LETTER
Nosocomial Transmission of Tuberculosis
Jordan B. Glaser, MD;
Carol Bosholm, MD; and
Dorothy Minucci, RN
1 October 1995 | Volume 123 Issue 7 | Pages 551-552
TO THE EDITOR:
We read with interest the recent article by Maloney and colleagues [1]. We have detected a similar increase and decrease in cases of multidrug-resistant tuberculosis at our institution; however, our experience contrasts with those described in their group's recent and previous articles [2]. The annual multidrug-resistant tuberculosis rates at our institution were 0 of 7 cases (0%) in 1990, 2 of 17 (12%) in 1991, 11 of 24 (46%) in 1992, 4 of 28 (15%) in 1993, and 4 of 22 (18%) in 1994. A significant increase (P < 0.05) and decrease (P < 0.04) for trend (chi-square test) was centered on 1992.
We are not convinced that the increase and decrease in drug-resistant tuberculosis rates seen in our institution were related to a hospital-based outbreak with subsequent initiation of improved control measures. Our employee tuberculin skin-test conversion rate has remained below 1% since 1990. Numerous reverse air-flow rooms have been available, and there has been a low threshold for isolating persons at risk for multidrug-resistant tuberculosis. Known exposures have mainly involved elderly persons with drug-sensitive tuberculosis, a finding described at another institution [3]. The decline of multidrug-resistant tuberculosis seen at our institution may have been related to improved community-based treatment programs [4]. Indeed, many patients with multidrug-resistant tuberculosis had received previous treatment with antituberculous medications (48%), which suggests acquired drug resistance rather than nosocomial infection.
Eighty-one percent of patients with multidrug-resistant tuberculosis had a history of ethanol or intravenous drug use, 48% were white, and 33% had private insurance. This finding is consistent with the demographic characteristics of Staten Island (population, 400 000), a predominantly white middle-class borough of New York City, and with our previous finding of a $43 000 median household income among HIV-infected intravenous drug users who live in Staten Island and have steady heterosexual partners [5]. Approximately 22 000 of the 200 000 intravenous drug users in New York State have an annual income of more than $25 000 [5]. Our experience shows that cases of multidrug-resistant tuberculosis will not remain confined to inner-city areas and reinforces the need for both institutionally based control measures and community-based, directly observed therapy programs in contiguous suburban areas.
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Author and Article Information
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Staten Island University Hospital; Staten Island, NY 10305
1. Maloney SA, Pearson ML, Gordon MT, Del Castillo R, Boyle JF, Jarvis WR. Efficacy of control measures in preventing nosocomial transmission of multidrug-resistant tuberculosis to patients and health care workers. Ann Intern Med. 1995; 122:90-5.
2. Pearson ML, Jereb JA, Frieden TR, Crawford JT, Davis BJ, Dooley SW, et al. Nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis. A risk to patients and health care workers. Ann Intern Med. 1992; 117:191-6.
3. Mathur P, Sacks L, Auten G, Sall R, Levy C, Gordin F. Delayed diagnosis of pulmonary tuberculosis in city hospitals. Arch Intern Med. 1994; 154:306-10.
4. Weis SE, Slocum PC, Blais FX, King B, Nunn M, Matney B, et al. The effect of directly observed therapy on the rates of drug resistance and relapse in tuberculosis. N Engl J Med. 1994; 330:1179-84.
5. Glaser JB, Strange TJ, Rosati D. Heterosexual human immunodeficiency virus transmission among the middle class. Arch Intern Med. 1989; 149:645-9.
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