To determine the cost of nonrespirator-related tuberculosis (TB) control measures at several hospitals, following publication of the Centers for Disease Control and Prevention (CDC)'s revised TB infection control guidelines.

Infection control (IC) and TB coordinators obtained cost information on tuberculin skin-test (TST) programs, addition of IC and employee health service (EHS) personnel, and the retrofit or new construction of environmental controls.

Four hospitals with, and one community hospital without, prior nosocomial multidrug-resistant TB transmission.

During the study period, the TST program costs remained constant at four of five hospitals and increased at one hospital (median 1994 TST program cost: $5,568; range, $2,393-$44,902). Additional IC or EHS personnel were hired at four of five hospitals (median cost increase, $125,500; range, $63,000-$228,000). The median cost of new construction or new equipment purchases (ie, sputum induction booths, ultraviolet lights, or portable high-efficiency particulate air filters) at study hospitals was $163,000 (range, $45,000-$524,000) and $70,000 (range, $31,000-$93,000), respectively.

Costs associated with implementing control measures similar to those recommended in the CDC TB IC guidelines varied widely by hospital. Engineering controls involved the largest capital outlay, but increases in personnel were the largest continuing cost. These costs represent improvements made to upgrade selected aspects of hospital TB control programs, not the cost of an optimal TB control program.

To document the actual tuberculosis (TB) control policies and procedures in a nonoutbreak setting in a variety of hospitals. To determine if any particular practices are linked to higher rates of employee tuberculin skin-test conversion.

Survey of hospital occupational health and infection control practitioners for the year 1994 regarding hospital TB policies. Review of hospital records to verify the number of patients with TB at each hospital and to verify the number of employees with positive tuberculin skin tests. Smoke-stick testing of negative-pressure ventilation rooms.

A 13-hospital health system in the Midwest.

Hospitals ranged in size from 40 to 1,208 beds (median 220) and employed 150 to 6,500 workers (median 875). There were seven rural and six urban centers, including four teaching hospitals. All 13 hospitals had TB control plans, and all performed annual tuberculin skin testing on employees. Annual skin-test positivity rates ranged from 0% to 1.0% (median 0.3%). Negative-pressure ventilation rooms were available in 11 hospitals. The percentage of negative-pressure rooms with effective negative pressure ranged from 44% to 100% (median 95%). Three of the 13 hospitals used high-efficiency particulate air (HEPA) masks as primary personal respiratory protection, and 8 used dust-mist or dust-mist-fume masks. We found no relation between the type of face mask used, number of functional negative-pressure rooms, or hospital TB risk category, and employee skin-test conversion rates.

Considerable variation existed in the TB control policies and procedures between hospitals, but employee TB skin-test conversion rates were low in all settings.

To describe the derivation and validation of a pulmonary tuberculosis (TB) prediction model that would enable early discontinuation of unnecessary respiratory isolation.

Patients placed in isolation for suspected pulmonary TB were studied retrospectively (derivation cohort) and prospectively (validation cohort). Independent predictors of pulmonary TB in the derivation cohort (January 1992-March 1994) were identified by retrospective analysis. Predictors in the model were assigned weights on the basis of the results of the multivariate analysis in order to quantitate the risk of TB in an individual patient. The prospective validation consisted of application of the model to patients placed in isolation during the period April 1994 to June 1995. The predictability of the model in the derivation and validation cohorts was evaluated using receiver operating characteristics (ROC), curve analysis, and calculation of the area under the ROC curve (AUC).

A university-affiliated, urban, public hospital with a large population of prison inmates and patients with human immunodeficiency virus infection.

Prospective application of the prediction model to patients placed in isolation during the validation period.

Four factors were found to be independent predictors of pulmonary TB among 296 isolation episodes in the derivation cohort: positive acid-fast sputum smear (odds ratio [OR], 5.8; 95% confidence interval [CI95], 3.0-11.0; weight=3 points), localized chest radiograph findings (OR, 2.5; CI95,1.3-4.9; weight=2 points), residence in a correctional facility (OR, 2.3; CI95, 1.2-4.4; weight=2 points), and history of weight loss (OR, 1.8; CI95, 1.0-3.2; weight=1 point). Infection control practitioners applied the model prospectively to 220 isolation episodes. The mean (土SE) AUCs of the ROC curve for the derivation and validation cohorts were not significantly different (.86±.04 vs.86±.07; P=.90). There was a significant decline in the mean duration of isolation from the onset of an automatic TB isolation policy in August 1992 to the end of the study (P=.045 by analysis of variance).

A pulmonary TB prediction model was derived and validated prospectively in a hospital with a moderately high prevalence of TB. The model quantitated the risk of TB in an individual patient and aided infection control practitioners and primary-care physicians in their decisions to discontinue isolation during the validation period. Utilization of the model was responsible, in part, for a decrease in the mean duration of isolation during the study period. Although the model may not have general applicability due to the uniqueness of the patient population studied, this study illustrates how prediction models can be developed and used effectively to deal with a clinical problem.

We sought to define the prevalence of tuberculin skin test (TST) positivity in a group of newly hospitalized patients, to identify risk factors for positive tests, and to examine the impact of testing on infection control practices.

Unblinded cohort study over 5 days in July 1992.

A 1,000-bed university-affiliated hospital.

All patients admitted (excluding obstetric patients and newborns) were interviewed. Patients without a history of tuberculosis (TB) or a positive TST were offered a TST with Candida and tetanus controls.

Of 346 patients offered the test, 21 (6%) had a prior history of TB or a positive TST, and 36 (10%) declined to participate; 279 of the remaining 289 completed the study. Anergy was demonstrated in 94 (33.7%) of 279 patients. New positive TSTs were identified in 19 (10.3%) of 185 nonanergic patients. Of the 19 TST-positive patients, 6 (32%) had infiltrates on chest radiographs and were evaluated for active TB. One patient was treated empirically for active TB, and five received isoniazid prophylaxis. Risk factors for a new positive TST included age (odds ratio [OR], 1.56 per decade of life; P=.021), African American race (OR, 4.81; P=.008), alcohol abuse (OR, 5.53; P=.005), and peptic ulcer disease (OR, 4.53; P=.017). Risk factors for anergy included admission to a surgical service (OR, 2.1; P=.006), current use of steroids (OR, 2.65; P=.005), and human immunodeficiency virus (HIV) infection (OR, undefined; P=.034).

Despite a high rate of anergy, routine tuberculin skin testing identified a substantial number of patients with TB infection who might otherwise have gone unrecognized.

To assess the efficacy of an infection control program as measured by tuberculin skin-test (TST) conversion rates in medical house staff.

Observational study.

University-based hospital in New York City serving a large indigent population.

Medical house staff.

TST conversions were measured every 6 months in medical house staff from June 1992 to June 1994. Compliance with the isolation policy was measured by identifying room locations 24 hours after admission of patients who had Mycobacterium tuberculosis recovered from respiratory specimens.

The TST conversion rate decreased from 5.8 to 0, 2.3, and 0 per 100 person years of exposure in successive 6-month periods. The estimated annual TST conversion rate among interns fell from 7 per 100 person years in June 1992 to 0 per 100 person years in June 1993 and 0 per 100 person years in June 1994 (P=.029). The proportion of patients with pulmonary tuberculosis who were isolated in negative-pressure rooms increased from 38% to 75% over the study period (P=.01).

Development of a multifaceted infection control program can decrease the risk of nosocomial tuberculosis infection in medical house staff.

To investigate a cluster of newly identified tuberculosis infections.

A field study was conducted including interviews; medical record reviews; checking of bills and invoices, pharmacy records, and drug manufacturer information; and clinical retesting.

Community residential facilities providing comprehensive services to retarded adults.

Twenty residential facility staff (not previously known to be purified protein derivative [PPD] positive).

Staff had been tested with 250 TU of PPD, and 9 of 20 were tuberculin positive. Retesting with 5 TU yielded no reaction.

Reactions were attributable to testing with a product not recommended for routine PPD screening. Healthcare workers planting PPD Mantoux tests always should check the vials to ensure that the appropriate strength solution is being used.