, a Virginia nurse developed a persistent cough but thought it was due to her smoking. By the time she was diagnosed, the tuberculosis had advanced beyond treatment and she died. In that case, about 1,700 patients, visitors, and co-workers were evaluated for tuberculosis. (See HEH, September 2004, page 114.)
Even a “smoker’s” cough warrants a chest X-ray, Armitige says. “I would be worried about cancer as much as I am worried about TB,” she says.
Costs mount to test, treat after exposures
Undetected tuberculosis is very disruptive and costly for hospitals. On September 18, the Center for Medicare & Medicaid Services declared that Providence Memorial’s deficiencies presented an “immediate jeopardy to patient health and safety.” As part of an action plan, Providence Memorial Hospital revised its policies. Health care workers with a positive TB test and TB symptoms will not be able to return to work until they have received a further follow-up, including a chest X-ray, and medical clearance, the hospital said.
The policy applies to employees, contractors, volunteers, and anyone else working in patient care areas.
Meanwhile, the chief nursing officer oversaw an audit of all health care worker files to make sure they had complied with TB screening. Infection Prevention and Control will continue to audit 30 random health files every month for at least six months to ensure 100% compliance, the hospital said in its plan. Occupational health nurses are required to complete online CDC training and to take re-training annually.
By the end of December the hospital had paid more than $260,000 to the city of El Paso for public health costs, including notification, testing and treatment of babies, the El Paso Times reported.
After another inspection, CMS fully restored the hospital’s “deemed” status. “The past few months have been trying, but I am confident that we will emerge from this an even better organization,” CEO J. Eric Evans said in a statement. “We take personally our obligation to care for our community, and we are relentlessly focused on protecting the health and wellbeing of those we are privileged to serve.”
The El Paso case may prompt discussions about the treatment of latent TB infection. Each case must be evaluated carefully, says Stricof. For example, while typically the risk of developing active TB is greatest in the first few years after infection, a health care worker may develop a health condition that compromises the immune system and raises the risk of active TB over time, she says.
TB blood tests are more specific than the skin tests, which may convince some health care workers who received the BCG vaccine that the positive result is a valid one. New, shorter regimens make it easier for patients to complete the treatment — and more likely they will accept it in the absence of active infection, says Armitige.
“With TB, you keep one person safe [through treatment] and you keep all the people around them safe,” she says.
An employee health nightmare unfolded in El Paso, TX, last year when a patient care technician with active tuberculosis spent months bathing and caring for newborns before she discovered the source of her cough and fatigue. Some 853 babies needed to be tested. At least two developed latent TB infection related to the exposure.
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