Thread: A nurse's cough turns into a public health crisis in Bronx

http://www.villagevoice.com/nyclife/071 ... 51,15.html

by Jeneen Interlandi
April 3rd, 2007 11:33 AM

For three weeks beginning in January, about 700 workers and patients at St. Barnabas Hospital in the Bronx, including 238 infants, were exposed to tuberculosis by an infected nurse. During that time, after the unidentified, foreign-born woman had developed a cough, she continued to report for regular shifts in the maternity ward and the nursery at the facility. When she finally reported her cough to a doctor, he noticed that she'd earlier tested positive for latent TB. A chest X-ray showed that the disease had turned infectious.

Following Centers for Disease Control and Prevention guidelines, the nurse was isolated in her home while she began a drug regimen. The hospital also notified the city's Bureau of Tuberculosis Control, which sent a team of epidemiologists into action. They marshaled months of hospital records and tried to track down every person who had crossed paths with the infectious nurse.

On March 15, when almost two months had passed since the investigation began and 271 potential victims still remained at-large, the city's Department of Health reached out to local media in an effort to track those patients down. More than 100 have come forward since then, and seven people in total have tested positive for latent tuberculosis, which they developed after being exposed to the infectious nurse.

The St. Barnabas case is reminiscent of a 2003 incident in which a nurse exposed 1,500 patients and co-workers at Bronx-Lebanon Hospital. She was also a foreign-born health care worker who had previously tested positive for latent TB. Like the nurse from St. Barnabas, she declined treatment, even though she worked with newborns. In that earlier case, the nurse showed symptoms for two months before she sought a diagnosis; only a third of those exposed were ever tracked down, and at least four infants tested positive for latent tuberculosis.

Both nurses fit an emerging profile. According to a recent report by the Bureau of Tuberculosis Control, the majority of health care workers with infectious tuberculosis are foreign- born female nurses between the ages of 35 and 54 who work in a hospital setting and have previously tested positive for latent infection.

Although the incidence of TB in New York City has declined steadily over the past decade, the percentage of cases in health care workers actually increased slightly over the same time period—from 3 percent at the height of the tuberculosis epidemic in the early 1990s to 4 percent in 2002, a small but significant change.

And convincing health care workers to do something about it has been one of the most difficult tasks for epidemiologists who have made tremendous progress on other fronts.

"It's a huge source of frustration," says Dr. Sonal Munsiff, an assistant health commissioner at the Bureau of Tuberculosis Control. "Especially given that they are working with some of the most vulnerable groups of people."

A nationwide nursing shortage is responsible for a large influx of foreign-born workers, many of them coming from regions of the world where TB persists in epidemic proportions.

"TB in foreign-born health care workers is increasingly likely to come from reactivation of old infections," Munsiff says, "acquired overseas, not in New York City."

And yet, not all health care workers get tested for tuberculosis when they are first hired. According to the Bureau of Tuberculosis Control, 20 percent of the 300 health care workers who contracted infectious tuberculosis between 1998 and 2002 had unknown results for the tuberculin skin test (TST) at hiring. But even those who are tested and are shown to carry the latent form of the disease—such as the nurses at St. Barnabas and Bronx-Lebanon—don't necessarily do anything about it. About half never get treatment.

"We don't know whether those who didn't get treated were not offered the treatment, or if they were offered and refused," Munsiff says. Either way, she would like to see more initiative on the part of hospitals. "I'd like to see them really make an effort to educate their workers, before just saying, 'OK, this person is not interested.' "

Health care workers, however, know that latent tuberculosis cannot be transmitted, does not cause symptoms, and in the overwhelming majority of cases, never progresses to the infectious state.

"A lack of symptoms diminishes people's sense of urgency," Munsiff says. "And with health care workers it's worse, because they already know the odds of developing active TB are small."

On top of that, the treatment for latent tuberculosis infection is burdensome, and in rare cases can lead to serious side effects.

"Taking Isoniazid every day for nine months is a big pain," explains Neil Schluger, an epidemiology professor at Columbia University's Mailman School of Public Health. "Doctors and nurses are a great example of 'Do as I say, not as I do.' " Schluger points out that health care workers' resistance to treatment goes beyond their sense of inconvenience.

"Many of them are extremely nervous about going on Isoniazid," he says. "But in 15 years of working with it, I've never seen a case of serious side effects."

And there are other reasons why health care workers may resist treatment.

"The disease still carries a stigma," says Joseph Lurio, a Bronx-based primary care physician who worked as a TB control officer for several years. "I had a nurse once who lied about her symptoms for fear of losing her job."

But because they work with those most susceptible to infection—newborns and people with compromised immune systems—health care workers with latent TB present a unique threat.

"It is important that patients be able to trust their health care providers to 'do no harm,' " Timothy Sterling, a scientist at Vanderbilt University School of Medicine in Tennessee, writes in a recent edition of The New England Journal of Medicine. "All health care workers in the United States, regardless of their country of birth, must earn that trust by doing everything possible to minimize the risk to patients."

This does not surprise me. I wonder if the nurse was from the Phillipines. Many foreign nurses come from there as well as Canada. In the province of Ontario any hospital employee who has patient contact get tested for TB every 6 months.
As for people going to work ill, if those hospitals are like the ones in Ontario then you get in trouble if you have too much sick time and often employees would go to work when ill.

The hospitals in my area are the same way. They are not sympathetic to their employees when they are ill, and are expected to show up no matter what.

In Texas, nurses have to have a TB test before going to work -- it's one of the pieces of documentation that have to be presented. Then they are tested every year. TB cases are reported to the Health Department and if you don't show up for treatment, the police are sent after you. Patients found with TB are also reported to the Health Department. The problem here is that illegals give incorrect names, addresses and then the Health Department can't find them.

Almost daily I am out and about and see many people I believe may be illegal aliens, coughing their lungs out practically, it is sooo scary. The scariest part is these people in this article are talking about nurses!

I can avoid someone I see a little away coughing heavily, but a nurse?

I know here, there are signs in all doctors offices and in hospitals saying they will REQUIRE you to wear a face mask if you have a cough, or you will be asked to leave.

One of the reasons to avoid hospitals at all costs-if at all possible.

The number of people who die in hospital care-even when they're in for relatively minor procedures-is staggering.

What I find amazing is that the nurse's coworkers didn't notice and complain or were they from the same country?
American Elizabeth, you mention people coughing alot and how scary it is, I agree and that is why I avoid shopping when they are alot of people out. It helps prevent catching an air borne disease as you aren't close to anyone. Police Officers really get it bad as they deal with ignorant people who don't even cover their mouth when they cough, aids victims, illegals who land on shore or ones caught committing a crime, homeless people and more. In fact jails in South Florida have a high rate of TB as does California. You don't hear much about the immigration detention centers and incidents of diseases such as TB but I am sure that they are there.

Swatchick, that's so true about police. My brother had been trained to be a county deputy reserve, and in that training, they talked a LOT about all sorts of diseases, and also about making sure they went in for routine testing of all sorts of thing, every six months they required it he told me.

I have heard that up here in the Pacific NW, we have a fairly high rate of TB, especially in the homeless, they say it is due to the soil and our damp climate (I'm sure Florida is right there being tropical and damp to).

Another disease we have a LOT of trouble with up here is Meningococol disease, why, no one knows (again probably has a lot to do with the cimate, wet soil and a lot of issues with black mold, I think, anyways).