Lilia P. Manangan

Feasibility of national surveillance of health-care-associated infections in home-care settings.

This article examines the rationale and strategies for surveillance of health-care-associated infections in home-care settings, the challenges of nonhospital-based surveillance, and the feasibility of developing a national surveillance system.

Status of tuberculosis infection control programs at United States hospitals, 1989 to 1992

BACKGROUND Recent nosocomial outbreaks have raised concern about the risk of Mycobacterium tuberculosis transmission in United States hospitals. METHODS To determine current tuberculosis (TB) infection control practices, we surveyed a sample of approximately 3000 acute care facilities about the number of patients with drug-susceptible or multidrug-resistant TB (MDR-TB), health care worker (HCW) tuberculin skin test (TST) results, and compliance with the 1990 Centers for Disease Control and Prevention (CDC) TB guidelines. Analyses were restricted to one response per hospital. RESULTS Personnel at 1494 (49.8%) hospitals returned a completed survey. Respondent hospitals had a mean of 881 HCWs (range 8 to 10,000) and 196 (range 6 to 2450) beds; 62% percent were community nonteaching hospitals. Of respondent hospitals providing data for 1989 through 1992, the proportion that cared for patients with TB or MDR-TB increased from 46.4% to 56.6% and 0.8% to 4.5%, respectively. The pooled mean HCW TST positivity rate at hire rose from 0.95% to 1.14%, and the pooled mean HCW TST conversion rate increased from 0.40% to 0.51%. In 1992, when we compared hospitals with zero, one to five, or six or greater patients with TB, the risk of a positive HCW TST result at hire or at routine testing significantly increased with increasing number of patients with TB. From 1989 through 1992, the number of hospitals reporting the use of surgical masks for HCW respiratory protection decreased from 96.8% to 66.8%. In 1992, 66% of the hospitals reported compliance with four or more of the AFB isolation room criteria specified in the 1990 CDC TB guidelines. CONCLUSIONS Contrary to prior surveys, this study shows that many U.S. community hospitals admit patients with TB less frequently than do teaching hospitals, and infrequently admit patients with MDR-TB. Because the risk of HCW TST conversion varies with hospital characteristics, these data show the importance of performing a risk assessment, as recommended in the CDC TB guidelines, for each ward and hospital so that TB control measures can be individualized.

Tuberculosis Screening by Tuberculosis Skin Test or QuantiFERON®-TB Gold In-Tube Assay among an Immigrant Population with a High Prevalence of Tuberculosis and BCG Vaccination

Rationale Each year 1 million persons acquire permanent U.S. residency visas after tuberculosis (TB) screening. Most applicants undergo a 2-stage screening with tuberculin skin test (TST) followed by CXR only if TST-positive at > 5 mm. Due to cross reaction with bacillus Calmette-Guérin (BCG), TST may yield false positive results in BCG-vaccinated persons. Interferon gamma release assays exclude antigens found in BCG. In Vietnam, like most high TB-prevalence countries, there is universal BCG vaccination at birth. Objectives 1. Compare the sensitivity of QuantiFERON ®-TB Gold In-Tube Assay (QFT) and TST for culture-positive pulmonary TB. 2. Compare the age-specific and overall prevalence of positive TST and QFT among applicants with normal and abnormal CXR. Methods We obtained TST and QFT results on 996 applicants with abnormal CXR, of whom 132 had TB, and 479 with normal CXR. Results The sensitivity for tuberculosis was 86.4% for QFT; 89.4%, 81.1%, and 52.3% for TST at 5, 10, and 15 mm. The estimated prevalence of positive results at age 15–19 years was 22% and 42% for QFT and TST at 10 mm, respectively. The prevalence increased thereafter by 0.7% year of age for TST and 2.1% for QFT, the latter being more consistent with the increase in TB among applicants. Conclusions During 2-stage screening, QFT is as sensitive as TST in detecting TB with fewer requiring CXR and being diagnosed with LTBI. These data support the use of QFT over TST in this population.

Sanitary care and maintenance of icestorage chests and ice-making machines in health care facilities

In response to a reported hospital outbreak traced to the use of contaminated ice in 1968, the Centers for Disease Control and Prevention (CDC) developed an advisory regarding the sanitary care and maintenance of ice-storage chests and ice-making machines. CDC has revised this unpublished advisory several times during the years to respond to requests for guidance from infection control professionals. Because CDC continues to receive inquiries about this topic from infection control professionals, this advisory is being published.

The National Tuberculosis Surveillance System training program to ensure accuracy of tuberculosis data.

OBJECTIVES The Centers for Disease Control and Prevention implemented a national training program for health care workers and surveillance staff to ensure accuracy of data reported to the Centers for Disease Control and Preventions National Tuberculosis Surveillance System and increase training capacity in tuberculosis surveillance. METHODS To address the changing epidemiology of tuberculosis and related reporting requirements, a working group of tuberculosis experts revised the Report of Verified Case of Tuberculosis (RVCT), the National Tuberculosis Surveillance System data collection form. The revision prompted a need for training in accurately completing the form. A Centers for Disease Control and Prevention interdisciplinary training team collaborated with key partners in assessing health care worker training needs regarding the RVCT. The team conducted 5 field tests to ensure instructional effectiveness of the training materials. Participants worked through materials, shared experiences, asked questions, and stated concerns about the RVCT. On the basis of these inputs, the team developed an innovative and comprehensive training program. RESULTS The training materials included instructions for completing each item on the RVCT form, case studies to enable participants to apply the instructions to real-life situations, and visual aids to enhance learning. In both quantitative and qualitative responses, participants indicated that the RVCT training course and self-study materials helped them gain the knowledge needed to accurately complete the RVCT. The team conducted 14 facilitator-led courses and trained 343 health care workers and surveillance staff; 82 of these were training-of-trainers participants. CONCLUSIONS Collaboration and innovation are essential in implementing an effective national surveillance-training program to ensure the accurate collection and reporting of tuberculosis surveillance data.

The infection control information system of the Hospital Infections Program, Centers for Disease Control and Prevention

In December 1990 the Investigation and Prevention Branch, Hospital Infections Program, Centers for Disease Control and Prevention (CDC), developed the Hospital Infections Program infection control information system (HIP ICIS) to respond more efficiently to more than 200 public inquiries (telephone or written) that HIP receives daily. The HIP ICIS allows anyone with a Touch-Tone telephone, fax machine, or computer to access CDC information that answers the most commonly asked questions from infection control practitioners and other health care workers. The HIP ICIS has received approximately 56,608 inquiries; of these, 33% were about CDC guidelines on prevention and control of nosocomial infections, 25% about issues related to HIV, 16% about sterilization and disinfection of medical devices, 8% about methicillin-resistant Staphylococcus aureus, 3% about long-term care facilities, and 17% miscellaneous topics (e.g., nosocomial infection rates, infection control courses, and ventilation, construction, and renovation of hospitals). The HIP ICIS is an efficient method of providing infection control guidance to the infection control community. In this article, we a) review the history of the HIP ICIS, b) present data on HIP ICIS usage, c) summarize the current HIP ICIS contents, and d) present step-by-step instructions on how to access the HIP ICIS.

Trends in Compliance With the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis Among New Jersey Hospitals, 1989 to 1996

OBJECTIVE To determine trends in compliance with the guidelines for preventing the transmission of Mycobacterium tuberculosis in healthcare facilities among New Jersey hospitals from 1989 through 1996. DESIGN A voluntary questionnaire was sent to all 96 New Jersey hospitals in 1992. The 53 that responded were resurveyed in 1996. RESULTS Of the 96 hospitals surveyed in 1992, 53 (55%) returned a completed questionnaire; 33 (64%) were community, nonteaching hospitals. In 1991, patients with tuberculosis (TB) were admitted at 38 (72%) of 53 hospitals, and from 1989 through 1991, patients with multidrug-resistant (MDR) TB were admitted at 15 (29%) of 52 hospitals. Twenty-nine (57%) of 51 reported having rooms meeting the Centers for Disease Control and Prevention (CDC) criteria for acid-fast bacilli (AFB) isolation. A nonfitted surgical mask was used as a respiratory protective device by healthcare workers (HCWs) at 28 (55%) of 51 hospitals. Attending physicians were included in tuberculin skin-testing (TST) programs at 5 (11%) of 45 hospitals. In the 1996 resurvey, 48 (94%) of 53 surveyed hospitals returned a completed questionnaire; 34 (81%) of 42 had TB patient admissions, and 4 (9%) of 43 had MDR TB patient admissions in 1996. Forty-five (96%) of 47 reported having rooms that met CDC criteria for AFB isolation. N95 respiratory devices were used by HCWs at 45 (94%) of 48 hospitals. Attending physicians were included in the TST programs at 22 (54%) of 41 hospitals. CONCLUSION New Jersey hospitals have made improvements in availability of AFB isolation rooms, use of proper respiratory protective devices, and expansion of TST programs for HCWs from 1989 through 1996.

Status of tuberculosis infection control programs at Texas hospitals, 1989 through 1991

BACKGROUND Paralleling the resurgence of tuberculosis (TB) in the United States, the reported number of persons with TB in Texas increased by 33% during 1985 through 1992, the third largest rise among all the states. This increase prompted us to survey hospitals in Texas to determine their degree of compliance with recommendations in the Centers for Disease Control and Prevention TB guidelines. METHODS In April 1992, we mailed a voluntary questionnaire about TB infection control practices, health care worker tuberculin skin testing procedures, and Mycobacterium tuberculosis laboratory methods to a convenience sample of hospitals in Texas. RESULTS Of 180 hospitals surveyed, 151 (83%) returned completed questionnaires. Of these, 90 (60%) were nonteaching community hospitals; 28 (19%) were teaching community hospitals; 13 (9%) were university-affiliated hospitals; and 20 (13%) were other hospitals. The number of hospitals to which patients with TB were admitted increased from 98 (65%) in 1989 to 122 (81%) in 1991. Respondent hospitals had a mean of 183 acute care beds (median 100, range 5 to 999), 6 acid-fast bacillus isolation rooms (median 2, range 0 to 57) and 7.5 admissions/year of patients with TB (median 2, range 0 to 202). Of hospitals responding to specific questions, 20% (27/137) admitted patients with multidrug-resistant TB, 18% (25/140) reported not having any acid-fast bacillus isolation rooms, and 28% (35/125) had no rooms meeting all of the Centers for Disease Control and Prevention criteria for acid-fast bacillus isolation (negative air pressure, > or = 6 air changes per hour, and air directly vented to the outside). The tuberculin skin test conversions among health care workers rose from 246 (0.6%) in 1989 to 547 (0.9%) in 1991. CONCLUSION Although the number of Texas hospitals admitting patients with TB increased during 1989 through 1991, many facilities still did not have infection control practices consistent with the 1992 Centers for Disease Control and Prevention TB guidelines.

National Surveillance of Healthcare- Associated Infections in Home Care Settings-Feasible or Not?

Despite the phenomenal growth of home care, the epidemiology of healthcare-associated infections in home care settings has not been defined. Therefore, a national system for surveillance of healthcare-associated infections in home care is needed not only to provide useful data on incidence and types of infections, but also to better identify risk factors for infection and develop national benchmarks for comparing infection rates and assessing prevention interventions. However, surveillance in home care settings poses several unique challenges, including lack of nationally accepted standard definitions of infection and methods of surveillance data collection, loss of patient follow-up, lack of trained infection control personnel in home care settings, difficulty capturing clinical and laboratory data, and difficulty obtaining numerator and denominator data for calculation of infection rates. In spite of these challenges, several groups are collecting data on healthcare-associated infections in home care or other outpatient areas. The collective information from these experiences may be useful in developing a national home healthcare surveillance system. Collaboration between home healthcare agencies, state and federal health agencies, private industry, and national or managed care organizations is essential to make this surveillance system feasible and functional.