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A Pseudo-Outbreak of Purified Protein Derivative Skin-Test Conversions Caused by Inappropriate Testing Materials

Published online by Cambridge University Press:  02 January 2015

John C. Grabau*
Affiliation:
Bureau of Tuberculosis Control, New York State Department of Health, Albany, New York
Daniel J. Burrows
Affiliation:
Bureau of Tuberculosis Control, New York State Department of Health, Albany, New York
Michelle L. Kern
Affiliation:
Bureau of Tuberculosis Control, New York State Department of Health, Albany, New York
*
Bureau of Tuberculosis Control, New York State Department of Health, Empire State Plaza, Corning Tower, Room 840, Albany, NY 12237-0669

Abstract

Objective:

To investigate a cluster of newly identified tuberculosis infections.

Design:

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

Setting:

Community residential facilities providing comprehensive services to retarded adults.

Participants:

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

Results:

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

Conclusions:

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.

Type
Original Articles
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1997

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