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Epidemiologic Notes and Reports Tuberculosis in a Nursing Care Facility -- Washington

In November 1980, a 95-year-old female nursing home resident was found to have sputum smears positive for acid-fast bacilli. She died in December 1980, less than a week after beginning multiple drug therapy for tuberculosis. Sputum culture results confirmed the diagnosis of tuberculosis; the organisms were sensitive to all antituberculosis drugs. Subsequently, 11 other individuals were found to have bacteriologically proven tuberculosis.

The index patient had been a resident of the nursing home since November 1969. In 1975, she was examined as a contact of two patients with tuberculosis in the facility. She had a significant skin test reaction and a normal chest radiograph. Preventive therapy with isoniazid (INH) was not given. During the year before death, she lost 52 pounds and was seen by a physician several times because of a recurrent cough and "flu-like" symptoms. However, sputum examination for tuberculosis was not performed until November 1980.

The index patient lived in a 156-bed skilled nursing care facility, which housed 139 other residents and had 118 employees. Since 1975, skin testing recommended by state regulation had identified 48 residents and 29 employees with significant skin-test reactions. None of the residents was given INH preventive therapy. Repeat skin testing of the other residents and employees in December 1980 and January 1981 identified 59 (65%) of 91 residents and 38 (44%) of 87 employees as newly infected. All those with new infections were started on preventive therapy with INH. Regular visitors to the nursing home were not examined as contacts except those who requested testing in February 1981 after reports of the outbreak appeared in a local newspaper.

Chest radiographs were performed on all persons, including visitors requesting examination, who had significant skin test reactions. Eleven individuals who had suspicious films were found to have current pulmonary tuberculosis, all with sputum cultures positive for Mycobacterium tuberculosis. Seven of these patients were residents of the facility, one was an employee, and three were visitors of the facility. None of the seven residents shared sleeping quarters with each other or the index patient, but they did share common hallway, activity center, and dining area space. The air circulation system drew air from the residents' rooms, the activity center, and dining areas, and expelled it through two vents at each end of the hallway.

M. tuberculosis isolates from the index patient and the 11 other patients were phage-typed at CDC. The index case had been excreting phage type 2. The same phage type was found in the sputum of five other residents, the one employee, and one visitor. For the preceding year, this visitor had spent 2-3 hours per day in the room of one of the residents with phage type 2. Two other visitors, a husband and wife, had phage type 5. The remaining two residents were infected with phage type 7. Reported by R Munger, MD, Chelan-Douglas Health District, K Anderson, R Leahy, MD, J Allard, PhD, JM Kobayashi, MD, State Epidemiologist, Washington State Dept of Social and Health Svcs; Mycobacteriology Section, Div of Bacterial Diseases, Center for Infectious Diseases, Div of Tuberculosis Control, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: This episode illustrates several aspects of tuberculosis control. First, health workers, particularly those serving high risk populations, such as those in nursing homes and prisons, must consider a diagnosis of tuberculosis in a person with chronic weight loss and respiratory symptoms (1,2). Early diagnosis of the index patient might have prevented some additional cases and new infections. Second, existence of a skin-testing program for nursing home employees and residents did not prevent the outbreak. Infected persons at high risk of developing disease who are identified in screening programs must be given INH treatment to prevent development of disease (3,4). Third, thorough and careful investigation of close contacts should be performed whenever exposure to infectious tuberculosis occurs, and treatment or preventive therapy should be given when indicated (5). Investigation of contacts in this outbreak identified 11 additional tuberculosis cases and a large number of newly infected persons, all of whom required treatment.

This report demonstrates the epidemiologic usefulness of phage typing in tuberculosis outbreaks (6). In an outbreak of drug-resistant tuberculosis in rural Mississippi, phage types corresponded well with the history of contact between patients (7). In this nursing home outbreak, the same phage type tubercle bacillus caused disease in the index case, five other residents, one employee, and a visitor, suggesting a common source for these infections. The other two visitors and two residents appear to have acquired infection from other sources. Phage typing of M. tuberculosis can be performed at CDC when circumstances suggest it may be useful in investigating a tuberculosis outbreak.


  1. Stead WW. Tuberculosis among elderly persons: an outbreak in a nursing home. Ann Intern Med 1981;94:606-10.

  2. Stead WW. Undetected tuberculosis in prison. Source of infection for community at large. JAMA 1978;240:2544-7.

  3. Kent DC, Atkinson ML, Eckmann BH, Hilman BC, McDonald RJ. Screening for pulmonary tuberculosis in institutions. Am Rev Respir Dis 1977;115:901-6.

  4. Barlow PB, Black M, Brummer DL, et al. Preventive therapy of tuberculous infection. Am Rev Respir Dis 1974;110:371-4.

  5. Iseman MD, Bentz RR, Fraser RI, Locks MO, Ostrow JH, Sewell EM. Guidelines for the investigation and management of tuberculosis contacts. Am Rev Respir Dis 1976;114:459-63.

  6. Jones WD Jr, Good RC, Thompson NJ, Kelly GD. Bacteriophage types of Mycobacterium tuberculosis in the United States. Am Rev Respir Dis 1982;125:640-3.

  7. Reves R, Blakey D, Snider DE Jr, Farer LS. Transmission of multiple drug-resistant tuberculosis: report of a school and community outbreak. Am J Epidemiol 1981;113:423-35.

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