- Email: [email protected]
An outbreak of tuberculosis in infants due to hospital infection
AN O U T B R E A K OF T U B E R C U L O S I S I N I N F A N T S D U E TO H O S P I T A L I N F E C T I O N ALTON S. POPE, M.D. BOSTON, MASS.
infection of infants and children f r o m tuberculous nursemaids T orH E other ho~u~ehold employees has been f r e q u e n t l y recognized and in some communities has led to organized a t t e m p t s by pediatricians to secure routine examinations of all housemaids as a condition of employ-ment. A situation of even more serious potentialities is the infection of infants or children in hospital wards b y a nurse with open but unrecognized p u l m o n a r y tuberculosis. On account of the seriousness and the possible legal implications of such multiple infections and the infrequency of their recognition, it seems worth while to record a recent hospital outbreak of tuberculosis resulting f r o m exposure df i n f a n t s on the m a t e r n i t y w a r d of a general hospitai to a nurse with open tuberculosis. A t the end of J a n u a r y , 1940, the attention of the D e p a r t m e n t of Public H e a l t h was called to two eases of miliary tuberculosis in infants in a small city n e a r Boston. Since disseminated tuberculosis in children is now a rare condition in Massachusetts, the attending physician at once a t t e m p t e d to locate the source of infection. Roentgenologie examination of all members of the two families proved negative as did similar examination of the attending physician and of the milk man, both of whom were common to the two families. The milk s u p p l y proved to be adequately pasteurized. Because both infants were delivered in the same hospital within a month of each other, the investigation next t u r n e d to the hospital personnel who had been in direct contact with the babies. R o u t i n e x-ray examination of the nursing staff, including two nurses f o r m e r l y on the obstetrical service who had then left the hospital, showed that one of the reg~dar night nurses had an infiltrative process of the right u p p e r lobe, characteristic of p u l m o n a r y tuberculosis, and her s p u t u m was found to contain tubercle bacilli. X-rays of the Other nurses proved negative. This nurse h a d been employed at the hospital since March 15, 1939, and her duties included all care of infants in the n u r s e r y f r o m 11 P.M. to 7 A.M. She gave all night feedings but did not p r e p a r e the formulas. Hospital regulations required that she wear a mask and gown for all n u r s e r y duty. H e r history showed t h a t at the beginning of her training in 1936 she had had an x-ray of the chest which was reported negative. She had not been re-examined till the present time. Although she denied a n y recent illness, she admitted she had had a cough for the past six months. l~rom the Massachusetts D e p a r t m e n t of Public Health, Division of Tuberculosis. 297
298
THE
JOURNAL
OF P E D I A T R I C S
Investigation showed that pasteurized certified milk had been used in the p r e p a r a t i o n of all formulas given on this w a r d during the period in question. I n view of the possibility o~ widespread infeetion of the infants eared f o r in this hospital during' the period the nurse might have been excreting tubercle bacilli, arrailgements were at once made with the hospital authorities and the local board of health for the examination of as m a n y as possible of the infants delivered between March 1, 1939, and J a n u a r y 30, 1940. The parents of such babies were requested b y the hospital to bring t h e m in to elinies to be held at specified hours at the hospital, and the examinations were made during F e b r u a r y and March, 1940. A t the first visit an intracutaneous tuberculin test was performed, using 0.01 mg. of old tuberculin. The tests were read on the second visit fortyeight hours later and the children who failed to react were retested with 1.0 mg. A p p r o x i m a t e l y 100 tests were made by a pediatrician on the hospital staff. An x-ray of the ehest o~ all reactors was made. The results of the tuberculin test are given in Table I. TABLE
I
TUBERCULIN REACTIONS AMONG INFANTS EXPOSED TO TUBERCULOSIS INFECTION IN A I-Io SPITAL I~URSERY
Total infants delivered in hospital March 1, 1939, to January 30~ 1940 Total infants tested (February and Marctb 1940) Total reactors to Mantoux Test s Percentage of reactors among infants tested * I n c l u d i n g t w o b a b i e s w h o d i e d of m i l i a r y
506 426 26 69
tuberculosis.
TABLE I I INCIDENCE OF REACTORS BY M O N T H OF BIRTFI MAR.
5
APR.
~
~
MAY
~
-
JUNE
-
~
JULY
~
~
AUG.
-
-
SEPT.
-
f
-
OCT.
NOV.
-
-
~
-
DEC.
~
-
JAN.
~
TOTAL
26
Although a certain n u m b e r of i'nfants in the general population would be expected to react to the tuberculin test at a mean age of 8 months, the reaction rate obtained in this group, 6.1 per eent, is three times the rate f o u n d among children tested in Massachusetts Well B a b y Clinics, at a mean age of 21/2 years. I t should be added t h a t of the 506 babies born in the hospital during this period, 12 had died of causes other than tubereulosis, as confirmed by the death certificates, in addition to the 2 who died of m i l i a r y tuberculosis. To get an idea as to whether the infection of infants at this hospital took place at any p a r t i c u l a r t~me, the reactors were tabulated by month of birth 9 There is of course no way of determining which babies aequired their infection while in hospital, but Table I I suggests t h a t infection m a y h a v e been taking place there r a t h e r continuously during the period in question.
POPE:
OUTBREAK OF TUBERCULOSIS DUE TO H O S P I T A L I N F E C T I O N
299
Of the twenty-six i~fants who reacted to the tuberculin test, seven showed roentgenologic evidence of tuberculosis. Two, as previously stated, died of miliary tuberculosis and the diagnosis was confirmed by autopsy. Two more of these reactors were subsequently admitted to the Children's Hospital, Boston, the first in April, 1940, with a diagnosis of pulmonary tuberculosis, and the second in August with a diagnosis of tuberculous tracheobronchial nodes with atelectasis. Both recovered. The remaining three infants showed traeheobronchial lymph node enlargement characteristic of tuberculosis but have not deVeloped symptoms of disease. To rule out the possibility of familial infection, as m a n y as possible of the contacts of the reacting infants were x-rayed. Examinations were completed on all members of seven families, but no cases of active tuberculosis were found. The a t t e m p t was made to follow all reacting infants with periodic roentgenograms and to retest all negative reactors born in the hospital between November ], 1939, and J a n u a r y 30, 1940, when the infectious nurse was removed from the nursery. Lack of interest on the p a r t of parents has made it impossible to secure any considerable number of retests, and only ten of the reacting children were brought in for x-ray in March, 1941. At that time none showed any evidence of p u l m o n a r y disease. COMMENT
A epidemiologic outline is presented of an outbreak of tuberculosis in infants, traceable to exposure to a nurse with open tuberculosis in a hospital nursery. Although recognition of the excess incidence of tuberculosis in student nurses and medical students has resulted in special examinations and regulations for the protection of these groups in most of the better hospitals, little consideration has been given to the possibility of the infection of patients by tuberculous personnel. In view of the experience cited, it is obvious that the examination of nnrses shauld not stop with the completion of training and that the prevention of tuberculous infection of infants in the hospitM is a definite responsibility of the administrator, the obstetrician, and the pediatrician. The examination of nurses for tuberculosis, for the protection of their own health and that of their patients, should start with an intracutaneous tuberculin test and an x-ray of the chest at the beginning of training. Negative reactors should be retested every six months and kept under close observation for approximately two years after this test becomes positive, and all student nurses x-rayed at least once a year, and upon the development of any symptoms suggestive of respiratory disease. Oil obstetrical wards and in nurseries, especially, all nurses and attendants who come in contact with patients should have regular radiographic examination of the chest annually and also upon any special indication. Strict medical asepsis is of course essential in the
300
THE
J O U R N A L OF P E D I A T R I C S
operation of nurseries, but this should not be Mlowed to take the place of p r o p e r examination of the nurse herself, nor does it afford her the protection to which she is entitled. F r o m the clinical standpoint this experience emphasizes two points: (a) t h a t babies can be infected with tuberculosis during the earliest days of life, and (b) t h a t such infections in certain cases tend to progress rapidly and often result fatally. Finally, the diagnosis of tuberculous meningitis or of generalized tuberculosis in an infant or child should be the signal for an immediate, intensive search for the source of infection. On account of the great reduction in the general incidence of tuberculosis during the past f o r t y years, such massive infection in an i n f a n t or young child almost inv a r i a b l y points to an open case of tuberculosis in the family or among other immediate associates. The prevention of f u r t h e r infection as well as t r e a t m e n t of the initial case must always be kept in mind.
infection of infants and children f r o m tuberculous nursemaids T orH E other ho~u~ehold employees has been f r e q u e n t l y recognized and in some communities has led to organized a t t e m p t s by pediatricians to secure routine examinations of all housemaids as a condition of employ-ment. A situation of even more serious potentialities is the infection of infants or children in hospital wards b y a nurse with open but unrecognized p u l m o n a r y tuberculosis. On account of the seriousness and the possible legal implications of such multiple infections and the infrequency of their recognition, it seems worth while to record a recent hospital outbreak of tuberculosis resulting f r o m exposure df i n f a n t s on the m a t e r n i t y w a r d of a general hospitai to a nurse with open tuberculosis. A t the end of J a n u a r y , 1940, the attention of the D e p a r t m e n t of Public H e a l t h was called to two eases of miliary tuberculosis in infants in a small city n e a r Boston. Since disseminated tuberculosis in children is now a rare condition in Massachusetts, the attending physician at once a t t e m p t e d to locate the source of infection. Roentgenologie examination of all members of the two families proved negative as did similar examination of the attending physician and of the milk man, both of whom were common to the two families. The milk s u p p l y proved to be adequately pasteurized. Because both infants were delivered in the same hospital within a month of each other, the investigation next t u r n e d to the hospital personnel who had been in direct contact with the babies. R o u t i n e x-ray examination of the nursing staff, including two nurses f o r m e r l y on the obstetrical service who had then left the hospital, showed that one of the reg~dar night nurses had an infiltrative process of the right u p p e r lobe, characteristic of p u l m o n a r y tuberculosis, and her s p u t u m was found to contain tubercle bacilli. X-rays of the Other nurses proved negative. This nurse h a d been employed at the hospital since March 15, 1939, and her duties included all care of infants in the n u r s e r y f r o m 11 P.M. to 7 A.M. She gave all night feedings but did not p r e p a r e the formulas. Hospital regulations required that she wear a mask and gown for all n u r s e r y duty. H e r history showed t h a t at the beginning of her training in 1936 she had had an x-ray of the chest which was reported negative. She had not been re-examined till the present time. Although she denied a n y recent illness, she admitted she had had a cough for the past six months. l~rom the Massachusetts D e p a r t m e n t of Public Health, Division of Tuberculosis. 297
298
THE
JOURNAL
OF P E D I A T R I C S
Investigation showed that pasteurized certified milk had been used in the p r e p a r a t i o n of all formulas given on this w a r d during the period in question. I n view of the possibility o~ widespread infeetion of the infants eared f o r in this hospital during' the period the nurse might have been excreting tubercle bacilli, arrailgements were at once made with the hospital authorities and the local board of health for the examination of as m a n y as possible of the infants delivered between March 1, 1939, and J a n u a r y 30, 1940. The parents of such babies were requested b y the hospital to bring t h e m in to elinies to be held at specified hours at the hospital, and the examinations were made during F e b r u a r y and March, 1940. A t the first visit an intracutaneous tuberculin test was performed, using 0.01 mg. of old tuberculin. The tests were read on the second visit fortyeight hours later and the children who failed to react were retested with 1.0 mg. A p p r o x i m a t e l y 100 tests were made by a pediatrician on the hospital staff. An x-ray of the ehest o~ all reactors was made. The results of the tuberculin test are given in Table I. TABLE
I
TUBERCULIN REACTIONS AMONG INFANTS EXPOSED TO TUBERCULOSIS INFECTION IN A I-Io SPITAL I~URSERY
Total infants delivered in hospital March 1, 1939, to January 30~ 1940 Total infants tested (February and Marctb 1940) Total reactors to Mantoux Test s Percentage of reactors among infants tested * I n c l u d i n g t w o b a b i e s w h o d i e d of m i l i a r y
506 426 26 69
tuberculosis.
TABLE I I INCIDENCE OF REACTORS BY M O N T H OF BIRTFI MAR.
5
APR.
~
~
MAY
~
-
JUNE
-
~
JULY
~
~
AUG.
-
-
SEPT.
-
f
-
OCT.
NOV.
-
-
~
-
DEC.
~
-
JAN.
~
TOTAL
26
Although a certain n u m b e r of i'nfants in the general population would be expected to react to the tuberculin test at a mean age of 8 months, the reaction rate obtained in this group, 6.1 per eent, is three times the rate f o u n d among children tested in Massachusetts Well B a b y Clinics, at a mean age of 21/2 years. I t should be added t h a t of the 506 babies born in the hospital during this period, 12 had died of causes other than tubereulosis, as confirmed by the death certificates, in addition to the 2 who died of m i l i a r y tuberculosis. To get an idea as to whether the infection of infants at this hospital took place at any p a r t i c u l a r t~me, the reactors were tabulated by month of birth 9 There is of course no way of determining which babies aequired their infection while in hospital, but Table I I suggests t h a t infection m a y h a v e been taking place there r a t h e r continuously during the period in question.
POPE:
OUTBREAK OF TUBERCULOSIS DUE TO H O S P I T A L I N F E C T I O N
299
Of the twenty-six i~fants who reacted to the tuberculin test, seven showed roentgenologic evidence of tuberculosis. Two, as previously stated, died of miliary tuberculosis and the diagnosis was confirmed by autopsy. Two more of these reactors were subsequently admitted to the Children's Hospital, Boston, the first in April, 1940, with a diagnosis of pulmonary tuberculosis, and the second in August with a diagnosis of tuberculous tracheobronchial nodes with atelectasis. Both recovered. The remaining three infants showed traeheobronchial lymph node enlargement characteristic of tuberculosis but have not deVeloped symptoms of disease. To rule out the possibility of familial infection, as m a n y as possible of the contacts of the reacting infants were x-rayed. Examinations were completed on all members of seven families, but no cases of active tuberculosis were found. The a t t e m p t was made to follow all reacting infants with periodic roentgenograms and to retest all negative reactors born in the hospital between November ], 1939, and J a n u a r y 30, 1940, when the infectious nurse was removed from the nursery. Lack of interest on the p a r t of parents has made it impossible to secure any considerable number of retests, and only ten of the reacting children were brought in for x-ray in March, 1941. At that time none showed any evidence of p u l m o n a r y disease. COMMENT
A epidemiologic outline is presented of an outbreak of tuberculosis in infants, traceable to exposure to a nurse with open tuberculosis in a hospital nursery. Although recognition of the excess incidence of tuberculosis in student nurses and medical students has resulted in special examinations and regulations for the protection of these groups in most of the better hospitals, little consideration has been given to the possibility of the infection of patients by tuberculous personnel. In view of the experience cited, it is obvious that the examination of nnrses shauld not stop with the completion of training and that the prevention of tuberculous infection of infants in the hospitM is a definite responsibility of the administrator, the obstetrician, and the pediatrician. The examination of nurses for tuberculosis, for the protection of their own health and that of their patients, should start with an intracutaneous tuberculin test and an x-ray of the chest at the beginning of training. Negative reactors should be retested every six months and kept under close observation for approximately two years after this test becomes positive, and all student nurses x-rayed at least once a year, and upon the development of any symptoms suggestive of respiratory disease. Oil obstetrical wards and in nurseries, especially, all nurses and attendants who come in contact with patients should have regular radiographic examination of the chest annually and also upon any special indication. Strict medical asepsis is of course essential in the
300
THE
J O U R N A L OF P E D I A T R I C S
operation of nurseries, but this should not be Mlowed to take the place of p r o p e r examination of the nurse herself, nor does it afford her the protection to which she is entitled. F r o m the clinical standpoint this experience emphasizes two points: (a) t h a t babies can be infected with tuberculosis during the earliest days of life, and (b) t h a t such infections in certain cases tend to progress rapidly and often result fatally. Finally, the diagnosis of tuberculous meningitis or of generalized tuberculosis in an infant or child should be the signal for an immediate, intensive search for the source of infection. On account of the great reduction in the general incidence of tuberculosis during the past f o r t y years, such massive infection in an i n f a n t or young child almost inv a r i a b l y points to an open case of tuberculosis in the family or among other immediate associates. The prevention of f u r t h e r infection as well as t r e a t m e n t of the initial case must always be kept in mind.