Nurse dies of TB, infects patients

Virginia case highlights ongoing TB risks

The death of a Virginia nurse who ignored her symptoms of tuberculosis for months and continued to work serves as a cautionary reminder for hospitals and health care workers: TB remains a risk in many states. Untreated infection can lead to a TB outbreak and even death. And health care workers who go to work sick may be endangering their patients.

The nurse worked part time at Chesapeake General Hospital on medical-surgical ward, primarily caring for orthopedic patients, says Chesapeake Health Department director Nancy Welch, MD, MHA, MBA. Many of them were elderly patients admitted for hip replacements.

The nurse’s annual TB skin test was negative in May 2003, but by that fall, she had a persistent cough. She thought it was related to her smoking and did not seek medical care, Welch says.

Yet she had active tuberculosis, and by that fall, the nurse already was unknowingly infecting patients, according to skin test results. As her health declined, she quit work April 6. By the time the nurse was hospitalized in June, her disease had advanced and treatment was not effective. "She was in the hospital for less than two weeks from time of admission to time of death," Welch notes.

The health department immediately began notifying patients, visitors, and others, such as hospital volunteers, who had contact with the nurse. As of July 20, the health department had conducted 2,107 skin tests and more than 300 chest X-rays, Welch continues. Of the 1,859 who returned for a reading of the skin test, 112 tested positive, she says.

That included 210 Chesapeake General Hospital associates — co-workers, physicians, volunteers, students, and contractors. Seven of those tested positive, according to the health department. One employee was identified with asymptomatic disease and is receiving treatment, Welch adds.

The health department expanded its testing to include people who had contact with the nurse as early as July 2003. "We found both patients and visitors who were there in the first week of October who became positive [in TB skin tests]," she explains. "That tells us that she was highly contagious and we did not go back far enough [with testing]."

Epidemiological evidence indicates that the nurse did not contract the disease from a patient at the hospital, Welch says.

While this case is unusual, it is not the first time a health care worker with TB has exposed patients. Last year, a physician in Duluth, MN, continued to work despite a persistent cough. He later learned that he had active TB. About 200 patients were tested but none had a positive skin test.

Although TB rates have declined steadily for 10 years, rates actually rose in 18 states last year, notes Lee Reichman, MD, MPH, executive director of the National Tuberculosis Center at the University of Medicine and Dentistry of New Jersey in Newark and author of Timebomb: The Global Epidemic of Multi-Drug Resistant Tuberculosis (McGraw Hill, 2001). Worldwide, TB kills more people than any other infectious disease, he says.

"Two million to 3 million people a year die of TB in the world, which of course, is a paradox. It’s totally preventable and curable," Reichman says.

"[This incident] raises attention to the fact that TB is still with us. TB still kills. It doesn’t only affect poor people or minority people in foreign countries," he adds.

When employees convert on a TB skin test, hospitals should encourage them to receive treatment for latent infection, Reichman points out. "We’re skin testing to find people to treat to keep them from getting TB. We’re not skin testing them just to see who converts."

Meanwhile, hospitals should continue to educate health care workers about the importance of staying home from work if they’re sick, public health officials say.

"We are guilty of denial in the health care field," Welch adds. "That’s a common malady, unfortunately, among health care workers. This is a reminder that we are human and we need to impose the same precautions on ourselves that we would for anyone else."

Donald Buckley, PhD, Chesapeake General Hospital president and CEO, notes that employees need to take responsibility for not coming to work sick. The hospital had numerous policies related to employee illness, TB skin testing, and TB infection control. But the hospital also is conducting a root-cause analysis to examine the incident, he adds.

The hospital benefited from a close working relationship with the local health department, Buckley says.

The incident also illustrates the importance of good communication, he notes. The hospital has a strong relationship with the public health department, which allowed employee health and infection control professionals to work closely with public health to address the issues, Buckley adds.

The hospital also took a proactive approach with the press, calling press conferences and providing daily updates, he points out. Providing information to a worried public is an important part of the hospital’s response, he says. "We brought in a state specialist on TB, and we set up call lines so anybody with a question could call in."